1995年法國Ravina在Lancet雜志上首次發(fā)表了子宮肌瘤的栓塞治療，1997年Goodwin發(fā)表在美國應(yīng)用經(jīng)子宮動(dòng)脈栓塞治療子宮肌瘤的經(jīng)驗(yàn)，此后子宮動(dòng)脈栓塞治療子宮肌瘤在全球范圍內(nèi)廣泛應(yīng)用。

根據(jù)美國介入放射學(xué)會(huì)的調(diào)查，從1997年到2000年已有超過1萬子宮肌瘤患者接受了子宮肌瘤栓塞治療，而且接受治療的患者還在增加。

隨著2007年Volkers在美國婦科與產(chǎn)科雜志和Edwards在新英格蘭雜志發(fā)表兩份子宮肌瘤栓塞與子宮肌瘤外科手術(shù)治療的隨機(jī)對(duì)照研究，其結(jié)果最終確立了子宮動(dòng)脈栓塞治療是子宮肌瘤的治療方法之一。

子宮動(dòng)脈栓塞治療子宮肌瘤的技術(shù)成功率為96%；減少對(duì)子宮肌瘤所致的月經(jīng)量過多的癥狀超過90%；子宮肌瘤體積縮小約50%-60%。

子宮肌瘤栓塞是指經(jīng)雙側(cè)子宮動(dòng)脈注入顆粒性栓塞劑堵塞細(xì)動(dòng)脈水平的血流，造成子宮肌瘤不可逆性的缺血損傷同時(shí)避免對(duì)子宮的永久性損傷。

技術(shù)操作簡單，一般大家最關(guān)心兩個(gè)問題

1．栓塞劑的選擇：

UAE可供選擇的栓塞劑較多，一般選擇顆粒型栓塞劑，總體可分為可吸收和不可吸收兩種，可吸收栓塞劑以海藻酸鈉微球顆粒（KMG）為代表，不可吸收栓塞劑以聚乙烯醇（PVA）為代表。而其他器官的常用栓塞劑如鋼圈、無水乙醇、超液態(tài)碘油等不建議在UAE中使用。

栓塞劑顆粒大小的選擇：栓塞劑的顆粒直徑以500~700 μm為主，部分也可選擇300~500 μm或700~900 μm。

栓塞后立即切除的肌壁間纖維瘤（F）周圍標(biāo)本的顯微照片（蘇木精-番紅-伊紅染色;放大倍數(shù)為200倍）顯示，直徑為500-700 μ m的校準(zhǔn)微球（箭頭）靶向閉塞了纖維瘤周圍動(dòng)脈叢。

例如，對(duì)于子宮肌瘤患者的UAE，一般選擇直徑500~700 μm的顆粒進(jìn)行單一栓塞；也可以選擇直徑300~500 μm的顆粒進(jìn)行內(nèi)層血管網(wǎng)栓塞，再用500~700 μm的顆粒進(jìn)行外層血管網(wǎng)的栓塞，最后用700~900 μm的顆粒進(jìn)行主干栓塞的"三層栓塞法"[14]。

而子宮腺肌病由于內(nèi)層血管網(wǎng)較為細(xì)小，外層血管網(wǎng)不明顯，為達(dá)到較好的栓塞效果可適當(dāng)選擇較小顆粒的栓塞劑。動(dòng)脈栓塞的效果與栓塞劑顆粒大小成反比。

2．栓塞程度：

栓塞分為完全性栓塞和不完全性栓塞兩種。

判斷不完全性栓塞，其根據(jù)是盡可能地只栓塞病灶的血管網(wǎng)而不栓塞子宮的正常血管網(wǎng)，在DSA中影像學(xué)表現(xiàn)為病灶血管網(wǎng)全部或部分消失，子宮的血管網(wǎng)存在，子宮動(dòng)脈顯影。

另1種為完全性栓塞，即將栓塞劑盡可能多地釋放，將病灶血管網(wǎng)和子宮動(dòng)脈對(duì)病灶主要供血的分支動(dòng)脈主干完全栓塞，在DSA中影像學(xué)表現(xiàn)為病灶染色完全消失，子宮動(dòng)脈的主干僅部分顯影或完全不顯影。

為獲得更好的臨床療效，子宮腺肌病的栓塞程度要明顯高于子宮肌瘤，而且必須是完全性栓塞。

（有一篇鏈接：點(diǎn)擊）

Abstract 摘要

Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.
子宮肌瘤和腺肌癥是常見的良性腫瘤，可能導(dǎo)致嚴(yán)重的有害健康影響，包括危及生命的貧血、月經(jīng)延長和盆腔疼痛；然而，高達(dá) 40%的女性未得到診斷。

傳統(tǒng)的治療方法，如肌瘤切除術(shù)或子宮切除術(shù)，可以有效地管理癥狀，但可能需要更長的住院時(shí)間并阻礙未來的生育。血管內(nèi)治療，如子宮動(dòng)脈栓塞（UAE），是一種微創(chuàng)手術(shù)，已成為手術(shù)選擇的良好替代方案，同時(shí)保留子宮并縮短住院時(shí)間。仔細(xì)的患者選擇和適當(dāng)?shù)募夹g(shù)對(duì)于實(shí)現(xiàn)最佳結(jié)果至關(guān)重要。近年來，在術(shù)前和術(shù)后護(hù)理方面取得了進(jìn)展，旨在提高結(jié)果并減輕 UAE 術(shù)前、術(shù)中及術(shù)后的不適。此外，成功率和再次干預(yù)率也可能取決于肌瘤的大小和位置。本文回顧了子宮肌瘤和腺肌癥的血管內(nèi)治療現(xiàn)狀。

Keywords:fibroid, adenomyosis, embolization, uterine artery embolization, interventional radiology
關(guān)鍵詞：子宮肌瘤、腺肌病、栓塞、子宮動(dòng)脈栓塞、介入放射學(xué)

先說結(jié)論：血管內(nèi)治療對(duì)腺肌病和子宮肌瘤都很有希望且有效。雖然傳統(tǒng)的手術(shù)方法在過去已經(jīng)取得了成功，但與之相關(guān)的并發(fā)癥增加和住院時(shí)間延長。子宮動(dòng)脈栓塞等血管內(nèi)治療具有微創(chuàng)和并發(fā)癥極少的優(yōu)點(diǎn)。需要注意的是，一些患者更喜歡侵入性較小的治療方案。因此，醫(yī)療保健提供者應(yīng)提供關(guān)于所有可用治療方案的全面咨詢，這可能包括保守治療、藥物治療、微創(chuàng)治療、手術(shù)治療或其組合，以幫助患者就其護(hù)理做出明智的決定。總之，預(yù)計(jì)血管內(nèi)治療在未來作為纖維瘤和腺肌病的管理工具將發(fā)揮更重要的作用。

Uterine fibroids and adenomyosis are common gynecological conditions that can lead to increased morbidity and negatively impact women's quality of life. According to Krentel and De Wilde, 1 adenomyosis was found 40% of the time in patients who underwent a hysterectomy for general uterine complications. Despite their prevalence, approximately 35 to 50% of women would have evidence of undiagnosed fibroids through ultrasound. 2 Along with their asymptomatic nature, they can manifest as prolonged menstrual bleeding that often results in pelvic pain, iron-deficiency anemia, and infertility. 3 While myomectomy and hysterectomy are well-established surgical options, these options are invasive and result in women having prolonged hospitalization times. 4 Uterine artery embolization is a uterus-sparing nonsurgical option, and it is widely reported to involve shorter hospital lengths of stay and less postprocedural pain. 5 This review aims to discuss the current endovascular treatment trends for uterine fibroids and adenomyosis.
子宮肌瘤和腺肌癥是常見的婦科疾病，可能導(dǎo)致發(fā)病率增加并負(fù)面影響女性的生活質(zhì)量。根據(jù) Krentel 和 De Wilde 的研究，40%的因一般子宮并發(fā)癥而行子宮切除術(shù)的患者被診斷為腺肌癥。盡管它們很普遍，大約有 35%至 50%的女性通過超聲檢查會(huì)有未診斷的子宮肌瘤的證據(jù)。除了它們的無癥狀性質(zhì)外，它們可以表現(xiàn)為長期月經(jīng)出血，這通常會(huì)導(dǎo)致盆腔疼痛、缺鐵性貧血和不孕。雖然肌瘤切除術(shù)和子宮切除術(shù)是已確立的手術(shù)選擇，但這些選擇是侵入性的，導(dǎo)致女性住院時(shí)間延長。子宮動(dòng)脈栓塞是一種保留子宮的非手術(shù)選擇，廣泛報(bào)道其涉及更短的住院時(shí)間和較少的術(shù)后疼痛。本綜述旨在討論目前子宮肌瘤和腺肌癥的血管內(nèi)治療趨勢。

