Helen Unruh (Host): Welcome back to the Well Within Reach podcast. I'm your host, Liz Unruh. And today, I'm going to be joined today by Dr. Amblee, who works in our Interventional Radiology Department at Riverside, to talk about the use of interventional radiology to treat uterine fibroids.

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Host: And we're back with Dr. Amblee. Thanks for joining me today.

Dr. Vaishak Amblee: Awesome. Thank you for having me.

Host: So, can we start with telling people a little bit about yourself?

Dr. Vaishak Amblee: Sure. So, my name is Dr. Vaishak Amblee. I'm originally from Chicago. I still live there actually with my wife and one daughter. I did my training in Diagnostic Radiology and Interventional Radiology at Rush University in the city. And I started at Riverside a little under a year ago in the Interventional Radiology Department. So, I am a diagnostic radiologist and I interpret images of all varieties, x-rays, ultrasounds, MRIs, CTs. And we also do a variety of minimally invasive procedures, which is what Interventional Radiology is all about.

Host: That's great. So, you know, you brought it up. What exactly is Interventional Radiology? I know some people are like, "Interventional, it must mean minimally invasive," kind of like what you said. But can you talk to us about how that would differ from like a traditional surgery approach?

Dr. Vaishak Amblee: Definitely. So, exactly like you mentioned, pretty much everything that we do is minimally invasive, which means that things are done without open incisions. And if there are incisions, they are, you know, tiny skin nicks, a few millimeters, sometimes just needle punctures. So, patients generally leave for most of our procedures the same day. They're generally outpatient procedures, and they all are performed using image guidance of some sort, which is the radiology part of it. So, if it's ultrasound or x-ray or live video x-ray, which is called fluoroscopy or even CAT scan imaging for three-dimensional imaging, we use imaging to guide our procedures, which can range anywhere from biopsies, aspirating fluid from different parts of the body where fluids has built up, venous access. But there are a lot of high-level interventional radiology procedures that are relatively new in the scope of medicine overall, but have been practiced a few decades already. And a lot of them are vascular procedures. So, they have to do with the blood vessels, arteries, or veins. And even procedures that have to deal with multiple different organ systems, including liver, kidney, and the GU system as well, we use image guidance to access those different parts of the body. And if they're vascular or non-vascular procedures, we can offer a non-surgical alternative, essentially, for some of these more complex pathologies. So, a lot of different things that would have previously required an open surgery, which can be pretty morbid, can now be taken care of in a relatively minimally invasive setting by us in IR.

Host: Yeah. That sounds really cool. It's amazing how far pictures have come and our ability to scan and use imaging to pinpoint where the issue is. I think that's really an impressive advancement in the medical field for sure. So today, we're talking specifically about uterine fibroid embolization. Can you tell us what that is and how does it work to treat the fibroids?

Dr. Vaishak Amblee: Sure. So yeah, it's one of the many procedures that we do, uterine fibroid embolization, some people call it uterine artery embolization. And basically, embolization means blocking off that blood vessel. So, exactly what the name kind of implies, fibroids, which many women experience unfortunately throughout the country, are overgrowths of muscle tissue in the uterus. And depending on where they are and what size they are, they can cause significant symptoms. And many women experience bulk symptoms, which means there's heaviness, pain, cramping, and difficulty with urination or going to the bathroom. Many women also experience abnormal or heavy bleeding with menstruation. So, depending on the location of the fibroids, they can range to asymptomatic if they're pretty small, but some of them can reach pretty large sizes and can be severely symptomatic.

So, traditionally, the approach to uterine fibroid treatment has been surgical, either with a complete hysterectomy, which is complete removal of the uterus or a myomectomy, which is still an open surgery where they try to morsel out the fibroids themselves. But they're both open surgeries and they do have their own associated morbidity and longer recovery times with them.

So, embolization has come about as a kind of a newer strategy to deal with fibroids where we basically, through small catheters, are able to navigate the arterial system that leads to the uterus and can block off blood supply to the fibroids. Without blood supply, the fibroids eventually shrink and reduce in size and thereby reducing symptoms also. So, most of the time, we've seen reduction of the fibroids by about 50%. So, the fibroids are still there. But essentially, they've involuted or shrunk down and there's no more future growth, which reduces symptoms by up to 85-90% in most patients, whether it be bleeding symptoms or the bulk symptoms.

