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procedure:ovarian_vein_embolization

Ovarian/Pelvic Vein Embolization

Reviewer:
Editor: Akshaar Brahmbhatt MD
Contributor: Akshaar Brahmbhatt, MD; Zachary Nuffer, MD

Introduction:

Pelvic venous disorders encompass a broad spectrum of venous anomalies that can cause pelvic pain, hematuria, pelvic, and lower extremity varicose veins, among other symptoms. Pelvic Congestion Syndrome falls under the umbrella of pelvic venous disorders. 1) In Pelvic Congestion Syndrome, incompetent ovarian veins cause reflux into and dilation of the pelvic venous system. PCS results from reflux mainly through thought the ovarian veins. This is usually due to acquired venous incompetence (e.g. increased venous capacity during pregnancy, venous dilation due to estrogen, etc.) or congenital absence of the venous valves. However, other causes of venous incompetence should be considered include Nut-Cracker syndrome, May-Thurner Syndrome, arteriovenous malformations, cirrhosis, central venous thrombosis, etc. These should be considered during patient work-up and during the procedure itself.2) 3) The pelvic venous system communicates with the veins of the pelvic organs including the uterus, ovaries, bladder, colon as well as major pelvic veins, including the iliac veins, inferior vena cava and left renal vein. These vessels also communicate through the pelvic floor and via perforating veins with the superficial and lower extremity vasculature. Due to the interconnected nature of these veins, patients can present with a variety of symptoms, including superficial pelvic varicosities, lower extremity varicose veins, urinary urgency, dysmenorrhea and dyspareunia. Although the mechanism of chronic pain is not fully understood, it is thought to result from the activation of perivascular nociceptors. 4) 5) After careful patient selection, patients may undergo catheter-based venographic evaluation of the ovarian veins through the left renal and directly from the IVC for evidence of venous incompetence, including reflux and dilation. Embolization of the incompetent ovarian veins can lead to symptomatic relief. Multiple studies have demonstrated durable symptomatic relief in patients with dysmenorrhea, dyspareunia, and urinary urgency.6)

Patient Selection:

Patient selection is critical when evaluating patients for pelvic congestion syndrome. It is important to consider the wide variety of other conditions that can cause pelvic pain.7)

Gastrointestinal Irritable Bowel Syndrome, Inflammatory bowel disease, Diverticulosis, etc.
Gynecological Endendometriosis, Pelvic inflammatory disease, Fibroids, Ovarian cysts, etc.
Musculoskeletal Myofascial Pain, Fibromyalgia, Ligamentous Strain, etc.
Neurological Neuralgia, Radiculopathy, etc.
Psychiatric Depression, Somatization, Abuse, etc.
Urological Cystitis, Renal Stones, etc.

Physical exam to evaluate for pelvic and lower extremity varicosities should be performed. Physical exam and patient positioning limitations may inform choice of access site, groin vs neck. Lastly, imaging can be used as an adjuvant to the history and physical exam. Trans-abdominal and Trans-vaginal ultrasound can be performed to look for dilated pelvic veins, those greater than 6mm. Advanced cross-sectional imaging such as CT and MRI can also be used for look for the presence of dilated ovarian and pelvic venous vessels while also helping to exclude other confounding pathologies.8)

Patients should be counseled on outcomes in that the vast majority of women have positive results with some improvement, but a complete resolution does not occur in the majority of cases. Additionally, a small fraction of patients experience no difference in pain symptoms. There are no known studies evaluating outcomes related to pregnancy, but several trials have reported successful pregnancy after this treatment.9) 10)


Indications:

Female patient presenting with chronic pelvic pain in the absence of other likely etiology. Factors that suggest PCS warranting catheter venography. History of multiple pregnancies, life-style factors including prolonged standing. Presence of gluteal, vulvar and/or perineal varicosities. Lower extremity varicosities originating from the upper inner thigh.

