Ovarian Vein Embolisation as Treatment for Pelvic Congestion

Pelvic Congestion Syndrome:
Technique And Results
Lindsay Machan, MD
University of British Columbia
Vancouver , British Columbia
Canada
Lindsay Machan, MD, FSIR
• Stock: A4L, Calgary Scientific, Endologix,
Harmonic Medical, Ikomed, Lombad
Medical, Middletoe Industries, Inc., NDC
•Consultant/Advisory Board: Boston
Scientific
Ovarian Vein Reflux
Clinical presentations
•
•
•
•
Pelvic congestion syndrome
Varicose veins
Thrombosis – acute pain
Incidental finding
Ovarian Vein Reflux
Clinical presentations
•
•
•
•
Pelvic congestion syndrome
Varicose veins
Thrombosis – acute pain
Incidental finding
Pelvic Congestion Syndrome
• SIR endorsed definition - chronic pelvic pain
> 6 months
– secondary to PVI
– associated pelvic venous distention
• Esp. multiparous, pre-menopausal women
– 20’s – 40’s
• 13 to 31% of patients with CPP
Pelvic congestion syndrome –
“classical” clinical features
•
chronic pelvic pain
•
•
•
Absence of other pelvic
pathology
pelvic pain worse
•
standing
•
Pre - menstrual
•
Fatigue / end of the day
relieved by laying supine
Ovarian vein reflux and lower
extremity varicosities
• Varicose veins
– Recur / persist after surgery
– Labia or buttocks
– Unusual distribution leg
• Increased importance with EVLT
Consultation with gynecologist
•
Laparoscopy
•
•
Minimal lesion endometriosis
Treatment – cauterization and medication
Pre-procedure imaging in patient
with suspected ovarian vein reflux
MRV
Chronic Pelvic Pain NYD
Pre-procedure
•
Transvaginal duplex
ultrasound
•
Dilated pelvic veins
•
Abnormal accentuation
with Valsalva
Left Renal Venogram
Selective Left Ovarian Venogram
Infusion of tetradecyl sulphate
• Infuse sclerosant until stasis
• 3% TDS / 0.5 cc contrast
• 4 – 10 cc typical
Coil Left Ovarian Vein
38 -8-10 MR Eye Coil (Cook, Inc)
Right Ovarian Venogram
Left Internal Iliac Venogram
Right Internal Iliac Venogram
Right Internal Iliac Embolization
Gelfoam / Lipiodol Slurry
/Coil
Internal Iliac Vein Embolization - TDS
Internal Iliac Vein Embolization - TDS
Internal Iliac Vein Embolization - TDS
Infuse TDS / contrast
until stasis
Coil
Durability of Symptom Relief
Kwon et al - 67 patients coil embolization for PCS
• F/U 3 months – 6 years
• 55 (82%) satisfied
– 5 (8%)complete absence of pain
– 50 (75%) sufficient pain reduction satisfied the
Rx
• 10 (15%) no change
• 2 (3%) pain worse
Cardiovasc Intervent Radiol 2007. 30:655-661
Durability of Symptom Relief
Kwon et al - 67 patients coil embolization for PCS
• 12 (18%) no change or increase in pain
– 9 surgical treatment
• 7 hysterectomy and uterosacral nerve ablation.
• 2 adhesiolysis
• 7 / 9 significant reduction pain
– 3 medical management
• 3 / 3 persistent pain
Cardiovasc Intervent Radiol (2007) 30:655–661
Durability of Embolization
Durability of Embolization
• 28 women age 40 – 75 (mean 53.5)
• 25.5% of Rx group
• Mean follow-up 7.5 years
– 11 - complete elimination all reflux
– 7 - elimination all truncal reflux
• minor reflux in vulval veins
– 6 - minor reflux 1 truncal vein
– 4 - significant reflux > truncal veins
Phlebology, 2015
Embolization PCS with Foam
• Technical success 100%
• 12-month follow-up
– No recurrent varicoceles
– Statistically significant improvement symptoms
•
Cardiovasc Intervent Radiol (2008) 31:778–784
Conclusion –ovarian vein embolization
•
•
Pelvic congestion syndrome
remains controversial
Patients with unexplained chronic
pelvic pain and ovarian vein
varicosities can be safely
embolized
Which of the following statements is true
regarding pelvic congestion syndrome?
• 1.
Pelvic congestion is the most common cause of
chronic pelvic pain in women.
• 2.
Pelvic, labial and lower limb varicosities are
unrelated entities.
• 3.
The SIR endorsed standard definition of pelvic
venous congestion syndrome refers to a condition of
chronic pelvic pain of greater than 6 months duration
secondary to PVI and associated pelvic venous
distention.
• 4.
The typical patient is nulliparous.
Which of the following statements is true
regarding pelvic congestion syndrome?
• 1.
Pelvic congestion is the most common cause of
chronic pelvic pain in women.
• 2.
Pelvic, labial and lower limb varicosities are
unrelated entities.
• 3.
The SIR endorsed standard definition of pelvic
venous congestion syndrome refers to a condition of
chronic pelvic pain of greater than 6 months duration
secondary to PVI and associated pelvic venous
distention.
• 4.
The typical patient is nulliparous.
• Reference: Durham JD, Machan L. Pelvic congestion
syndrome. Semin Intervent Radiol. 2013 Dec;30(4):37280.
Which of the following statements about ovarian /
pelvic venous reflux is not true?
• 1. Pregnancy is associated with recurrent pelvic vein reflux in
women previously treated with coil embolisation.
• 2. Relying solely on vein diameter is not suitable for the
diagnosis of ovarian vein reflux.
• 3. Pelvic venous reflux is a major contributing cause of varicose
veins recurrent after surgery.
• 4. There is Level 1 evidence for the role of embolization in
pelvic congestion.
• 5. Chronic pelvic venous ectasia is normal after pregnancy.
Which of the following statements about ovarian /
pelvic venous reflux is not true?
• 1. Pregnancy is associated with recurrent pelvic vein reflux in
women previously treated with coil embolisation.
• 2. Relying solely on vein diameter is not suitable for the
diagnosis of ovarian vein reflux.
• 3. Pelvic venous reflux is a major contributing cause of varicose
veins recurrent after surgery.
• 4. There is Level 1 evidence for the role of embolization in
pelvic congestion.
• 5. Chronic pelvic venous ectasia is normal after pregnancy.
• Reference: Phillips D, Deipolyi AR, Hesketh RL, et al. Pelvic
congestion syndrome: etiology of pain, diagnosis, and clinical
management. J Vasc Interv Radiol. 2014 May; 25(5):725-33.