uterine artery fibroid embolisation ( uae ) has now been used in clinical practice for > 2 decades in the management of symptomatic uterine fibroids [ 1 , 2 ] .
it is estimated that > 50,000 procedures have been performed worldwide since ravina reported his series in france in 1995 [ 3 , 4 ] .
uae is emerging as an effective alternative to hysterectomy and myomectomy in women with fibroids .
although long - term follow up data are still lacking , early reports regarding its safety and efficacy have been encouraging , and the procedure is increasingly being accepted . however , there is a lack of evidence on future fertility and pregnancy outcomes in women undergoing uae .
a 44-year - old nulliparous woman with a body mass index of 27 underwent uae in july 2008 for symptomatic relief of heavy menstrual bleeding .
she had previously undergone endoscopic resection of a submucous fibroid in 2002 and open myomectomy in 2003 .
she subsequently underwent exploratory laparotomy and division of adhesions for relief of small - bowel obstruction in february 2007 . a subsequent hysteroscopy in november
2007 showed a large cavity distorted by fibroids . a pelvic ultrasound scan before her procedure showed an antiverted , enlarged uterus measuring approximately 13.5    8    9  cm .
the myometrium was noted to be diffusely heterogenous , containing multiple fibroids in the anterior and posterior walls .
femoral artery puncture using a 5f sheath , a 4f catheter , and a 3f coaxial catheter .
multiple injections of contrast were administered into the internal iliac arteries and uterine arteries . the uterus was noted to be hypervascular and supplied by hypertrophied uterine arteries .
each uterine artery was selectively catheterised and embolised with polyvinyl alcohol particles ( william cook europe , bjaeverskov , denmark ) .
one vial of particles 350500  m in diameter and two vials of particles 510700  m in diameter were used .
the end point of the embolisation process was near - stasis in the uterine artery .
the plan was for her to be on bed rest for 12 h for observation of the puncture site for bleeding or swelling and administration of analgesia ( diclofenac sodium and paracetamol ) .
nineteen hours after the procedure , the patient had sudden - onset shortness of breath and collapsed .
she received cardiopulmonary resuscitation ( cpr ) for > 1  h. however , there was no cardiac activity throughout cpr , and she was noted to have pulseless electrical activity on cardiac monitoring .
cpr was discontinued after 1 h and 10  min , and the patient was pronounced dead .
to our knowledge this is the first reported case in the united kingdom in which death occurred from pulmonary embolisation after uae . the embolisation procedure had appeared routine .
the size of the uterus was not considered likely to have caused compression and stasis in the lower - limb venous structures .
certainly , patients with symptoms from a uterus of greater size than that seen in this patient have been treated at our institution .
it is not clear from the postmortem autopsy if the origin of the embolus was from the pelvic or the lower - limb veins . theoretically , it is possible to surmise that pelvic veins are enlarged and engorged in the presence of multiple hyper vascular fibroids , which consequently have decreased flow after embolisation , thus producing a potential scenario for thrombosis .
relative contrast stasis can be visualised in veins draining the uterus during any embolisation procedure .
if the treatment had been carried out as a day case , then death would have occurred at home .
the precipitous nature of the events raises the question as to whether there was a pre - existing thrombosis , which may have rapidly progressed after uae .
there was a history of previous pelvic surgery ; however , there was no clinical evidence for pelvic or lower - limb venous thrombosis or clinical history of thrombotic tendency before the embolisation procedure was performed .
two women died after uae from septic shock , one in the united kingdom   and the other in the netherlands .
one woman with known breast cancer died in italy several days after uae from a pulmonary embolus , and two women died in the united states from pulmonary emboli after the procedure . although the risk of developing a fatal venous thromboembolus is considered low , there have so far been at least four reported cases in the literature .
we advocate that women undergoing this procedure should routinely receive thromboprophylaxis in the form of thromboembolic - deterrent stockings . however , these would be of no benefit from an embolus originating in the pelvic veins .
further research is needed to assess the role of thromboprophylaxis using heparin - like agents with this procedure . at present
indeed , the use of such agents to decrease the incidence of embolic events ( which are already rare relative to the number of procedures performed ) may be accompanied by increased bleeding complications or more ineffective embolisation procedures ( and therefore poor clinical outcomes ) that rely on inducing local vessel thrombosis as well as physical occlusion .
it is not possible to say if patients with a previous history of pelvic surgery are at greater risk of embolus after uae .
the continued reporting of all uae cases to a national registry would allow us to monitor the number of women undergoing the procedure , the number and type of complications , and the fertility outcomes in all such cases .
 we report a 44-year - old woman who developed a fatal pulmonary embolus after uterine artery fibroid embolisation ( uae ) . 
 bilateral uae was carried out through a single right - femoral artery puncture . 
 the largest fibroid in the anterior fundal wall measured 4.5  cm , and the largest fibroid in the posterior fundal wall measured 6  cm . 
 the appearances after uae were satisfactory , and the procedure was apparently uneventful . 
 no immediate complications were noted . 
 the patient developed sudden - onset shortness of breath and went into cardiac arrest 19 h after the procedure . 
 postmortem autopsy confirmed that the cause of a death was a pulmonary embolism . to our knowledge 
 this is the first reported case in the united kingdom in which death occurred from a pulmonary embolus after uae . 
Introduction
Case Report
Discussion