Journal of Vascular Surgery
Volume 28, Issue 5 , Pages 862-868, November 1998

Pelvic congestion syndrome: Early clinical results after transcatheter ovarian vein embolization☆☆☆★★★

Presented at the Tenth Annual Meeting of the American Venous Forum, Lake Buena Vista, Fla, Feb 18–21, 1998.

Honolulu, Hawaii

Received 25 February 1998; accepted 8 May 1998.

Article Outline

Abstract 

Purpose: This case series describes the early radiographic and clinical results of attempted transcatheter ovarian vein (OV) embolization in 11 women with symptoms that were suggestive of the pelvic congestion syndrome (PCS). Methods: Eleven women (mean age, 33.1 years) who were multiparous were referred for lower extremity or vulvar varicosities (n = 8) or for tubo-ovarian varicosities (n = 3). After a clinical diagnosis of PCS was established, the women underwent ovarian (n = 5) or ovarian and iliac vein (n = 6) venography. Enlarged or incompetent OVs were embolized with 0.035-inch stainless steel coils or with 0.018-inch platinum microcoils and absorbable gelatin sponge. Incompetent tributaries to hypogastric veins were embolized as well (n = l). Symptoms before embolization and after embolization were recorded with a standard questionnaire, and the post-embolization symptoms were expressed as individual and overall percent relief. Results: Nine of the 11 women underwent embolization. Embolization of both OVs (n = 4), of the left OV alone (n = 4), or of a left obturator vein that communicated with vulvar varices (n = l) was performed. Eight of the 9 women (88.9%) had more than 80% immediate relief. Overall and individual symptom relief varied from 40% to 100% at the mean 13.4-month follow-up. One woman with variant anatomy and one woman with evidence of prior left OV thrombosis were not treated. There were no major complications. Two women had a mild to moderate return of the symptoms at 6 and 22 months. Conclusions: Transcatheter embolization provides excellent initial and variable midterm relief in women with typical PCS symptoms and with OV or OV and internal iliac (hypogastric) tributary vein incompetence. This interventional technique may replace or complement the traditional surgical approaches to this rarely recognized and poorly understood disease. (J Vasc Surg 1998;28:862-8.)

 

Chronic pelvic pain (CPP), defined as noncyclic abdominal and pelvic pain of at least 6-months duration, may account for approximately 10% of outpatient gynecologic visits and for one third of diagnostic laparoscopy performed.1 The contributing causal conditions include the following: endometriosis, pelvic adhesions, atypical menstrual pain, urologic disorders, irritable bowel syndrome, and psychosocial issues. The diagnosis and the management of CPP are difficult, and exhaustive evaluation often identifies no specific organic cause. In the late 1940s and the early 1950s, investigators reported the findings of venous pelvic congestion in women with CPP.2, 3, 4, 5, 6 A 1966 autopsy series7 and a 1968 series of selective renal venography8 supported the concept of ovarian vein (OV) incompetence as a potential cause for CPP. In 1984, a series that correlated laparoscopic and venographic findings in women with unexplained CPP showed that up to 91% of the women had marked pelvic venous congestion.9 Pelvic congestion syndrome (PCS), a condition associated with OV incompetence, is manifested by pelvic pain of variable intensity that is heightened before or during menses and that is aggravated by prolonged standing, fatigue, and coitus. Women also may report pelvic or perineal heaviness and bladder urgency. The traditional therapy for PCS has included both medical approaches (eg, dihydroergotamine, ovarian suppression, and rheologic agents) and surgical approaches (uterine ventrosuspension, hysterectomy, OV ligation, and excision). This paper is a consecutive case series that describes the early clinical and radiographic results of OV embolization, a relatively recent, less invasive approach to perhaps more accurately diagnose and definitively treat women with this troubling disorder.

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MATERIALS AND METHODS 

Duplex scanning 

Lower-extremity venous duplex scan studies (Advanced Technology Laboratories, HDI 3000, Bothell, Wash) were performed when indicated with a P32 2 to 5 MHz sector probe to evaluate varicose veins. The women were positioned in 20-degree reverse Trendelenburg position. The methods used to produce reflux included proximal compression and Valsalva's maneuver. The greater saphenous vein, the lesser saphenous vein, the common femoral vein, and the popliteal veins were interrogated. In addition, bilateral OV duplex studies were attempted (with an L47 4 to 7 MHz linear array probe; Advanced Technology Laboratories) with the women in a similar position via an anterior transabdominal approach. Valsalva's maneuver was used to elicit reflux.

Venography 

With the patient in a supine position, venographic access was obtained with the Seldinger technique via either a right common femoral vein or with an internal jugular vein approach, and a guidewire was advanced into the inferior vena cava (IVC). After the placement of a 6F introducer sheath and a 5F Cobra catheter (Cook, Bloomington, Ind), a left renal venogram was performed to evaluate the left OV during both normal breathing and Valsalva's maneuver. The IVC and the left renal vein pressures were not measured routinely. Selective proximal and distal injection of the left OV then was performed (Fig l A).

