Pelvic Congestion Syndrome

Pelvic Congestion SyndromeDurham JD, Machan LSemin Intervent Radiol. 2013;30:372380Presentan: Daniel N. AjiDesember 2014EpidemiologyChronic pelvic pain in women 18-50 yo: 15% (USA)60% women with chronic pelvic pain the cause remains undiscoveredChronic pelvic pain pelvic congestion syndrome (PCS)PCS: 31% in symptomatic populationBelenkey et al (2002): ovarian varices prevalence 9.9% (27/273); mostly reported chronic pelvic pain

27/273 22 of 27 reported chronic pelvic pain2DefinitionChronic pelvic pain: noncyclic pelvic pain of more than 6 months duration Pelvic congestion syndrome: chronic pelvic pain secondary to PVI and associated pelvic venous distensionPelvic venous insufficiency: retrograde flow through incompetent gonadal and pelvic veinsBlack CM, Thorpe K, Venrbux A, et al. Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol 2010;21:796 803Anatomy

Lower uterus & Vagina uterine vein internal iliac veinLeft ovarian plexus left ovarian vein left renal vein Right ovarian plexus inferior vena cavaPatophysiologyPCS: ovarian vein reflux and/or pelvic varicosities (Ovarian vein diameter >5 mm)Primary: congenital / aqcuired ovarian vein absence/incompetence (nonobstructive)Secondary: nutcracker syndrome, May-Thurner syndromeWomen > men, multiparous womenOvarian varicosities are seen more frequently after pregnancyMany pelvic veins are devoid of valves and have weak attachments between the adventitia and supporting connective tissue nutcracker syndrome (left renal vein compression by the superior mesenteric artery) or MayThurner syndrome (left iliac vein compression by the right internal iliac artery), 5

Venkatachalam S, Bumpus K, Kapadia SR, Gray B, Lyden S, Shishehbor MH. The nutcracker syndrome. Ann Vasc Surg 2011;25(8): 11541164DiagnosisPCS: clinical syndrome + anatomic findings chronic pelvic pain of greater than 6 months duration secondary to PVI and associated pelvic venous distentionSymptoms: Noncyclical, positional lower back, pelvic, and upper thigh painPain is exacerbated before or during menses and may be associated with dyspareunia and prolonged postcoital discomfortmost severe at the end of the day, exacerbated by standing or heavy activity, and are diminished with supine positioning.

Diagnosis (2)Pelvic examination: cervical motion and ovarian point tenderness. Postcoital ache + ovarian point tenderness 94% sensitive and 77% specific for PVI Patients undergoing evaluation for PCS and PVI fall into: incidentally found pelvic varicesunusual vulvar or upper thigh varices that complicate lower extremity insufficiency with or without pelvic pain painful pelvic varicosities secondary to PVI

Jung SC, Lee W, Chung JW, et al. Unusual causes of varicose veins in the lower extremities: CT venographic and Doppler US findings. Radiographics 2009;29(2):525536In general, valvular incompetence of the ovarian veins is thought to result in vulvoperineal varicosity. 9

Jung SC, Lee W, Chung JW, et al. Unusual causes of varicose veins in the lower extremities: CT venographic and Doppler US findings. Radiographics 2009;29(2):525536Imaging EvaluationExclude common causes of intrinsic pelvic pathology (endometriosis, PID, postoperative adhesions, adenomyosis or leiomyoma) Transabdominal + transvaginal US pelvic varices and ovarian venous refluxSonographic findings: enlarged ovarian veins greater than 6 mm in diameter with reversed bloodflow; pelvic varicocele (>5 mm); dilated (>5 mm) arcuate veins crossing the uterine myometrium between pelvic varicoceles

Park SJ, Lim JW, Ko YT, et al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol 2004;182(3):683688

Park SJ, Lim JW, Ko YT, et al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol 2004;182(3):683688Imaging Evaluation (2)Venography is indicated when a suspicion for PCS exists (although US normal)Confirm the diagnosis & therapyVenography findings: Renal vein reflux into dilated ovarian veins (>5mm),stagnation of contrast in the pelvic veins, contralateral reflux across the midline, and demonstration of vulvoperineal or thigh varicesTreatmentCoil embolization of the ovarian vein, unilaterally or bilaterally, has been the most common approach to eradicate ovarian vein refluxPartial or significant relief of symptoms in 70 to 100% patients Improvement in 82% with coil embolization alone (Kwon 2007)Improvement of VAS in 94% patients (Laborda 2013)

