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Re: Fatal Sepsis after Uterine Artery Embolization with Microspheres
406
•
April 2004
Letters to the Editor
ogy is necessary, and technical training, particularly with the use of new embolization agents, should be obtained. Radiologic societies such as the Society of Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe are already involved in training and workshops for radiologists interested in UAE. Again, we would like to thank de Blok et al (1) for publishing this fatal complication of UAE. It is never easy to publish complications, but it is the only way we can inform our colleagues. We should keep in mind that, even if the complication rate of UAE is lower than the surgical rate, all radiologists should be aware of potential risks associated with the procedure. Major complications of embolization are now better understood, and prevention can be successfully applied thanks to the experience and reports of other groups. References 1. de Blok S, de Vries C, Prinssen HM, Blaauwgeers HLG, JornaMeijer LB. Fatal sepsis after uterine artery embolization with microspheres. J Vasc Interv Radiol 2003; 14:779 –783. 2. Walker WJ, Pelage JP, Sutton C. Fibroid embolisation. Clin Radiol 2002; 57:325–331. 3. Takamizawa S, Minakami H, Usui R, et al. Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynecol Obstet Invest 1999; 48:193–196. 4. Pelage JP, Laurent A, Wassef M, et al. Uterine artery embolization in sheep: comparison of acute affects with polyvinyl alcohol particles and calibrated microspheres. Radiology 2002; 224:436 – 445. 5. Spies JB, Benenati JE, Worthington-Kirsch R, Pelage JP. Initial experience with tris-acryl gelatin microspheres for uterine artery embolization for leiomyomata. J Vasc Interv Radiol 2001; 12: 1059 –1063. 6. Pelage JP, Le Dref O, Beregi JP, et al. Limited uterine artery embolization with tris-acryl gelatin microspheres for uterine fibroids. J Vasc Interv Radiol 2003; 14:15–20.
Drs. De Blok et al respond: We thank Dr. Pelage and colleagues for commenting on our article. There is not much to add but the following. The amount of necrosis and ischemia found at autopsy in our patient was thought to be the effect of overembolization, like Dr. Pelage states. This so-called overembolization was the state-of-the-art strategy in uterine artery embolization with use of polyvinyl alcohol particles at that time (2001). Instead of polyvinyl alcohol, we used absorbable microspheres and, because we knew that these particles could penetrate further into the capillary bed of the uterus, we used particles that were larger than the polyvinyl alcohol particles used in embolization (500 –700 m vs. 300 –500 m). The necrosis found was far beyond the area we embolized. Because ischemic changes were found in the heart, lungs, and intestines, there must have been a cumulative effect of the embolization and toxic shock resulting from the hemolytic Streptococcus sepsis. This implies that we still do not know to what extent the necrosis would have occurred solely on the basis of the embolization. In the case of a hemolytic Streptococcus infection, even the smallest ischemic lesion can be devastating and life-threatening. Although we also changed our embolization strategy from a standing column of contrast material in the uterine artery to the
DOI: 10.1097/01.RVI.0000121402.46920.49
JVIR
pruned-tree method advocated by Dr. Pelage, we have to bear in mind that we are still making the uterus ischemic or even necrotic. Monitoring the patient after the embolization and instructing the patient what to do in the case of worsening pelvic pain, increasing fever, or vaginal discharge may be of greater importance in preventing major complications than solely adjusting the embolization technique. The treatment of uterine fibroids should be done by interventional radiologists who are trained to do so and know how to recognize the complications. Sjoerd de Blok, MD, PhD, Cees de Vries, MD, Helma M. Prinssen, MD, Hans L.G. Blaauwgeers, MD, and Lorine B. Jorna-Meijer, MD Departments of Obstetrics and Gynaecology (S.d.B., H.M.P.), Radiology and Nuclear Medicine (C.d.V.), and Pathology (H.L.G.B., L.B.J.M.), Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
Endometritis after Uterine Artery Embolization with Gold-colored Gelatin Microspheres From: Howard M. Richard, III, MD, Gary P. Siskin, MD, and Brian F. Stainken, MD Division of Interventional Radiology (H.M.R., B.F.S.) Department of Diagnostic Imaging University of Maryland Medical System Baltimore, Maryland Division of Vascular and Interventional Radiology (G.P.S.) Institute for Vascular Health and Disease Albany Medical College Albany, New York From the 2002 SCVIR Annual Meeting. Address correspondence to H.M.R., Interventional Radiology, Washington Hospital Center, 110 Irving St NW, Washington, DC 20010 Editor: This brief report summarizes our multicenter experience with noninfective endometritis after uterine artery embolization (UAE) performed with gold-colored gelatin microspheres (EmboGold; Biosphere Medical, Rockland, MA). Endometritis can be defined as an inflammation of the inner lining (endometrium) of the uterus after UAE, resulting in pelvic pain, watery vaginal discharge, fever, and/or leukocytosis within days to weeks of the procedure. Endometritis is rare after UAE, with Spies et al (1) reporting a 0.5% incidence. Because etiologies include infectious and noninfectious causes, the diagnosis of noninfective endometritis was made in patients experiencing these signs and symptoms without evidence of infection. Seven patients who underwent UAE with gold-colored gelatin microspheres developed noninfective endometritis. None of these patients reported a history of smoking, pelvic infection, or vaginal discharge before UAE. All patients received cefazolin (Ancef; SmithKline Beecham, Philadel-
