JBR–BTR, 2004, 87: 1-8. Pelvic varicosities are a poorly standardized questionnaire. The

JBR–BTR, 2004, 87: 1-8.
THE PELVIC CONGESTION SYNDROME: ROLE OF THE “NUTCRACKER
PHENOMENON” AND RESULTS OF ENDOVASCULAR TREATMENT
O. d’Archambeau, M. Maes, A.M. De Schepper1
Purpose: Pelvic Congestion Syndrome (PCS) is a less known pathologic condition in multiparous women. The major
symptoms are: low abdominal pain, dyspareunia or postcoïtal ache, gluteal or thigh varices, and emotional disturbances. The purpose of this retrospective study is to evaluate the pathogenesis, diagnosis and immediate, and longterm clinical results of the endovascular treatment of PCS.
Methods and Materials: From February 1992 until January 2000, 67 diagnostic ovarian vein phlebographies followed
by transcatheter embolization were performed in 66 patients with pelvic varicosities. These patients were traced
back and submitted to a standardized questionnaire. The data of 48 patients was obtained this way.
Results: In 83%, extrinsic compression of the left renal vein between the aorta and the superior mesenteric artery known as the “nutcracker phenomenon”- was observed together with congestion of the left ovarian vein and pelvic
varicosities. The technical success rate of endovascular embolization was 96%. The initial clinical success rate was
86%, with a long-term benefit for 75% of the patients. After embolization there was a reduction in pain intensity, pain
attacks, and emotional disturbances. Globally there was a mean reduction of complaints of 73% (Visual Analog
Scale).
Conclusion: The “nutcracker phenomenon” was detected in most of the treated patients and could explain the congestion of the left ovarian vein. Transcatheter embolotherapy is an effective way of treating pelvic varicosities, resulting in a great improvement of the quality of life for most of the patients. In experienced hands the procedure is relatively simple, and it is well tolerated. Moreover it can be performed in one step with the diagnostic phlebographic
procedure.
Keywords: Veins, ovarian – Varices – Veins, therapeutic blockade.
Pelvic varicosities are a poorly
understood pathologic condition in
multiparous women that may cause
a variety of symptoms. With few
exceptions the affected women are
multigravid, and most frequently
they complain of chronic abdominal
pain, with or without dyspareunia
and/or postcoital ache. Other symptoms, as menstrual disorders, urinary complaints, gluteal or thigh varices, and emotional instability can
supplement the clinical picture. In
the literature this clinical entity is
known as “Pelvic congestion syndrome” (PCS) ((1-4() More seldom a
patient with pelvic varicosities may
present with renal colics, due to ureteral compression by a dilated ovarian vein. This is known as “Ovarian
vein syndrome” ((5-10).
It was Richet who first described
pelvic varicosities in 1854 (11).
Freund postulated a vascular origin
in 1885 (12) and Cotte in 1928 believed that the etiology was vascular
insufficiency due to postpartum
thrombophlebitis (13). PCS as such
was first described by Taylor in 1949
confirming vascular insufficiency as
a major etiologic factor (14-16).
In case of clinical suspicion of
pelvic varicosities, the diagnosis can
be confirmed by means of ultrasound, abdominal CT-scan, pelvic
MRI or ovarian vein phlebography
(17-22). Phlebography is still considered the “gold standard” for diagnosis. Once the diagnosis is confirmed, patients may be treated surgically (3, 23-27) or, as it is the case in
our institution, by transcatheter
embolization of the dilated ovarian
vein. Although the first paper describing a case of successful transcatheter ovarian vein embolization was
published by Edwards in 1993,
transcatheter ovarian vein embolization procedures are performed in
our department since the early
1980’s. This retrospective study was
undertaken to evaluate the technical
and clinical results of embolization
procedures performed between
1992 and 2000 and the phlebographies were reviewed to evaluate the
possible mechanical factors contributing to the pathogenesis.
Methods and materials
From February 1992 until January
2000, 67 transcatheter embolization
procedures were performed in
66 patients presenting with a clinical
picture of PCS and sonographic, CTscan or MRI evidence of pelvic varicosities.
The patients were contacted for
an interview on the basis of a
From: Department of Radiology, University Hospital Antwerp, Antwerp, Belgium.
