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Review of Readmissions Due to Complications from Uterine Fibroid Embolization
Clinical Radiology (2002) 57: 1122±1124 doi:10.1053/crad.2002.1102, available online at http://www.idealibrary.com on
Review of Readmissions Due to Complications from Uterine Fibroid Embolization H . ME H TA , C . SA N D H U , M . M AT S O N , A . - M . B E L L I Department of Radiology, St. George's Hospital, Blackshaw Road, London SW17 OQT, U.K. Received: 21 March 2002 Revised: 9 July 2002 Accepted: 20 July 2002 AIM: To determine the frequency, nature and outcome of complications resulting in readmission to hospital following uterine artery embolization (UAE). MATERIAL AND METHODS: A retrospective review of the medical notes and available imaging of 42 consecutive patients who had undergone elective uterine artery embolization for the treatment of ®broid disease was performed. RESULTS: The mean age of the patients was 42 years (range 31±54 years) and seven patients (17%) were readmitted to hospital. The median time to readmission was 3 weeks (range 1±29 weeks). All seven patients were admitted with signs and symptoms of infection. In four patients an organism was isolated from high vaginal swabs, and in one patient the midstream urine sample was con®rmed as the source of infection. In the other two patients no de®nite source of infection was identi®ed. All patients were treated with intravenous antibiotics. Six of the seven patients responded to treatment. The remaining patient required hysterectomy for uncontrolled uterine sepsis. CONCLUSION: Readmission following UAE is common and arises secondary to infection. Infection can occur several months after the procedure. Mehta, H., et al. (2002). Clinical Radiology 57, 1122±1124. # 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved Key words: embolization, ®broid, uterine artery.
INTRODUCTION
PATIENTS AND METHODS
Uterine artery embolization (UAE) was ®rst reported in the late 1970s as a treatment for post-partum haemorrhage. More recently Ravina et al. [1] described its successful use as a treatment for symptomatic uterine ®broids. Short-term results from clinical series are encouraging and demonstrate reduction in uterine size as well as improvement in clinical symptoms [2±4]. Furthermore, UAE avoids the risks associated with surgery, which is often dicult due to large uterine size and the presence of adhesions. Subsequently recovery time and hospital stay are shorter in patients who have undergone UAE and the procedure may be more cost-eective than surgery. However, complications have been reported following UAE [5,6] and may necessitate hospital readmission. It is important to know the nature and timing of such complications so that women can be informed during the consent process. This study was designed to determine the reasons for and rate of readmission following UAE at our institution.
A retrospective review of the medical notes and available imaging on 42 patients treated by UAE for uterine ®broids between June 1998 and April 2000 was performed. All patients were referred by a gynaecologist who had discussed the surgical options and advocated intervention. Following informed consent the patients underwent a pre-procedure evaluation. This included routine laboratory tests ( full blood count, follicle stimulating hormone, luteinizing hormone, oestradiol and pregnancy test) to exclude anaemia and to evaluate ovarian function. Concurrent infection was excluded by clinical history, observation of temperature, and blood results; vaginal swabs or urine tests were not routinely performed. A baseline ultrasound examination was performed to establish the number, size and location of ®broids. The mean age of the patients was 42 years (range 31±54 years). Thirty-six (86%) were Afro-Caribbean, four (9%) Caucasian and two (5%) Asian. Menorrhagia or dysmenorrhoea were the main complaints in the majority of patients (76%) whilst the remainder (24%) complained of symptoms of uterine bulk, such as urinary frequency. On baseline ultrasound examination 38 patients had multiple ®broids, and the remaining four patients had single ®broids.
Author for correspondence and guarantor of study: Dr Anna-Maria Belli. Tel: 44 208725 1481; Fax: 44 208725 2936. 0009-9260/02/$35
# 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved
1123
COMPLICATIONS FROM FIBROID EMBOLIZATION
RESULTS
Table 1 ± Clinical features of the patients who were readmitted following uterine artery embolization Patient
Age (years)
Time from procedure to readmission (weeks)
Diameter of largest ®broid (cm)
1 2 3 4 5 6 7
42 33 43 32 52 49 34
29 5 1 3 20 1 and 4 3 and 4
9 16 10 10 7 n/a 10
n/a: not available.
