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Fibroid-related Menorrhagia: Treatment with Superselective Embolization of the Uterine Arteries and Midterm Follow-up¹

¹ From the Departments of Body and Vascular Imaging (J.P.P., O.L.D., P.S., M.K., H.D., M.A., R.R.), Neuroradiology (J.J.M.), and Obstetrics and Gynecology (J.H.R.), Lariboisière Hospital-Public Assistance Hospital of Paris, 2 rue Ambroise Paré, 75475 Paris cedex 10, France; and the Laboratory of Experimental Radiology, Université Paris VII, France (J.P.P., P.S.). Received December 16, 1998; revision requested February 15, 1999; final revision received August 17; accepted September 1. Address correspondence to J.P.P. (e-mail: jean-pierre.pelage@lrb.ap-hop-paris.fr).

	Abstract

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To prospectively evaluate the effectiveness and safety of selective embolization of the uterine arteries in the management of symptomatic uterine leiomyoma.

MATERIALS AND METHODS: Eighty consecutive women (mean age, 44.7 years) with symptomatic uterine leiomyoma, none of whom desired future pregnancy, underwent superselective embolization of the uterine arteries with polyvinyl alcohol particles. In all women, arterial embolization was performed because of persistent, fibroid-related menorrhagia after failure of hormonal therapy. Follow-up consisted of office visits at 2, 6, 12, and 24 months and of ultrasonography at 2 and 6 months after the procedure.

RESULTS: Bilateral embolization of the uterine arteries was performed in 76 women; unilateral embolization, in four women. Menorrhagia disappeared in 72 (90%) women. In five (6%) women (including three women with unilateral embolization), clinical improvement was not observed, and myomectomy was needed. In one woman with a large submucosal uterine leiomyoma, hysterectomy was needed because of septic uterine necrosis. Normal menstruation resumed in all but six women. Full-term pregnancy occurred in three women after the procedure.

CONCLUSION: Superselective arterial embolization of the uterine arteries is an effective means of controlling symptomatic uterine leiomyoma. However, the ideal embolic regimen remains to be determined.

Index terms: Arteries, therapeutic embolization, 989.1264 • Uterus, interventional procedures, 854.1264 • Uterus, neoplasms, 854.315 • Uterus, radiography, 854.1247 • Uterus, US, 854.1298, 854.12989

	Introduction

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Uterine leiomyoma, which occurs in one of every four to five women during reproductive life, is the most common solid pelvic tumor in women (1). Menstrual abnormalities—especially menorrhagia, which often leads to iron-deficiency anemia—are the most common complications of uterine leiomyoma (1).

To our knowledge at the time this article was written, no consensus exists on the most appropriate management. Medical treatment combining progestogen and hormonal therapy—gonadotropin-releasing hormone agonists—often meets with encouraging but transient results in uterine leiomyomas (2). Surgical procedures including myomectomy and hysterectomy often are needed later during the course of events (3,4). In addition to the risks associated with surgical procedures, hysterectomy may be a cause of emotional trauma (5,6). The use of arterial embolization of the uterine arteries to treat symptomatic leiomyoma has been reported as an alternative to surgery (7–9).

The purpose of our study was to prospectively evaluate the effectiveness and safety of arterial embolization of the uterine arteries in the management of uterine leiomyoma and to report the midterm results of this procedure after the failure of medical therapy in a large series of patients.

	MATERIALS AND METHODS

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From June 1991 to December 1996, 80 consecutive women with hemorrhage related to uterine leiomyoma were treated with selective arterial embolization of the uterine arteries. The mean age of the women was 44.7 years (range, 30–54 years). All women presented with refractory vaginal bleeding, which was considered the dominant symptom and the main inclusion criterion. Pelvic pain was the most frequent symptom and was encountered in 55 (69%) women.