Address for correspondence: O. d’Archambeau, MD, Department of Interventional
Radiology, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium.
standardized questionnaire. The
questionnaire contained a list of
symptoms and localizations of
which the presence or absence
before and immediately after treatment as well as at the time of the
study was noted. The overall results
of the treatment were rated using a
visual analogous scale (28) indicating the severity of complaints (from
none to unbearable). The questionnaire was completed by 48 patients
and the collected data were sufficient for statistical analysis. The
mean age of the 48 patients was
37.2 years (20-73) and the mean gravidity at the time of treatment was
2.7 (0-7.3 nulliparous patients). The
patient’s history included 14 laparascopies (29%), pelvic inflammatory disease in eight (17%), six appendectomies (12.5%) and two cases of
endometriosis (4%). Before treatment most patients complained of
pain in the lower abdominal region
(80%), the lower back (35%), the
right side (35%) or the left side
(21%). Other locations noted were
the groins and even the upper leg.
Frequently the ache was localized in
more than one of the above mentioned regions. The pain often occurred
after a long maintained erect position (60%), during or immediately
after sexual intercourse (44%), or
during the premenstrual period
(28%). Fifteen patients (31%) experienced a continuous gnawing feeling superimposed by pain attacks.
All the patients were selected for
2
JBR–BTR, 2004, 87 (1)
Table I. — Grading of pelvic varicosities according to
De Schepper.
Grade I
Grade II
Grade III
dilated left ovarian vein/plexus
+ dilated left uterovaginal vein plexus
+ dilated right uterovaginal plexus and
right ovarian vein
Table II. — Original grading of extrinsic left renal vein
compression at the aortomesenteric fork. The “nutcracker phenomenon” according to d’Archambeau
and De Schepper.
Grade I
Grade II
Grade III
Extrinsic impression with retrograde
filling of paralumbar veins and/or ovarian vein
Extrinsic compression with retrograde
filling of side branches including the
ovarian vein and reflux towards the
renal hilum
Total “cut-off” of the renal vein
Fig. 1. — Diagnostic phlebography (left) with a 4F cobra
catheter. Grade 3 pelvic varicosities with contralateral filling of
the right ovarian vein (arrow). “One-step” embolization of the
left ovarian vein (right) using Gianturco coils at the level of the
sacro-iliac joint (arrow).
ovarian phlebography when the initial abdominal ultrasound, CT-scan
or MRI performed for clinical symptoms of PCS revealed pelvic varicosities without other pathology. In 35
out of the 48 patients more than one
non-invasive radiological examination was performed prior to the
phlebography. The patients underwent ovarian vein phlebography
that confirmed the suspected diagnosis of pelvic varicosities by
demonstrating a dilated left and/or
right ovarian vein in all. The procedures were performed from a
femoral approach using a 0.038”
hydrophilic guide-wire (Terumo
Europe, Herent, Belgium) and a 4 or
5F Cobra-shaped catheter (Terumo
Europe, Herent, Belgium) for the left
side or a Simmons 1 or 2-shaped
catheter (Terumo Europe, Herent,
Belgium) for the right side. The left
ovarian vein was usually catheterized first. Low-osmolar contrast
(Hexabrix 320, Laboratoire Guerbet,
Aulnay-Sous-Bois, France) was
injected manually with the patient in
a semi-upright position allowing
good opacification of the enlarged
ovarian vein, collaterals and varices.
Pelvic varicosities were graded
according to De Schepper (18, 29)
(Table I). Consequently, the enlarged
ovarian vein was embolized in one
step with the diagnostic phlebographic procedure (Fig. 1). A total of
55 embolization procedures were
performed, 42 left and 6 bilateral
with one patient needing a right
ovarian vein embolization 3 months
after the left ovarian vein was embolized due to incomplete disappearance of symptoms.
Embolization was achieved using
MReye 0.038” Gianturco Coils
(William Cook Europe, Bjaeverskov,
Denmark) in 45 patients. The coils
were pushed through the catheter
with the guide-wire and usually
placed at the level of the sacroiliac
joint. An average of 4-5 coils were
necessary for complete occlusion
sizing from 3-20 mm in width and
40-200 mm in total length.
Collaterals were identified in
21 patients and embolized with
small coils (3 or 5 mm in diameter
and 40 or 50 mm in length). In 3,
included from another hospital, a
mixture of lipiodol (Laboratoire
Guerbet, Aulnay-Sous-Bois, France)
and glue (Histocryl Transparant, B.
Braun, Melsungen, Germany) was
used and delivered using a coaxial
5F-3F catheter system.
