| Uterine myoma (UM) is the most common benign leiomyoma of women in our country, incidence of a disease is about25%. UM can cause menstruation too much, infertility and the symptom such as frequent micturition, which impact on the quality of life of the patients. UM-UAE has effectively relieve the clinical symptoms, the length of time is short, the faster postoperative recovery etc, and receiving more and more attention.UAE can improve the symptom cused by UM significantly in immediate and long-term follow-up. Popovic et al found that the UAE postoperative period overmuch, dysmenorrhea, compression symptoms, fatigue and depression, life is limited were89%,79%,89%,76%,92%and78%, and77%. Such as Kim et al through the sixteen cases of patients were followed up for four years to found profuse menstruation, dysmenorrhea and oppression of the symptoms GaiShanLv for89%,100%and78%,42%fibroids disappear completely, uterine fibroids and smaller rate is80%and36%. Voogt et al study found that68%of patients the sexual function improved after UM-UAE. Relative with hysterectomy and myomectomy, studies found that UAE can better to improve the menstrual symptoms and quality of life of UM patients.After preliminary studies, scholars believe that the effect factors of impact UM-UAE are position, number and size of Ieimyoma. Isonishi et al analyzed postoperative recurrence factors of UM-UAE, found that blood flow and fibroids fibroids number is risk factors of UM-UAE. The authors think that the recurrence rate increased with the increasing of the number of fibroids and blood flow. So if the blood flow of fibroids affect UM-UAE need further study.Now the major research methods of blood supply to the source about blood flow and vascular network characteristics are anatomic study and Digital Subtraction Angiography (Digital Subtraction Angiography, DSA). Anatomic study can through the autopsy to observe UM and blood supply to of uterus, and through the blood vessel casting technology to observe the distribution of blood supply of fibroids. But these methods are in the corpse, so large scale and careful research are impossible. DSA can be through the iliac artery or uterine artery angiography to shows the blood supply to the uterus fibroids and source of fibroids, this is also the main method at present. Lan et al first to observe the UM through DSA imaging characteristics in our country. In their study the blood vessels of fibroids are divided into3types: unilateral predominated, bilateral balanced and unilateral uterine artery nurtured leiomyoma singly. And think the vascularity of leiomyoma was characterized as two layers of vascular net The superficial thick layer in the pseudo-capsule spherically surrounded the surface of leiomyoma. Dense capillary network, the other vascular layer, was found inside the leiomyoma. But the number of that study only156cases, so a small number of cases which ovarian artery provide the blood supplement for leiomyoma singly have not been found. Therefore need to expand the cases in further.Although the documents of clinical effect of UM-UAE the domestic and international have many, most studies stop in two to three years after UM-UAE. This is mainly because most of the research limited by number of cases, and long time of follow-up will reduce the number of cases. We collected patients from1999and collected data with preoperative imaging and fibroid volume368cases. First of all, this study investigated the DSA images of368consecutive symptomatic uterine leiomyoma patients treated by UAE, the blood supply and flow of leiomyoma were analyzed and classified. Then statistics analysis follow-up data of5years of UM-UAE, and combined with DSA material, to analysis if the blood flow of fibroids is factor which affecting the efficacy of UM-UAE.This research is divided into three parts: Part One Digital Subtraction Angiography imaging characteristics of the uterine fibroids[Purpose]Through the observation of the UM digital subtraction angiography (DSA) to analysis the blood supply and characteristics of UM, and then to decide the target blood vessels embolic agents doses of UAE.