Pelvic Congestion SyndromeDiagnosis and Treatment

Hadjipolycarpou AndreasVascular Surgery Clinic, Nicosia General Hospital

Director Dr Ch. Bekos

Vascular Surgical Society of Cyprus @ LIVEPatra, 2018

Incidence

Pelvic VV present in 10% women

15% women ages 18-50 years suffer chronic pelvic pain

– Pelvic VV >60% --> explain symptoms

Differential Diagnosis

– Endometriosis, uterine fibroma, pelvic cancer

OBGyn exam mandatory even if pelvic vv are present

PCS can cause atypical or recurrence of lower limb vv

Mathias SD, et al: Chronic pelvic pain: prevalence. Obstet Gynecol87:321-327,1996

Clinical Findings

Mainly young women (late 20s to early 30s)

Multiparous

Symptoms disappear after menopause

Rare in men (venous obstructive disease, varicocele)

Clinical Findings

Chronic pelvic pain (6 months)

– Heaviness increases during the day, relieved by lying down

Dyspareunia , Dysmenorrhea , urinary and rectal symptoms

Symptoms predominantly unilateral , can be bilateral

Diagnosis – Non Invasive

Duplex scanning (transabdominal and tranvaginal)

– 3 days no residue diet, empty stomach

– Pelvic VV: dilated tubular structures around uterus and ovaries with diameter >5mm

– Internal iliac v and genital v: reflux using Valsalva m.

– Positive predictive value of 6mm ovarian v for PCS is 83.3%

– Common Iliac v, IVC , and Renal v checked for obstruction

– Lower limb duplex for secondary vv

Park SJ, et al: Diagnosis of pcs using tranabdominal and tranvaginalsonography. AJR Am J Roentgenol 182:683-688, 2004

Diagnosis – Non Invasive

CTV and MRV– CTV evaluate portal , genital and renal veins, separate imaging later for

pelvic and iliocaval veins

– Ovarian vein Incompetent : completely opacified during arterial

phase

Dilated : >7mm at greatest diameter

– Search for other causes , mainly endometriosis, venous obstructive disease

– Severely underestimate venous disease , performed supine

Rozenblit AM, et al: Incompetent and dilated ovarian veins: a common CT finding. AJR AM J Roentgenol 176119-122, 2001

Diagnosis

Left ovarian vein

Diagnosis

Phlebography

– Gold standard

– Common femoral v or Jugular v approach

– Urinary catheter

– Image both Internal iliac v and Gonadal v

– with/without Valsalva m.

– 4F or 5F Cobra 2 catheter, Simmons for right gonadal v

– Study of Iliac v , IVC and LRV for obstructive disease

Diagnosis

Phlebographic criteria

Beard and colleagues and Chung and Huh (values 1 to 3, >5 -> PCS)

– Ovarian vein >5mm

– Contrast retention >20s

– Congestion in the pelvic venous plexus or opacifation of the Internal iliac v (contra/ipsilateral)

– Filling of vulvovaginal and thigh varicosities

Chung M, et al:Comparison of treatments for pcs. Tohoku J Exp Med 201:131-138, 2003

Medical Treatment

Medroxyprogestorone acetate (progestin)– 30mg OD for 6 months

73% report >50% pain improvement (33% placebo)

– Not maintained 9 months after discontinuation

Goserelin acetate (GNRH agonist)– 3.6mg OM for 6 months (statistically significant

better results)

Daflon– 500mg BD for 6 months

– Statistical improvement

Soysal ME, et al: A randomized control trial of goserelin and medroxyprogesterone in the treatment of pcs Hum Reprod 16:931-939,2001

Surgical Treatment

Conventional and Laparoscopic surgery

– Ovarian and/or internal iliac vein ligation

– Ovarian and uterine artery and vein ligation

– Oophorectomy uni/bilateral, hormone replacement therapy

– Total hysterectomy

Surgical TreatmentSeries No of

patientsTechnique Follow

up (Mo)

Asymptomatic (%)

Improved (%)

Rundquist et al

15 LOV restriction 67 73

Beard et al 36 Hysterectomy+ bilat OO +HRT 12 100

Richardson et al

67 OV resection ns 87

Belenky et al 13 Lt nephrectomy+ LOV ligation ns 54 23

Tourne et al 8 OV resection 14 100

Scultetus et al

125

OV resectionIITD

148 91.760

Chung and Huh

2727

Hysterectomy+ bilat OO +HRTHysterectomy+ unilat OO

2122

Improv.No improv.

Gargiulo et al

23 Bilat OV ligation 12 100

Endovascular treatment

Coil embolisation and/or Foam sclerotherapy

Some rules :

– Whole internal iliac v must NOT be embolised (balloon occlusion, avoid main trunk embolization)

– Embolisation of gonadic v proximal to last collateral (prevent recurrences)

Endovascular treatment

Coils .035 for 4F/5F

Vascular plugs (Amplatzer)

Foam

– Before coiling

– Sandwich techique (coil plus 2% polidocanol) greater improvement rate

Endovascular treatment

Complications <4%

– Hematoma access site

– Extravasation of contrast

– Coil/glue embolization

– DVT

– Pulmonary embolism

– Transient cardiac arrhythmia

Endovascular treatmentSeries No of

patientsVeins Technique Follow

up(Mo)Improved (%)

Kim et al 127 OV Gelfoam+sodiummorrhuate+coils

45 83

Chung and Huh

52 OV Coils 26.6 Stat. impr.

Kwon et al 67 OV Coils 40 82

Maleux et al 41 OV Enbucrilate+coils 19.9 68.2

Pieri et al 33 OV 3% STS 9 61

Creton et al 24 OV+IIVT Coils 36 76

Machan et al 23 OV Coils 15 78

Richardsonand Driver

28 OV Coils + foam 22.2 Stat. impr.

Thank you for your attention!