Laborda 2013: All procedures were performed via right common femoralvein under local anesthesia, with a 5-Fr introducer sheath(Radiofocus, Terumo Europe, Leuven, Belgium). Catheterization of the ovarian veins was accomplished with a 5-FrCobra II catheter (Terumo Europe) or, in some cases, weselected a 5-Fr Simmons I or II catheter (Cordis Johnson &Johnson Europe NV; Roden, Netherlands) over a hydrophilic guidewire (Glidewire, Terumo Europe). At the sametime, the hypogastric, external iliac, and common femoralveins were evaluated. Systematic catheterization was followed beginning with the left renal vein and performing aretrograde venogram, under Valsalvas maneuver.Embolization started at the lower aspect of the ovarianvein, trying to avoid the occlusion of the deep pelvicplexus, with 0.035 stainless steel or fibered platinum coils(Nester coil, Cook Europe, Bjaeverskov, Denmark) ofseveral sizes (420 mm). During the interventional procedure, the following data were gathered: occluded venousaxis (left ovaric, right ovaric, left hypogastric, and righthypogastric), intervention time length, radiation dose, andcomplications15

Kwon SH, Oh JH, Ko KR, Park HC, Huh JY. Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol 2007;30(4):655661With the patient in a supine position, venographic accesswas obtained with the Seldinger technique via the rightcommon femoral vein, or using the internal jugular venousapproach. The guidewire was advanced into the inferiorvena cava (IVC) and, after placement of a 6 Fr introducersheath and a 5 Fr Cobra catheter (Cook, Bloomington, IN,USA), a selective left ovarian venography was performedto evaluate the left ovarian vein both during normalbreathing and with Valsalvas maneuver. After the leftovarian venography, the right ovarian vein was selectivelycatheterized and venography was performed. A selectiveright ovarian vein study was performed with direct cannulation from the IVC. The IVC and the left renal veinpressures were not routinely measured. However, possiblecompression of the left renal vein by the superior mesenteric artery (SMA) was carefully considered while performing venography.Indications for coil embolization included: (1) dilatationof the ovarian vein (>5 mm), (2) ovarian vein reflux intothe pelvic cavity involving an incompetent valve, (3) severe congestion of the pelvic venous plexus, (4) significantstasis of contrast medium in the pelvic veins, (5) abnormalfilling of the pelvic veins across the midline, and (6) fillingof vulvovaginal or thigh varicosities. An enlarged orincompetent ovarian vein was treated with transcathetercoil embolization. Parallel ovarian vein trunks that enteredthe main trunk or that directly entered the left renal veinwere embolized as well. However, we did not performsmall collateral vein embolizations along the main ovarianvein, selectively.Embolizations were performed using coils of optimalsize and number (0.0350.038 inch, 515 mm, Cook,Bloomington, IN, USA). An average of 5.8 coils (range 38) was used per embolized ovarian vein. No liquid sclerosants or other embolic substances were used. Afterembolization, repeat venography was performed to confirmocclusion of the ovarian vein as well as that of the concomitant parallel trunks.16Treatment (2)Direct sclerosing of abnormal pelvic vein was introduced by Venbrux (2002) using 5% sodium morrhuate mixed with gelfoamSignificant & partial response in 96% subjectDecrease of pain level

Gandini R, Chiocchi M, Konda D, et al. Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol 2008; 31(4): 77884Patients were treated in a day-hospital setting. After localanesthesia was administered with a transdermic needleusing 2 ml of lidocaine, the right antecubital vein waspunctured using an 18-gauge needle and a 0.035-in., Jtipped, 180-cm-long hydrophilic guidewire (Radiofocus;Terumo, Tokyo) was introduced and advanced into theinnominate vein. The percutaneous access was dilated witha 5-Fr, 25-cm-long introducer sheath (Introducer II; Terumo) to avoid venous damage during subsequentmanipulations of the diagnostic catheter. A 4-Fr Simmons2 (Radiofocus Glidecath; Terumo) diagnostic catheter wasused to selectively catheterize the left ovarian vein. First,the catheter was advanced into the left renal vein and,during Valsalvas maneuver, a preliminary renal phlebography was performed to visualize the confluence of theovarian vein. Then the ovarian vein was selectivelyengaged by the tip of the catheter, and a retrograde phlebography by energetic hand injection of contrast mediumwith a 20-ml Luer Lok syringe was carried out to assess thevolume of the blood in the pelvic varices and to demonstrate their anatomy.

