Pelvic Congestion Syndrome: When to Treat and How

Gloria Salazar, MDMassachussets General Hospital

Boston, MA

Faculty Disclosures

Gloria Salazar: Consultant – Medtronic Vascular

Dr. Gloria Salazar has disclosed that the off-label use of Wallstentfor vein stenting will be discussed.

Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.

When to Treat?Checklist• Clinical history: 3Ps (postural, post-coital,

and pelvic pain)• Obstruction vs Reflux (US, MRV)

• Associated conditions: Vulvar varices, Escape points, Hematuria, Back pain

• Non-saphenous varicosities in the leg?

• Trial of ovarian suppression

Rule out• Endometriosis• Fibroids

• Malignancy• Pelvic infection• Mass–effect

• Neurological dx

Where?

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Internal iliac

veins Left

Renal vein

Ovarian veins

Gonadal vein refluxPelvic VaricesMay-Thurner Syndrome

Escape points

Nutcracker Syndrome

Journal of Vascular and Interventional Radiology 2019 30, 781-789DOI: (10.1016/j.jvir.2018.10.008) Copyright © 2018 SIR Terms and Conditions

Research Priorities in Pelvic Venous Disorders (PeVD) in Women: Recommendations from a Multidisciplinary Research

Consensus Panel

US Deep Veins Protocol

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Vein diameter >5 mm crossing the uterine body Specificity of 91%(95% CI;77-98%)

Reversed caudal flow ovarian vein sensitivity 100% (95% CI; 84-100%)Ovarian vein diameter > 5 or > 6 mm PPV 71.2% or 83.3%

Pelvic varicoceles: sensitivity/ specificity of 100% (95% CI; 89-100%) and 83-100%(95% CI; 66-93%)

PSV differential between LRV at point of compression & hilum Ratio >5.0 (80%/94% S/S)

>50% stenosis + post stenotic to prestenotic peak vein velocity ratio of 2.5.

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):683–688. Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg. 2007 Jul;46(1):101-7Steenbeck MP, et al. Noninvasive diagnostic tools for Pelvic Congestion Syndrome: A systematic review.Acta Obstet Gynecol Scand. 2018;97(7):776-786.Kim SH, Cho SW, Kim HD, Chung JW, Park JH, Han MC. Nutcracker syndrome: diagnosis with Doppler US. Radiology. 1996 Jan;198(1):93-7.

MRV versus another diagnostic modality (invasive venography and IVUS)

• 100 % sensitive (proximal venous obstruction)

• Specificity (22.8 %) • False-positive rate: 41.5 %

Time-resolved contrast-enhanced MR

• Dynamic assessment of the direction of flow in the ovarian veins

Massenburg BB, et al. Ann Vasc Surg. 2015;29(8):1619-1624. Yang DM, et al. Br J Radiol. 2012;85(1014):e117-e122.

How?Treatment Options PeVD

• Medical (NSAIDS/Medroxyprogesterone acetate): suppress ovarian function

• Ovarian vein ligation: open or laparoscopic

• Hysterectomy: 33% residual pain

Interventional procedures: Ovarian vein embo+/-Sclerotherapy vulvar varices +/- internal iliac veins and

stenting (vein compression)

Farquhar CM, Rogers V, Franks S, Pearce S, Wadsworth J, Beard RW. A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J Obstet Gynaecol 1989;96:1153–62Chung MH, Huh CY. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med 2003;201:131–8.Gargiulo T, Mais V, Brokaj L, Cossu E, Melis GB. Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome. J Am Assoc Gynecol Laparosc 2003;10:501–4.Beard RW, Kennedy RG, Gangar KF, Stones RW, Rogers V, Reginald PW, et al. Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelviccongestion. Br J Obstet Gynaecol 1991;98:988–92

Systematic Review of Embolization for PeVD

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2003 2002-2006 2008

2016

N=1308 (mostly reproductive age)

Champaneria R, Shah L, Moss J, Gupta JK, Birch J, Middleton LJ, Daniels JP. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess 2016;20(5).

Systematic Review of Embolization for PeVD1. No high-quality studies

2. Effectiveness: presumed prospective case series

3. N=1308 (reproductive age and parous)

4. 1/3 cases: bilateral embolization (coil placement being the dominant technique)

10Champaneria R, Shah L, Moss J, Gupta JK, Birch J, Middleton LJ, Daniels JP. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess 2016;20(5).

Not All the Same!

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Not All the Same!

1. Classic: multiparous women

2. Compression syndromes

3. Escape Points: Vulvar varices + leg

varicosities

4. Anatomical variant

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Classic PresentationGuidelines SVS/AVF

Coil embolization, plugs, or transcatheter sclerotherapy as

standard treatments,

with a grade 2B level of evidence

13Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practiceguidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53(5 suppl):2S–48S

Embolization

Ovarian vein embolization

• Combination of coils/sclerosant

• Coils alone • Sclerosants alone

Internal iliac vein embolization

• Prefer sclerosants; less nontarget embolization risk

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Venography: IVC/left renal /ovarian/common/internal iliac

Embolization of OV• Select OV distally inject liquid

embolic material: – 5% Sodium morrhuate/3 % STS mixed

with gelfoam slurry – Gelfoam slurry volume

– 3 % STS mixed with air at 1:4 ratio, inject performing Valsalva maneuver

AND /OR

• Coil embolization distal to 2-3 cm from the origin

• 100% technical success

15Daniels 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. J Vasc Interv Radiol. 2016 Oct;27(10):1478-1486.

