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'''Uterine artery embolization''' is a procedure in which an [[interventional radiologist]] uses a [[catheter]] to deliver small particles that block the [[blood]] supply to the uterine body. The procedure is done for the treatment of [[uterine fibroid]]s and [[adenomyosis]].<ref>{{cite journal |vauthors=Siskin GP, Tublin ME, Stainken BF | year = 2001 | title = Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging | journal = American Journal of Roentgenology | volume = 177 | issue = 2| pages = 297–302 | doi=10.2214/ajr.177.2.1770297| pmid = 11461849 |display-authors=etal}}</ref><ref>Chen C, Liu P, Lu J, et al. [Uterine arterial embolization in the treatment of adenomyosis]. Zhonghua Fu Chan Ke Za Zhi 2002; 37:77.</ref> This minimally invasive procedure is commonly used in the treatment of uterine fibroids and is also called '''uterine fibroid embolization'''.
'''Uterine artery embolization''' (UAE) is a procedure in which an [[interventional radiologist]] uses a [[catheter]] to deliver small particles that block the [[blood]] supply to the uterine body. The procedure is primarily done for the treatment of [[uterine fibroid]]s and [[adenomyosis]].<ref>{{cite journal |vauthors=Siskin GP, Tublin ME, Stainken BF | year = 2001 | title = Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging | journal = American Journal of Roentgenology | volume = 177 | issue = 2| pages = 297–302 | doi=10.2214/ajr.177.2.1770297| pmid = 11461849 |display-authors=etal}}</ref><ref>Chen C, Liu P, Lu J, et al. [Uterine arterial embolization in the treatment of adenomyosis]. Zhonghua Fu Chan Ke Za Zhi 2002; 37:77.</ref> However, it may also be used to treat postpartum hemorrhage and uterine arteriovenous fistulas.<ref>{{Cite journal |date=2018 |editor-last=Keefe |editor-first=Nicole A. |editor2-last=Haskal |editor2-first=Ziv J |editor3-last=Park |editor3-first=Auh Whan |editor4-last=Angle |editor4-first=John F. |title=IR Playbook |url=http://dx.doi.org/10.1007/978-3-319-71300-7 |doi=10.1007/978-3-319-71300-7}}</ref> Since this minimally invasive procedure is commonly used in the treatment of uterine fibroids and is also called '''uterine fibroid embolization'''.