All women included in the study underwent abdominal and endovaginal ultrasonography (US) of the pelvis, and most of them were found to have intramural (63 women [79%]) and multiple (55 women [69%]) leiomyomas (Table). The mean diameter of the largest leiomyoma was 58 mm (range, 21–100 mm). All of the women included in the study previously had been unsuccessfully treated medically by using progestogen, hemostatic agents, or gonadotropin-releasing hormone agonists. Fifteen women (19%) had undergone prior myomectomy for refractory menorrhagia. In all women, because of insufficient results with hormonal therapy, a surgical procedure that consisted of myomectomy or hysterectomy was planned. The decision to perform embolization as an alternative to surgery was made on the basis of persistent menorrhagia associated with anemia. The potential risks and benefits of the procedure were explained fully to the women, and written informed consent was obtained from all the women. The procedure was also approved by the ethics committee of the Lariboisiére Hospital.

Contralateral internal iliac arteriography and selective arteriography of the anterior division of the internal iliac artery to analyze the uterine artery was then performed with a single 5-F, cobra-shaped catheter (Cobra; Terumo, Tokyo, Japan) and with a hydrophilic polymer–coated, 0.032-inch guide wire (Radifocus; Terumo) (10). In five women with vasospasm or with a narrow uterine artery, a 3-F microcatheter (Tracker 18; Boston Scientific/Target Therapeutics, Watertown, Mass) was used to perform free-flow embolization. Intraarterial injection of vasodilators, which included nitroglycerin, was used only at the beginning of our experience because of inconsistent results. Superselective arteriography of the uterine artery was attempted in all women.

A cobra-shaped catheter was also inserted into the ipsilateral internal iliac artery and uterine artery, by using the same technique described previously. Dehydrated polyvinyl alcohol particles (Ivalon; Nycomed, Paris, France) with a diameter of 150–300 µm were introduced under fluoroscopic control in free-flow to obtain complete devascularization of the leiomyoma. Fifty milligrams of 1% lidocaine hydrochloride (Xylocaine; Laboratoire Roger Bellon, Neuilly, France) was injected as an analgesic directly into each uterine artery. Before injection, it was mixed in a cup with the polyvinyl alcohol particles and with iodinated contrast material (iohexol [Omnipaque 300; Nycomed]). Postembolization arteriography was performed to ensure the occlusion of the vessels. For pelvic pain during the procedure, 2 mg of morphine hydrochloride was administered subcutaneously every 15 minutes to ensure patient comfort. The procedure lasted 45–90 minutes.

After the procedure, the patients returned to the department of gynecology for further observation. The management of postembolization pelvic pain consisted of narcotic analgesia administered with a patient-controlled pump.

Evaluation after the procedure was based on clinical follow-up. Each woman underwent gynecologic examination 4–7 weeks after embolization and at regular intervals thereafter, which included examinations at 12 and 24 months in all women. The women were asked to evaluate the changes in their symptoms—bleeding and pelvic pain—after the procedure. Answers were graded by using a five-point scale. A grade of 1 corresponded to symptoms that completely resolved. Grades of 2, 3, 4, and 5 corresponded to marked improvement of symptoms, slight improvement of symptoms, no improvement of symptoms, and worsening of symptoms, respectively. Ultrasonographic (US) follow-up consisting of transabdominal and endovaginal pelvic studies with measurements of the largest leiomyoma also was performed in all women by the same physician (M.A.) 2 and 6 months after embolization.

	RESULTS

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Arteriographic Findings and Midterm Clinical Results
Pelvic arteriography demonstrated diffuse hypervascularity without extravasation of iodinated contrast material in 68 (85%) women (Fig 1). Bilateral embolization of the uterine arteries was successful in 76 (95%) women. Unilateral embolization was performed in four (5%) women because vasospasm of the pelvic arteries in two women and anatomic variations in two other women prevented the successful superselective catheterization of the contralateral uterine artery. Injection of nitroglycerin into the uterine artery was not always effective in reducing spasm.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. Pelvic arteriography in a 42-year-old woman with a polymyomatous uterus. Superselective, left-anterior-oblique images of the right uterine artery (arrow) demonstrate (a) an enlarged uterine artery with a characteristic peripheral network (arrowheads) that surrounds the myoma and (b) hypervascularity (*) of the uterus in the late arterial phase.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. Pelvic arteriography in a 42-year-old woman with a polymyomatous uterus. Superselective, left-anterior-oblique images of the right uterine artery (arrow) demonstrate (a) an enlarged uterine artery with a characteristic peripheral network (arrowheads) that surrounds the myoma and (b) hypervascularity (*) of the uterus in the late arterial phase.