A manual control injection was
performed in the ovarian vein and
left renal vein to assess the result of
the embolization. In 40 out of the
48 patients (83%) an extrinsic compression of the left renal vein at the
crossing site with the aorta was
observed. This was most obvious
after embolization when opacification of the reno-azygolumbar plexus
and sometimes contrast reflux in
the renal vein towards the renal pelvis was observed. We graded extrinsic compression of the left renal
vein at the crossing site with the
aorta as follows (Table II): extrinsic
impression with filling of paralumbar veins and/or ovarian vein: Grade
1 (Fig. 2A); extrinsic compression
with filling of various side branches
including the ovarian vein and
THE PELVIC CONGESTION SYNDROME — D’ARCHAMBEAU et al.
A
3
B
Fig. 2. — The “nutcracker phenomenon”. Grade 1 (A): extrinsic
impression of the left renal vein at the aortomesenteric fork
with filling of the ovarian vein (long arrow). Grade 2 (B): extrinsic compression with ovarian and paralumbar venous reflux
(short arrows). Grade 3 (C): total “cut-off” of the left renal vein
and paralumbar collateral filling of the inferior caval vein (long
arrow).
ranging from no complaint to unbearable pain representing the severity of symptoms before and after treatment. For each patient the denoted grade of symptoms was converted to a numerical score (VA score,
0-10), that could be statistically analysed. General improvement of the
symptoms was noted as the difference between the VA score before
and after treatment (Table III) and
symptomatic improvement in term
of percentage was calculated using
the following formula :
%improvement = 100 / VA score
pre x (VA score pre - post). This was
done for all 48 patients. The mean
follow-up was 43,4 months (2.084.3).
C
reflux towards the renal hilum:
Grade 2 (Fig. 2B); total “cut-off” of
the left renal vein: Grade 3 (Fig. 2C).
Pressure measurements were not
Results
performed because of lack of value
in the absence of a control group.
We assessed the clinical success
rate using a visual analogous scale,
Complete occlusion was achieved
in 46 patients (53 embolizations: 40
left-sided, 1 right-sided and 6 bilateral), partial occlusion in 2 patients
4
JBR–BTR, 2004, 87 (1)
Table III. — Visual-analogous score for all 48 patients, before and after
treatment.
N = 48
MEAN
RANGE
SD
VA score before treatment
VA score after treatment
Improvement
Improvement (%)
7.88
2.15
5.74
73.31
5.0-10.0
0.0-10.0
-1.0-10.0
-12.5-100
1.67
3.25
3.44
37.6
% improvement =
100
VA score pre
(2 left-sided embolizations), as
observed by phlebography at completion of the embolizations, resulting in a technical success rate of
96,4%.
There were no major complications. In one patient, proximal coil
misplacement resulted in migration
to the left inferior pulmonary lobe
artery needing a snare loop for coil
retrieval.
The clinical success rate was evaluated using a visual analogous
scale. We found an overall statistically significant reduction of the VA
score from 7.88 before treatment to
2.15 after transcatheter embolotherapy (p < 0.001; Wilcoxon Signed
Ranks Test), corresponding to a
mean proportional improvement of
complaints of 73,3% (Table III).
Although symptoms did not disappear completely for all patients,
most of them experienced an improvement in their “quality of life” that
remained constant over the years of
follow-up.
A total of seven patients (14.5%)
did not respond favourably to the
embolization. Six patients (12.5%)
had unchanged symptoms, one
patient (2%) experienced a slight
worsening of her complaints. It
should be noted that from those
seven patients, three were younger
than 30 years and nulliparous and
three were older than 50 year, what
could suggest another origin of their
complaints.
In the follow-up (2-84.3 months,
mean 43.4 months), five patients
(10%) experienced a relapse of
symptoms after a period of 232 months (mean 14.3 months),
meaning a long-term clinical success rate of 75%. A control phlebography was performed in 3 patients
with recurrent complaints, but only
in 1 patient there was evidence of
residual varicosities, due to a collateral circulation through the renal
pelvic venous plexus, not observed
during the initial procedure. In the
x
(VA score pre - post)
other 2, even iliac catheterization
could not demonstrate the pelvic
varicosities shown on sonography.
The effect of embolotherapy on
pain was also studied. After embolization there was a decreased frequency of pain attacks and less
areas were involved. This reduction
was significant (Wilcoxon Signed
Rank Test, p < 0.05) for several of the
inquired parameters (Table IV).
Other physical complaints such as
menstrual disorders, urinary complaints and external varices were
less frequently mentioned after treatment. Emotional disturbances
(depression, anxiety, stress,...) were
mentioned by 25 of the 48 women
(52%) and 21 women (44%) complained of dyspareunia before treatment. After treatment this number
decreased to 10 (21%) and 8 women
(17%) respectively. This reduction in
emotional complaints and dyspareunia was statistically significant
(Wilcoxon Signed Rank Test, p <
0.001).