  • View full-size image.

  • Fig l. A, Selective left OV injection shows free reflux into broad ligament. Maximum left OV diameter is 12 mm. B, Left OV is successfully embolized to proximal aspect. Note circumaortic left renal vein. C, Right OV dilation and reflux shown on selective injection. Note small distal parallel ovarian vein channels (frequent finding).

An enlarged or incompetent left OV was treated with transcatheter coil embolization with Gianturco 0.035-inch stainless steel coils (Cook) or 0.018-inch platinum microcoils (Cook; Fig l B). An average of 16 coils was used for each OV that was embolized (range, 6 to 24 coils). No liquid sclerosants were used. Distal coil deployment occasionally required the placement of a coaxial 3F Tracker system (Target Therapeutics, Fremont, Calif) via the Cobra catheter. The criteria for embolization included the following: an OV diameter of more than 10 mm, moderate to severe congestion of the ovarian plexus, uterine venous engorgement, and filling of the contralateral pelvic veins. Parallel OV trunks that entered the main trunk or that directly entered the left renal vein were embolized as well. After embolization, repeat venography was performed to confirm OV thrombosis, the thrombosis of the concomitant parallel trunks, and the patency of the left renal vein. A selective right OV study was performed with direct cannulation from the IVC and was dealt with in similar fashion (Fig l C). Fig. 2 shows a completion kidneys-ureters-bladder after successful bilateral OV embolization.

The iliac vein studies consisted of left and right common iliac and external and internal iliac vein injections. Enlarged or incompetent internal iliac tributaries or tributaries that communicated with vulvar varices were embolized after selective internal iliac vein catheterization. Left common iliac vein compression was evaluated further with the measurement of pressure gradients. Patients with vulvar varices underwent vulvar varicography in an attempt to identify a source of reflux.

Questionnaire 

A standard questionnaire was administered by the primary author both before and after the embolization. The women were asked to express symptomatic relief as a percent relief of each presenting symptom (eg, pelvic pain with long periods of standing: 80% relief after embolization).

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RESULTS 

Eleven women were referred to the vascular clinic for the evaluation of the following: lower extremity varicosities (n = 6), vulvar varices (n = 2), tubo-ovarian varicosities diagnosed either by laparoscopy for chronic pelvic pain (n = l) or by transvaginal ultrasound scan for chronic pelvic pain (n = l), or laparotomy for chronic abdominal pain (n = l). Ten women were multiparous (Gravida 2 Para 2 or higher), and one was primigravida. Seven women had pelvic symptoms after the second or third pregnancy, and four after the first. Eight women reported either lower-extremity varicose veins (n = 5) or spider telangiectasias (n = 3). One woman had undergone 2 prior right lower-extremity venous surgeries. Physical examination revealed vulvar varices in 9 women and varices involving the buttocks in 3 women. Pelvic congestion symptoms of the 11 women at presentation are shown in Table I.

Table I. Pelvic congestion symptoms of 11 women at presentation
SymptomsNo. of women (%)
Long periods of standing11 (100)
Perineal heaviness9 (82)
Postcoital discomfort9 (82)
Discomfort with fatigue9 (82)
Premenstrual pelvic pain8 (73)
Bladder urgency7 (64)
Dyspareunia6 (55)
Pelvic pain during menses3 (27)

Six women underwent lower extremity duplex scanning. All of the deep and superficial veins were competent in each woman, except for one in whom the greater saphenous vein was incompetent. Two women underwent OV duplex scanning. In one, neither OV could be seen despite a clear visualization of the left renal vein and the IVC. In the other, a vein without reflux was seen that was presumed to be the left OV. Subsequent venography in both women showed chronic left OV occlusion and normal-caliber competent right OVs.

All of the women (n = 11) underwent venography. Nine women underwent embolization with a mean follow-up of 13.4 months (range, 3 to 28 months). One of the attempted embolizations was postponed for 1 week as a result of early contrast extravasation (88.9% initial technical success). Post-embolization results are shown in Table II.

Table II. Average percent relief by symptoms at most recent follow-up in 9 women who underwent embolization
No. of women with symptoms*Average improvement(%)Range(%)
Postcoital discomfort68340 to 100
Perineal heaviness78140 to 100
Long periods of standing98040 to 100
Bladder urgency67850 to 100
Discomfort with fatigue87240 to 100
Premenstrual pelvic pain97040 to 100
Dyspareunia3600 to 100
Pelvic pain during menses140—

*Not all women complained of every symptom upon presentation.

Mean follow-up time was 13.4 months.