Two 10-ml Luer Lok syringes containing 2 ml of 3%STS (Fibrovein; STD Pharmaceuticals) and 8 ml of air,respectively, were connected through a three-way stopcockand their contents were mixed together until a homogeneous foam was obtained. In the case of cross-pelvicvarices, TCFS was only performed from the left ovarianvein using*30 ml of STS foam (Fig.1). In the case ofnon-cross-pelvic varices, *30 ml of STS foam wasselectively injected distally through the left ovarian veininto the varices (Fig. 2). A contralateral ovarian phlebography was then performed using a 4-Fr multipurposecatheter (Torcon NB Advantage; William Cook EuropeApS, Bjaeverskov, Denmark) to assess the eventual presence of right ovarian varices. When ovarian varices werefound also on this side, *20 ml of STS foam was selectively injected distally through the right ovarian vein. Foaminjection was continued until no refluxing into the variceswas observed after manual injection of contrast agentthrough the catheter.STS foam was always injected while asking the patientto perform Valsalvas maneuver in order to avoid accidental dislocation of the sclerosing agent and to maximizeits effects on the endothelial surface. After the procedure,the patient was invited to maintain a moderate Valsalvasmaneuver for an additional 10 min.The patients were discharged 1 hour after the procedurewith a 3-day oral anti-inflammatory (29100 mg/day nimesulide) and a 5-day oral antibiotic (1 g/day amoxicillin)therapy. In the case of pain developing within a few daysafter the procedure, a 10-day intramuscular anti-inflammatory therapy was commenced (4 950 mg/day ketoprofen)18Gandini R, Chiocchi M, Konda D, et al. Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol 2008; 31(4): 77884

Treatment (3)Combination of multiple sclerosant & ovarian vein mechanical occlusionGandini (2008): 3% sodium tetradecyl sulfate (STS) foamFoam was injected until venous stasisVolume of sclerosant required typically ranges from 2.5 to 12.5 cc per ovarian veinTreatment (4)Treatmant of PVI secondary to nutcracker or May-Thurner syndrome limited data/ experienceSurgical approach better than endovascular?Self expanding stent?Treatment (5)Ovarian suppression with medroxyprogesterone or goserelin, or Surgical ovarian suppression with bilateral salpingo-oophorectomy Surgical VS endovascular : embolization more effective at reducing pelvic pain

ComplicationMajor complication: rareVenous access site complicationCoil migrationMild to moderate postembolization pelvic and flank painPreprocedure CareNot related to menstrual or pain cyclePatient should be restricted to clear fluids after midnight for a morning appointment, and clear fluids after breakfast for an afternoon appointment.Admission to day carePostprocedure Care and Follow UpPatient is observed for several hours to permit hemostasis at the puncture siteAvoid heavy lifting or exertion more intense than walking for 3 to 7 days postdischargeFirst menstrual period after embolization is often unusually heavyReevaluation at 3 months (transvaginal US)Unimproved pain at 6 month indication to repeat venography (recanalized ovarian vein, undiagnosed outflow obstruction, continued filling or pelvic varicosities)Case 143 yo G3P3 with pelvic pain for 7 years, worsened since last pregnancy (4 years)Large left-sided vulvar varices, hemorrhoidDull generalized ache, worse with exercise, at the end of the day, and excruciating for 2 to 3 days before period, severe cramping after intercourseHer mother and grandmother had similar symptoms

ApproachBefore venography, patient was sedated (5 mg of versed and 200 g of fentanyl)A sheath was introduced into the right internal jugular vein Multipurpose catheter was directed into the left renal vein and a diagnostic renal venogram performed during Valsalva maneuver

3 months laterPain improvedDyspareunia had not resolvedTransvaginal US: residual paraovarian veins, with normal Valsalva

Case 231 yo, premenopausal, nulliparous with pelvic pain (left inguinal area) worsened over 2 yearsPain worse with menses and ovulationHemorrhoids and urinary frequency, postcoital painThere isnt lower extremity or vulvoperineal varicositiesNutcracker syndrome (CT demonstrated renal vein compression and an enlarged left gonadal vein)

1 month later: pelvic pain resolved, left flank pain persistedThis case demonstrates the need to relieve downstream obstruction when PVI is found to be secondary to another underlying causeCase 345 yo, G4P2 with vulvar varices, recurrent lower extremities varices, no pelvic painClinical exam: extensive varicose veins in the greater saphenous distribution bilaterally, and left vulvar varicositiesTransvaginal US: dilated paraovarian veins with abnormal Valsalva flow accentuation, worse on the leftVenography: Marked left ovarian vein refluxLeft ovarian vein was embolized using STS and coils

3 months later: vulvar and varicose veins were unchanged.Patient underwent direct puncture and sclerotherapy 2.5 cc of 0.5% STS foam was injected on the left and 1.5 cc on the right

conclusionPCS is diagnosed clinically + ImagingThe Society of Vascular Surgery has recommendaed the endovascular treatment of PCSEndovascular therapy: eliminate ovarian refluxUpstream obstruction needs to be amelioratedThank you