Patient Selection 患者選擇

UAE is a treatment option for adenomyosis and uterine fibroids, with both entities sharing common symptoms including prolonged menstrual bleeding, pelvic pressure, and dyspareunia. Patients commonly experience some form of combination of these symptoms; however, confirmation with history, physical exam, and imaging findings remains key to ensure that other conditions that often can present with similar symptoms are appropriately excluded. 6 The Uterine Fibroid Symptom Health-Related Quality of Life Questionnaire (UFS-QOL) is a tool specifically designed to assess the symptoms associated with uterine fibroids. The UFS-QOL was developed to measure symptoms and health-related quality of life in women with uterine fibroids. 7
UAE是治療腺肌病和子宮肌瘤的一種選擇，這兩種疾病都共有一些常見癥狀，包括月經(jīng)出血延長、盆腔壓迫癥狀和性交疼痛。患者通常會(huì)有這些癥狀的一種或幾種的組合；然而，通過病史、體格檢查和影像學(xué)檢查進(jìn)行確認(rèn)，仍然是確保適當(dāng)排除其他可能具有類似癥狀的疾病的關(guān)鍵。 6 子宮肌瘤癥狀與健康相關(guān)生活質(zhì)量問卷（UFS-QOL）是一種專門設(shè)計(jì)來評(píng)估與子宮肌瘤相關(guān)癥狀的工具。UFS-QOL 旨在測量患有子宮肌瘤女性的癥狀和與健康相關(guān)的生活質(zhì)量。 7

Image modalities such as contrast-enhanced magnetic resonance imaging (MRI) and transvaginal ultrasound (TVUS) are the preferred methods to evaluate size, location, and number of fibroids. 8 Adenomyosis is often diagnosed on TVUS with the hallmark finding of a thickened endometrium and the presence of myometrial cysts. 9 Similarly, on MRI, adenomyosis is identified by myometrial cysts and a thickened junctional zone exceeding 12 mm. 9 On the other hand, uterine fibroids are usually defined by specific characteristics and enhancement patterns seen on MRI. 10 Highly cellular fibroids demonstrate a high signal intensity on T2-weighted images (WI) with characteristic avid postcontrast enhancement. However, degenerated fibroids tend to appear highly variable on MRI. 10 A study of 30 patients by ?ak?r et al 11 found that fibroids with higher T2-WI signal intensity in the preprocedural MRI were associated with a higher rate of post-UAE technical success.
影像學(xué)檢查方法，如對(duì)比增強(qiáng)磁共振成像（MRI）和經(jīng)陰道超聲（TVUS），是評(píng)估子宮肌瘤大小、位置和數(shù)量的首選方法。 8 子宮腺肌病通常通過 TVUS 診斷，標(biāo)志性發(fā)現(xiàn)為子宮內(nèi)膜增厚和肌層囊腫的存在。 9 類似地，在 MRI 上，子宮腺肌病通過肌層囊腫和超過 12 毫米的增厚交界區(qū)來識(shí)別。 9 另一方面，子宮肌瘤通常通過 MRI 上的特定特征和增強(qiáng)模式來定義。 10 高細(xì)胞密度的子宮肌瘤在 T2 加權(quán)圖像（WI）上表現(xiàn)出高信號(hào)強(qiáng)度，并具有特征性的對(duì)比增強(qiáng)。然而，退化的子宮肌瘤在 MRI 上往往表現(xiàn)出高度可變性。 10 ?ak?r 等人的一項(xiàng)針對(duì) 30 名患者的調(diào)查顯示，術(shù)前 MRI 中 T2-WI 信號(hào)強(qiáng)度較高的子宮肌瘤與 UAE 術(shù)后技術(shù)成功率較高的相關(guān)性。

Fibroid Location 子宮肌瘤位置

During the initial patient encounter, clinicians should pay close attention to the location of the fibroids. Appropriately classifying fibroids is necessary for treatment planning and complication prevention. The Federation Internationale de Gynecolgie et Obstetriqueue (FIGO) classification system was developed to uniformly and consistently describe and classify uterine fibroid to facilitate communication, clinical care, and research ( Fig. 1 ). The FIGO system categorizes fibroids that are submucosal, other fibroids, and hybrid fibroids. The recent article by Munro et al 12 proposed an MRI reporting template for structured reporting of uterine fibroids using the FIGO classification system. While the FIGO classification system guides physicians with a more standardized algorithm for describing as well as characterizing uterine fibroids and treatment decision making, clinical findings and patient preference play an important role as well in deciding the best treatment strategy. Also, significant inter-reader variability has been found between gynecologists and radiologists when reporting FIGO types. In 2017, Lacayo et al 13 conducted a study that showed that the size of uterine fibroids did not affect the infarction rate, but rather the location of the fibroid was the only influencing factor. Pedunculated serosal tumors were less likely to have complete infarction compared to transmural fibroids. Additionally, multivariate analysis revealed that fibroids located at the cervix and lower uterine body, as well as the anterior wall of the uterus, were more likely to have an incomplete infarction. However, the reasons for this finding remain unclear and may be related to collateral arterial supply.
在初次接診患者時(shí)，臨床醫(yī)生應(yīng)密切關(guān)注子宮肌瘤的位置。對(duì)子宮肌瘤進(jìn)行適當(dāng)?shù)姆诸悓?duì)于治療計(jì)劃和并發(fā)癥預(yù)防是必要的。國際婦產(chǎn)科學(xué)會(huì)（FIGO）的分類系統(tǒng)是為了統(tǒng)一和一致地描述和分類子宮肌瘤，以促進(jìn)溝通、臨床護(hù)理和研究而開發(fā)的（ Fig. 1 ）。

FIGO 系統(tǒng)將子宮肌瘤分為黏膜下肌瘤、其他肌瘤和混合肌瘤。

Munro 等人最近的文章 12 提出了使用 FIGO 分類系統(tǒng)對(duì)子宮肌瘤進(jìn)行結(jié)構(gòu)化報(bào)告的 MRI 報(bào)告模板。雖然 FIGO 分類系統(tǒng)為醫(yī)生提供了更標(biāo)準(zhǔn)化的算法來描述和表征子宮肌瘤以及治療決策，但在決定最佳治療方案時(shí)，臨床發(fā)現(xiàn)和患者偏好也起著重要作用。此外，在報(bào)告 FIGO 類型時(shí)，婦科醫(yī)生和放射科醫(yī)生之間發(fā)現(xiàn)了顯著的閱讀者間差異。 2017 年，Lacayo 等人進(jìn)行了一項(xiàng)研究，該研究顯示子宮肌瘤的大小不影響梗死率，而是肌瘤的位置是唯一的影響因素。

有蒂漿膜下腫瘤比穿透性肌瘤發(fā)生完全梗死的可能性更低。此外，多變量分析顯示，位于宮頸和子宮下段以及子宮前壁的肌瘤更容易發(fā)生不完全梗死。然而，這一發(fā)現(xiàn)的原因尚不清楚，可能與側(cè)支動(dòng)脈供應(yīng)有關(guān)。

Fig. 1. 圖 1.

