Interventional treatment of pelvic congestion syndrome Geert Maleux, MD, PhD Department of Radiology University Hospitals Leuven
Introduction: definition of PCS • Varices of pelvic veins associated with • noncyclic abdominal and pelvic pain • > 6 months of duration
• Exclusion of other pelvic causes of pelvic pain • • • • • • • •
endometriosis uterine myomata malignant tumors adenomyosis prolapse inflammatory processes irritable bowel syndrome ….
Introduction : definition of PCS • Varices of pelvic veins associated with • noncyclic abdominal and pelvic pain • > 6 months of duration • • • • • • •
pain is worse during premenstrual period fullness in the legs increase after coitus bladder irritability & frequency varicose veins on both sides of the vulva upper thigh varices ….
Etiology of PCS • Multifactorial – absence of ovarian vein valves – mechanical factors • dilatation of the vein -> pregnancy
– hormonal factors • premenopausal women
– external vascular compression • nutcracker syndrome • left renal vein (aorta – SMA)
– secondary ovarian vessel compression • portal hypertension • acquired inferior vena cava syndrome
Radiological diagnosis • Duplex ultrasound (MRI / CT) – – – – – –
dilated left ovarian vein slow blood flow - reversed caudal flow dilated arcuate veins crossing the midline variable duplex waveform during Valsalva maneuver polycystic changes in the ovaries
Park et al. Am J Roentgenol 2004
Radiological diagnosis • Gold standard: invasive catheter-based venography • Pre/postprocedural care – – – – –
ambulatory procedure local anesthesia (right groin) venous puncture / manual compression 4 hours bed rest anti-inflammatory medication (post-embolization syndrome)
Bittles et al. Semin Intervent Radiol 2008
Invasive venography • • • •
sterile draping local anesthesia dedicated angio suite (ultrasound-guided) puncture right common femoral vein • catheterization of the renal veins – – – –
cobra-like catheter iodized contrast medium semi-upright position Valsalva maneuver
Invasive venography • Venographic signs of PCS – – – – –
reflux of contrast medium into the ovarian vein diameter of the insufficient ovarian vein ≥ 1 cm opacification of the utero-ovarian venous plexus crossing the midline opacification of • • •
contralateral (right) ovarian vein vulvovaginal varices thigh varices
• Other veins – right ovarian vein (inferior vena cava) – right / left internal iliac vein
What and how to embolize • Goal of endovascular therapy – completely occlude the insufficient ovarian vein / proximal internal iliac vein: no more reflux – no embolization of deep pelvic veins or utero-ovarian venous plexus
• Technique – guiding catheter 6F (Cook Medical, Bjaeverskov, Denmark) – Microcatheter (>< spasms) – embolics
What and how to embolize Which embolics? – coils / microcoils – Amplatzer plugs – glue • Enbucrilates . Histoacryl / Lipiodol . Trufill . Glubran
• Onyx?
– detergent liquids • aethoxisclerol • foamed sodium tetradecyl
Pros and cons of these embolics Glue – Pros: • • • •
fast complete occlusion of the whole vein very low recanalization rate cheap
– Cons: • experienced operator • painful • post-embolization syndrome
Pros and cons of these embolics Coils – Pros • no pain • common use of coils: most interventional radiologists are familiar with coils / microcoils • availability of coils
– Cons • time consuming - increasing radiation dose • cost of coils • late recanalization of the coiled segment
Procedures complications • Non-target embolization – coil / glue migration to the lung circulation (lung embolus) – renal vein / inferior vena cava (local thrombosis)
• Post-embolization syndrome (glue) – abdominal pain (2-4 days): infiltration of the perivascular soft tissues – mild fever (38°C) – nausea – anti-inflammatory medication
Early recurrence / no improvement • Technical failure – suboptimal vein occlusion • collaterals above and below the occluded segment • technically inadequate occlusion • incomplete search for insufficient pelvic veins
• Insufficient pelvic vein – not (only) the cause of the pelvic pain
Late recurrence
• Collaterals above and below the occluded segment • Recanalization of the coiled / glued veins
Clinical results : long-term outcome
Clinical results
Conclusions: PCS • Clinical diagnostic challenge • Radiological tools – duplex ultrasound – (MR – CT) – invasive catheter-based venography
• Embolization procedure – safe / ambulatory procedure – low complication rate – clinical improvement: 40% – 80%
THANK YOU FOR YOUR ATTENTION
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