The data are expressed as average percent relief with symptoms in descending order from symptoms most relieved to least relieved. Table III shows venographic findings, treatment, overall percent relief, and pertinent data by patient. Four patients underwent left OV embolization alone. Among the 4 patients, in 3, the right OV could not be located, and, in 1, it appeared competent.

Table III. Venographic findings, treatment, and relief (by patient)
Patient no.Age(years)Veins studiedFindingsEmbolizationVariant anatomyVenographic complicationsOverall % reliefFollow-up (months)
137Left OVLeft OV incLeft OVRetroaortic left RVContrast extravasation95%4
231Bilateral OVBilateral OV enlarged, incBoth OVsNoneLeft lower lobe coil pulmonary embolus(retrieved)90%, until 22 months; 40%, 22 to 28 months28
343Left OVLeft OV incLeft OVNoneNone80%19
429Left OVLeft OV enlarged, incLeft OVNoneContrast extravasation85%16
535AllBilat OV enlarged, incBoth OVsLeft common iliac vein compressionNone100%, 4 to 6 months; 80%, after 6 months17
627Bilateral OVLeft OV inc; right OV competentLeft OVCircumaortic left RVNone95%13
740AllOVs not locatedNonePersistent left IVC, crossed renal ectopiaNoneNot embolized12
834AllBilat OV enlarged, incBoth OVsCircumaortic left RV; left hypogastric varixNone100%7
931AllLeft OV discontinuous; right OV competentNoneNoneContrast extravasationNot embolized12
1020AllBilat OV enlarged, incBoth OVsCircumaortic left RVNone40%14
1127AllLeft OV chronic occlusionLeft obturator veinLeft obturator to external iliac vein connectionNone80%3

OV, Ovarian vein; RV, renal vein; inc, incompetent; All, both ovarian veins and both common/external/internal iliac veins; IVC, inferior vena cava.

One woman in whom the right OV could not be located had had a prior right salpingo-oophorectomy. One woman with evidence of chronic left OV thrombosis underwent embolization of the left obturator vein, which communicated with left-sided vulvar varices.

Although 8 of the 9 embolized women (88.9%) experienced excellent initial pain relief (>80%), 2 complained of symptom return. One woman (Table III, no. 3) related a 95% to 100% overall symptom relief for 22 months that then deteriorated to a 30% to 40% relief. She has not been studied again. The other woman (Table III, no. 5) noted a milder return of symptoms at 6 months after an initial 100% relief. This woman was studied again with ovarian and iliac vein venography (initial OVs only). Both OVs remained thrombosed. Left common iliac vein compression (60% diameter reduction) was shown with preferential filling of a large ascending lumbar vein. In addition, there was significant cross-filling of pelvic collaterals from left to right via the hypogastric veins. No treatment was performed. A third patient noted a 40% inital overall symptom relief with no subsequent improvement. Repeat venography at 15 months revealed only an incompetent right hypogastric vein (main trunk). No treatment was performed.

Two women were not treated (Table III, nos. 7 and 9). Venography in 1 woman (no. 7) showed a persistent left inferior cava and a crossed renal ectopia with extensive pelvic collaterals (Fig. 3).

  • View full-size image.
  • Fig. 3. 

    Right common femoral vein venogram. Selective left external iliac vein injection shows persistent left IVC and crossed renal ectopia (both right and left renal collecting systems located to right of spine); prominent pelvic venous collaterals.

Neither OV could be identified. Venography in the second (no. 9) showed a tortuous and discontinuous left OV and a normal iliac venous system. No treatment was performed in either patient.

The complications that occurred during venography included the following: a contrast extravasation in 3 women (no sequelae), a left lower-lobe coil pulmonary embolus in 1 woman (retrieved), and a self-limited tachyarrhythmia in 1 woman. There were no major morbidity rates and no mortality rate.

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DISCUSSION 

These data show that OV venography with embolization for PCS can be performed with a high degree of technical success, although the identification of the right OV-IVC confluence is difficult. Eight of the nine women (89%) treated with embolization reported excellent initial symptom relief (>80%). In 2 women, the symptoms have returned—1 mild, 1 moderate. One woman reported a 40% overall symptom relief, but repeat venography failed to identify the cause for her persistent pain. Anatomic venous variation was common. However, an uncommon embryologic variant precluded treatment in 1 patient. One woman showed venographic evidence of prior left OV thrombophlebitis. There were no major complications related to this procedure.