==Medical uses==
==Medical uses==
Uterine artery [[embolization]] is used to treat bothersome bulk-related symptoms or abnormal or [[Menorrhagia|heavy uterine bleeding]] due to [[uterine fibroids]] or for the treatment of [[adenomyosis]]. Fibroid size, number, and location are three potential predictors of a successful outcome.<ref>{{cite journal |vauthors=Spies JB, Roth AR, Jha RC | year = 2002 | title = Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome | journal = Radiology | volume = 222 | issue = 1| pages = 45–52 | doi=10.1148/radiol.2221010661|display-authors=etal | pmid=11756703}}</ref><ref>{{cite journal |vauthors=Pelage JP, Walker WJ, Le Dref O | year = 2001 | title = Treatment of uterine fibroids | journal = Lancet | volume = 357 | issue = 9267| page = 1530 | doi=10.1016/s0140-6736(00)04683-3| pmid = 11383541 | pmc = 5267678 |display-authors=etal}}</ref><ref>{{cite journal |vauthors=Katsumori T, Nakajima K, Mihara T | year = 2003 | title = Is a large fibroid a high-risk factor for uterine artery embolization? | journal = American Journal of Roentgenology | volume = 181 | issue = 5| pages = 1309–1314 | doi=10.2214/ajr.181.5.1811309| pmid = 14573425 }}</ref>
Uterine fibroids are the most common type of benign uterine tumor and are composed of smooth muscle.<ref>{{Cite journal |last=Donnez |first=Jacques |last2=Dolmans |first2=Marie-Madeleine |date=2016-07-27 |title=Uterine fibroid management: from the present to the future |url=https://doi.org/10.1093/humupd/dmw023 |journal=Human Reproduction Update |volume=22 |issue=6 |pages=665–686 |doi=10.1093/humupd/dmw023 |issn=1355-4786 |pmc=PMC5853598 |pmid=27466209}}</ref> They often cause bulk-related symptoms, which can be characterized by back pain, heaviness in the pelvic area, abdominal bloating.<ref>{{Cite journal |last=Gonsalves |first=Carin |date=2008-12 |title=Uterine Artery Embolization for Treatment of Symptomatic Fibroids |url=http://www.thieme-connect.de/DOI/DOI?10.1055/s-0028-1103001 |journal=Seminars in Interventional Radiology |language=en |volume=25 |issue=04 |pages=369–377 |doi=10.1055/s-0028-1103001 |issn=0739-9529}}</ref> UAE may be used to treat these bothersome bulk-related symptoms as well as abnormal or [[Menorrhagia|heavy uterine bleeding]] due to [[uterine fibroids]]. Fibroid size, number, and location are three potential predictors of a successful outcome.<ref>{{cite journal |vauthors=Spies JB, Roth AR, Jha RC | year = 2002 | title = Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome | journal = Radiology | volume = 222 | issue = 1| pages = 45–52 | doi=10.1148/radiol.2221010661|display-authors=etal | pmid=11756703}}</ref><ref>{{cite journal |vauthors=Pelage JP, Walker WJ, Le Dref O | year = 2001 | title = Treatment of uterine fibroids | journal = Lancet | volume = 357 | issue = 9267| page = 1530 | doi=10.1016/s0140-6736(00)04683-3| pmid = 11383541 | pmc = 5267678 |display-authors=etal}}</ref><ref>{{cite journal |vauthors=Katsumori T, Nakajima K, Mihara T | year = 2003 | title = Is a large fibroid a high-risk factor for uterine artery embolization? | journal = American Journal of Roentgenology | volume = 181 | issue = 5| pages = 1309–1314 | doi=10.2214/ajr.181.5.1811309| pmid = 14573425 }}</ref> UAE may also be appropriate for the treatment of adenomyosis, which is when the lining of the uterus aberrantly grows into the muscle of the uterus.<ref>{{Cite journal |last=Garcia |first=Lydia |last2=Isaacson |first2=Keith |date=2011-07 |title=Adenomyosis: Review of the Literature |url=https://doi.org/10.1016/j.jmig.2011.04.004 |journal=Journal of Minimally Invasive Gynecology |volume=18 |issue=4 |pages=428–437 |doi=10.1016/j.jmig.2011.04.004 |issn=1553-4650}}</ref> Symptoms of adenomyosis include heavy or prolonged menstrual bleeding and painful menstrual periods.<ref>{{Citation |last=Gunther |first=Rutger |title=Adenomyosis |date=2023 |url=http://www.ncbi.nlm.nih.gov/books/NBK539868/ |work=StatPearls |access-date=2023-10-29 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30969690 |last2=Walker |first2=Christopher}}</ref>


Long-term patient satisfaction outcomes are similar to that of surgery.<ref name=Gupta2014/> There is tentative evidence that traditional surgery may result in better fertility.<ref name=Gupta2014/> Uterine artery embolization also appears to require more repeat procedures than if surgery was done initially.<ref name=Gupta2014>{{cite journal|last1=Gupta|first1=JK|last2=Sinha|first2=A|last3=Lumsden|first3=MA|last4=Hickey|first4=M|title=Uterine artery embolization for symptomatic uterine fibroids|journal=The Cochrane Database of Systematic Reviews|date=26 December 2014|volume=12|issue=12|pages=CD005073|pmid=25541260|doi=10.1002/14651858.CD005073.pub4}}</ref>
Long-term patient satisfaction outcomes are similar to that of surgery.<ref name=Gupta2014/> There is tentative evidence that traditional surgery may result in better fertility.<ref name=Gupta2014/> UAE also appears to require more repeat procedures than if surgery was done initially.<ref name=Gupta2014>{{cite journal|last1=Gupta|first1=JK|last2=Sinha|first2=A|last3=Lumsden|first3=MA|last4=Hickey|first4=M|title=Uterine artery embolization for symptomatic uterine fibroids|journal=The Cochrane Database of Systematic Reviews|date=26 December 2014|volume=12|issue=12|pages=CD005073|pmid=25541260|doi=10.1002/14651858.CD005073.pub4}}</ref>