Complications
Six (8%) women complained of amenorrhea after the procedure. Of these six women, two had transient amenorrhea and four had permanent amenorrhea. Necrotic fragments of a pedunculated submucosal myoma were expelled through the cervix during the 1st month after the procedure in four women. In another woman with a large submucosal fibroid, hysterectomy had to be performed because of acute septic uterine necrosis that was revealed by pelvic pain, fever, and an increased leukocyte count 17 days after embolization.

In 68 (85%) women, the immediate postoperative course was characterized by intense pelvic pain, which was managed by using the patient-controlled analgesic pump. Pelvic pain with cramps lasted 24 hours in most women. In six (9%) additional women with large leiomyomas, delayed symptoms occurred 3–5 days after embolization and consisted of pelvic pain, nausea, and fever. This syndrome resolved with the use of nonsteroidal antiinflammatory drugs (ketoprofene [Bi-Profenid; Specia, Paris, France]) and analgesic drugs (dextropropoxiphene paracetamol [Di-Antalvic; Laboratoires Houdé, Paris, France]).

A local complication was observed in one woman and consisted of the partial dissection of the left uterine artery. This complication did not impede superselective catheterization and embolization and had no clinical consequences.

US Follow-up
Abdominal and endovaginal US was performed in all women. Before embolization, the mean diameter of the solitary or largest leiomyoma was 58 mm (range, 21–100 mm). At 2 months follow-up, the mean diameter was 48 mm (range, 19–91 mm); at 6 months, 38 mm (range, 18–68 mm), which corresponded to a mean size reduction of 20% and 52%, respectively. The number of leiomyomas was not modified except in 14 (18%) women in whom intramural leiomyomas were no longer visible because of the diffuse heterogeneity of the uterus at US.

	DISCUSSION

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Transcatheter arterial embolization of the uterine arteries has been used to control intractable bleeding associated with various obstetric and gynecologic disorders (11–13). In to our knowledge the first study in which the use of embolization in the management of uterine leiomyoma was reported (7), therapeutic embolization was performed as the last-resort treatment for symptomatic leiomyoma in patients with contraindications to surgery, which included symptomatic acquired immunodeficiency syndrome, or AIDS, and severe thromboembolic disease. In the study, most women demonstrated a dramatic improvement in their symptoms and a marked reduction in the sizes of their leiomyomas at US follow-up. In our study, the use of embolization as an alternative to surgery was investigated in 80 women with fibroid-related bleeding after the failure of medical therapy.

Our 90% success rate in treating fibroid-related symptoms is comparable to that reported in other articles (8,9). Clinical failure was observed in three of the four women who underwent unilateral embolization. Although this small number of cases precludes any statistically significant conclusion, one must notice that the failure of embolization in unilateral treatment has been reported previously in the management of postpartum bleeding (14). It has been assumed that the failure of embolization was due to the presence of numerous pelvic anastomoses (14).

The blood supply of uterine leiomyomas has been described on the basis of surgically obtained gross specimens and in vitro injections (15,16). Arteriograms confirm that there is no specific artery that supplies blood to the leiomyoma. Conversely, there is a well-developed peripheral network originating from an enlarged uterine artery and a centripetal supply originating from the peripheral network (Fig 1). The anastomotic blood supply between both uterine arteries is the cause of unsuccessful treatment in cases of unilateral embolization (7,17).

In our study, embolization was performed by using a single 5-F catheter in 75 (94%) women. In the remaining five (6%) women, a 3-F microcatheter was needed because of flow-limiting arterial spasm that was related to associated hormonal therapy at the time of embolization in four women and that was of iatrogenic origin in one woman. Therefore, it is reasonable that hormonal therapy should be stopped at least 1–2 months before the procedure. However, a failure to achieve superselective catheterization that led to unilateral embolization was noticed during our early experience.