Although extensive literature on the diagnosis and the treatment of PCS exists,10, 11, 12, 13, 14, 15, 16, 17, 18, 19 studies of 56 women who underwent OV embolization are currently published or in press from 1993 to the present.20, 21, 22, 23, 24, 25 With follow-up ranging from 6 to 15.4 months, relief varied from “cure” to no change or a worsening of the symptoms. In April 1997, Capasso et al20 reported the results of OV embolization in 19 women. Variable symptomatic relief was seen in 73.7% of the cases (14 of 19), with complete relief in 57.9% at a 15.4-month follow-up. Eight women who complained of dyspareunia before embolization reported partial or no pain relief. Dyspareunia was considered a poor prognostic factor. In February 1998, Vogelzang et al25 reported the results of 23 women with PCS that was treated with embolization. At a 15-month follow-up, 78% of the women (18 of 23) reported an improvement in the pain severity and frequency, 13% had no change, and 9% reported that the pain was worse. The visual analogue pain scales showed significant improvement after treatment. Although all of the patients in our study reported an initial improvement, these studies and ours highlight the variable nature of midterm symptom relief and the tendency, in some cases, for symptoms to recur. The study of Vogelzang et al25 is the first to apply objective parameters to the measurement of pain relief, an absolute requirement for future studies and a valid criticism of our study.

Several surgical series focus on OV ligation or resection for PCS. Lechter et al26, 27 described exposure and ligation of the OVs via an extraperitoneal approach bilaterally in 32 women, right OV only in 12 and left side only in 6, with “excellent” results. Hobbs28, 29 describes a similar approach. Rundquist et al30 reported either “cure” or significant symptomatic improvement in 11 of 15 patients after extraperitoneal resection of the left OV with a 6-month to 3-year follow-up. Villavicencio et al31 reported the long-term relief of symptoms in 95% of the women who underwent extraperitoneal resection of OVs, ligation of internal iliac vein tributaries, and sclerotherapy or local excision of residual vulval varicosities (mean, 12.6-year follow-up). Although the reported surgical results of OV ligation and resection appear favorable, most series lack a valid methodology for pain assessment before and after embolization. Mathis et al32 reported the first patient treated for PCS with transperitoneal laparoscopic bilateral OV ligation and resection. Beard et al33 showed effective treatment of PCS in 36 women with bilateral oophorectomy and hysterectomy with hormone replacement. In his series, the median pain scores decreased from 10 to 0 at 1 year and the median frequency of sexual intercourse increased from from 1 to 8 times per month after surgery. Of note, the uterus was histologically normal in 25 of 36 women.

The results of our study must be viewed with caution. Symptomatic improvement after embolization, or lack thereof, was measured with a questionnaire and not with a validated pain scale method. Symptom reporting was subject to potential bias because the primary author, not a blinded interviewer, administered all of the questionnaires. Because OV embolization was not compared with surgery, psychotherapy, or any other form of therapy in a prospective, randomized fashion, it is impossible to draw strong conclusions about the relative effectiveness of this technique. The embolization results appear favorable and perhaps comparable with surgery (OV ligation and excision, ligation of internal iliac tributaries), but whether durable relief31 can be achieved is currently unknown. A careful pretreatment evaluation, a standardized venographic technique, and quantitative measures of pain response are needed to accurately assess each treatment method.

OV duplex scanning was attempted unsuccessfully in our series. The technical aspects of performing OV duplex scanning were not worked out well in our vascular laboratory, and perhaps upright positioning may help. The venographic studies were performed with the women in a supine position. Most authors recommend venography in a semi-erect position to allow maximum reflux and filling of pelvic veins. Cineangiography may be a useful technique,31 although radiation exposure is significantly higher than with digital or cut-film techniques. Although we did not suspect mesoaortic compression of the left renal vein in our patients on the basis of supine venography, the “nutcracker syndrome” must be considered in PCS patients as well.31

In conclusion, OV or OV and iliac vein embolization is a minimally invasive, well-tolerated interventional technique that may represent a viable alternative to surgery for women with PCS. Because of the multifactorial and often complex nature of CPP, we recommend a multidisciplinary approach with a complete gynecologic and vascular surgical evaluation before treatment. The venographic technique and the criteria for embolization must be standardized as must the evaluation methods for gauging pain relief. A heightened level of awareness by referring primary care providers, gynecologists, and vascular surgeons may help many women with this potentially treatable condition.

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References 

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☆ From the Department of Surgery, Section of Vascular Surgery (Drs Cordts, Buckley, and DeMaioribus), and the Department of Radiology, Section of Interventional Radiology (Drs Eclavea, Cockerill, and Yeager), Tripler Army Medical Center.

☆☆ The opinions expressed herein are those of the authors and are not to be construed as reflecting the views of Tripler Army Medical Center, the Department of the Army, or the Department of Defense.

★ Reprint requests: Paul R. Cordts, LTC, MC, Department of Surgery, MCHK DSG, CDR TAMC, 1 Jarrett White Rd, Tripler Army Medical Center, HI 96859-5000.

★★ 24/6/92672

PII: S0741-5214(98)70062-X

Journal of Vascular Surgery
Volume 28, Issue 5 , Pages 862-868, November 1998

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