The phlebographies of all
patients were reviewed and the
grade of pelvic varicosities was
noted according to De Schepper
(Table I). We noted a grade 1 in 10
patients (21%), a grade 2 in 22
patients (46%) and a grade 3 in 16
patients (33%).
In 40 patients (83%) extrinsic
compression of the left renal vein at
the level of the aortomesenteric fork
was found to be the major contributing factor to the pathogenesis and
graded according our original grading system (Table II).
We found a grade 1 in 12 patients
(25%), grade 2 in 16 patients (33%)
and a grade 3 in the other 12
patients (25%). No extrinsic impression or compression was detected
in the remaining 8 patients (17%),
due to insufficient imaging of the
left renal vein in 5 patients. Absent
or incompetent valves could possibly be the cause of reflux in the
remaining 3 patients.
By comparing the patient’s VA
scores and phlebographies, we
noted that the patients with a more
pronounced extrinsic compression
of the left renal vein (grade 2 and 3
in Table II) had the largest ovarian
veins and varices (grade 2 and 3 in
Table I) and a higher VA score before embolization, although this finding was not statistically analyzed.
Discussion
Pelvic varicosities are associated
with a marked increase in diameter
and tortuosity of visceral pelvic
veins. The diameter of the ovarian
Table IV. — Pain localization percentage before and after treatment
Before
N = 48
%
After
N = 48
%
38
10
17
17
35
80
21
35
35
73
19
4
10
6
17
40
8
21
13
36
< 0.001
0.014
0.008
0.001
< 0.001
Long standing
Sexual intercourse
Continuous
Premenstrual
During menstruation
Fatigue
Others
29
21
15
13
10
12
17
60
44
31
27
21
25
35
13
8
0
2
8
4
12
27
17
0
4
17
8
25
< 0.001
< 0.001
< 0.001
0.001
0.157 (NS)
0.005
0.025
Wilcoxon Signed Ranks Test
n = number of patients
NS = not
significant (p > 0.05)
Pain
Significance
Localization
Lower abdomen
Left side
Right side
Back
Others
Time of occurrence
THE PELVIC CONGESTION SYNDROME — D’ARCHAMBEAU et al.
5
A
Fig. 3. — The “nutcracker phenomenon”. CT-scan (A) and
venous phase of aortography (B) show a distinct compression
of the left renal vein in the aortomesenteric fork (long arrow)
and retrograde filling of an enlarged left ovarian vein (short
arrow).
vein and ovarian vein plexuses is larger than 6 mm. The connecting veins
are usually larger than 4 mm. When
symptomatic, this condition is
known as the “Pelvic congestion
syndrome” (PCS) (1, 2, 3, 4). PCS is a
vascular syndrome most frequently
found in multigravid females in their
3rd-4th decade of life (30). The exact
prevalence is unknown, but pelvic
varicosities are probably present in
up to 30% of females with unexplained chronic pelvic pain (31-33).
Symptoms appear shortly after
pregnancy and include lower abdominal or back pain, dyspareunia,
external varicosities, urinary and
menstrual problems as well as emotional disturbances (2, 3). Patient’s
history and clinical examination are
important diagnostic tools.
Diagnosis is made using various
imaging modalities. Intravenous
urography shows only indirect signs
of pelvic varicosities which are more
obvious in erect position. Pelvic
color Doppler ultrasound is a good
screening method, but with a large
number of false negative results due
to slow blood flow in pelvic varicosities. Computed tomography or
MRI has the capability to exclude
other pelvic pathologies. Vulvar varicography and transuterine venography are obsolete and today widely
abandoned. Laparoscopy yields a
high number of false negative
results due to emptying of the vessels in the recumbent position. The
“gold standard” for the diagnosis of
pelvic varicosities remains the phlebography which enables us to look
for abnormalities of the ovarian and
B
iliac veins as well as to treat the
pathology.
Etiopathogenesis of PCS is multifactorial. The symptoms are worse
in the premenstrual phase suggesting a hormonal etiology (2, 3). Progesterone induces a venodilatation
and its blood level increases from
ovulation until shortly before menstruation. There is also a tenfold increase in progesterone blood level
during pregnancy, what could be an
explanation for the development of
varices.
The role of psychological factors
is not well defined as many patients
describe a long history of emotional
stress, which could be a cause as
well as a consequence of longstanding PCS.