[Method]DSA image data of patients from July1999to December2010in GuangZhou First People’s Hospital and Nan Fang Hospital in UM-UAE were analyzed. MRI were done before UAE in all of368patients.1. DSA imaging conditions:The speed and dose of nonionic contrast media agent (Ultravist370mg Iodine/ml, Schering, Berlin, Germany) was determined by the size of uterine leiomyoma and diameter of artery. The contrast media agent was injected by high pressure injector under a68kPa pressure.1) Abdominal aortography:10ml/s,30ml;2) Internal iliac arteriography:5-6ml/s,13-16ml;3) uterine arterial angiography:3-4ml/s,8-10ml.1s delay DSA angiograph of abdominal aorta, iliac artery or uterine artery were obtained to observe the blood supply, size, location, shape and number of uterine leiomyoma.2. The classification of blood supply of uterine leiomyomaBased on DSA images, the blood supply of uterine leiomyoma was categorized as4types:(1) Type â… (unilateral predominated):unilateral uterine artery+/-ipsilateral ovarian artery provided more than1/2blood supply for leiomyoma;(2) Type â…¡ (bilateral balanced):bilateral uterine artery+/-ipsilateral ovarian artery shared about1/2blood supply for leiomyoma respectively;(3) Type III:unilateral uterine artery nurtured leiomyoma singly;(4)Type â…£:ovarian artery provide the blood supplement for leiomyoma singly.3. The grades of vascularity in uterine leiomyomaAll angiograms were evaluated jointly by two interventional radiologists. The enhancement degree compared with myometrium and vascular net of uterine leiomyoma during DSA process was considered to be the determinant factor for the classification. We qualitatively assigned the vascularity of uterine leiomyoma to4grades:(1) Extreme hypervascular (relative to myometrium):extremely dense vessels with obvious enhancement than myometrium. We could clearly see the thick outer and dense inner vascular network of uterine leiomyoma.(2) Hypervascular:dense vessels with obvious enhancement than myometrium but slighter than extreme hypervascular leiomyoma. Thick outer and fuzzy or flocculent inner vascular network could still be seen clearly in angiograms.(3) Isovascular: different shades of fibroid vascular network with a slight enhancementdarker staining than myometrium. Outer vascular layer was still clear but inner vascular network blurred.(4) Hypovascular: the vascular network appeared as a blur with equal or slighter enhancement than myometrium. Tiny outer vascular layer and absent inner vascular network were observed. [Results]1. The supplying artery of uterine leiomyomaIn our study, uterine artery fed the majority of uterine leiomyoma, which accounts for91.73%(477/520). Ovarian artery participated in the blood supply of4.23%(22/520) uterine leiomyoma, and among them4cases (0.77%) was completely supplied by ovarian artery. In that4cases, we did not find leiomyoma vessels during the internal iliac artery angiography, however, abdominal aortography showed a spiral downward ovarian artery reached uterus with branches supplying the leiomyoma. Nonetheless, there were3.27%(17/520) patients whose leiomyoma blood supply were failed to be classified due to the unclear visualization by double-side internal iliac arteriography or uterine arterial angiography.2. The types of uterine leiomyoma blood supplyThe blood supply to leiomyoma was classified as four types according to the predominated vessel branches and their supporting ratio. Except for type IV in4cases (0.77%), leiomyoma simply nurtured by ovarian artery, uterine artery was the predominated blood supplying vessel in the other3types. We demonstrated that type â…¡ (bilateral balanced) as the most common one, accounting for49.04%(255/520). Followed by type â… (unilateral predominated), accounting for36.34%(189/520). Unilateral uterine artery supplying leiomyoma singly (Type â…¢) were found in55cases, accounting for10.58%. Moreover, the blood supplement in17cases (3.27%) were failed to be classified due to the unclear visualization.3. The visualization of ovarian vessels netIn left uterine or internal iliac artery angiography, ovarian vessels were seen in234cases (45.00%), and162cases (31.15%) in the right angiography. Among them, ascending branch of uterine artery was showed to supply ovary by uteroovarian anastomosis or ovarian artery was showed to directly nurtured ovary. 4. The characteristics and grades of uterine leiomyoma vascularityIn angiograms, the vascularity of leiomyoma was characterized as two layers of vascular net. The superficial thick layer in the pseudo-capsule spherically surrounded the surface of leiomyoma. Dense capillary network, the other vascular layer, was found inside the leiomyoma. The larger the leiomyoma was, the more obvious the characteristic described above was.The fibroids vascularity was categorized as4types. Hypervascular was the major type, accounting for46.15%(240/520);then was isovascular, hypovascular and extreme hypervascular type. accounting for33.46%(174/520),11.73%(61/520) and8.66%(45/520) respectively.