根據(jù) FIGO 分類，子宮肌瘤的亞型根據(jù)是否存在黏膜下成分分為兩組。

具有黏膜下成分的子宮肌瘤包括

0 型（有蒂宮腔內(nèi)）、

1 型（黏膜下成分≥50%）、

2 型（黏膜下成分<50%）和

混合型子宮肌瘤（2-5 型）。

另一方面，無黏膜下成分的子宮肌瘤包括

3 型（子宮內(nèi)膜接觸的肌壁間子宮肌瘤）、

4 型（無子宮內(nèi)膜接觸的肌壁間子宮肌瘤）、

5 型（≥50%漿膜下成分的肌壁間子宮肌瘤）、

6 型（<50%漿膜下成分的肌壁間子宮肌瘤）、

7 型（有蒂漿膜下）、

8 型（非子宮肌層位置，如宮頸、闊韌帶或寄生性子宮肌瘤）。

EIA，外髂動(dòng)脈；IIA，內(nèi)髂動(dòng)脈。（數(shù)字插圖由 Merve Ozen，MD 制作。）

Koziarz et al 14 conducted a meta-analysis of seven observational studies on UAE in patients with pedunculated subserosal fibroids to evaluate the effectiveness and safety of this treatment. The analysis showed that the risk of adverse events after UAE in patients with pedunculated subserosal fibroids was 1.7%. Furthermore, all adverse events were classified as mild using the SIR guidelines. 15
科齊亞茨等人對(duì)七項(xiàng)關(guān)于 UAE治療有蒂漿膜下子宮肌瘤患者的觀察性研究進(jìn)行了薈萃分析，以評(píng)估該治療的有效性和安全性。分析顯示，有蒂漿膜下子宮肌瘤患者在接受 UAE 治療后發(fā)生不良事件的概率為 1.7%。此外，所有不良事件均根據(jù) SIR 指南被歸類為輕微。

Fibroids that are mainly submucosal or transmural, with a volume of less than 66 mL, are more likely to be expelled following UFE. The average timeframe for fibroid expulsion after UFE is 15 weeks, with most occurrences taking place within 3 months. However, some expulsions have been recorded as early as a few days after the procedure, while others have been reported as late as 50 months after. Typically, the size of expelled fibroids is around 6 to 8 cm on average. 16 These conflicting findings suggest that further investigation is necessary to determine whether certain locations of fibroids may be more prone to incomplete treatment by UAE. There are only case reports documenting instances of expulsion following UAE for adenomyosis.
子宮肌瘤主要為黏膜下或穿透肌層，體積小于 66 毫升的，在 UFE 后更容易排出。UFE 后子宮肌瘤排出的平均時(shí)間為 15 周，大多數(shù)情況發(fā)生在 3 個(gè)月內(nèi)。然而，有些排出發(fā)生在手術(shù)后的幾天內(nèi)，而有些則報(bào)告發(fā)生在術(shù)后 50 個(gè)月。通常，排出的子宮肌瘤大小平均為 6 到 8 厘米。這些相互矛盾的結(jié)果表明，有必要進(jìn)一步調(diào)查以確定某些子宮肌瘤的位置是否可能更容易受到 UAE 的不完全治療。目前只有關(guān)于 UAE 后腺肌癥排出的病例報(bào)告。

Contraindications 禁忌癥

The presence of an intrauterine device is not an absolute contraindication for UAE, and its removal prior to UAE is not mandatory but accepted as a relative contraindication. Absolute contraindications for UAE include a viable pregnancy, an active infection, and gynecologic malignancy. 17 Other relative contraindications that require extra caution are coagulopathy, severe contrast agent allergy, renal impairment, immunocompromised patients, chronic endometritis, and previous pelvic irradiation or surgery. 17 Intracavity fibroids are another relative contraindication for UAE as they have a higher rate of sepsis and fibroid expulsion, which will be discussed in an upcoming section. While a myomectomy has been limited by fibroid size and number, it has been found that a combined approach of both UAE and myomectomy for intracavity fibroids may be a safe and effective approach. 18
宮內(nèi)節(jié)育器的存在不是 UAE 的絕對(duì)禁忌癥，在 UAE 之前移除它不是強(qiáng)制性的，但被視為相對(duì)禁忌癥。

UAE 的絕對(duì)禁忌癥包括懷孕、活動(dòng)性感染和婦科惡性腫瘤。

其他需要額外小心的相對(duì)禁忌癥包括凝血病、嚴(yán)重對(duì)比劑過敏、腎功能損害、免疫抑制患者、慢性子宮內(nèi)膜炎以及既往盆腔放療或手術(shù)。 17

宮腔內(nèi)肌瘤是 UAE 的另一個(gè)相對(duì)禁忌癥，因?yàn)樗鼈冇懈叩臄⊙Y和肌瘤排出率，這將在下一節(jié)中討論。雖然子宮肌瘤切除術(shù)受肌瘤大小和數(shù)量的限制，但發(fā)現(xiàn)對(duì)于宮腔內(nèi)肌瘤，UAE 和子宮肌瘤切除術(shù)的聯(lián)合方法可能是一種安全有效的途徑。 17

Procedural Workup 程序評(píng)估

UAEs are best performed as part of a collaborative effort between the interventional radiologist and gynecologist who has already discussed medical and surgical options with the patient. The interventional radiologist should set up a consultation before the procedure to review the patient's demographic information and symptoms and assess the risk for the procedure to see if the patient is a good candidate for UAE. 19
UAEs 最好作為介入放射科醫(yī)生和已經(jīng)與患者討論過醫(yī)療和手術(shù)方案的婦科醫(yī)生之間的協(xié)作努力的一部分進(jìn)行。介入放射科醫(yī)生應(yīng)在手術(shù)前安排會(huì)診，以審查患者的人口統(tǒng)計(jì)信息和癥狀，并評(píng)估手術(shù)風(fēng)險(xiǎn)，以確定患者是否是 UAE 的良好候選人。

As many as two-thirds of all women will have one or more fibroids in their lifetime, and only a fourth of them will have symptoms significant enough to warrant treatment. Symptoms may include abnormal uterine bleeding (AUB), bulk and pressure symptoms, and urinary symptoms. Pregnancy or fertility complications can also be associated with fibroids. 20
多達(dá)三分之二的女性在其一生中會(huì)患有至少一個(gè)子宮肌瘤，其中只有四分之一的人會(huì)出現(xiàn)足夠嚴(yán)重的癥狀需要治療。癥狀可能包括異常子宮出血（AUB）、體積和壓迫癥狀，以及排尿癥狀。子宮肌瘤還可能與妊娠或生育并發(fā)癥相關(guān)。

Patients with fibroids experiencing AUB should also be evaluated for other possible causes of abnormal bleeding. A thorough history and physical examination are essential. The International Federation of Gynecology and Obstetrics classifies AUB using PALM-COIEN. PALM represents anatomic etiologies, including polyps, adenomyosis, leiomyomas, and malignancy. COIEN represents medical causes, including coagulopathies, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise specified. Imaging, such as TVUS and MRI, can identify most anatomic etiologies, except for malignancies. All patients should undergo cervical cancer screening, and patients older than 45 or 40 years with risk factors for endometrial adenocarcinoma, including obesity or another history of unopposed estrogen, should undergo endometrial sampling, either with an office biopsy or a dilation and curettage in the office prior to undergoing further management. 21
子宮肌瘤患者出現(xiàn)異常子宮出血（AUB）時(shí)，還應(yīng)評(píng)估其他可能的異常出血原因。詳細(xì)的病史和體格檢查是必不可少的。國際婦產(chǎn)科學(xué)會(huì)聯(lián)合會(huì)使用 PALM-COIEN 對(duì) AUB 進(jìn)行分類。

