Interventional treatment of pelvic congestion syndrome. Geert Maleux, MD, PhD Department of Radiology University Hospitals Leuven

Interventional treatment of pelvic congestion syndrome Geert Maleux, MD, PhD Department of Radiology University Hospitals Leuven Introduction: defin...
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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 [email protected]

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