DOI: 10.1097/01.RVI.0000121403.46920.00
•
April 2004
Letters to the Editor
ogy is necessary, and technical training, particularly with the use of new embolization agents, should be obtained. Radiologic societies such as the Society of Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe are already involved in training and workshops for radiologists interested in UAE. Again, we would like to thank de Blok et al (1) for publishing this fatal complication of UAE. It is never easy to publish complications, but it is the only way we can inform our colleagues. We should keep in mind that, even if the complication rate of UAE is lower than the surgical rate, all radiologists should be aware of potential risks associated with the procedure. Major complications of embolization are now better understood, and prevention can be successfully applied thanks to the experience and reports of other groups. References 1. de Blok S, de Vries C, Prinssen HM, Blaauwgeers HLG, JornaMeijer LB. Fatal sepsis after uterine artery embolization with microspheres. J Vasc Interv Radiol 2003; 14:779 –783. 2. Walker WJ, Pelage JP, Sutton C. Fibroid embolisation. Clin Radiol 2002; 57:325–331. 3. Takamizawa S, Minakami H, Usui R, et al. Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynecol Obstet Invest 1999; 48:193–196. 4. Pelage JP, Laurent A, Wassef M, et al. Uterine artery embolization in sheep: comparison of acute affects with polyvinyl alcohol particles and calibrated microspheres. Radiology 2002; 224:436 – 445. 5. Spies JB, Benenati JE, Worthington-Kirsch R, Pelage JP. Initial experience with tris-acryl gelatin microspheres for uterine artery embolization for leiomyomata. J Vasc Interv Radiol 2001; 12: 1059 –1063. 6. Pelage JP, Le Dref O, Beregi JP, et al. Limited uterine artery embolization with tris-acryl gelatin microspheres for uterine fibroids. J Vasc Interv Radiol 2003; 14:15–20.
Drs. De Blok et al respond: We thank Dr. Pelage and colleagues for commenting on our article. There is not much to add but the following. The amount of necrosis and ischemia found at autopsy in our patient was thought to be the effect of overembolization, like Dr. Pelage states. This so-called overembolization was the state-of-the-art strategy in uterine artery embolization with use of polyvinyl alcohol particles at that time (2001). Instead of polyvinyl alcohol, we used absorbable microspheres and, because we knew that these particles could penetrate further into the capillary bed of the uterus, we used particles that were larger than the polyvinyl alcohol particles used in embolization (500 –700 m vs. 300 –500 m). The necrosis found was far beyond the area we embolized. Because ischemic changes were found in the heart, lungs, and intestines, there must have been a cumulative effect of the embolization and toxic shock resulting from the hemolytic Streptococcus sepsis. This implies that we still do not know to what extent the necrosis would have occurred solely on the basis of the embolization. In the case of a hemolytic Streptococcus infection, even the smallest ischemic lesion can be devastating and life-threatening. Although we also changed our embolization strategy from a standing column of contrast material in the uterine artery to the
DOI: 10.1097/01.RVI.0000121402.46920.49
JVIR
pruned-tree method advocated by Dr. Pelage, we have to bear in mind that we are still making the uterus ischemic or even necrotic. Monitoring the patient after the embolization and instructing the patient what to do in the case of worsening pelvic pain, increasing fever, or vaginal discharge may be of greater importance in preventing major complications than solely adjusting the embolization technique. The treatment of uterine fibroids should be done by interventional radiologists who are trained to do so and know how to recognize the complications. Sjoerd de Blok, MD, PhD, Cees de Vries, MD, Helma M. Prinssen, MD, Hans L.G. Blaauwgeers, MD, and Lorine B. Jorna-Meijer, MD Departments of Obstetrics and Gynaecology (S.d.B., H.M.P.), Radiology and Nuclear Medicine (C.d.V.), and Pathology (H.L.G.B., L.B.J.M.), Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
Endometritis after Uterine Artery Embolization with Gold-colored Gelatin Microspheres From: Howard M. Richard, III, MD, Gary P. Siskin, MD, and Brian F. Stainken, MD Division of Interventional Radiology (H.M.R., B.F.S.) Department of Diagnostic Imaging University of Maryland Medical System Baltimore, Maryland Division of Vascular and Interventional Radiology (G.P.S.) Institute for Vascular Health and Disease Albany Medical College Albany, New York From the 2002 SCVIR Annual Meeting. Address correspondence to H.M.R., Interventional Radiology, Washington Hospital Center, 110 Irving St NW, Washington, DC 20010 Editor: This brief report summarizes our multicenter experience with noninfective endometritis after uterine artery embolization (UAE) performed with gold-colored gelatin microspheres (EmboGold; Biosphere Medical, Rockland, MA). Endometritis can be defined as an inflammation of the inner lining (endometrium) of the uterus after UAE, resulting in pelvic pain, watery vaginal discharge, fever, and/or leukocytosis within days to weeks of the procedure. Endometritis is rare after UAE, with Spies et al (1) reporting a 0.5% incidence. Because etiologies include infectious and noninfectious causes, the diagnosis of noninfective endometritis was made in patients experiencing these signs and symptoms without evidence of infection. Seven patients who underwent UAE with gold-colored gelatin microspheres developed noninfective endometritis. None of these patients reported a history of smoking, pelvic infection, or vaginal discharge before UAE. All patients received cefazolin (Ancef; SmithKline Beecham, Philadel-
DOI: 10.1097/01.RVI.0000121403.46920.00