It has shorter recovery times.<ref name=":0">{{Cite journal|last1=Gupta|first1=Janesh K.|last2=Sinha|first2=Anju|last3=Lumsden|first3=M. A.|last4=Hickey|first4=Martha|date=2014-12-26|title=Uterine artery embolization for symptomatic uterine fibroids|journal=The Cochrane Database of Systematic Reviews|issue=12|pages=CD005073|doi=10.1002/14651858.CD005073.pub4|issn=1469-493X|pmid=25541260}}</ref> Uterine artery embolization is thought to work because uterine fibroids have abnormal vasculature together with aberrant responses to hypoxia (inadequate oxygenation to tissues).<ref name="TalSegars2013">{{cite journal|last1=Tal|first1=R.|last2=Segars|first2=J. H.|title=The role of angiogenic factors in fibroid pathogenesis: potential implications for future therapy|journal=Human Reproduction Update|volume=20|issue=2|year=2013|pages=194–216|issn=1355-4786|doi=10.1093/humupd/dmt042|pmid=24077979|pmc=3922145}}</ref>
It has shorter recovery times.<ref name=":0">{{Cite journal|last1=Gupta|first1=Janesh K.|last2=Sinha|first2=Anju|last3=Lumsden|first3=M. A.|last4=Hickey|first4=Martha|date=2014-12-26|title=Uterine artery embolization for symptomatic uterine fibroids|journal=The Cochrane Database of Systematic Reviews|issue=12|pages=CD005073|doi=10.1002/14651858.CD005073.pub4|issn=1469-493X|pmid=25541260}}</ref> UAE is thought to work because uterine fibroids have abnormal vasculature together with aberrant responses to hypoxia (inadequate oxygenation to tissues).<ref name="TalSegars2013">{{cite journal|last1=Tal|first1=R.|last2=Segars|first2=J. H.|title=The role of angiogenic factors in fibroid pathogenesis: potential implications for future therapy|journal=Human Reproduction Update|volume=20|issue=2|year=2013|pages=194–216|issn=1355-4786|doi=10.1093/humupd/dmt042|pmid=24077979|pmc=3922145}}</ref>


Uterine artery embolization can also be used to control heavy uterine bleeding for reasons other than fibroids, such as postpartum [[obstetrical hemorrhage]].<ref>[http://bja.oxfordjournals.org/cgi/content/full/93/4/591 Management of severe postpartum haemorrhage by uterine artery embolization]</ref> and adenomyosis.
UAE can also be used to control heavy uterine bleeding for reasons other than fibroids, such as postpartum [[obstetrical hemorrhage]].<ref>[http://bja.oxfordjournals.org/cgi/content/full/93/4/591 Management of severe postpartum haemorrhage by uterine artery embolization]</ref> and adenomyosis.


According to the American Journal of Gynecology, uterine artery embolization costs 12% less than hysterectomy and 8% less than myomectomy.<ref>{{cite journal |last1=Al-Fozan |first1=Haya |last2=Dufort |first2=Joanne |last3=Kaplow |first3=Marilyn |last4=Valenti |first4=David |last5=Tulandi |first5=Togas |title=Cost analysis of myomectomy, hysterectomy, and uterine artery embolization |journal=American Journal of Obstetrics and Gynecology |date=November 2002 |volume=187 |issue=5 |pages=1401–1404 |doi=10.1067/mob.2002.127374|pmid=12439538 }}</ref>
According to the American Journal of Gynecology, UAE costs 12% less than hysterectomy and 8% less than myomectomy.<ref>{{cite journal |last1=Al-Fozan |first1=Haya |last2=Dufort |first2=Joanne |last3=Kaplow |first3=Marilyn |last4=Valenti |first4=David |last5=Tulandi |first5=Togas |title=Cost analysis of myomectomy, hysterectomy, and uterine artery embolization |journal=American Journal of Obstetrics and Gynecology |date=November 2002 |volume=187 |issue=5 |pages=1401–1404 |doi=10.1067/mob.2002.127374|pmid=12439538 }}</ref>


==Adverse effects==
==Adverse effects==

Revision as of 14:03, 29 October 2023

Uterine artery embolization
Arteries of the female reproductive tract (posterior view): uterine artery, ovarian artery and vaginal arteries.
SpecialtyInterventional radiology

Uterine artery embolization (UAE) is a procedure in which an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. The procedure is primarily done for the treatment of uterine fibroids and adenomyosis.[1][2] However, it may also be used to treat postpartum hemorrhage and uterine arteriovenous fistulas.[3] Since this minimally invasive procedure is commonly used in the treatment of uterine fibroids and is also called uterine fibroid embolization.