The maximum diameter of the ®broids ranged from 5±22 cm. All patients were routinely admitted for 3 days and received pre-procedural antibiotics (Co-amoxiclav i.v. 1.2 g three times a day and metronidazole p.r. 1 g twice daily), which were continued for 48 hours after the procedure. Pain control was managed by an anaesthetist-led pain control team, who administered a 100 mg diclofenac suppository prior to the procedure and supervised patient controlled opiate analgesia for 48 hours following the procedure. The bladder was catheterized and embolization was performed using a standard technique [1,7,8]; via a single right common femoral artery puncture both uterine arteries were selectively catheterized and embolized with polyvinyl alcohol particles (PVA 300±500 mm diameter). Embolization was continued until stasis of blood ¯ow was achieved. Both uterine arteries were successfully embolized in all but one patient in whom a unilateral UAE was performed. There were no immediate post-procedure complications and all patients were discharged from hospital after 48 hours. Following discharge, patients were followed up with ultrasound at 6 weeks and 6 months. Clinical review was at the gynaecologist's discretion. All patients were reviewed within 6 months of the procedure. The median length of clinical follow up was 12 months (range 4±16 months), three patients were subsequently lost to follow up.
Seven patients (17%) required readmission (Table 1). All the patients presented to hospital; none were identi®ed at routine follow-up. One patient was admitted to their local hospital and the rest were readmitted to St George's Hospital. The median time to readmission was 3 weeks (range 1±29 weeks). Two patients were admitted on two separate occasions. All patients presented as an emergency with a short history of fever and abdominal pain. In addition, ®ve patients complained of a vaginal discharge and one patient was unable to pass urine. On examination all patients were febrile and four patients had uterine tenderness. An organism was isolated from the female reproductive tract in four of the seven patients (Table 2). In three patients organisms were isolated from high vaginal swabs, and in one patient from an extruded ®broid. One patient was diagnosed with a urinary tract infection and in the other two patients no de®nite source of infection was identi®ed. Three patients also underwent ultrasound examination and in all cases a degenerating ®broid was seen. In one patient, who was diagnosed with a urinary tract infection, air was identi®ed within the degenerating ®broid. Of the seven patients, three improved on antibiotic therapy alone. Three patients also required manual removal of an extruding ®broid. The remaining patient failed to improve and required total abdominal hysterectomy for pyometritis. The mean in-patient stay at readmission was 12.6 days (range 4±21 days). On follow-up, one patient developed ovarian failure, which was considered to be unrelated to the procedure, and one patient had a normal full-term pregnancy. DISCUSSION
Over recent years UAE has been developed as an eective alternative treatment for ®broid disease [2±4]. However, complications have also been recognized. These include pain, infection and ®broid impaction [5,6], which in some patients necessitates hospital admission. This retrospective review has indicated a readmission rate of 17% in our
Table 2 ± Diagnosis, management and clinical outcome of the patients who were readmitted Patient
Nature and source of infection
Extrusion of ®broid
Length of hospital stay (days)
Clinical outcome
1 2
Anaerobic organisms from HVS Gram-negative and anaerobic organisms from ®broid culture Coliforms from MSU Coliforms from MSU No source identi®ed No source identi®ed Coliforms from MSU Gram-negative and anaerobic organisms from HVS No source identi®ed
Spontaneous Manually extracted under GA
4 20
Uncomplicated Uncomplicated
No No No No Manually extracted under GA
8 21 8 5 16
Amenorrhoea, ovarian failure Menorrhagia Hysterectomy Uncomplicated
3 4 5 6a b 7a
No
GA, general anaesthetic; HVS, high vaginal swab; MSU, midstream urine.