[Conclusion]In about half of the patients, uterine leiomyoma has bilateral uterine artery balanced blood supply,which is characterized by rich blood flow and thick vascular network in pseudo capsule of leiomyoma. Moreover, ovarian artery provides blood supplied by about5%patients;therefore, attention should be paid on the collateral circulation during UAE procedure.Part Two overall efficacy trend of UM-UAE[Purpose]Through to the UM-UAE post-operative long-term efficacy of follow-up, this paper summarizes the UEA postoperative fibroid volume change trend, and draw up the volume curve, used to guide UM-UAE postoperative review and the choice of treatment time again.[Method]From July1999to December2010for UM in guangzhou first people’s hospital and southern medical university hospital line of southern UAE in368cases.Patients mean age,39.14+/-5.92years, with a single sex uterine fibroids in201cases, multiple uterine fibroids167cases. The mucous membrane in single sex fibroids fibroids and intramural fibroids, subserosal fibroids and a single unknown location for patients, are24cases and71cases,36cases and70cases. There are1patients in six years ago respectively have UAE treatment,22people had done the myomectomy. All of the patients by b-ultrasonography and MR diagnosed as uterine fibroids, clinical blow out endometrial lesions, and preoperative examination ovarian endocrine function exclude ovarian function abnormal persons. Embolic agents:fresh gelatin sponge particles (gelfoam, GF), polyvinyl alcohol (polyvinyl alcohol, PVA) particle or sodium alginate microspheres (KMG). Postoperative1,3, June and1-5years or telephone line each year questionnaire follow-up, and the registration of patients with menstruation, dysmenorrhea, pregnancy and have complications, parallel B ultrasound or MRI observation of and fibroid volume change and have fibroids necrosis.Statistical methods:in the software SPSS13.0to obtain statistical data processing, compared with T test group of patients age, uterine fibroids and preoperative volume, variance, normal regression of all sexual inspection. One-Way ANOVA test comparing different time efficient, volume and tumor size decreased rate. P<0.05said statistically significant.[Results]UM-UAE postoperative patients after1,2and5years of efficient and recurrence rates were93.48%,92.00%,78.81%and2.17%,4.00%,6.62%, said the time efficient, without efficiency and the recurrence rate between statistically significant (p<0.05).35patients because of the original fibroids increase or new hair fibroids and in return after surgery,12of which a hysterectomy, and pedestrian fibroids eliminate art, one line again intervention,8people choose to continue to watch. Fibroid volume narrow were54.15%%,rate of50.18%and40.01%. Most patients in postoperative profuse menstruation symptom such as dysmenorrhea, improved obviously. According to the change of the UM volume in rendering the UM-UAE postoperative curative effect curve, and according to the curve can be divided into4curative effect will):6months after UM volume down the most obvious, and the overall rate of70%of the narrow, called the speed of narrow; Postoperative June-2years UM volume still has narrowed, but before a narrow slowly, about30%of the overall rate of narrow, called slow narrow period; After two years-three years UM after two years in volume maintain level no change or risen slightly, called platform period; After3-5years, fibroids significantly reduced in size rate, a part of the patients found new fibroids or the original fibroid volume increases, will this phase is called recurrence period.[Conclusion]UM-UAE has good curative effect of rotational acetabular osteotomy to significantly improve patients with profuse menstruation, menstruation is mixed the symptom such as dysmenorrhea. In the short term after UM to significantly reduced, and maintain curative effect in3years, only a few patients in three years later will recur.Part three Different blood supply type of uterine fibroids artery embolization postoperative curative effect trend[Purpose]Blood flow to different source type of UM-UAE treatment trends for the summary and analysis, rendering the various groups of the curative effect of UM graph, intends to explore different types of blood flow sources UM-UAE curative effect trend characteristics, the choice of the ways of treatment for patients and curative effect evaluation with certain reference. [Method]In the analysis of source UM DSA blood type, on the basis of5years of follow-up UM-UAE groups results concluded and analyzed, and the comparison between the time the UM-UAE curative effect, rendering the UAE before and after treatment fibroid volume curve, the overall efficacy analysis curves and different types of blood flow sources curative effect curve relationship.Statistical methods:in the software SPSS13.0to obtain statistical data processing, the measurement data to mean±standard deviation () said, count data to rate said. Use One-Way ANOVA comparison of the age, preoperative patients with uterine fibroids and different type of source volume blood flow between the group fibroid volume and tumor size decreased rate, variance, normal characteristic of all inspection. P<0.05said statistically significant.