Embolization was performed by using 150–300-µm polyvinyl alcohol particles. Polyvinyl alcohol is a semipermanent occlusive agent with a limited potential for recanalization (18). The use of larger polyvinyl alcohol particles has been reported in a previous study (8). It may be hypothesized that the durable clinical response and the high percentage of complete resolution of symptoms in our patients may have been due to the use of smaller particles, which led to better devascularization of the leiomyoma (8). Conversely, the frequency of ischemia-related complications observed in our series (ie, pelvic pain) seemed to be higher than that observed in the other study (8). Severe pelvic pain with cramps, for which neuroleptic analgesia during the postembolization period was required, was encountered in almost all of the women. Other groups (8,9) performing embolization with larger-diameter polyvinyl alcohol particles reported mild pain that was easily controlled with oral analgesic in most patients.

The delayed vaginal expulsion of necrotic fragments that corresponded to submucosal fibroid shrinkage, encountered in four women in our series, also has been reported previously (19). An evaluation of the size reduction of the fibroids was performed at US follow-up. US examination is used widely to study the uterus and fibroids, with an acceptable accuracy (20). In our study, we used the diameter of the largest leiomyoma to assess size reduction. Reduction in volume has also been evaluated in other studies (19) by using magnetic resonance imaging. The reported size reduction was 40%–50% for uterine volume at 2 months (8,9,19) follow-up and up to 66% for largest-fibroid diameter at 2 months follow-up (9,19).

Even if the complications of therapeutic embolization are minimal in skilled hands, the size of the particles may influence the safety of the procedure. High flow rate to the uterine arteries tends to protect against the unexpected reflux of embolic material into nontargeted arteries. Of interest, an ischemic complication leading to emergent hysterectomy—due to acute uterine infarction with endometritis—was encountered in a woman with a large submucosal fibroid. Such a complication has been reported before (8,9). The same predisposing factor—the large diameter of the leiomyoma—can be identified in all women.

Another group (21) reported two cases of emergent hysterectomy related to fibroid infection, with perforation of the fundic myometrium in one case and a tubo-ovarian abscess in the second case. Even if embolization already has been attempted in large fibroids, embolization should not be reasonably performed for multiple fibroids of more than 10 cm each (19). Other ischemic complications after pelvic embolization reported in the literature always were found in elderly patients (22,23).

The effects of the procedure on the ovaries should also be of priority consideration. The exposure of women to radiation during the procedure should be kept to an absolute minimum, even when women who desire future pregnancy are excluded, as they were in our series. The estimated exposure is equivalent to that of one to three barium enema examinations (19,21).

The other serious complication following uterine embolization is the development of premature amenorrhea, which is associated with ovarian failure in up to 5% of women (7,19). It may be hypothesized that ovarian vascularization has been compromised by the bilateral embolization of the uterine arteries via utero-ovarian anastomoses (Fig 2). It already has been reported that surgery may compromise the vascular supply to the ovary. Women who undergo hysterectomy with ovarian conservation have a premature loss of ovarian function; that is, in this group of women, menopause occurs at a younger age than spontaneous menopause in women who do not undergo hysterectomy (24).

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Pelvic arteriography in a 47-year-old woman with interstitial leiomyoma. Selective, left-anterior-oblique image of the right uterine artery (arrowhead) demonstrates retrograde filling of the right ovarian artery (arrow).

In conclusion, results of our preliminary study show that selective arterial embolization of the uterine arteries in the treatment of symptomatic fibroids is an effective alternative to surgery when medical therapy has failed. Women who are treated can expect excellent midterm results with regard to menorrhagia and the size reduction of leiomyomas. The ideal embolic regimen in terms of the size of the polyvinyl alcohol particles remains to be determined. To our knowledge, the effect of this procedure on fertility has not been adequately studied, despite several reported pregnancies. Further studies are needed to determine the effect of embolization of the uterine arteries on fertility.

	Footnotes

 
Author contributions: Guarantors of integrity of entire study, J.P.P., J.J.M., J.H.R., R.R.; study concepts, J.P.P., O.L.D.; study design, J.P.P., P.S.; definition of intellectual content, J.P.P., R.R.; literature research, J.P.P., M.A.; clinical studies, J.P.P., O.L.D., P.S., M.K., H.D.; data acquisition, J.P.P., O.L.D., P.S., H.D.; data analysis, J.P.P., O.L.D., P.S.; manuscript preparation, J.P.P.; manuscript editing, J.P.P., P.S.; manuscript review, J.P.P., O.L.D., P.S.

