Uterine Artery Embolization (UAE) in India and UAE | Complete Patient Guide

• IDEAL CANDIDATES:

• Women with symptomatic uterine fibroids causing heavy menstrual bleeding (HMB), pelvic pain, or bulk symptoms who desire uterine preservation

• Patients who wish to avoid general anaesthesia or major open/laparoscopic surgery

• Women with prior abdominal surgeries who are at elevated risk for adhesions with myomectomy

• Patients with anaemia secondary to chronic menorrhagia who have optimised haemoglobin (ideally ≥8 g/dL) pre-procedure with iron supplementation or GnRH agonist therapy (e.g., Leuprolide, Ulipristal acetate)

• Women with multiple fibroids (where myomectomy would carry high recurrence or technical complexity)

• Patients with large fibroid uteri (up to 20–24 weeks size) who are not candidates for hysteroscopic resection

• REQUIRED PRE-PROCEDURE DIAGNOSTICS:

• Pelvic MRI with contrast (gold standard): defines fibroid FIGO classification, location, dimensions, enhancement pattern, and rules out adenomyosis or leiomyosarcoma

• Transvaginal/transabdominal ultrasound (TVUS): initial fibroid mapping and endometrial assessment

• Complete Blood Count (CBC): quantifies anaemia severity; Serum Ferritin and Iron Studies

• Coagulation profile: PT/INR, aPTT, platelet count

• Renal function panel (eGFR/creatinine): essential prior to iodinated contrast administration

• Endometrial biopsy / Pipelle sampling: mandatory if irregular bleeding pattern raises concern for endometrial pathology

• Cervical smear (Pap test): must be current and normal

• FSH, LH, AMH levels: to assess ovarian reserve, particularly relevant in women considering future fertility

• Pelvic MR Angiography (optional, high-volume centres): pre-procedural vascular mapping

• COVID-19 / pre-anaesthesia fitness assessment per institutional protocol

• RELATIVE CONTRAINDICATIONS:

• Active pelvic infection or endometritis (must be treated and resolved before UAE)

• Desire for future pregnancy (UAE is not absolutely contraindicated but is not the preferred first-line option; myomectomy is generally preferred for women actively planning conception — patients must be extensively counselled)

• Submucosal fibroids Type 0–1 amenable to hysteroscopic myomectomy (a less invasive alternative should be considered first)

• Pedunculated subserosal fibroids with a stalk diameter <2 cm (risk of stalk infarction and peritoneal complications)

• Suspected or confirmed uterine malignancy or leiomyosarcoma

• Severe contrast allergy not manageable with pre-medication

• Significant coagulopathy uncorrectable pre-procedure

• Compromised renal function (eGFR <30 mL/min/1.73m²) requiring nephroprotective protocol or alternative planning

• Prior pelvic radiation significantly altering vasculature

• Anatomic vascular variants precluding safe catheter access (relative; experienced operators may navigate variant anatomy)

UAE IS THE CORE PROCEDURE — TECHNICAL METHODS:

1. STANDARD BILATERAL UAE WITH TRIS-ACRYL GELATIN MICROSPHERES (TAGM) The procedure is performed in a dedicated biplane or single-plane digital subtraction angiography (DSA) suite under fluoroscopic guidance. Access is most commonly gained via the right common femoral artery (Seldinger technique) using a 4–5 Fr sheath. A selective catheter (e.g., Roberts Uterine Catheter, Waltman loop, or Cobra catheter) is advanced into the anterior division of the internal iliac artery, and superselective catheterisation of each uterine artery is achieved — often with a coaxial microcatheter (2.7–2.8 Fr) system for precision. Arteriography confirms the classic 'corkscrewing' hypertrophied uterine artery feeding the fibroid blush. Embolic agent injection proceeds until near-stasis is achieved ('pruned-tree' appearance on fluoroscopy). The procedure is then repeated on the contralateral uterine artery, typically through the same femoral access using catheter repositioning or a Waltman loop technique. Tris-acryl gelatin microspheres (Embosphere®, Merit Medical) sized 500–900 µm are the most extensively studied embolic agent, offering predictable, non-resorbable occlusion at the arteriolar level with favourable safety and efficacy data.