Host: Yeah, for sure. I mean, you've mentioned a lot of key benefits here already, but is there anything else that comes to mind by using this type of procedure compared to one of those more traditional or previously used approaches like the total hysterectomy?

Dr. Vaishak Amblee: Yeah. Well, one of the things, just logistically speaking, is that since this is a minimally invasive procedure and it's not an open surgery, it's an outpatient same-day procedure. Generally, people leave the same day or have a single overnight stay in the hospital for pain control and can leave the very next day. Like I said, there's no open incision, there's just a small skin nick in the area of the groin where we access the femoral artery for our initial access. And the recovery time is significantly better improved, compared to surgical options. Within a few days, really a lot of the symptoms do resolve of the initial procedure. Within a week, generally patients are back to normal. They don't have any heavy lifting restrictions or weight restrictions like they would with the open surgery.

Another key benefit is actually related to fertility. So, with this hysterectomy, you're clearly removing the uterus and you're essentially infertile at that point. For women who are suffering from fibroids who may be younger and still wanting to preserve fertility, uterine fibroid embolization is a pretty good option since the uterus remains intact. And, actually, a lot of women have trouble with fertility and conception and pregnancy because of fibroids, depending on once again the size and location of the fibroid. So, by treating these fibroids and reducing their size, sometimes it actually aids women in getting pregnant. But obviously, the fact that the uterus remains intact preserves fertility, which is a huge benefIt..

Host: Oh, yeah. So, we've talked about a lot of the great benefits that the uterine fibroid embolization has for patients, but can you talk us through what the typical procedure would look like, what a patient can expect before, during, and after the treatment?

Dr. Vaishak Amblee: Sure. So, first off, we see every patient in our clinic in Interventional Radiology, and we counsel them on the procedure, what they can expect, and the risks and benefits of the procedure. Like I mentioned, since this is not an open surgery, patients don't have to undergo general anesthesia, just a minimal sedation or twilight sedation as they call it, like with other minor surgeries like colonoscopies or other things.

So, the procedure itself is generally outpatient, so they can often leave the same day, if not the next day after one day of pain control, or overnight stay for pain control. So, patients are generally instructed to not eat or drink anything after midnight the night before. They arrive that morning in a radiology suite, an IV is started, through which we give them IV meds to get them sedated. But there's no intubation, there's no breathing tube in their throat. The procedure itself is relatively quick, often under 90 minutes, under 60 minutes sometimes, depending on how easy the anatomy is to navigate. But there's, like I said, a small skin nick made in the region of the groin through which we access the femoral artery in the groin with the small needle puncture. The patient is sedated by this time, and a numbing medicine is used in the area to prevent any pain. And so, after that initial access into the artery, which the patient might feel a little bit of pressure, there's really no significant pain during the actual procedure.

So, through small catheters and wires, we navigate the arteries of the pelvis. And we use contrast injections to kind of give us a road map of the entire arterial system. Our microcatheters are navigated inside the uterine artery on both sides, between both uterine arteries, on the right and the left. And, once we're in an appropriate position, we inject microparticles, which are extremely tiny particles that kind of lodge themselves inside the blood vessel to block off flow to the uterine fibroids. We know exactly where we are. We're doing intermittent contrast injections to preserve flow to the remainder of the structures in the pelvis so that we're not damaging any of the other vessels or other structures. And once we're done, we remove all our catheters and wires and we close up the little hole we've made in the artery with a dissolvable plug. So, patients generally wait anywhere from three to four hours before we can walk them with assistance and then they can go home the same day if their pain is well controlled. Some patients, depending on the size of the fibroids and how much tissue we've had to embolize, do have significant pain. So, we can keep them overnight for IV pain control. We give them steroids for anti-inflammatory effect and, like I said, IV pain medication, and they generally go home the next day. Usually, symptoms subside after a few days, definitely within a week. And patients can expect, you know, hopefully, less bulk symptoms, less bleeding symptoms, during their next cycle.

Now, blood supply to the fibroids are cut off immediately, but they do take time to shrink down. And so, we do tell them it'll be a slower process and it could take multiple weeks, a couple months for the fibroids to get back to their new normal size, which is hopefully smaller than before. We do a followup imaging, MRI pelvis study six months down the line after the procedure, and that kind of gives us a complete view of how much the fibers have shrunk and whether or not there are any residual fibroids that are remaining. If some of these fibroids were not completely treated and are still enhancing, which means they still have blood flow, we can possibly retreat again and for a more complete effect.