	References

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 

1. Vollenhoven BJ, Lawrence AS, Healy DL. Uterine fibroids: a clinical review. Br J Obstet Gynaecol 1990; 97:285-298.[Medline]
2. Healy DL, Vollenhoven BJ. The role of GnRH agonists in the treatment of uterine fibroids. Br J Obstet Gynaecol 1992; 99:23-26.
3. Benagiano G, Morini A, Primiero FM. Fibroids: overview of current and future treatment options. Br J Obstet Gynaecol 1992; 99:18-22.
4. Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. N Engl J Med 1993; 328:856-860.[Free Full Text]
5. Iverson RE, Chelmow D, Strohbehn K, Waldman L, Evantash EG. Relative morbidity and mortality of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol 1996; 88:415-419.[Abstract]
6. Schofield MJ, Bennet A, Redman S, Walters WA, Sanson-Fisher RW. Self-reported long-term outcomes of hysterectomy. Br J Obstet Gynaecol 1991; 98:1129-1136.[Medline]
7. Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat myomata. Lancet 1995; 346:671-672.[Medline]
8. Goodwin SC, Vedantham S, McLucas B, Forno AE, Perella R. Preliminary experience with uterine artery embolization for uterine fibroids. J Vasc Intervent Radiol 1997; 8:517-526.[Medline]
9. Worthington-Kirsch RL, Popky GL, Hutchins FL, Jr. Uterine arterial embolization for the management of leiomyomas: quality-of-life assessment and clinical response. Radiology 1998; 208:625-629.[Abstract]
10. Pelage JP, Soyer P, Le Dref O, et al. Uterine arteries: bilateral catheterization with a single femoral approach and a single 5-F catheter—technical note. Radiology 1999; 210:573-575.[Abstract/Free Full Text]
11. Mitty HA, Sterling KM, Alvarez M, Gendler R. Obstetric hemorrhage: prophylactic and emergency arterial catheterization and embolotherapy. Radiology 1993; 188:183-187.[Abstract]
12. Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997; 176:938-948.[Medline]
13. Pelage JP, Le Dref O, Mateo J, et al. Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 1998; 208:359-362.[Abstract]
14. Rosenthal DM, Colapinto R. Angiographic arterial embolization in the management of post-operative vaginal hemorrhage. Am J Obstet Gynecol 1985; 151:227-231.[Medline]
15. Holmgren B. Some observations on the blood vessels of the uterus under normal conditions and in myoma. Acta Obstet Gynecol Scand 1938; 18:192-213.
16. Farrer-Brown G, Beilby JO, Tarbit MH. The vascular pattern in myomatous uteri. J Obstet Gynaecol Br Com 1970; 77:967-975.[Medline]
17. Chait A, Moltz A, Nelson JH. The collateral arterial circulation in the pelvis: an angiographic study. AJR Am J Roentgenol 1968; 102:392-400.[Abstract/Free Full Text]
18. Lang EK. Transcatheter embolization of pelvic vessels for control of intractable hemorrhage. Radiology 1981; 140:331-339.[Abstract]
19. Bradley EA, Reidy JF, Forman RG, Jarosz J, Braude PR. Transcatheter uterine embolisation to treat large uterine fibroids. Br J Obstet Gynaecol 1998; 105:235-240.[Medline]
20. Tsuda H, Kawabata M, Nakamoto O, Yamamoto K. Clinical predictors in the natural history of uterine leiomyoma: preliminary study. J Ultrasound Med 1998; 17:17-20.[Abstract]
21. Walker WJ, Dover R, Sutton C. Bilateral uterine artery embolisation for fibroids (abstr). Min Invas Ther Allied Technol 1998; 7(suppl):26.
22. Hare WS, Lond FR, Holland CJ. Paresis following internal iliac artery embolization. Radiology 1983; 146:47-51.[Abstract]
23. Sieber PR. Bladder necrosis secondary to pelvic artery embolization: case report and literature review. J Urol 1994; 151:422.[Medline]
24. Siddle N, Sarrel P, Whitehead M. The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review. Fertil Steril 1987; 47:94-100.[Medline]
25. Chow TWP, Nwosu EC, Gould DA, Richmond DH. Pregnancy following successful embolization of a uterine vascular malformation. Br J Obstet Gynaecol 1995; 102:166-168.[Medline]
26. Stancato-Pasik A, Mitty HA, Richard HM, Eshkar N. Obstetric embolotherapy: effects on menses and pregnancy. Radiology 1997; 204:791-793.[Abstract]