[Result]After3months of type I (side artery blood supply to give priority to type), type II (bilateral arterial blood equilibrium type) and III type (simple side uterine artery for blood type) of fibroid volume narrow rates were50.02%,51.43%and57.42%, after one year as70.47.60%,62.20%and73.82%, after5years was68.05%,59.70%and88.06%(there were no significant differences). For only the ovary blood type IV patients currently only2cases in the visit, there were no recurrence, cannot the clinical curative effect and the three other type of contrast.Three blood supply source type of fibroids and uterus changes are smaller rate close to general curative effect, can be divided into4period. Among them with type III (simple side uterine artery for blood type) the long-term efficacy of best, postoperative but statistical results is no statistical difference (p>0.05). And three kind of blood type fibroid volume for the change trend of the overall efficacy are similar trends, can be divided into rapidly narrow period, slow narrow period, platform and recurrence period of stage4.[Conclusion]UM blood supply to the different source will not affect the UAE curative effect. Ovary blood supply to patients were done UM-UAE also can get good effect.Part Four Different blood flow of uterine fibroids artery embolization postoperative curative effect trend[Purpose]The flow of blood to different UM the curative effect of the trend for the summary and analysis, rendering the various groups of the curative effect of UM graph, found that the flow of blood to different UM-UAE curative effect trend characteristics, the choice of the ways of treatment for patients and curative effect evaluation with certain reference.[Method]In previous DSA UM blood flow characteristics analysis based on the result of5years of follow-up of UM-UAE groups results concluded and analyzed, and the comparison between the time the UM-UAE curative effect, rendering the UAE before and after treatment fibroid volume curve, the overall efficacy analysis curves and different blood flow curve relationship curative effect.Statistical methods:in the software SPSS13.0to obtain statistical data processing, compared with T test group of patients age, uterine fibroids and preoperative volume, variance, normal regression of all sexual inspection. One-Way ANOVA test comparing different blood flow between group of efficient, volume and tumor size decreased rate. P<0.05said statistically significant.[Results]Postoperative June extremely rich blood flow type, rich blood flow type,type and a rich general blood flow of blood type fibroid volume narrow rate of61.07%compared,54.47%,57.56%and38.15%, after5years was90.51%,28.68%,21.96%and57.61%(there were no significant differences).Four types of blood flow UM5years curative effect graph shows:extremely rich blood flow type of6months for fast narrow period, June-1year for no slow narrow period, without platform period, after one-five annual average for recurrence period; Rich blood flow after6months for fast type of narrow, without obvious slowly shrink period, June-1year as the platform),1-5years for recurrence period; General blood type group called after3months of rapid shrink,3months to a year for slow narrow period, without obvious platform period, after one year-five years for recurrence period; The rich blood type no obvious recurrence period, after3years in only a portion of the patients experienced recurrence. Fibroid volume in three months after the rapid shrink, on March1years of relatively slow narrow, respectively in the narrow rate50%. we call it the fast and slow period of narrow narrow,2-5annual average for platform period. Blood group and very rich blood flow of the recurrence of time for group respectively after one year and two years, general blood flow type and the rich blood flow of time are recurrent type after3years.[Conclusion]Blood flow of the effect of different UM curve each are not identical, along with the increase of blood flow abundance extent recently the better the results but poor long-term outcome. To blood flow of the most abundant UM patients should be in September-four years after close follow-up, and deal with patients relapse. |
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