Host: Yeah. That was going to be my next question. If there's an opportunity where like maybe one didn't get treated all the way, do you just go back in and, for lack of a better way to say it, try again?

Dr. Vaishak Amblee: Yeah. And it 100% depends on the patient's symptoms, right? So, if the patient feels significantly better, that one fibroid that for whatever reason did not get treated isn't causing a lot of issues, it doesn't have to be re-treated. But if it is still causing issues or if it's still causing bleeding because of its location, we can definitely go back and re-treat.

Speaking about location, I just wanted to say fibroids in the uterus can be in multiple different areas. So, we say submucosal, which means it's in the very center of the fibroids under the endometrial lining. And those are the fibroids that cause more of the bleeding issues and also can cause issues with conception and fertility. Most of the fibroids are within the muscle of the uterus, which are called intramural fibroids, and those cause more of the bulk symptoms and the cramping and heaviness. So, depending on where the fibroids are, when they're treated and when they start to shrink and die off, patients might have different experiences also.

Sometimes, rarely, patients do pass pieces of the fibroid, and that's completely normal. We do ask patients in over the next few weeks after the procedure to kind of keep an eye out for infectious symptoms, because very rarely, less than 1% of the time, some of the fibroids if they're large enough, the center can get necrotic or die off. And if fluid builds up there, an infection could form. That's one of the rare, rare complications we counsel patients on. But generally, they uniformly shrink without any of these things happening.

Host: Yeah. That sounds great. I'm sure that's part of the minimally invasive part, is that you are decreasing that infection risk for sure. So, how do you determine if a patient is a good candidate for the uterine fibroid embolization? Are there specific criteria or evaluations you use?

Dr. Vaishak Amblee: Yeah. So, it's a combination of a clinical evaluation and imaging evaluation. So, we definitely want an MRI of the pelvis with contrast. This gives us an idea of where the fibroids are, how big they are; how well they enhance, which means how good the blood supply is to the fibroids. And the more enhancing fibroids and the larger fibroids are the ones that are probably causing most of the symptoms. And they'll allow us to basically evaluate whether or not this will be a successful procedure.

In addition, you know, during our initial clinic evaluation, we talk to the patient, and depending on how significant their symptoms are, it kind of illustrates how well they'll respond to the fibroids to the treatment. So, a combination of imaging and clinical evaluation is used. And like I said, we have close followup afterwards and imaging followup as well to see how well they've been treated.

Host: Yeah. So, you've kind of touched on like some of the recovery process from the procedure. After that six-month mark where you do the scans to check the sizes and everything, is there additional followup that happens after that?

Dr. Vaishak Amblee: So, after that, it's basically what we could say PRN followup or followup as needed. In the future, just because we've treated these existing fibroids doesn't mean that new ones can't pop up. They often do. And so, in the future if the patient has recurrent symptoms, we can always re-evaluate, re-image, and re-treat.

Host: Great to know that after that six-month mark, it could just be as needed if symptoms reoccur. Are there any type of long-term effects or considerations for women who undergo this procedure? I know we talked about fertility earlier. Does it change like a menstrual cycle at all?

Dr. Vaishak Amblee: So, good question. There aren't any really well-performed studies to kind of delineate the relationship between uterine fibroid embolization and pregnancy. Like we mentioned, ironically, because we're treating fibroids and shrinking them, it could help some women even become pregnant and reduce their risk of childbirth complications. But some studies have implied maybe that in women over the age of 45, there is a slightly reduced rate of conception. So, generally, there hasn't been a great correlation between the two. But women over the age of 45, there may be a reduced risk of conception. That's one of the few things. But in the long-term, there really isn't any significant detriments to the procedure.

Host: Okay. So, if someone listened today and is saying, "Huh, this might be something that I have," how would someone go about being referred to the Interventional Radiology Clinic at Riverside?

Dr. Vaishak Amblee: So, you can get a referral through your primary care physician, your OB-GYN as well. You can also self-refer, so you can call our Interventional Radiology Clinic at Riverside and make an appointment with our staff. And we have clinics twice a week on Tuesdays and Thursdays and we can see you at the earliest convenience.

Host: Yeah. Sounds great. Thank you for sharing all this information and thank you for joining us today, Dr. Amblee. And thank you, listeners, for tuning in to the Well Within Reach podcast brought to you by Riverside Healthcare. For more information, visit riversidehealthcare.org.

Dr. Vaishak Amblee: Thank you.