PALM 代表解剖學(xué)病因，包括息肉、腺肌病、平滑肌瘤和惡性腫瘤。COIEN 代表醫(yī)學(xué)原因，包括凝血病、排卵功能障礙、子宮內(nèi)膜、醫(yī)源性和未指定的其他原因。

影像學(xué)檢查，如經(jīng)陰道超聲（TVUS）和磁共振成像（MRI），可以識(shí)別大多數(shù)解剖學(xué)病因，但不能識(shí)別惡性腫瘤。所有患者都應(yīng)進(jìn)行宮頸癌篩查，并且年齡超過 45 歲或 40 歲且具有子宮內(nèi)膜腺癌風(fēng)險(xiǎn)因素的患者，包括肥胖或未經(jīng)拮抗的雌激素病史，應(yīng)在進(jìn)行進(jìn)一步管理之前進(jìn)行子宮內(nèi)膜取樣，無論是通過門診活檢還是門診擴(kuò)張刮宮。

Patients with urinary symptoms or infertility should complete full workups by specialists in urinary dysfunction and infertility, respectively, before undergoing intervention of fibroids for these conditions. If fibroids are asymptomatic, patients and their doctors should discuss whether intervention is needed. For example, a patient who has infertility should make sure their partner undergoes a semen analysis prior to undergoing an invasive procedure with the expectation of solving their infertility.
患者在進(jìn)行子宮肌瘤干預(yù)之前，應(yīng)分別由泌尿功能障礙和不孕癥專家進(jìn)行全面檢查。如果子宮肌瘤無癥狀，患者和醫(yī)生應(yīng)討論是否需要干預(yù)。例如，不孕癥患者在進(jìn)行旨在解決其不孕癥的侵入性手術(shù)之前，應(yīng)確保其伴侶進(jìn)行精液分析。

Patients undergoing any procedure should not only understand the risks and benefits but also the alternatives for that procedure. As most women with fibroids are asymptomatic, many only need reassurance. For those suffering from AUB, hormonal intervention, including combined hormonal contraception, progesterone therapy, including systemic and intrauterine devices, as well as gonadotropin-releasing hormone agonists or antagonists, can be considered. Many patients looking into UAE have already been counseled on hysterectomy and myomectomy. However, a hysteroscopic myomectomy can treat the problem with minimal recovery if bleeding symptoms are related to an intracavitary fibroid, provided it is amenable to hysteroscopic resection.
患者在接受任何手術(shù)時(shí)，不僅應(yīng)了解手術(shù)的風(fēng)險(xiǎn)和益處，還應(yīng)了解該手術(shù)的替代方案。由于大多數(shù)子宮肌瘤女性沒有癥狀，許多人只需要得到安慰。對(duì)于患有異常子宮出血（AUB）的女性，可以考慮激素干預(yù)，包括復(fù)方激素避孕藥、孕激素治療，包括全身和宮內(nèi)裝置，以及促性腺激素釋放激素激動(dòng)劑或拮抗劑。許多考慮進(jìn)行 UAE（子宮動(dòng)脈栓塞術(shù)）的患者已經(jīng)接受了子宮切除術(shù)和肌瘤切除術(shù)的咨詢。然而，如果出血癥狀與宮腔內(nèi)肌瘤有關(guān)，并且適合進(jìn)行宮腔鏡下切除，那么宮腔鏡下肌瘤切除術(shù)可以以最小的恢復(fù)期治療該問題。

Procedure 程序
Anatomy 解剖學(xué)

Uterine arteries can have many variants occurring in up to 10 to 15% of the population. 22 During the procedure, it is important to examine the anterior division of the iliac artery since, in 51% of cases, the uterine artery arises from it 22 ( Fig. 2 ). While there are many variants, branches on both sides of the body are symmetrical in 91% of patients. 22
子宮動(dòng)脈在人群中可存在多種變異，發(fā)生率高達(dá) 10%至 15%。 22 在手術(shù)過程中，檢查髂動(dòng)脈前支非常重要，因?yàn)樵?51%的病例中，子宮動(dòng)脈由此處起源 22 （ Fig. 2 ）。盡管存在許多變異，但在 91%的患者中，身體兩側(cè)的分支是對(duì)稱的。 22

Fig. 2. 圖 2。

( a ) 1 型指的是最常見的情況，即子宮動(dòng)脈起源于臀下動(dòng)脈。

( b ) 2 型中，子宮動(dòng)脈是臀下動(dòng)脈的第二或第三分支，而陰部內(nèi)動(dòng)脈等其他分支可能是第一分支。

( c ) 3 型以臀下動(dòng)脈、臀上動(dòng)脈和子宮動(dòng)脈都起源于同一水平（三叉）為特征。

( d ) 最后，4 型是指子宮動(dòng)脈起源于臀下動(dòng)脈和臀上動(dòng)脈之前。(數(shù)字插圖由 Merve Ozen，MD 提供。)（沒必要記，見招拆招就行）

In 10% of patients, ovarian arteries can provide collateral arterial supply for adenomyosis and fibroids. Several studies have concluded that some failures after UAE have been associated with underlying ovarian collateral supply of the uterus. 23 24 25 26 Other collateral supply sources, such as the round ligament and inferior mesenteric arteries, have also been reported in case reports. One fear clinicians have in performing ovarian artery embolization is ovarian failure. There is also contradictory literature with Razavi et al 27 concluding that ovarian artery embolization should only be performed unilaterally. Most recent discussions about ovarian artery embolization are based on case reports and mostly retained ovarian function after the procedure. 28 In the FIRSTT study where UAE was compared with MRI-guided focused US (MRgFUS), UAE showed a significantly greater absolute decrease in anti-Müllerian hormone levels at 24 months compared with MRgFUS. 29 However, a higher incidence of a second fibroid procedure was observed in patients who underwent MRgFUS compared to those who underwent UAE, and the degree of symptom alleviation was comparatively lower with MRgFUS.
在 10%的患者中，卵巢動(dòng)脈可以為腺肌癥和子宮肌瘤提供側(cè)支動(dòng)脈供應(yīng)。幾項(xiàng)研究得出結(jié)論，UAE（子宮動(dòng)脈栓塞術(shù)）后的某些失敗與子宮的潛在卵巢側(cè)支供應(yīng)有關(guān)。

其他側(cè)支供應(yīng)來源，如圓韌帶和腸系膜下動(dòng)脈，也有病例報(bào)告。。臨床醫(yī)生在進(jìn)行卵巢動(dòng)脈栓塞時(shí)擔(dān)心的是卵巢功能衰竭。 關(guān)于卵 巢動(dòng)脈栓塞的文獻(xiàn)也存在矛盾，Razavi 等人認(rèn)為卵巢動(dòng)脈栓塞應(yīng)僅限單側(cè)進(jìn)行。最近關(guān)于卵巢動(dòng)脈栓塞的討論主要基于病例報(bào)告，并且大多數(shù)情況下術(shù)后卵巢功能得以保留。

在 FIRSTT 研究中，UAE 與 MRI 引導(dǎo)的聚焦超聲（MRgFUS）進(jìn)行了比較，UAE 在 24 個(gè)月時(shí)與 MRgFUS 相比，抗米勒管激素（ anti-Müllerian hormone） 水平顯著降低。然而，與 UAE 相比，接受 MRgFUS 的患者中觀察到第二次子宮肌瘤手術(shù)的發(fā)生率更高，并且與 MRgFUS 相比，癥狀緩解程度較低。（譯者：海扶刀消融遜于UAE，當(dāng)然也有人持保留態(tài)度，目前仍有爭議，需要更多RCT研究數(shù)據(jù)）