2. POLYVINYL ALCOHOL (PVA) PARTICLES An older but still utilised embolic agent (150–500 µm range). PVA particles tend to aggregate more than calibrated microspheres, potentially leading to more proximal occlusion. Most high-volume centres have transitioned to calibrated microspheres for more consistent endpoints.

3. RADIAL ARTERY ACCESS (TRANS-RADIAL UAE) An advanced, increasingly adopted approach using the radial artery at the wrist as vascular access point rather than the femoral artery. Advantages include same-day ambulation, elimination of bed rest post-procedure, reduced access-site haematoma risk, and improved patient comfort. Requires specialised long-shaft catheters and an operator experienced in trans-radial interventional techniques. High-volume centres in India (e.g., those with robust cardiac cath lab infrastructure) have extended trans-radial expertise to UAE procedures.

4. CONE-BEAM CT (CBCT) GUIDED UAE Integration of intraoperative cone-beam CT (available on modern Siemens Artis Zee or Philips Azurion flat-panel angiography systems) with 3D rotational angiography allows real-time volumetric confirmation of fibroid vascularity, embolic distribution, and non-target embolisation risk assessment. This technology is available in premium interventional suites across leading Indian and UAE hospitals and represents the current state-of-the-art in procedural safety.

5. MR-GUIDED FOCUSED ULTRASOUND (MRgFUS / HIFU) — COMPARISON ALTERNATIVE While not strictly UAE, MR-guided High-Intensity Focused Ultrasound (Exablate 2100®, InSightec) is a non-invasive, no-incision alternative that uses focused ultrasound energy to thermally ablate fibroid tissue under MRI guidance. It requires no vascular access, carries a lower post-procedural pain burden, and permits same-day discharge. However, it is suitable only for a subset of patients (accessible anterior fundal fibroids, specific fibroid characteristics on MRI T2 signal), has lower fibroid volume reduction rates (~20–30% at 6 months vs. 40–70% with UAE), and is available at select premium centres in India and the UAE. It is not a direct UAE substitute but should be discussed during patient counselling as part of a comprehensive, shared decision-making framework.

6. PAIN MANAGEMENT PROTOCOL — CRITICAL TO UAE SUCCESS Post-embolisation syndrome (PES) — characterised by pelvic cramping, low-grade fever, nausea, and malaise — is an expected sequel of UAE lasting 48–72 hours. Modern centres employ multimodal analgesia protocols including: pre-procedural non-steroidal anti-inflammatory drugs (NSAIDs, e.g., IV Ketorolac), intraoperative intra-arterial lidocaine infusion via the uterine catheter, patient-controlled analgesia (PCA) with IV Morphine or Oxycodone during the first 12–24 hours, scheduled oral NSAIDs (Ibuprofen 800 mg TID), and anti-emetics (Ondansetron, Metoclopramide). Adequate pain protocol planning distinguishes high-quality UAE programmes from basic providers.

PRE-ARRIVAL (4–8 WEEKS BEFORE PROCEDURE):

• GAF Healthcare coordinates remote tele-consultation with the interventional radiologist: review of all imaging (MRI preferred; TVUS acceptable as baseline), blood reports, and clinical history

• Gynaecology co-consultation may be arranged to exclude endometrial pathology and confirm UAE candidacy

• If haemoglobin is <8 g/dL, a 6–8 week course of GnRH agonist (e.g., Lupron Depot / Leuprolide 3.75 mg monthly) or high-dose progestin (Norethisterone) combined with IV iron infusion (Ferric carboxymaltose) is initiated to optimise pre-procedure haematological status

• Medical visa application initiated by GAF Healthcare for Indian destination (e-Medical visa for eligible countries); UAE entry visa/medical tourism facilitation arranged as applicable