2
Normal
1124
CLINICAL RADIOLOGY
hospital, all as a result of infective complications. Infective complications are a recognized risk of UAE, although the true incidence is uncertain, as some patients will be successfully treated in the community and not come to hospital attention. Severe infection has been reported following UAE including a case of fatal septicaemia [5]. In order to reduce this risk some units have adopted a policy of administering peri-procedural antibiotics. However, the eectiveness of this approach is questionable. First, in concordance with previous studies [5±6], our series demonstrates that infective complications often occur weeks or months following the procedure. Second, it has been suggested that prophylactic antibiotics destroy normal Gram-positive organisms allowing Gram-negative bacteria to proliferate [6]. Furthermore, prophylactic antibiotic use is not without risk, as exempli®ed by a recent report of antibiotic-related pseudo-membranous colitis post-UAE [11]. The role of antibiotics in UAE is therefore unclear and identi®cation of patients at risk of post-procedure infection may be helpful. Infective complications may be related to the size of ®broids. Ravina's group have recently reported a case of septic uterine necrosis post-UAE in a patient with a large submucosal ®broid requiring total hysterectomy [12]. Furthermore, large ®broids are more common in the Afro-Caribbean population [13], which may explain the high infective complication rate observed in our group of patients. However, in our series although the patients who were readmitted had relatively large ®broids ranging in size from 7±16 cm (mean 10.3 cm), a similar ®broid size was observed in those patients who were not readmitted. There was delayed onset of such complications in two cases, who presented at 20 and 29 weeks respectively, emphasizing the importance of providing adequate information to patients at the time of the procedure. The role of routine radiological or clinical follow-up in order to detect post-procedural complications is less certain. In this study all patients referred themselves to medical attention and none were identi®ed at follow-up. Patients can re-present up to 6 months post-embolization with signs of pelvic infection, and in all such cases an extruding ®broid must be excluded in the ®rst instance. Prompt treatment with intravenous antibiotics to cover Gram-negative bacilli (coliforms) and anaerobes must be initiated following appropriate blood, urine and vaginal cultures. It is important that the postembolization syndrome [9] of fever, leucocytosis, raised in¯ammatory markers, nausea, vomiting and discomfort at the site of embolization is not confused with infection.
This syndrome usually occurs within 24±48 hours of the procedure, lasts for up to 7 days, and is more severe when a large volume of tissue has been embolized [10]. In our series, no patients were readmitted for the postembolization syndrome. The one early readmission had a documented urinary tract infection and it is possible that this was catheter-related. In conclusion, there is a signi®cant readmission rate following UAE that is related to infective complications despite the use of prophylactic antibiotics at the time of the procedure. Patients should be informed of this risk and advised to seek medical attention should symptoms develop up to at least 6 months after the procedure. There does not appear to be any role for routine radiological follow-up for the detection of complications. REFERENCES 1 Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat uterine myomata. Lancet 1995;346:671±672. 2 Hurst BS, Stackhouse DJ, Matthews ML, Marshburn PB. Uterine artery embolization for symptomatic uterine myomas. Fertil Steril 2000 Nov;74:855±869. 3 Goodwin SC, McLucas B, Lee M, et al. Uterine artery embolization for the treatment of uterine leiomyomata midterm results. J Vasc Interv Radiol 1999;10:1159±1165. 4 Spies JB, Scialli AR, Jha RC, et al. Initial results from uterine ®broid embolization for symptomatic leiomyomata. J Vasc Interv Radiol 1999;10:1149±1157. 5 Vashisht A, Studd J, Carey A, Burn P. Fatal septicaemia after ®broid embolisation. Lancet 1999;354:307±308. 6 Walker W, Green A, Sutton C. Bilateral uterine artery embolisation for myomata: results, complications and failures. Min Invas Ther & Allied Technol 1999;8:449±454. 7 Goodwin SC, Walker WJ. Uterine artery embolization for the treatment of uterine ®broids. Curr Opin Obstet Gynecol 1998;10: 315±320. 8 Braude P, Reidy J, Nott V, Taylor A, Forman R. Reembolization of uterine artery leiyomyomata: Current concepts in management. Hum Reprod Update 2000;6:603±608. 9 Hemingway A, Allison D. Complications of embolisation: analysis of 410 procedures. Radiology 1988;166:669±672. 10 Sutton D, Gregson R. Arteriography and interventional Angiography. In: Sutton D, ed. A Textbook of Radiology and Imaging. Sidcup, England: Churchill and Livinstone, 1997, 694. 11 Young AE, Malinak LR, Harper A, Barth MH, Soltes G, Brady J. Uterine artery embolization for the treatment of symptomatic leiomyomata. Obstet Gynecol 2000;95(Suppl. 1): S26. 12 Pelage JP, Le Dref O, Soyer P, et al. Fibroid related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology 2000;215:428±431. 13 Kjerul KH, Langenberg P, Seidman JD, Stolley PD, Guzinski GM. Uterine leiomyomas. Racial dierences in severity, symptoms and age at diagnosis. J Reprod Med 1996;41:483±490.