Vascular Access 血管通路

UAE is traditionally performed using femoral artery access, but in recent years, radial artery access has become more prevalent. Growing literature demonstrates increased success rate and decreased incidence of complications, leading us to consider transradial (TR) access as a preferred option for UAE. In some clinical situations, an alternative route to the more conventional transfemoral access (TFA) is a necessity, such as obesity and extensive peripheral lower extremity vascular disease. 30
UAE 傳統(tǒng)上使用股動(dòng)脈通路進(jìn)行手術(shù)，但近年來，橈動(dòng)脈通路的使用越來越普遍。越來越多的文獻(xiàn)表明，經(jīng)橈動(dòng)脈（TR）通路的成功率提高，并發(fā)癥發(fā)生率降低，這使我們考慮將 TR 通路作為 UAE 的首選方案。在某些臨床情況下，與更傳統(tǒng)的經(jīng)股動(dòng)脈通路（TFA）相比，選擇替代通路是必要的，例如肥胖和廣泛的周圍下肢血管疾病。

The results of Sher et al's 31 retrospective study involving 374 patients are promising, as it suggests that TR UAE for symptomatic fibroids can be performed using a same-day discharge protocol with low rates of patient return. Additionally, Nakhaei et al 32 found that TRA UAE resulted in only five access site hematomas in 90 patients and one vasospasm in 92 cases, which is also reassuring for TR access.
Sher 等人進(jìn)行的涉及 374 名患者的回顧性研究結(jié)果顯示令人鼓舞，因?yàn)樗砻鳎瑢?duì)于有癥狀的子宮肌瘤，可以使用同一天出院方案進(jìn)行經(jīng)皮經(jīng)腔子宮動(dòng)脈栓塞術(shù)（TR UAE），且患者返院率低。此外，Nakhaei 等人發(fā)現(xiàn)，在 90 名患者中，經(jīng)皮經(jīng)腔子宮動(dòng)脈栓塞術(shù)（TRA UAE）僅導(dǎo)致 5 個(gè)穿刺部位血腫，在 92 個(gè)病例中導(dǎo)致 1 例血管痙攣，這也對(duì) TR 途徑是令人放心的。

Embolic Agents 栓塞劑

One area of active research in UAE is the different embolic agents. During UAE, specific embolic agents must be used based on the physicians' experience as well as the size and location of the fibroids. 13 Several different embolic agents have been approved by the FDA for use in UAE, including polyvinyl alcohol particles (PVAs) and tris-acryl gelatin microspheres (TAGMs). A systemic review found that PVA was better at complete fibroid infarction after the first 24 hours when compared to TAGMs, but TAGM was better than PVA at <90% infarction rate outcome. 33 Regardless, nonspherical PVA particles and TAGMs produced similar rates of uterine fibroid infarction. 13
UAE研究活躍的一個(gè)領(lǐng)域是不同的栓塞劑。在 UAE 過程中，必須根據(jù)醫(yī)生的經(jīng)驗(yàn)以及子宮肌瘤的大小和位置來選擇特定的栓塞劑。FDA 已批準(zhǔn)多種栓塞劑用于 UAE，包括聚乙烯醇顆粒（PVAs）和三丙烯酸凝膠微球（TAGMs）。一項(xiàng)系統(tǒng)綜述發(fā)現(xiàn)，與 TAGMs 相比，PVA 在首次 24 小時(shí)后對(duì)完全子宮肌瘤梗塞的效果更好，但 TAGM 在<90%梗塞率的結(jié)果上優(yōu)于 PVA。無論如何，非球形 PVA 顆粒和 TAGMs 產(chǎn)生相似的子宮肌瘤梗塞率。

Calibrated microspheres are another type of embolic agent that is commonly used in the UAE. An advantage of calibrated microspheres is that, unlike PVA, they are more uniform in size, which results in more predictable embolization and minimizes the clogging of the catheters used during UAE. 34 In a prospective multicenter study, microspheres showed a low rate of adverse events, reduced uterine fibroid volumes, and improved quality of life. 35 In another prospective clinical trial, 8Spheres (Suzhou Hengrui Callisyn Biomedical Technology, China), a type of conformal microsphere, has been shown to relieve heavy menstrual bleeding effectively and has no significant impact on ovarian function. 36 Embozenes microspheres (Varian, United States) are another type of tightly calibrated microsphere that can be used as an embolic agent.
校準(zhǔn)微球是另一種在 UAE 中常用的栓塞劑。校準(zhǔn)微球的優(yōu)勢在于，與 PVA 不同，它們?cè)诔叽缟细泳鶆颍@導(dǎo)致栓塞更加可預(yù)測，并最小化了在 UAE 過程中使用的導(dǎo)管堵塞。在一項(xiàng)前瞻性多中心研究中，微球顯示出低的不良事件發(fā)生率，減少了子宮肌瘤體積，并改善了生活質(zhì)量。在另一項(xiàng)前瞻性臨床試驗(yàn)中，8Spheres（蘇州恒瑞凱瑞森生物醫(yī)藥技術(shù)，中國），一種符合性微球，已被證明可以有效緩解經(jīng)量過多，并且對(duì)卵巢功能沒有顯著影響。Embozenes 微球（Varian，美國）是另一種可以用作栓塞劑的緊密校準(zhǔn)微球。

Small-sized PVAs ranging between 100 and 300 μm were found to be safe and effective in treating adenomyosis in a study conducted by Yuan et al, 37 with an average follow-up of 42 months. They found no significant relationship between the clinical outcomes, the initial presence of adenomyosis, with or without fibroids, and the JZ thickness. 37
Yuan 等人在一項(xiàng)研究中發(fā)現(xiàn)，直徑在 100 至 300 微米之間的PVAs在治療腺肌癥方面安全有效，平均隨訪時(shí)間為 42 個(gè)月。他們發(fā)現(xiàn)，臨床結(jié)果與腺肌癥初始存在與否、有無子宮肌瘤以及 JZ 厚度之間沒有顯著關(guān)聯(lián)。

Regardless of type, embolic agents play an important role in the success of uterine artery embolization. Another important factor in the success of UAE is the determination of embolization end point strategy. Embolization with an endpoint of near stasis, as opposed to complete stasis, has been reported to result in less postprocedural pain. 38 It is now widely accepted that embolizing the uterine artery with a 5 to 10 heart-beat stasis is an adequate endpoint 39 ( Fig. 3 ).
無論類型如何，栓塞劑在子宮動(dòng)脈栓塞術(shù)的成功中發(fā)揮著重要作用。UAE 成功的一個(gè)重要因素是確定栓塞終點(diǎn)策略。

與完全靜止相比，以近乎靜止為終點(diǎn)的栓塞已被報(bào)道可導(dǎo)致術(shù)后疼痛減輕。現(xiàn)在普遍認(rèn)為，以 5 至 10 個(gè)心跳靜止為終點(diǎn)的子宮動(dòng)脈栓塞是一個(gè)足夠的終點(diǎn)。

Fig. 3. 圖 3。

一名34歲的女性出現(xiàn)大量和長期的月經(jīng)出血，盆腔疼痛和壓力癥狀。提供了只有子宮切除術(shù)作為一種治療選擇的時(shí)候，她進(jìn)行了自己的研究后，來到我們的診所尋求照顧。

(a)UAE（子宮動(dòng)脈栓塞術(shù)）前矢狀位T1加權(quán)脂肪飽和對(duì)比增強(qiáng)（CE）圖像顯示多發(fā)性增強(qiáng)肌瘤。(b)栓塞前左UA橫段（箭頭）的數(shù)字減影血管造影（DSA）顯示UA肥大和多發(fā)性肌瘤染色。(c)栓塞后左UA DSA顯示UA閉塞和宮頸-陰道分支通暢（箭頭）。(d)6個(gè)月隨訪CE MRI顯示子宮尺寸減小，肌瘤無增強(qiáng)，與囊性變性一致。在臨床隨訪期間，她表示重度、持續(xù)出血和大塊癥狀已消退。