Medical uses

Uterine fibroids are the most common type of benign uterine tumor and are composed of smooth muscle.[4] They often cause bulk-related symptoms, which can be characterized by back pain, heaviness in the pelvic area, abdominal bloating.[5] UAE may be used to treat these bothersome bulk-related symptoms as well as abnormal or heavy uterine bleeding due to uterine fibroids. Fibroid size, number, and location are three potential predictors of a successful outcome.[6][7][8] UAE may also be appropriate for the treatment of adenomyosis, which is when the lining of the uterus aberrantly grows into the muscle of the uterus.[9] Symptoms of adenomyosis include heavy or prolonged menstrual bleeding and painful menstrual periods.[10]

Long-term patient satisfaction outcomes are similar to that of surgery.[11] There is tentative evidence that traditional surgery may result in better fertility.[11] UAE also appears to require more repeat procedures than if surgery was done initially.[11]

It has shorter recovery times.[12] UAE is thought to work because uterine fibroids have abnormal vasculature together with aberrant responses to hypoxia (inadequate oxygenation to tissues).[13]

UAE can also be used to control heavy uterine bleeding for reasons other than fibroids, such as postpartum obstetrical hemorrhage.[14] and adenomyosis.

According to the American Journal of Gynecology, UAE costs 12% less than hysterectomy and 8% less than myomectomy.[15]

Adverse effects

The rate of serious complications is comparable to that of myomectomy or hysterectomy. The advantage of somewhat faster recovery time is offset by a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure.[12] An analysis of 15,000 women found that those who had myomectomy required fewer additional procedures to mange fibroids (including hysterectomies) over the next 5 years than those who had UAE.[16][17]

Complications include the following:

  • Death from embolism, or sepsis (the presence of pus-forming or other pathogenic organisms, or their toxins, in the blood or tissues) resulting in multiple organ failure[18]
  • Infection from tissue death of fibroids, leading to endometritis (infection of the uterus) resulting in lengthy hospitalization for administration of intravenous antibiotics[19]
  • Misembolization from microspheres or polyvinyl alcohol particles flowing or drifting into organs or tissues where they were not intended to be, causing damage to other organs or other parts of the body[20] such as ovaries, bladder, rectum, and rarely small bowel, uterus, vagina, and labia.[21]
  • Loss of ovarian function, infertility,[22] and loss of orgasm[citation needed]
  • Failure – continued fibroid growth, regrowth within four months[citation needed]
  • Menopause – iatrogenic, abnormal, cessation of menstruation and follicle stimulating hormones elevated to menopausal levels[23]
  • Post-embolization syndrome – characterized by acute and/or chronic pain, fevers, malaise, nausea, vomiting and severe night sweats; foul vaginal odor coming from infected, necrotic tissue which remains inside the uterus; hysterectomy due to infection, pain or failure of embolization[24]
  • Severe, persistent pain, resulting in the need for morphine or synthetic narcotics[25]
  • Hematoma,[21] blood clot at the incision site; vaginal discharge containing pus and blood, bleeding from incision site, bleeding from vagina, fibroid expulsion (fibroids pushing out through the vagina), unsuccessful fibroid expulsion (fibroids trapped in the cervix causing infection and requiring surgical removal),[citation needed] life-threatening allergic reaction to the contrast material,[21] and uterine adhesions[citation needed]