Contraindications

Absolute:

  1. Bacteremia or active infection

Relative:

  1. Concomitant or possible confounding etiologies of pelvic pain should be addressed prior to treatment of PCS.
  2. PCS tends to resolve after menopause, it may be worth considering symptomatic treatment or other etiologies in peri- and post-menopausal patients.
  3. Uncorrected coagulopathy

Outcomes

Article Study Outcome Results
Kim et al[6] (JVIR) N=131

Retrospectively treated consecutive patients followed prospectively
Visual Analog Scale for pain at 3 months, 6 months and annually (mean follow up 45 months)Mean pelvic pain significantly improved in the majority of patients 83% improved, 13% remained unchanged and 4% reported worsening symptoms.
Chung and Huh[8] (Journal of Experimental Medicine)N=106 (52 treated with embolization)

RCT (three groups, embolotherapy, hysterectomy + bilateral oophorectomy + hormone replacement therapy, hysterectomy with unilateral oophorectomy)
Visual analog scale for pain at 3, 6, and 12 months after the procedure Statistically significant decrease in VAS scores with emblotherapy and hysterectomy. However more significant decrease with Embolotherapy.
Laborda et al. [9] (CVIR) N = 202 Visual Analog Scale with follow up at 1, 3, 6 months and annually for 5 years. Clinical success in 93.85% of patients with decrease in VAS scores. Complete resolution of symptoms in 33.52% of patients.

Pre-Procedure

  • H&P
    Should document patient’s symptoms, and a thorough evaluation of potentially confounding underlying or concomitant conditions should be investigated.
    • The presence of pelvic and/or lower extremity varicosities.
    • Anatomic considerations may affect choice of access site.
    • The cardiopulmonary status may affect sedation choices.
  • Labs
    • Should include CBC, BMP, and INR
  • Imaging
    • Pre-Procedural imaging should begin with ultrasound if clinically warranted.
    • It is important to review prior imaging, as pelvic venous varicosities are often not mentioned if not the focus/indication for the study.
    • Many patients with pelvic congestion syndrome often go through an extensive work up to rule out other conditions, a review of these studies and tests can be helpful to look for potentially missed diagnosis, anatomic considerations, etc.

Procedure

  • Anesthesia
    • Moderate sedation is the preferred method of anesthesia. Anesthesia consultation can be considered in patients with a high risk of sedation related complications.
  • Positioning
    • Patients are positioned in the supine position with the arms at the side.
  • Access
    • Percutaneous access is usually obtained via the right femoral or jugular approach. The Jugular approach may facilitate easier access into the gonadal and internal iliac veins.
  • Trajectory/Selection
    • After access is obtained into the venous system, the bilateral ovarian veins should be selectively catheterized. This can be accomplished using a hydrophilic catheter (most commonly a Cora 2 or Sim 1) and guidewire.
    • The left ovarian vein drains into the left renal vein in greater than 99% of all individuals. The right ovarian vein can be more variable with the majority 60% draining to the IVC and about 30% draining to the right renal vein. Right ovarian veins can also drain into intrarenal branches. 11)
    • Once selected contrast runs should be performed to evaluate for PCS at rest and during Valsalva.
    • In addition to venous reflux in the ovarian vein findings of PCS include dilated pelvic veins and slow flow pelvic, vulvovaginal or thigh veins. 12) In addition to the venographic signs of PCS, one should also consider PCS secondary to Nut-Cracker syndrome and May-Thurner.13) 14)
    • If venographic evidence of PCS is found, embolization can be performed using coils, occlusion devices, liquid sclerosants, foam sclerosants or a combination. Embolization of the entire ovarian veins is recommended to prevent recanalization or the formation of new varicosities. 15)
    • Most embolization is started in the pelvis inferior to the lower half of the sacroiliac joint. Then the gonadal vein is excluded with micro coils or via a .035” system, however liquid embolic and sclerosants can be used in combination with balloon occlusion. Many providers employ a sandwich technique by placing a distal and proximal coil, which is then filled in with liquid embolic. Vascular occlusion plugs have also been used. The decision to embolize both sides varies based on anatomic and venographic findings, as well as the degree of reflux. 16)17)
    • In addition to the bilateral ovarian veins, the internal iliac veins should also be evaluated for venous incompetence. If found, these should also be treated. Given the extensive nature of these vessels and the increased flow, a balloon occlusion technique with liquid or foam sclerosants should be used after a test injection. 18)19)

:popcorn: ButterBoy Pro-Tip
Sandwich Technique
Use a 6 F Fogarty balloon catheter and 0.035“ coils. Deploy the coils through the catheter and then inflate the balloon and inject the sclerotherapy solution (e.g. 2 mL 3%Sodium_tetradecyl_sulfate + 1 mL lipiodol foamed with 6 mL air.) Wait 5 minutes and then deploy then next set of coils. Retract and repeat.