Mechanical factors are undoubtedly the most contributing factors
in pelvic varicosities. Pelvic varicosities develop due to venous reflux
and flow reversal in the left ovarian
vein. Varices can extend to the
plexus uterovaginalis, vulvaris, vesicalis, rectalis, and finally the right
ovarian vein. De Schepper explained
this phenomenon by the so-called
“left-to-right” theory of PCS (29).
Causes for reflux in the left ovarian
vein are multiple. First of all congenital absence of valves in the ovarian veins (29, 34-38). Ahlberg found
a congenital absence of valves in
15% of the females on the left side
and in 6% on the right side [38].
Secondly many patients have
incompetent valves. This could be
the case for 43% on the left side and
35-41% on the right side (38). The
causes of valvular incompetence are
multifactorial (35). It could be congenital or due to previous thrombophlebitis of the ovarian vein, but
most frequently it is due to an extreme dilation of the ovarian vein
during pregnancy. Reflux in the left
ovarian vein may be caused by a
pressure increase in the left renal
vein secondary to thrombosis,
tumoral compression or invasion of
the left renal vein, inferior vena cava
anomalies and even portal hypertension (35, 39, 40), but as demonstated in more than 80% of our
patients is most frequently caused
by extrinsic compres- sion at the
aortic crossing. In rare instances,
this can be attributed to a retroaortic
or circumaortic course of the left
renal vein, but CT, MRI or ultrasound
performed in all patients during
investigation of chronic pelvic pain
did not reveal this finding. Instead,
crushing of the left renal vein at the
aortomesenteric fork, the so-called
“nutcracker phenomenon” (29, 34,
35, 37, 40, 41) was demonstrated
(Fig. 3). It causes an increase in
venous pressure in the left renal
vein with reflux in the left ovarian
vein and reno-azygo-lumbar plexus
as a consequence. The flow reversal
in the ovarian vein is more pronounced with absent or incompetent valves and in an upright position (29,
34, 35, 37, 41). This is also the reason
why PCS is more frequently found
in multigravid women. During pregnancy, the ovarian veins enlarge
due to increase in uterus size and
blood volume. This enlargement
induces valvular incompetence
which may be transient but some-
6
JBR–BTR, 2004, 87 (1)
Fig. 4. — Pelvic congestion syndrome”. Enlarged left ovarian
vein with high flow through multiple connecting veins to the
left external iliac vein (short arrow).
times permanent, favouring reflux
and varices. The “nutcracker phenomenon” can easily be demonstrated
on venography as an extrinsic compression or even total “cut-off” of
the left renal vein at the aortomesenteric fork with reflux in the left
ovarian vein and/or azygolumbar
veins.
An argument in favour of the
“Nutcracker phenomenon” is that
the patients with grade 2 and 3 extrinsic renal vein compression had
the largest ovarian veins and frequently experienced discomfort in
the left kidney region after embolization, which could be explained by a
sudden pressure raise in the left
renal vein due to blocking of a large
collateral channel. The discomfort
was transient and lasted from a few
hours to a few days.
Another argument in favour of
the “nutcracker phenomenon” and
the concomitant “left-to-right” pressure gradient in the ovarian-uterine
venous system is found in our own
series in which we have never seen
filling of the left ovarian vein during
phlebography of the right ovarian
vein. Retrograde filling of the right
ovarian vein during phlebographies
of the inferior vena cava is never
seen, moreover, preferential filling
of right venous structures during
transuterine
phlebography
in
patients with PCS is in our opinion a
consequence of the same “left-toright” pressure gradient phenomenon (42). De Schepper graded
Fig. 5. — Diagnostic phlebography of the right ovarian vein
using a 4F Simmons catheter after coil embolization of the left
ovarian vein. Filling of the superior mesenteric vein (long
arrow) through connecting veins (short arrow).
pelvic varicosities according to this
theory (18, 29) (Table I). He performed pressure measurements in the
left renal vein and inferior caval vein
in a total of 29 patients (21 with normal phlebographic findings and 8
with PCS and “nutcracker phenomenon”). As a result, he found a
mean pressure gradient of 2mmHg
in the normal group (mean caval
pressure: 9mmHg, mean left renal
vein pressure: 11 mmHg) and
5mmHg in the pathologic group
(mean caval pressure: 10mmHg,
mean left renal vein pressure:
15mmHg) (29). In our study, no pressure measurements were performed because no control group was
available. Therefore, a comparative
study was not possible.
Treatment of PCS may be medical, surgical or endovascular.