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				J L Hughes and J F Reidy Imaging and treatment of uterine fibroids including the role of uterine artery embolisation Imaging, June 1, 2003; 15(2): 79 - 88. [Abstract] [Full Text] [PDF]

				T. J. Kroencke, A. Gauruder-Burmester, C. N.H. Enzweiler, M. Taupitz, and B. Hamm Disintegration and stepwise expulsion of a large uterine leiomyoma with restoration of the uterine architecture after successful uterine fibroid embolization: Case report Hum. Reprod., April 1, 2003; 18(4): 863 - 865. [Abstract] [Full Text] [PDF]

				I. Pinto, P. Chimeno, A. Romo, L. Paul, J. Haya, M. A. de la Cal, and J. Bajo Uterine Fibroids: Uterine Artery Embolization versus Abdominal Hysterectomy for Treatment--A Prospective, Randomized, and Controlled Clinical Trial Radiology, February 1, 2003; 226(2): 425 - 431. [Abstract] [Full Text] [PDF]

				L.-Y. Huang, Y.-F. Cheng, C.-C. Huang, S.-Y. Chang, and F.-T. Kung Incomplete vaginal expulsion of pyoadenomyoma with sepsis and focal bladder necrosis after uterine artery embolization for symptomatic adenomyosis: Case report Hum. Reprod., January 1, 2003; 18(1): 167 - 171. [Abstract] [Full Text] [PDF]

				M. S. Broder, S. Goodwin, G. Chen, L. J. Tang, M. M. Costantino, M. H. Nguyen, T. N. Yegul, and H. Erberich Comparison of Long-Term Outcomes of Myomectomy and Uterine Artery Embolization Obstet. Gynecol., November 1, 2002; 100(5): 864 - 868. [Abstract] [Full Text] [PDF]

				J. B. Spies, A. Spector, A. R. Roth, C. M. Baker, L. Mauro, and K. Murphy-Skrynarz Complications After Uterine Artery Embolization for Leiomyomas Obstet. Gynecol., November 1, 2002; 100(5): 873 - 880. [Abstract] [Full Text] [PDF]

				J. F. Payne, S. J. Robboy, and A. F. Haney Embolic Microspheres Within Ovarian Arterial Vasculature After Uterine Artery Embolization Obstet. Gynecol., November 1, 2002; 100(5): 883 - 886. [Abstract] [Full Text] [PDF]

				J. P. Cottier, A. Fignon, F. Tranquart, and D. Herbreteau Uterine Necrosis After Arterial Embolization for Postpartum Hemorrhage Obstet. Gynecol., November 1, 2002; 100(5): 1074 - 1077. [Abstract] [Full Text] [PDF]

				M. K. Razavi, K. A. Wolanske, G. L. Hwang, D. Y. Sze, S. T. Kee, and M. D. Dake Angiographic Classification of Ovarian Artery-to-Uterine Artery Anastomoses: Initial Observations in Uterine Fibroid Embolization Radiology, September 1, 2002; 224(3): 707 - 712. [Abstract] [Full Text] [PDF]

				J.-P. Pelage, A. Laurent, M. Wassef, M. Bonneau, D. Germain, R. Rymer, P. Flaud, J. Martal, and J.-J. Merland Uterine Artery Embolization in Sheep: Comparison of Acute Effects with Polyvinyl Alcohol Particles and Calibrated Microspheres Radiology, August 1, 2002; 224(2): 436 - 445. [Abstract] [Full Text] [PDF]