其他一些病例

Periprocedural Pain Management
圍手術(shù)期疼痛管理

UAE can be associated with moderate to severe postprocedural pain, and effective pain management is important for patient comfort and satisfaction. Several studies have recently investigated the use of different pain management strategies after UAE. These strategies include preprocedural oral analgesics, local anesthesia, epidural patient-controlled analgesia, conscious sedation, and general anesthesia. 40
UAE 可能與術(shù)后中到重度疼痛相關(guān)，有效的疼痛管理對(duì)患者的舒適度和滿意度至關(guān)重要。（無痛治療對(duì)患者非常重要）

最近有幾項(xiàng)研究調(diào)查了 UAE 后使用不同的疼痛管理策略。這些策略包括術(shù)前口服鎮(zhèn)痛藥、局部麻醉、硬膜外患者自控鎮(zhèn)痛、鎮(zhèn)靜麻醉和全身麻醉。

Some interventional radiologists prefer administering pain medications before or during the UAE to minimize postprocedural pain. The combination of medications that can be administered is a loading dose of hydromorphone hydrochloride or nonsteroidal anti-inflammatory drugs (NSAIDs) and a patient-controlled analgesia. Ondansetron is the preferred antiemetic due to its effectiveness and tolerability. 39 This approach is also believed to avoid postembolization syndrome (PES), which will be discussed as one of the most common postprocedural complications after UAE for fibroids and adenomyosis.
一些介入放射科醫(yī)生更喜歡在 UAE 前后或期間給予止痛藥，以最大限度地減少術(shù)后疼痛。可以給予的藥物組合是鹽酸氫嗎啡酮或非甾體抗炎藥（NSAIDs）的負(fù)荷劑量以及患者控制的鎮(zhèn)痛。由于奧丹司瓊的有效性和耐受性，它是首選的抗惡心藥。 39 這種方法也被認(rèn)為可以避免栓塞后綜合征（PES），這將在討論 UAE 治療子宮肌瘤和腺肌病后最常見的術(shù)后并發(fā)癥之一時(shí)進(jìn)行討論。

A study from Katsumori et al 41 investigating intra-arterial lidocaine administration immediately after UAE with TAGM for leiomyoma was found to be safe. Still, it did not contribute to a significant reduction in pain or amount of narcotic agents administered. 41
一項(xiàng)由 Katsumori 等人進(jìn)行的研究發(fā)現(xiàn)，在 UAE 后立即通過動(dòng)脈內(nèi)給予利多卡因治療子宮肌瘤是安全的。然而，它并沒有導(dǎo)致疼痛或使用的麻醉劑劑量的顯著減少。

Another approach gaining more popularity for periprocedural pain is superior hypogastric nerve block. Yoon et al 42 showed that superior hypogastric nerve block significantly decreased pain and nausea after uterine artery embolization as compared with a sham procedure.
另一種越來越受歡迎的圍手術(shù)期疼痛治療方法是高位腹下神經(jīng)阻滯。Yoon 等人 42 的研究表明，與安慰劑手術(shù)相比，高位腹下神經(jīng)阻滯顯著降低了子宮動(dòng)脈栓塞術(shù)后的疼痛和惡心。

In a recent systematic review of post-UAE pain control regimens, the authors compared the average maximum pain scores of 26 studies that tested various medications, such as opioids, NSAIDs, acetaminophen, intra-arterial lidocaine, steroids, ketamine, or α2 adrenergic receptor agonists. After analyzing these groups' mean maximal pain scores, the authors concluded that there was no significant difference between them. Thus, they suggested that using opioids along with NSAIDs and acetaminophen may be sufficient in controlling post-UAE pain. 43
在最近的一項(xiàng)關(guān)于 UAE 術(shù)后疼痛控制方案的系統(tǒng)性綜述中，作者比較了 26 項(xiàng)研究測試的平均最大疼痛評(píng)分，這些研究測試了各種藥物，如阿片類藥物、非甾體抗炎藥、對(duì)乙酰氨基酚、動(dòng)脈內(nèi)利多卡因、類固醇、氯胺酮或α2 腎上腺素能受體激動(dòng)劑。在分析這些組的平均最大疼痛評(píng)分后，作者得出結(jié)論，它們之間沒有顯著差異。因此，他們建議使用阿片類藥物與 NSAIDs 和對(duì)乙酰氨基酚聯(lián)合使用可能足以控制 UAE 術(shù)后疼痛。

Overall, the choice of pain management strategy after UAE should be individualized based on patient factors and preferences. Further research is needed to evaluate the benefits and risks of the different alternatives. Furthermore, providing detailed preprocedural counseling to patients regarding post-UAE pain timeline and severity can manage patient's expectations and reduce procedure-related anxiety.
總體而言，UAE 后疼痛管理策略的選擇應(yīng)根據(jù)患者因素和偏好個(gè)性化。需要進(jìn)一步研究以評(píng)估不同替代方案的利益和風(fēng)險(xiǎn)。此外，向患者提供有關(guān) UAE 后疼痛時(shí)間表和嚴(yán)重程度的詳細(xì)術(shù)前咨詢，可以管理患者的期望并減少與手術(shù)相關(guān)的焦慮。

Postprocedural Care 術(shù)后護(hù)理

After undergoing UAE to treat fibroids and adenomyosis, most patients undergo a similar cascade of events referred to as PES. PES consists of pelvic pain, nausea, vomiting, and fever that start around 10 to 20 minutes after the procedure and usually peaks at around the eighth hour. 44 Diagnosis of PES can be difficult for non-interventionalists and may warrant further investigation to exclude other differentials like sepsis. 45 While it is not completely understood, the etiology of PES is believed to be due to the release of inflammatory mediators from tissue infarction after embolization. 46 One prospective study assessed that women who underwent UAE had a mean postprocedural score of 7/10 (±2.47) and an average hospital stay of 31.2 hours. 39 Many therapies have been tried to decrease postprocedural pain, such as intra-arterial lidocaine and steroids. A randomized prospective study showed that using intra-arterial lidocaine caused a significant reduction in the early hours of postprocedural pain. 47 Another study showed that administration of a single-dose intravenous infusion of dexamethasone decreased pain scores 12 hours after UAE as well as the incidence of nausea and vomiting. 48 After controlling the nausea and vomiting, the patient is discharged with narcotic agents to be taken on an as-needed basis. 39
經(jīng) UAE 治療子宮肌瘤和腺肌癥后，大多數(shù)患者會(huì)經(jīng)歷被稱為 PES 的類似事件鏈。PES 包括盆腔疼痛、惡心、嘔吐和發(fā)熱，通常在手術(shù)后 10 至 20 分鐘開始，通常在第 8 小時(shí)左右達(dá)到高峰。

PES 的診斷對(duì)于非介入醫(yī)生來說可能很困難，可能需要進(jìn)一步調(diào)查以排除其他不同病因，如敗血癥。雖然原因尚不完全清楚，但 PES 的病因被認(rèn)為是由于栓塞后組織梗死釋放炎癥介質(zhì)。一項(xiàng)前瞻性研究評(píng)估了接受 UAE 的婦女的平均術(shù)后評(píng)分為 7/10（±2.47），平均住院時(shí)間為 31.2 小時(shí)。許多治療方法已被嘗試以減少術(shù)后疼痛，如動(dòng)脈內(nèi)利多卡因和類固醇。一項(xiàng)隨機(jī)前瞻性研究顯示，使用動(dòng)脈內(nèi)利多卡因可顯著減少術(shù)后早期疼痛。 一項(xiàng)研究顯示，單劑量靜脈滴注地塞米松可降低 UAE 后 12 小時(shí)的疼痛評(píng)分，以及惡心和嘔吐的發(fā)生率。控制惡心和嘔吐后，患者帶用麻醉劑出院，按需服用。