Medical treatment with medroxyprogesterone acetate (Provera,
Upjohn) which suppresses ovarian
function is not always effective.
Dihydroergotamine is a venoconstrictor only effective during the
acute phase of PCS and only for a
few days. The efficacy of NSAID in
the treatment of PCS is not proven.
Surgical ligation of the ovarian
vein whether transabdominal, translumbar or laparascopic is effective
but invasive (22-24). Hospitalization
is mandatory and complications are
not rare. Total hysterectomy is also
effective but radical (25, 26).
Although transcatheter embolization is the treatment of choice in our
department for more than 15 years,
not many reports were published in
the literature (43-49).
The embolization procedure is
performed in one step with the diagnostic phlebography and on an
outpatient basis. Different embolic
materials may be used, including
detachable balloons, coils, sclerosing agents and glue. We do not
recommend the use of sclerosing
agents and glue in the ovarian vein
for different reasons. First, the ovarian vein, unlike the testicular vein
has only few collaterals and usually
with a more distal origin. Secondly,
the ovarian vein in PCS is frequently
larger than 1 cm with a high retrograde blood flow rate. Therefore it is
more difficult to control the polymerisation of glue and embolization of
the plexus pampiniformis ovarica or
passage of glue into the iliac vein is
possible (Fig. 4). Reflux in the renal
vein with pulmonary migration is
also a concern as is embolization of
mesenteric veins through connecting channels (Fig. 5).
In our department, Gianturco
Coils (Cook) are used and placed at
the level of the sacroiliac joint. If
necessary, small collaterals are
selectively catheterized and embolized.
Since we strongly believe in the
“left-right” theory, we tried to avoid
embolization of enlarged right ovarian veins. Embolization is only performed in cases of massive retrograde flow with filling of the peri-
THE PELVIC CONGESTION SYNDROME — D’ARCHAMBEAU et al.
ovarian venous plexus in a semiupright position. This was the case
in 7 patients (15%) although right
ovarian vein dilatation was found in
19 patiens (40%).
A control phlebography of the
ovarian and renal vein is performed
after embolization, confirming the
occlusion and the non-filling of
renal pelvic collaterals. One complication occurred. In this case, the last
coil was released too proximally in
the ovarian vein, with the catheter in
an unstable position resulting in
misplacement and migration into a
left lower pulmonary lobe artery.
The coil was successfully retrieved
using a snare-loop.
The clinical results were evaluated using a visual analogous scale.
The use of a VA scale in a retrospective study could be questioned, but
the symptoms before treatment
were usually severe and long-standing and the included patients had
no trouble in remembering the
immediate effect of the procedure
on their complaints. The VA scale is
a good method for evaluation of
symptomatic relief, since we do not
know if the symptoms can be attributed to the pelvic varicosities
alone. Some symptoms may have
another origin, and embolization,
although technically successful will
only result in a partial relief of symptoms.
It is not always necessary to
achieve total symptomatic relief in
order to improve the “quality of life”.
In our study there was an overall
symptomatic relief of 73.3%.
Bearing in mind that 7 patients did
not respond to the treatment, we
found a symptomatic improvement
of 85.9% and a long-term clinical
benefit in 75% of the patients. There
was a 60% decrease in the number
of patients with emotional problems
(52% before, 20% after) and dyspareunia (44% before, 17% after).
Our findings correlate well with
those of other authors [43-49]. They
indicate that transcatheter embolotherapy of ovarian veins is an effective treatment modality for female
patients suffering from pelvic varicosities. The results are similar to
those of surgical treatment, but
embolotherapy is a less invasive
technique. Moreover, it has the
advantage to be performed on an
outpatient base and in one step with
the diagnostic phlebographic procedure.
Finally, phlebographic review
demonstrated the “nutcracker phenomenon” as the major contributing factor in the etiopathogenesis
of “Pelvic Congestion Syndrome”
although objective confirmation
was not available as we did not perform pressure measurements.
References
1. Railo J.E.: The pain syndrome in ovarian varicocele. Acta Chir Scand,
1968, 134: 157-159.
2. Hobbs J.T.: The pelvic congestion
syndrome. Practitioner, 1976, 216:
529-540.
3. Hobbs JT.: The pelvic congestion syndrome. Brit J Hosp Med, 1990, 43:
200-206.
4. Beard R.W.: Clinical features of
women with chronic lower abdominal pain and pelvic congestion. Brit J
Obstet Gynaec, 1989, 96: 153-161.
5. Clark J.C.: The right ovarian vein syndrome. In: Emmett J.L., ed. Clin uro
diagn, 1964 vol. 2: 1227-1236 W.B.