Post-Procedure

Multiple studies have reported transient pain following embolization or a “post-embolization syndrome” which included lumbar pain, transient fever. Patients can also develop phlebitis at the access site. These can be treated symptomatically with non-steroid anti-inflammatory medication and usually self-resolve. 20) 21)


Complications

The majority of complications do not result in significant morbidity or mortality. The most common finding after treatment is transient pain after embolization. This is more common with the use of sclerosants. 22)

Complication Frequency
Transient pain following embolization 8-100%
Coil Migration or embolic <2%
Vein Perforation <1%

Follow Up

Patients should be followed clinically. It is recommended that patients are followed up in clinic several weeks and again several months after the procedure to access for symptom recurrence and possible venous recanalization. 23)


Images

Sclerosis through a Fogarty balloon catheter
Completed STS and coil embolization
1) , 4)
Khilnani NM, Meissner MH, Learman LA, Gibson KD, Daniels JP, Winokur RS, et al. Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel. Journal of Vascular and Interventional Radiology. 2019;30(6):781-9. doi: 10.1016/j.jvir.2018.10.008.
2) , 11)
Borghi C, Dell'Atti L. Pelvic congestion syndrome: the current state of the literature. Arch Gynecol Obstet. 2016;293(2):291-301. Epub 2015/09/26. doi: 10.1007/s00404-015-3895-7. PubMed PMID: 26404449.
3) , 13)
Khan TA, Rudolph KP, Huber TS, Fatima J. May-Thurner syndrome presenting as pelvic congestion syndrome and vulvar varicosities in a nonpregnant adolescent. J Vasc Surg Cases Innov Tech. 2019;5(3):252-4. Epub 2019/07/16. doi: 10.1016/j.jvscit.2019.02.008. PubMed PMID: 31304434; PubMed Central PMCID: PMCPMC6600079.
5) , 6)
Brown CL, Rizer M, Alexander R, Sharpe EE, 3rd, Rochon PJ. Pelvic Congestion Syndrome: Systematic Review of Treatment Success. Semin Intervent Radiol. 2018;35(1):35-40. Epub 2018/04/10. doi: 10.1055/s-0038-1636519. PubMed PMID: 29628614; PubMed Central PMCID: PMCPMC5886772.
7) , 8)
Phillips D, Deipolyi AR, Hesketh RL, Midia M, Oklu R. Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management. Journal of vascular and interventional radiology : JVIR. 2014;25(5):725-33. Epub 2014/04/22. doi: 10.1016/j.jvir.2014.01.030. PubMed PMID: 24745902.
9)
Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. Journal of vascular and interventional radiology : JVIR. 2006;17(2 Pt 1):289-97. Epub 2006/03/07. doi: 10.1097/01.Rvi.0000194870.11980.F8. PubMed PMID: 16517774.
10) , 20) , 22)
Daniels JP, Champaneria R, Shah L, Gupta JK, Birch J, Moss JG. Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review. Journal of vascular and interventional radiology : JVIR. 2016;27(10):1478-86.e8. Epub 2016/07/12. doi: 10.1016/j.jvir.2016.04.016. PubMed PMID: 27397619.
12)
Arnoldussen CW, de Wolf MA, Wittens CH. Diagnostic imaging of pelvic congestive syndrome. Phlebology. 2015;30(1 Suppl):67-72. Epub 2015/03/03. doi: 10.1177/0268355514568063. PubMed PMID: 25729070.
14)
d'Archambeau O, Maes M, De Schepper AM. The pelvic congestion syndrome: role of the “nutcracker phenomenon” and results of endovascular treatment. Jbr-btr. 2004;87(1):1-8. Epub 2004/04/02. PubMed PMID: 15055326.
15) , 16) , 18) , 21) , 23)
Koo S, Fan C-M. Pelvic Congestion Syndrome and Pelvic Varicosities. Techniques in vascular and interventional radiology. 2014;17(2):90-5. doi: https://doi.org/10.1053/j.tvir.2014.02.005.
17) , 19)
Corrêa MP, Bianchini L, Saleh JN, Noel RS, Bajerski JC. Pelvic congestion syndrome and embolization of pelvic varicose veins. J Vasc Bras. 2019;18:e20190061. Epub 2019/11/26. doi: 10.1590/1677-5449.190061. PubMed PMID: 31762775; PubMed Central PMCID: PMCPMC6852702.
procedure/ovarian_vein_embolization.txt · Last modified: 2020/07/22 17:57 by admin