Aside from PES, other complications, although rare, can also arise after UAE. Fibroid expulsions (FEs) are a late complication that may occur where the necrotic fragments of the fibroid are expulsed through the cervical canal. 45 Symptoms can include vaginal bleeding, cramping, and pelvic pain. Larger sloughed off fibroids can also cause a blockage at the cervical os, which could lead to infection. Certain factors predispose patients to FE, such as size and location of the tumor, with submucosal and transmural fibroids having the highest risk. 49 Pedunculated fibroids, while historically thought of as high risk, have a low risk of adverse events and FE; they can safely be treated with UAE. 14 The treatment of FE depends on a case-by-case basis, as most women tolerate FE well, with 50% needing no operative intervention. 50 While the rate of fibroid expulsion ranges from 1.7 to 50%, 50 it is still a serious complication that must be addressed. Another rare complication that may arise from UAE involves chronic vaginal discharge. While often asymptomatic, one study found vaginal discharge mixed with spherical particles from intramural and submucosal fibroids. 51
除 PES 外，其他并發(fā)癥雖然罕見，但在 UAE 后也可能發(fā)生。子宮肌瘤排出（FEs）是一種晚期并發(fā)癥，可能發(fā)生在肌瘤的壞死碎片通過宮頸管排出時(shí)。

癥狀可能包括陰道出血、痙攣和盆腔疼痛。較大的脫落的子宮肌瘤也可能導(dǎo)致宮頸口阻塞，這可能導(dǎo)致感染。某些因素使患者易患 FE，如腫瘤的大小和位置，黏膜下和穿透肌層的子宮肌瘤風(fēng)險(xiǎn)最高。

有蒂子宮肌瘤，雖然歷史上被認(rèn)為是高風(fēng)險(xiǎn)，但不良事件和 FE 的風(fēng)險(xiǎn)較低；它們可以安全地通過 UAE 治療。FE 的治療取決于個(gè)案，因?yàn)榇蠖鄶?shù)女性對(duì) FE 的耐受性良好，其中 50%的女性不需要手術(shù)干預(yù)。盡管子宮肌瘤排出的發(fā)生率在 1.7%到 50%之間，但這仍然是一種嚴(yán)重的并發(fā)癥，必須加以解決。UAE 可能引起的另一種罕見并發(fā)癥是慢性陰道分泌物。雖然通常無癥狀，但一項(xiàng)研究發(fā)現(xiàn)，陰道分泌物中混合有來自肌層和黏膜下子宮肌瘤的球形顆粒。

Outcomes 結(jié)果

The outcomes of UAE on uterine fibroids are 50 to 60% fibroid size reduction, 88 to 92% reduction of bulk symptoms, greater than 90% elimination of uterine bleeding, and 75% elimination of symptoms. 52 The complications of UAE on uterine fibroids include 2 to 17% with prolonged vaginal discharge, 3 to 15% with fibroid expulsion, and 1 to 3% with septicemia according to SIR Standards of Practice Guidelines. 52 UAE has lower success with adenomyosis, where 76% of women had a resolution of symptoms. 53 Complications of UAE in adenomyosis are postprocedural pain in 87% of patients, persistent amenorrhea in 6 to 21% of patients, and need for hysterectomy in 14% of patients. 54
子宮肌瘤 UAE 治療的結(jié)果是 50 至 60%的肌瘤體積減小，88 至 92%的體積癥狀減輕，超過 90%的子宮出血消除，以及 75%的癥狀消除。 52

子宮肌瘤 UAE 治療的并發(fā)癥包括 2 至 17%的陰道分泌物延長，3 至 15%的肌瘤排出，以及 1 至 3%的敗血癥，根據(jù) SIR 實(shí)踐指南標(biāo)準(zhǔn)。 52 UAE 在腺肌病治療中的成功率較低，其中 76%的女性癥狀得到緩解。 53 腺肌病中 UAE 的并發(fā)癥包括 87%的患者術(shù)后疼痛，6 至 21%的患者持續(xù)閉經(jīng)，以及 14%的患者需要子宮切除術(shù)。 54

While the outcomes of UAE for both fibroids and adenomyosis are high, success also depends on the size of the embolic agent being used. According to one study, the use of only 500 to 700 μm particles resulted in a high rate of failed tumor infarction in uterine fibroids. 55 That same study showed that using 700- to 900-μm particles resulted in better imaging results and fewer repeat interventions. 55 TAGM particles can also be a great embolic agent for adenomyosis. One study showed that using microspheres ranging from 500 to 700 μm in size achieved a necrosis rate of 44.1%. 56
盡管 UAE 治療子宮肌瘤和腺肌癥的效果良好，但成功也取決于所使用的栓塞劑的大小。

根據(jù)一項(xiàng)研究，僅使用 500 至 700 微米的顆粒會(huì)導(dǎo)致子宮肌瘤腫瘤梗死失敗率較高。該研究還顯示，使用 700 至 900 微米的顆粒可以獲得更好的成像結(jié)果和更少的重復(fù)干預(yù)。TAGM 顆粒也可以是腺肌癥的一個(gè)很好的栓塞劑。一項(xiàng)研究表明，使用 500 至 700 微米范圍的微球可以達(dá)到 44.1%的壞死率。

A recent deep learning-based study on predicting UAE outcomes found that there was no significant difference in UAE treatment response between fibroids' locations. 57 Similar to this finding, Firouznia et al 58 found that lesion location is not a factor in determining the clinical outcome of UAE. However, a study by Katsumori et al 59 showed that fibroid location within the uterus affects the likelihood of infarction after embolization. More specifically, they found that the anteriorly located fibroids and cervical fibroids have a lower infarction rate after UAE. The reasons for incomplete infarction of fibroids at these locations are unclear, but could be related to collateral arterial supply. One possible explanation for this phenomenon is that it may be linked to either the distribution of microspheres influenced by gravity during procedures performed while the patient is supine or hormonal changes resulting in shifts between watershed regions of the uterus, ovaries, or vagina based on the menstrual cycle phase. 60 The location of the fibroids is also important, as discussed earlier, due to the potential risk of expulsion. Sher et al 31 also found that submucosal location and pain are predictors of symptom recurrence.
近期一項(xiàng)基于深度學(xué)習(xí)預(yù)測 UAE 結(jié)果的研究發(fā)現(xiàn)，在纖維瘤的位置方面，UAE 治療反應(yīng)沒有顯著差異。與這一發(fā)現(xiàn)相似，F(xiàn)irouznia 等人發(fā)現(xiàn)，病變位置不是決定 UAE 臨床結(jié)果的因素。

然而，Katsumori 等人的研究表明，子宮內(nèi)纖維瘤的位置會(huì)影響栓塞后的梗死可能性。更具體地說，他們發(fā)現(xiàn)，位于前方的纖維瘤和宮頸纖維瘤在 UAE 后的梗死率較低。這些位置纖維瘤不完全梗死的原因尚不清楚，但可能與側(cè)支動(dòng)脈供應(yīng)有關(guān)。這種現(xiàn)象的一個(gè)可能解釋是，它可能與患者仰臥時(shí)手術(shù)過程中受重力影響的微球分布有關(guān)，或者與月經(jīng)周期階段導(dǎo)致的子宮、卵巢或陰道分水嶺區(qū)域的變化有關(guān)。如前所述，纖維瘤的位置也很重要，因?yàn)榇嬖谂懦龅臐撛陲L(fēng)險(xiǎn)。 Sher 等人 31 還發(fā)現(xiàn)，黏膜下位置和疼痛是癥狀復(fù)發(fā)的預(yù)測因素。