Saunders, Philadelphia.
6. Melnick G.S., Bramwit D.N.: Bilateral
ovarian vein syndrome. Am J Roentgenol Radium Therapy and Nuclear
Medicine, 1971, 113: 509-517.
7. Dyckhuizen RF, Roberts JA. The ovarian vein syndrome. Surg Gynecol
Obstet, 1970, 130: 443-452.
8. Reynolds S.R.M.: Right ovarian vein
syndrome. Obstet Gynecol, 1971, 37:
308-313.
9. Ali Khan S., Jayachandran S.,
Desai P.G., Bonheim P.: Renal colic, a
presenting symptom of pelviureteric
varices. Int Urol Nephrol, 1985, 17:
11-14.
10. Montagnac
R.,
Schillinger
F.,
Schillinger D.: Le syndrome de la
veine ovarienne. Rev Fr Gynecol
Obstet, 1989, 84: 11-14.
11. Richet A.: Traité pratique d’anatomie
médicochirurgicale 755 Lauwereyns,
Paris, 1854.
12. Freund W.A.: Gynakol Klin 1885, I:
203-326.
13. Cotte G.: Les troubles fonctionnels
de l’appareil génital de la femme.
Masson & Cie, Paris,, 1928.
14. Taylor H.C.: Vascular congestion and
hyperemia: their effect on function
and structure in the female reproductive organs. Part I. Physiological
basis and history of the concept. Am
J Obstet Gynecol, 1949, 57: 211-230.
15. Taylor H.C.: Vascular congestion and
hyperemia : their effect on function
and structure in the female reproductive organs. Part II. Clinical concepts
of the congestion-fibrosis syndrome.
Am J Obstet Gynecol, 1949, 57: 637653.
16. Taylor H.C.: Vascular congestion and
hyperemia : their effect on function
and structure in the female reproductive organs. Part III. Etiology and therapy. Am J Obstet Gynecol, 1949, 57:
654-668.
17. Giacchetto C., Cotroneo G.B., Marincolo F., et al.: Ovarian varicocele :
ultrasonic and phlebographic evaluation. J Clin Ultrasound, 1990, 18:
551-555.
7
18. De Schepper A., Van Rompaey W.:
Computed tomographic diagnosis of
dilated ovarian veins in a case of
“ovarian vein syndrome”. Eur J
Radiol, 1983, 3: 324-327.
19. Kennedy A., Hemingway A.: Radiology of ovarian varices. Brit J Hosp
Med, 1990, 44: 38-43.
20. Radin D.R., Marilyn J.R., Harrison E.,
et al.: CT demonstration of ovarian
varices. J Comput Assist Tomo, 1986,
10: 361-362.
21. Perlman S.J.: Varix of the left gonadal
vein. J Ultras Med, 1993, 12: 483-485.
22. Hodgson T.J., Reed M.W.R., Peck R.J.,
et al.: Case report : the ultrasound
and Doppler appearances of pelvic
varices. Clin Radiol, 1991, 44: 208209.
23. Takeuchi K., Mochizuki M., Kitagaki S.: Laparoscopic varicocoele
ligation for pelvic congestion syndrome. Int J Gynecol Obstet, 1996, 55:
177-178.
24. Mathis B.V., Miller J.S., Lukens M.L.,
et al.: Pelvic congestion syndrome : a
new approach to an unusual problem. Am Surgeon, 1995, 6: 10161018.
25. Grabham
J.A.,
Barrie
W.W.:
Laparascopic approach to pelvic congestion syndrome. Brit J Surg, 1997,
84: 1264.
26. Beard
R.W.,
Kennedy
R.G.,
Gangar K.F., et al.: Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelvic congestion. Brit
J Obstet Gynecol, 1991, 98: 988-992.
27. Emge L.A.: The surgical treatment of
varicose veins of the female pelvis. J
Am Med Ass, 1995, 85: 1690-1693.
28. Huskisson E.C.: Measurement of
pain. Lancet, 1974, 2: 1127-1131.
29. De Schepper A.: Studie van het ovarieel syndroom door flebografie van
de linker vena ovarica. Ph D
thesis.University of Antwerp, 1976 .
30. Beard R.W.: Clinical features of
women with chronic lower abdominal pain and pelvic congestion. Brit J
Obstet Gynaecol, 1988, 95: 153-161.
31. Mathias S.D., Kupperman M.,
Lieberman R.F., et al.: Chronic Pelvic
Pain : prevalence, health-related quality of life and economic correlates.