Procedure

The procedure is performed by an interventional radiologist under conscious sedation.[21] Access is commonly through the radial[citation needed] or femoral artery via the wrist or groin,[21] respectively. After anesthetizing the skin over the artery of choice, the artery is accessed by a needle puncture using Seldinger technique.[21] An access sheath and guidewire are then introduced into the artery. In order to select the uterine vessels for subsequent embolization, a guiding catheter is commonly used and placed into the uterine artery under X-ray fluoroscopy guidance. Once at the level of the uterine artery an angiogram with contrast is performed to confirm placement of the catheter and the embolizing agent (spheres or beads) is released. Blood flow to the fibroid will slow significantly or cease altogether, causing the fibroid to shrink. This process can be repeated for as many arteries as are supplying the fibroid. This is done bilaterally from the initial puncture site as unilateral uterine artery embolizations have a high risk of failure. With both uterine arteries occluded, abundant collateral circulation prevents uterine necrosis, and the fibroids decrease in size and vascularity as they receive the bulk of the embolization material. The procedure can be performed in a hospital, surgical center or office setting and commonly take no longer than an hour to perform. Post-procedurally if access was gained via a femoral artery puncture an occlusion device can be used to hasten healing of the puncture site and the patient is asked to remain with the leg extended for several hours but many patients are discharged the same day with some remaining in the hospital for a single day admission for pain control and observation. If access was gained via the radial artery the patient will be able to get off the table and walk out immediately following the procedure. The procedure is not a surgical intervention, and allows the uterus to be kept in place, avoiding many of the associated surgical complications.[citation needed]