During the initial workup, the total volume and bulk of the fibroids are considered as part of the treatment decision making. Current evidence supports UAE as a safe and effective option to treat giant fibroids (volume ≥700 cc) causing bulk symptoms. However, the limited available data indicate a relatively higher risk of complications and reinterventions when compared with nongiant fibroids. Patients should be selected, counseled, and managed in a multidisciplinary fashion, as bulk symptoms take longer to improve after UAE. 61
在初步檢查過程中，子宮肌瘤的總體積和體積被視為治療決策的一部分。現(xiàn)有證據(jù)支持 UAE（子宮動(dòng)脈栓塞術(shù)）作為一種安全有效的治療巨大子宮肌瘤（體積≥700 cc）引起體積癥狀的選項(xiàng)。然而，有限的可獲得數(shù)據(jù)表明，與非巨大子宮肌瘤相比，UAE 的并發(fā)癥和再次干預(yù)的風(fēng)險(xiǎn)相對(duì)較高。患者應(yīng)通過多學(xué)科方式選擇、咨詢和管理，因?yàn)?UAE 后體積癥狀的改善需要更長的時(shí)間。 61

While patients receive an extensive workup to rule out malignancy as described in the workup section, it may be difficult to differentiate leiomyoma from leiomyosarcoma on MRI. In a study that reviewed more than 300 patients who had follow-up after UAE, 4 were found to have leiomyosarcoma after UAE for presumed fibroids. 62 This study highlights that patients should be carefully assessed for underlying leiomyosarcoma and counseled accordingly.
在患者接受廣泛的檢查以排除惡性病變，如檢查部分所述的同時(shí)，在 MRI 上區(qū)分平滑肌瘤和平滑肌肉瘤可能很困難。在一項(xiàng)回顧了超過 300 名接受 UAE 術(shù)后隨訪的患者的研究中，發(fā)現(xiàn)有 4 名患者在 UAE 治療后被診斷為平滑肌肉瘤。 62 這項(xiàng)研究強(qiáng)調(diào)，應(yīng)仔細(xì)評(píng)估患者是否存在潛在平滑肌肉瘤，并據(jù)此進(jìn)行咨詢。

Fertility and UAE 生育與 UAE

Unlike hysterectomy, minimally invasive interventions such as UAE may help preserve fertility, especially in cases of symptomatic adenomyosis and large fibroids, according to recent studies. 63In fact, research indicates that even patients with larger uteri and fibroids greater than 10 cm do not experience significantly higher complication rates, suggesting that fibroid size should not be a contraindication for UAE.63However, one study found that miscarriage rates were highest in the UAE group compared to other minimally invasive techniques like HIFU and transcervical radiofrequency ablation.64Nonetheless, this study identified maternal age as a confounding variable that could have contributed to the odds of fetal and maternal complications.64Another systematic review was conducted on a cohort of 2,000 women, out of which 1,575 underwent myomectomies, while 424 underwent UAE, as reported by Zanolli et al.65The study revealed that the birth rate outcome was 60.6% for both UAE and myomectomies, compared to 75.6% for the latter. There was a higher rate of spontaneous abortion of 27.4% for the UAE, as opposed to 19.0% for myomectomies.65Again, the study indicated that the patients who underwent UAE were older and had smaller fibroids when compared to those who underwent laparoscopic myomectomy.65On the other hand, a meta-analysis of 189 patients, of which 44 became pregnant (23.3%) after UAE, found that the live birth rate was estimated to be 88.6% among patients aged 24.5 to 33 years, indicating that UAE does not significantly affect birth rates compared to the general population.66A meta-analysis by Jiang et al67investigated the overall pregnancy outcomes after uterus-sparing nonexcisional treatments such as UAE and ablation in patients with adenomyosis. Between January 2000 and 2022, 13 studies with 1,319 patients with adenomyosis were included. The pregnancy and miscarriage rates after nonexcisional treatments were 51 and 22%, respectively, without a statistically significant difference compared to adenomyosis excision outcomes. Overall, recent literature suggests that UAE on a young cohort does not have a negative impact on fertility or pregnancy outcomes when compared to the general population.
與子宮切除術(shù)不同，根據(jù)最近的研究，微創(chuàng)干預(yù)措施如 UAE 可能有助于保留生育能力，尤其是在有癥狀的腺肌癥和大型子宮肌瘤的情況下。

事實(shí)上，研究表明，即使子宮較大且子宮肌瘤大于 10 厘米的患者，并發(fā)癥發(fā)生率也并未顯著升高，這表明子宮肌瘤的大小不應(yīng)成為 UAE 的禁忌癥。然而，一項(xiàng)研究發(fā)現(xiàn)，與 HIFU 和經(jīng)宮頸射頻消融等微創(chuàng)技術(shù)相比，UAE 組的流產(chǎn)率最高。盡管如此，這項(xiàng)研究將母體年齡確定為可能影響胎兒和母體并發(fā)癥發(fā)生幾率的混雜變量。

Zanolli 等人對(duì) 2000 名女性進(jìn)行了另一項(xiàng)系統(tǒng)綜述，其中 1575 名女性接受了子宮肌瘤切除術(shù)，而 424 名女性接受了 UAE。該研究顯示，UAE 和子宮肌瘤切除術(shù)的出生率結(jié)果均為 60.6%，而后者為 75.6%。

UAE 組的自然流產(chǎn)率較高，為 27.4%，而子宮肌瘤切除術(shù)組為 19.0%。 65

再次，該研究指出，與接受腹腔鏡子宮肌瘤切除術(shù)的患者相比，接受 UAE 的患者年齡較大，子宮肌瘤較小。 65

另一方面，一項(xiàng)對(duì) 189 名患者的薈萃分析，其中 44 名（23.3%）在 UAE 后懷孕，發(fā)現(xiàn) 24.5 至 33 歲年齡段的患者的活產(chǎn)率估計(jì)為 88.6%，表明與普通人群相比，UAE 對(duì)生育率沒有顯著影響。 66

Jiang 等人進(jìn)行的一項(xiàng)薈萃分析研究了腺肌病患者接受子宮保留非切除性治療（如 UAE 和消融術(shù)）后的整體妊娠結(jié)果。從 2000 年 1 月到 2022 年，納入了 13 項(xiàng)研究，共涉及 1,319 名腺肌病患者。非切除性治療后的妊娠率和流產(chǎn)率分別為 51%和 22%，與腺肌病切除性治療結(jié)果相比，沒有統(tǒng)計(jì)學(xué)上的顯著差異。總的來說，近期文獻(xiàn)表明，與普通人群相比，UAE 對(duì)年輕人群的生育能力或妊娠結(jié)果沒有負(fù)面影響。

Conclusion 結(jié)論

Endovascular treatments are promising and effective for both adenomyosis and uterine fibroids. While traditional surgical approaches have been successful in the past, there was an increase in complications and longer hospital times associated with them. Endovascular treatments like uterine artery embolization are minimally invasive with very few complications. It is important to note that some patients prefer less invasive treatment options. Therefore, healthcare providers should provide comprehensive counseling on all available treatment options, which may include conservative, medical, minimally invasive, surgical, or a combination thereof, to help patients make informed decisions about their care. In conclusion, endovascular treatment is expected to play a more significant role as a management tool for both fibroids and adenomyosis in the future.
血管內(nèi)治療對(duì)腺肌病和子宮肌瘤都很有希望且有效。雖然傳統(tǒng)的手術(shù)方法在過去已經(jīng)取得了成功，但與之相關(guān)的并發(fā)癥增加和住院時(shí)間延長。

子宮動(dòng)脈栓塞等血管內(nèi)治療具有微創(chuàng)和并發(fā)癥極少的優(yōu)點(diǎn)。需要注意的是，一些患者更喜歡侵入性較小的治療方案。因此，醫(yī)療保健提供者應(yīng)提供關(guān)于所有可用治療方案的全面咨詢，這可能包括保守治療、藥物治療、微創(chuàng)治療、手術(shù)治療或其組合，以幫助患者就其護(hù)理做出明智的決定。

總之，預(yù)計(jì)血管內(nèi)治療在未來作為纖維瘤和腺肌病的管理工具將發(fā)揮更重要的作用。

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