• Travel, accommodation, and hospital appointment scheduling confirmed

DAY OF ARRIVAL & PRE-PROCEDURE (DAY –1 TO DAY 0):

• Airport pickup by GAF Healthcare ground team; transfer to accredited hospital or nearby partner accommodation

• Hospital admission and pre-procedural assessment: anaesthesia/sedation fitness, contrast allergy screening, renal function confirmation, NPO (nil by mouth) from midnight

• Pre-procedure MRI reviewed by interventional radiologist for final vascular road-mapping

• Informed consent process: detailed discussion of UAE risks, alternatives (myomectomy, hysterectomy, MRgFUS), fertility implications, and expected recovery timeline

• Pre-medication administered: antibiotics (IV Cefazolin or Cefoxitin), IV NSAID (Ketorolac), anti-emetic, anxiolytic if required

PROCEDURE DAY (DAY 0 — DURATION: 45–90 MINUTES):

• Patient transferred to interventional radiology suite; moderate conscious sedation administered (IV Midazolam + Fentanyl) — general anaesthesia is rarely required

• Femoral (or radial) artery access obtained under sterile technique

• Diagnostic pelvic arteriogram performed to map uterine artery anatomy and fibroid blush

• Superselective bilateral uterine artery embolisation performed using calibrated microspheres (500–900 µm TAGM)

• Final check arteriogram confirms stasis; catheter and sheath removed; haemostasis achieved (manual compression or vascular closure device for femoral access)

• Patient returned to recovery room; vital signs monitored; PCA analgesia initiated

POST-PROCEDURE — HOSPITAL STAY (DAY 0–2):

• Night 1 (Day 0–1): IV analgesia, hydration, anti-emetics; monitoring for post-embolisation syndrome (expected: cramping, low-grade fever ≤38.5°C, nausea)

• Morning of Day 1: Oral diet resumed; transition to oral analgesia (NSAID + weak opioid if needed); ambulation encouraged (especially with trans-radial access)

• Day 2: Clinical assessment by interventional radiologist; haemoglobin check; discharge criteria confirmed

• Discharge with: oral NSAID (7–10 days), proton pump inhibitor (gastroprotection), anti-emetic PRN, written post-procedure instructions

WEEK 1 (DAYS 2–7) — EARLY RECOVERY:

• Rest at GAF Healthcare partner accommodation (recommended to remain in-country)

• Expected: vaginal discharge/spotting (normal fibroid expulsion process), fatigue, mild pelvic discomfort

• Avoid: strenuous activity, sexual intercourse, submerging in baths/pools

• Teleconsultation check-in with treating team on Day 5–7

• Haematological re-check if pre-procedure anaemia was significant

WEEK 2 (DAYS 7–14) — FIT-TO-FLY ASSESSMENT:

• Clinical review: absence of fever, resolving pain, stable vital signs, no signs of infection or non-target embolisation

• Most patients are cleared for international air travel at Day 10–14 post-procedure

• Deep Vein Thrombosis (DVT) prophylaxis for the flight: compression stockings, adequate hydration, mobility during flight; LMWH (Low Molecular Weight Heparin, e.g., Enoxaparin) may be prescribed for long-haul flights based on individual risk assessment

WEEKS 3–6 — RETURN TO NORMAL ACTIVITY:

• Return to desk work: typically 1–2 weeks post-procedure

• Return to physical exercise: 4–6 weeks

• First menstrual period post-UAE: expected at 4–6 weeks; may be heavier initially then progressively lighter over 3 cycles

• HMB resolution: clinically measurable improvement by 3 months in 85–90% of patients

3–6 MONTH FOLLOW-UP:

• Repeat pelvic MRI with contrast: quantifies fibroid volume reduction (expected 40–70%), confirms uterine perfusion, and evaluates treatment response

• Symptom assessment using validated tools: Uterine Fibroid Symptom and Quality of Life Questionnaire (UFS-QOL), Pictorial Blood Loss Assessment Chart (PBAC)

• Gynaecology review: haemoglobin, menstrual pattern, symptom scores; further management planned if inadequate response