Coils Alone Author/ Year N Procedure Outcomes

Chung and Huh 2003

106 OV or IIV embo (52) Vs. Hysterectomy (54)

Significant decrease in VAS (12 mo), more effective than hysterectomy

Creton et al.2007

24 OV or IIV embo VAS significantly decreased (dysmenorrhea/dyspareunia/ venous pain)

Kwon et al.2007

67 LOV (96%) 82% total or significant pain reduction (2 coil migrations)

Ratnam et al. 2008

218 OV or IIV embo + VV surgery

Repeat TVUS (n=193) up to 13% reflux

Asciutto et al. 2009

35 OV , IIV embo or both VAS improved/ 47% sustained improvement (45 mo)

D’Archambeauet al. 2010

193 Bilateral OV (4.7%)LOV (94.3%)ROV ( 1%)

89.2% improvement on VAS 5.7% re-embolized (3 mo – 6 years)

Sclerosants Alone

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Author/ Year N Procedure Outcomes

Pieri et al.2003

33 OV foam sclero (64% bilateral)

61% improvement of pain(1mo)7 pts transient flank pain

Gandini et al.2008

67 Bilateral OV foam sclero(3% STSF)

VAS significantly decreased(12 mo) (dysmenorrhea/dyspareunia/ urinary urgency)

Tropeano et al. 2008

20 OV foam sclero (15% bilateral)

85% women reported marked improvement (6 mo)

Tinelli et al. 2012

28 OV foam sclero (29% bilaterally)

100% technical success/need for analgesics in 21% patients

Van der Vleuten et al. 2012

21 Bilateral OV sclero or unilateral

76.2% moderate / obvious improvement (2mo survey), 42% second embo

Coils and Sclerosant

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Author/ Year N Procedure Outcomes

Venbrux et al.2002

56 Bilateral OV coil+foamsclero (Gelfoam-Morrhuate) 85% IIV coils

VAS significantly decreased(12 mo)No significant change is cycle length

Kim et al.2006

127 Bilateral OV coil+foamsclero85% IIV sclero

VAS significantly decreased(45 mo)80% significant improvement (two coil migrations)

Leal Monedero et al. 2006

239 OV/ IIV coil +/- foam sclero

50.2% women reported complete resolution 36.8% partial resolution (6 mo)

Meneses et al. 2013

10 Combined OV/ IIV Sclero + Sodium morrhuate +coil

VAS significantly decreasedVCSS significantly decreased (3 months)

Results

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. J Vasc Interv Radiol. 2016 Oct;27(10):1478-1486.

• No predictors for clinical improvement

• Best results in multiparous women

• Coils alone (89% and 100%) of clinical improvement vs sclerosants (75%)

• Short-term pain and fevers are common with sclerosants vs. coils

Variant 2- Compression Syndromes Iliac Vein Compression

• Stenting

• More data available

Renal Vein Compression

• IR– Stenting

– Embolization

• Surgical – LRV/SMA transposition/Gonadocaval bypass

Reed NR, Kalra M, Bower TC, Vrtiska TJ, Ricotta JJ 2nd, Gloviczki P. Left renal vein transposition for nutcracker syndrome. J Vasc Surg. 2009 Feb;49(2):386-93

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PeVD and Iliac Vein Stenosis

Santoshi RKN, Lakhanpal S, Satwah V, Lakhanpal G, Malone M, Pappas PJ. Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2018 Mar;6(2):202-211. doi: 10.1016/j.jvsv.2017.09.007. Epub 2017 Dec 29.

• 80% pts (significant iliac vein stenosis)

22Santoshi RKN, Lakhanpal S, Satwah V, Lakhanpal G, Malone M, Pappas PJ. Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2018 Mar;6(2):202-211. doi: 10.1016/j.jvsv.2017.09.007. Epub 2017 Dec 29.

Variant 3 – Escape Points 55

Gluteal vein Vulvar veinsPosterolateralthigh perforator

vein

Sciatic nerve vein

Popliteal fossavein

Knee perforator

vein

Lowerposterior thigh vein

Fig. 4.4 Non-saphenous vein refl ux patterns (Used with permission) [ 5 ]

4 Refl ux Management

Phlebology, Vein Surgery and Ultrasonography

Eric Mowatt-Larssen • Sapan S. Desai Anahita Dua • Cynthia E.K. Shortell Editors © Springer International Publishing Switzerland 2014

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Variant 4- Anatomical Variant

Conclusion and Key Learning Points

• Heterogeneity of studies BUT proper diagnosis and patient selection is key

• Ovarian vein and internal iliac vein embolization minimally invasive, low risk, outpatient treatment: 70-98% positive clinical response to treatment

• Stenting is also indicated in the setting of PeVD but more studies are needed

• Renal vein compression still controversial • Look for escape points veins and anatomical variants

But most importantly …

It has truly been life changing. You have taken away so much

unbearable pain. Some of my symptoms have gone away completely and others have improved substantially.

Thank you so much for understanding and validating my pain, and providing me with a treatment option.

Thank you so much Dr. Salazar you have made an immense difference in my life. I hope you can help many, many other women with

this pain and more importantly spread your expertise and knowledge of PCS in the medical community.

Gloria Salazar MD @Gsalazar_MD

Thank You