Review of Readmissions Due to Complications from Uterine Fibroid Embolization H . ME H TA , C . SA N D H U , M . M AT S O N , A . - M . B E L L I Department of Radiology, St. George's Hospital, Blackshaw Road, London SW17 OQT, U.K. Received: 21 March 2002 Revised: 9 July 2002 Accepted: 20 July 2002 AIM: To determine the frequency, nature and outcome of complications resulting in readmission to hospital following uterine artery embolization (UAE). MATERIAL AND METHODS: A retrospective review of the medical notes and available imaging of 42 consecutive patients who had undergone elective uterine artery embolization for the treatment of ®broid disease was performed. RESULTS: The mean age of the patients was 42 years (range 31±54 years) and seven patients (17%) were readmitted to hospital. The median time to readmission was 3 weeks (range 1±29 weeks). All seven patients were admitted with signs and symptoms of infection. In four patients an organism was isolated from high vaginal swabs, and in one patient the midstream urine sample was con®rmed as the source of infection. In the other two patients no de®nite source of infection was identi®ed. All patients were treated with intravenous antibiotics. Six of the seven patients responded to treatment. The remaining patient required hysterectomy for uncontrolled uterine sepsis. CONCLUSION: Readmission following UAE is common and arises secondary to infection. Infection can occur several months after the procedure. Mehta, H., et al. (2002). Clinical Radiology 57, 1122±1124. # 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved Key words: embolization, ®broid, uterine artery.
INTRODUCTION
PATIENTS AND METHODS
Uterine artery embolization (UAE) was ®rst reported in the late 1970s as a treatment for post-partum haemorrhage. More recently Ravina et al. [1] described its successful use as a treatment for symptomatic uterine ®broids. Short-term results from clinical series are encouraging and demonstrate reduction in uterine size as well as improvement in clinical symptoms [2±4]. Furthermore, UAE avoids the risks associated with surgery, which is often dicult due to large uterine size and the presence of adhesions. Subsequently recovery time and hospital stay are shorter in patients who have undergone UAE and the procedure may be more cost-eective than surgery. However, complications have been reported following UAE [5,6] and may necessitate hospital readmission. It is important to know the nature and timing of such complications so that women can be informed during the consent process. This study was designed to determine the reasons for and rate of readmission following UAE at our institution.
A retrospective review of the medical notes and available imaging on 42 patients treated by UAE for uterine ®broids between June 1998 and April 2000 was performed. All patients were referred by a gynaecologist who had discussed the surgical options and advocated intervention. Following informed consent the patients underwent a pre-procedure evaluation. This included routine laboratory tests ( full blood count, follicle stimulating hormone, luteinizing hormone, oestradiol and pregnancy test) to exclude anaemia and to evaluate ovarian function. Concurrent infection was excluded by clinical history, observation of temperature, and blood results; vaginal swabs or urine tests were not routinely performed. A baseline ultrasound examination was performed to establish the number, size and location of ®broids. The mean age of the patients was 42 years (range 31±54 years). Thirty-six (86%) were Afro-Caribbean, four (9%) Caucasian and two (5%) Asian. Menorrhagia or dysmenorrhoea were the main complaints in the majority of patients (76%) whilst the remainder (24%) complained of symptoms of uterine bulk, such as urinary frequency. On baseline ultrasound examination 38 patients had multiple ®broids, and the remaining four patients had single ®broids.
Author for correspondence and guarantor of study: Dr Anna-Maria Belli. Tel: 44 208725 1481; Fax: 44 208725 2936. 0009-9260/02/$35
# 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved
1123
COMPLICATIONS FROM FIBROID EMBOLIZATION
RESULTS
Table 1 ± Clinical features of the patients who were readmitted following uterine artery embolization Patient
Age (years)
Time from procedure to readmission (weeks)
Diameter of largest ®broid (cm)
1 2 3 4 5 6 7
42 33 43 32 52 49 34
29 5 1 3 20 1 and 4 3 and 4
9 16 10 10 7 n/a 10
n/a: not available.