Obstet Gynecol, 1996, 87: 321-327.
32. Priou G., Arvis P., Rind A., et al.: Etude
de l’apport diagnostique de la coelioscopie dans le bilan des algies pelviennes chroniques. J Gynecol
Obstet Biol Repr, 1984, 13: 395-402.
33. Beard R.W., Highman J.H., Pearce S.,
et al.: Diagnosis of pelvic varicosities
in women with chronic pelvic pain.
Lancet, 1984, 2: 946-949.
34. Chait A.: Vascular impressions on the
ureters. Am J Roentgenol Radium
Therapy and Nuclear Medicine, 1971,
111: 729-749.
35. Melnick G.S., Bramwit D.N.: Bilateral
ovarian vein syndrome. Am J Roentgenol Radium Therapy and Nuclear
Medicine, 1971, 113: 509-517.
36. Chidekel N.: Female pelvic veins
demonstrated by selective renal
8
37.
38.
39.
40.
41.
42.
JBR–BTR, 2004, 87 (1)
phlebography with particular reference to pelvic varicosities. Acta
Radiol Diagn, 1968, 7: 193-211.
Helander
C.G.,
Lindbom
A.:
Varicocele of the broad ligament.
Acta Radiol, 1960, 53: 97-104.
Ahlberg N.: Circumference of the left
gonadal vein. Acta Radiol, 1965, 3:
503-512.
Coolsaet B.L.R.A.: Ureteric pathology
in relation to right and left gonadal
veins. Urology, 1978, 12: 40-49.
Perlman S.J.: Varix of the left gonadal
vein. J Ultrasound Med, 1993, 12:
483-485.
Grant J.C.B.: Method of anatomy.
Williams & Wilkins, Baltimore 158,
1937.
Chidekel N., Edlundh K.O.: Transuterine phlebography with particular
43.
44.
45.
46.
reference to pelvic varicosities. Acta
Radiol Diagn, 1968, 7: 1-12.
Edwards R.D., Robertson I.R.,
Maclean A.B., et al.: Case report : pelvic pain syndrome – succesful treatment of a case by ovarian vein
embolization. Clin Radiol, 1993, 47:
429-431.
Sichlau M.J., Yao J.S., Vogelzang R.L.:
Transcatheter embolotherapy for the
treatment of pelvic congestion syndrome. Obstet Gynecol, 1994, 83:
892-896 .
Tarazov P.G., Prozorovskij K.V.,
Ryzhkov V.K.: Pelvic pain syndrome
caused by ovarian varices. Treatment
by transcatheter embolization. Acta
Radiol, 1997, 38: 1023-1025.
Capasso P., Simons C., Trotteur G., et
al.: Treatment of symptomatic pelvic
varices by ovarian vein embolisation.
Cardiovasc Inter Rad, 1997, 20: 107111.
47. Cordts P.R., Eclavea A., Buckley P.J.,
et al.: Pelvic congestion syndrome :
early clinical results after transcatheter ovarian vein embolization. J Vasc
Surg, 1998, 28: 862-868.
48. Maleux G., Stockx L., Wilms G., et al.:
Ovarian vein embolization for the treatment of pelvic congestion syndrome : long-term technical and clinical
results. JVIR, 2000, 11: 859-864.
49. Venbrux A.C., Chang A.H., Kim H.S.,
et al.: Pelvic Congestion Syndrome
(Pelvic Venous
Incompetence):
Impact of Ovarian and Internal Iliac
Vein Embolotherapy on Menstrual
Cycle and Chronic Pelvic Pain. J Vasc
Interv Rad, 13: 171-178.
CLASSIFIED SERVICES
Le Centre Hospitalier Jolimont-Lobbes annonce l’ouverture d’un poste de radiologue, orientation échographie
(HDI 5000, ANTARES), CT-Scanner (4 – 16 canaux) et RMN (1,5 Tesla) sur le site de Jolimont (650 lits).
Toute personne intéressée par ce poste peut adresser des demandes de renseignements à l’adresse ci-dessous.
De ziekenhuisinstelling Jolimont-Lobbes, site Jolimont (650 bedden), heeft een vacature voor een radioloog,
oriëntatie echografie (HDI 5000, ANTARES), CT-scanner (4 – 16 kanalen) en NMR (1,5 Tesla).
Geïnteresseerden kunnen meer inlichtingen bekomen op onderstaand adres:
C. FAUCON
Administrateur-Délégué
C.H. Jolimont-Lobbes
Rue Ferrer, 159
7100 HAINE ST PAUL