References

  1. ^ Siskin GP, Tublin ME, Stainken BF, et al. (2001). "Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging". American Journal of Roentgenology. 177 (2): 297–302. doi:10.2214/ajr.177.2.1770297. PMID 11461849.
  2. ^ Chen C, Liu P, Lu J, et al. [Uterine arterial embolization in the treatment of adenomyosis]. Zhonghua Fu Chan Ke Za Zhi 2002; 37:77.
  3. ^ Keefe, Nicole A.; Haskal, Ziv J; Park, Auh Whan; Angle, John F., eds. (2018). "IR Playbook". doi:10.1007/978-3-319-71300-7. {{cite journal}}: Cite journal requires |journal= (help)
  4. ^ Donnez, Jacques; Dolmans, Marie-Madeleine (2016-07-27). "Uterine fibroid management: from the present to the future". Human Reproduction Update. 22 (6): 665–686. doi:10.1093/humupd/dmw023. ISSN 1355-4786. PMC 5853598. PMID 27466209.{{cite journal}}: CS1 maint: PMC format (link)
  5. ^ Gonsalves, Carin (2008-12). "Uterine Artery Embolization for Treatment of Symptomatic Fibroids". Seminars in Interventional Radiology. 25 (04): 369–377. doi:10.1055/s-0028-1103001. ISSN 0739-9529. {{cite journal}}: Check date values in: |date= (help)
  6. ^ Spies JB, Roth AR, Jha RC, et al. (2002). "Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome". Radiology. 222 (1): 45–52. doi:10.1148/radiol.2221010661. PMID 11756703.
  7. ^ Pelage JP, Walker WJ, Le Dref O, et al. (2001). "Treatment of uterine fibroids". Lancet. 357 (9267): 1530. doi:10.1016/s0140-6736(00)04683-3. PMC 5267678. PMID 11383541.
  8. ^ Katsumori T, Nakajima K, Mihara T (2003). "Is a large fibroid a high-risk factor for uterine artery embolization?". American Journal of Roentgenology. 181 (5): 1309–1314. doi:10.2214/ajr.181.5.1811309. PMID 14573425.
  9. ^ Garcia, Lydia; Isaacson, Keith (2011-07). "Adenomyosis: Review of the Literature". Journal of Minimally Invasive Gynecology. 18 (4): 428–437. doi:10.1016/j.jmig.2011.04.004. ISSN 1553-4650. {{cite journal}}: Check date values in: |date= (help)
  10. ^ Gunther, Rutger; Walker, Christopher (2023), "Adenomyosis", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30969690, retrieved 2023-10-29
  11. ^ a b c Gupta, JK; Sinha, A; Lumsden, MA; Hickey, M (26 December 2014). "Uterine artery embolization for symptomatic uterine fibroids". The Cochrane Database of Systematic Reviews. 12 (12): CD005073. doi:10.1002/14651858.CD005073.pub4. PMID 25541260.
  12. ^ a b Gupta, Janesh K.; Sinha, Anju; Lumsden, M. A.; Hickey, Martha (2014-12-26). "Uterine artery embolization for symptomatic uterine fibroids". The Cochrane Database of Systematic Reviews (12): CD005073. doi:10.1002/14651858.CD005073.pub4. ISSN 1469-493X. PMID 25541260.
  13. ^ Tal, R.; Segars, J. H. (2013). "The role of angiogenic factors in fibroid pathogenesis: potential implications for future therapy". Human Reproduction Update. 20 (2): 194–216. doi:10.1093/humupd/dmt042. ISSN 1355-4786. PMC 3922145. PMID 24077979.
  14. ^ Management of severe postpartum haemorrhage by uterine artery embolization
  15. ^ Al-Fozan, Haya; Dufort, Joanne; Kaplow, Marilyn; Valenti, David; Tulandi, Togas (November 2002). "Cost analysis of myomectomy, hysterectomy, and uterine artery embolization". American Journal of Obstetrics and Gynecology. 187 (5): 1401–1404. doi:10.1067/mob.2002.127374. PMID 12439538.
  16. ^ Amoah, Alison; Quinn, Stephen D. (1 June 2023). "Uterine‐preserving treatments or hysterectomy reintervention after myomectomy or uterine artery embolisation: A retrospective cohort study of long‐term outcomes". BJOG: An International Journal of Obstetrics & Gynaecology. 130 (7): 823–831. doi:10.1111/1471-0528.17412. ISSN 1470-0328.
  17. ^ "Surgical removal of fibroids has better long-term outcomes than blocking blood vessels". NIHR Evidence. 22 September 2023.
  18. ^ Vashisht A, Studd JW, Carey AH (2000). "Fibroid Embolisation: A Technique Not Without Significant Complications". British Journal of Obstetrics and Gynaecology. 107 (9): 1166–1170. doi:10.1111/j.1471-0528.2000.tb11119.x. PMID 11002964. S2CID 12959753.
  19. ^ de Block S, de Bries C, Prinssen HM (2003). "Fatal Sepss after Uterine Artery Embolization with Microspheres". Journal of Vascular and Interventional Radiology. 14 (6): 779–783. doi:10.1097/01.rvi.0000079988.80153.61. PMID 12817046.
  20. ^ Dietz DM, Stahfeld KR, Bansal SK (2004). "Buttock Necrosis After Uterine Artery Embolization". Obstetrics & Gynecology. 104 (Supplement): 1159–1161. doi:10.1097/01.AOG.0000141567.25541.26. PMID 15516436. S2CID 39409507.
  21. ^ a b c d e f Rand, Thomas; Patel, Rafiuddin; Magerle, Wolfgang; Uberoi, Raman (December 2020). "CIRSE standards of practice on gynaecological and obstetric haemorrhage". CVIR Endovascular. 3 (1): 85. doi:10.1186/s42155-020-00174-7. ISSN 2520-8934. PMC 7695782. PMID 33245432.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  22. ^ Robson S, Wilson K, David M (1999). "Pelvic Sepsis Complicating Embolization of a Uterine Fibroid". The Australian and New Zealand Journal of Obstetrics and Gynaecology. 39 (4): 516–517. doi:10.1111/j.1479-828X.1999.tb03150.x. PMID 10687781. S2CID 19991414.
  23. ^ Walker WJ, Pelage JP, Sutton C (2002). "Fibroid Embolization". Clinical Radiology. 57 (5): 325–331. doi:10.1053/crad.2002.0945. PMID 12014926.
  24. ^ Common AA, Mocarski E, Kolin A (2001). "Leiomyosarcoma". Journal of Vascular and Interventional Radiology. 12 (12): 1449–1452. doi:10.1016/s1051-0443(07)61708-4. PMID 11742024.
  25. ^ Soulen MC, Fairman RM, Baum R (2000). "Embolization of the Internal Iliac Artery: Still More to Learn". Journal of Vascular and Interventional Radiology. 11 (5): 543–545. doi:10.1016/S1051-0443(07)61604-2. PMID 10834483.
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