The maximum diameter of the ®broids ranged from 5±22 cm. All patients were routinely admitted for 3 days and received pre-procedural antibiotics (Co-amoxiclav i.v. 1.2 g three times a day and metronidazole p.r. 1 g twice daily), which were continued for 48 hours after the procedure. Pain control was managed by an anaesthetist-led pain control team, who administered a 100 mg diclofenac suppository prior to the procedure and supervised patient controlled opiate analgesia for 48 hours following the procedure. The bladder was catheterized and embolization was performed using a standard technique [1,7,8]; via a single right common femoral artery puncture both uterine arteries were selectively catheterized and embolized with polyvinyl alcohol particles (PVA 300±500 mm diameter). Embolization was continued until stasis of blood ¯ow was achieved. Both uterine arteries were successfully embolized in all but one patient in whom a unilateral UAE was performed. There were no immediate post-procedure complications and all patients were discharged from hospital after 48 hours. Following discharge, patients were followed up with ultrasound at 6 weeks and 6 months. Clinical review was at the gynaecologist's discretion. All patients were reviewed within 6 months of the procedure. The median length of clinical follow up was 12 months (range 4±16 months), three patients were subsequently lost to follow up.
Seven patients (17%) required readmission (Table 1). All the patients presented to hospital; none were identi®ed at routine follow-up. One patient was admitted to their local hospital and the rest were readmitted to St George's Hospital. The median time to readmission was 3 weeks (range 1±29 weeks). Two patients were admitted on two separate occasions. All patients presented as an emergency with a short history of fever and abdominal pain. In addition, ®ve patients complained of a vaginal discharge and one patient was unable to pass urine. On examination all patients were febrile and four patients had uterine tenderness. An organism was isolated from the female reproductive tract in four of the seven patients (Table 2). In three patients organisms were isolated from high vaginal swabs, and in one patient from an extruded ®broid. One patient was diagnosed with a urinary tract infection and in the other two patients no de®nite source of infection was identi®ed. Three patients also underwent ultrasound examination and in all cases a degenerating ®broid was seen. In one patient, who was diagnosed with a urinary tract infection, air was identi®ed within the degenerating ®broid. Of the seven patients, three improved on antibiotic therapy alone. Three patients also required manual removal of an extruding ®broid. The remaining patient failed to improve and required total abdominal hysterectomy for pyometritis. The mean in-patient stay at readmission was 12.6 days (range 4±21 days). On follow-up, one patient developed ovarian failure, which was considered to be unrelated to the procedure, and one patient had a normal full-term pregnancy. DISCUSSION
Over recent years UAE has been developed as an eective alternative treatment for ®broid disease [2±4]. However, complications have also been recognized. These include pain, infection and ®broid impaction [5,6], which in some patients necessitates hospital admission. This retrospective review has indicated a readmission rate of 17% in our
Table 2 ± Diagnosis, management and clinical outcome of the patients who were readmitted Patient
Nature and source of infection
Extrusion of ®broid
Length of hospital stay (days)
Clinical outcome
1 2
Anaerobic organisms from HVS Gram-negative and anaerobic organisms from ®broid culture Coliforms from MSU Coliforms from MSU No source identi®ed No source identi®ed Coliforms from MSU Gram-negative and anaerobic organisms from HVS No source identi®ed
Spontaneous Manually extracted under GA
4 20
Uncomplicated Uncomplicated
No No No No Manually extracted under GA
8 21 8 5 16
Amenorrhoea, ovarian failure Menorrhagia Hysterectomy Uncomplicated
3 4 5 6a b 7a
No
GA, general anaesthetic; HVS, high vaginal swab; MSU, midstream urine.
2
Normal
1124
CLINICAL RADIOLOGY
hospital, all as a result of infective complications. Infective complications are a recognized risk of UAE, although the true incidence is uncertain, as some patients will be successfully treated in the community and not come to hospital attention. Severe infection has been reported following UAE including a case of fatal septicaemia [5]. In order to reduce this risk some units have adopted a policy of administering peri-procedural antibiotics. However, the eectiveness of this approach is questionable. First, in concordance with previous studies [5±6], our series demonstrates that infective complications often occur weeks or months following the procedure. Second, it has been suggested that prophylactic antibiotics destroy normal Gram-positive organisms allowing Gram-negative bacteria to proliferate [6]. Furthermore, prophylactic antibiotic use is not without risk, as exempli®ed by a recent report of antibiotic-related pseudo-membranous colitis post-UAE [11]. The role of antibiotics in UAE is therefore unclear and identi®cation of patients at risk of post-procedure infection may be helpful. Infective complications may be related to the size of ®broids. Ravina's group have recently reported a case of septic uterine necrosis post-UAE in a patient with a large submucosal ®broid requiring total hysterectomy [12]. Furthermore, large ®broids are more common in the Afro-Caribbean population [13], which may explain the high infective complication rate observed in our group of patients. However, in our series although the patients who were readmitted had relatively large ®broids ranging in size from 7±16 cm (mean 10.3 cm), a similar ®broid size was observed in those patients who were not readmitted. There was delayed onset of such complications in two cases, who presented at 20 and 29 weeks respectively, emphasizing the importance of providing adequate information to patients at the time of the procedure. The role of routine radiological or clinical follow-up in order to detect post-procedural complications is less certain. In this study all patients referred themselves to medical attention and none were identi®ed at follow-up. Patients can re-present up to 6 months post-embolization with signs of pelvic infection, and in all such cases an extruding ®broid must be excluded in the ®rst instance. Prompt treatment with intravenous antibiotics to cover Gram-negative bacilli (coliforms) and anaerobes must be initiated following appropriate blood, urine and vaginal cultures. It is important that the postembolization syndrome [9] of fever, leucocytosis, raised in¯ammatory markers, nausea, vomiting and discomfort at the site of embolization is not confused with infection.
This syndrome usually occurs within 24±48 hours of the procedure, lasts for up to 7 days, and is more severe when a large volume of tissue has been embolized [10]. In our series, no patients were readmitted for the postembolization syndrome. The one early readmission had a documented urinary tract infection and it is possible that this was catheter-related. In conclusion, there is a signi®cant readmission rate following UAE that is related to infective complications despite the use of prophylactic antibiotics at the time of the procedure. Patients should be informed of this risk and advised to seek medical attention should symptoms develop up to at least 6 months after the procedure. There does not appear to be any role for routine radiological follow-up for the detection of complications. REFERENCES 1 Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat uterine myomata. Lancet 1995;346:671±672. 2 Hurst BS, Stackhouse DJ, Matthews ML, Marshburn PB. Uterine artery embolization for symptomatic uterine myomas. Fertil Steril 2000 Nov;74:855±869. 3 Goodwin SC, McLucas B, Lee M, et al. Uterine artery embolization for the treatment of uterine leiomyomata midterm results. J Vasc Interv Radiol 1999;10:1159±1165. 4 Spies JB, Scialli AR, Jha RC, et al. Initial results from uterine ®broid embolization for symptomatic leiomyomata. J Vasc Interv Radiol 1999;10:1149±1157. 5 Vashisht A, Studd J, Carey A, Burn P. Fatal septicaemia after ®broid embolisation. Lancet 1999;354:307±308. 6 Walker W, Green A, Sutton C. Bilateral uterine artery embolisation for myomata: results, complications and failures. Min Invas Ther & Allied Technol 1999;8:449±454. 7 Goodwin SC, Walker WJ. Uterine artery embolization for the treatment of uterine ®broids. Curr Opin Obstet Gynecol 1998;10: 315±320. 8 Braude P, Reidy J, Nott V, Taylor A, Forman R. Reembolization of uterine artery leiyomyomata: Current concepts in management. Hum Reprod Update 2000;6:603±608. 9 Hemingway A, Allison D. Complications of embolisation: analysis of 410 procedures. Radiology 1988;166:669±672. 10 Sutton D, Gregson R. Arteriography and interventional Angiography. In: Sutton D, ed. A Textbook of Radiology and Imaging. Sidcup, England: Churchill and Livinstone, 1997, 694. 11 Young AE, Malinak LR, Harper A, Barth MH, Soltes G, Brady J. Uterine artery embolization for the treatment of symptomatic leiomyomata. Obstet Gynecol 2000;95(Suppl. 1): S26. 12 Pelage JP, Le Dref O, Soyer P, et al. Fibroid related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology 2000;215:428±431. 13 Kjerul KH, Langenberg P, Seidman JD, Stolley PD, Guzinski GM. Uterine leiomyomas. Racial dierences in severity, symptoms and age at diagnosis. J Reprod Med 1996;41:483±490.