Disclosures: none Pelvic Congestion Syndrome David Rigberg, M.D. Clinical Professor of Surgery Division of Vascular Surgery University of California Los Angeles 1
Pelvic Pain Pelvic Pain Common problem • Multiple Causes – Noncyclic pain > 6 months -endometriosis – 40% of women at some point -cysts – Multiple specialties evaluate primary care -PID Ob/Gyn -interstitial cystitits ER -IBS GI -urologic issues Surgeons Pain docs -Inflammatory bowel syndrome -urologic issues • Much pathology to exclude! Pelvic Venous Disorders Pelvic Venous Disorders Need to understand venous Two Syndromes anatomy 3 connections: Pelvic Congestion Syndrome +/- Pelvic Varices pain -ovarian gluteal dyspareunia perineal -hypograstric dysuria vulvar -femoral All interconnected Also cross pelvic drainage Ovarian: parametrium, cervix, mesosalpinx, pampiniform Trunks combine at ≈ L4 (R IVC, L LRV) 2-3 valves, reflux common! Ovarian reflux Hypogastric reflux Nutcracker Syndrome 2
Hypogastric Anatomy Clinical Presentation: Pelvic Venous Insufficiency Pelvic Congestion Syndrome -Pain -Pressure Pelvic Varices -Gluteal -Perineal -Labial Combined pelvic and LE sx Dx of Pelvic Venous Dx of Pelvic Venous Disorders Disorders H & P Venography should include - Post-coital pain -IVC, L renal vein, bilateral ovarian veins, bilateral -Ovarian tenderness hypogastric veins -Varices with an unusual distribution Femoral access usually ok; may be difficult for R ovarian Duplex Exam vein -transvaginal/abdominal Diagnostic Criteria -Ovarian vein reflux with vein > 6 mm -Ovarian vein/uterine veins > 6 mm -Pelvic VVE with reflux and > 5 mm -Free reflux in ovarian vein -Large uterine crossing veins -contralateral reflux across the midline CT/MRV -visualization of thigh/vulvar varicosities -Stagnation of contrast Venography 3
Diagnosis Diagnosis Laborda et al. 2013 Whom to treat? Ovarian Vein Sclero/Embo Right CFV or IJV Patients usually have undergone exhaustive w/u 7 Fr RDC or 6F Raabe Relatively safe procedures 5 Fr selective cath -venous access site -Cobra-2, Sos Omni, VS2 -coil migration Micro cath through selective -paradoxical embolism -Renegade STC 0.018 -inadvertent sclerosant placement (paravert/mesenteric) Sclerotherapy R/O other pathology first! -Compliant balloon -1:1 Ethiodol: 3% STS -Liquid or foam Coiling - Place coils to upper ½ of SI joint -5-15 mm, 0.035 or 0.018 coils (Interlock) 4
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I Hypogastric Vein Treatment Treatment of Varicosities Controversial – may stage (see how patient does with Associated VVE’s of labial/vulvar regions ovarian treatment first) Typically, can puncture directly Selective branch catheterization “Map” the VVE’s with venography -Obturator Inject foam based on venography -Int Pudendal branches Try to limit cranial extension -Gluteals of sclerosant Balloon occlusion imaging Can do phlebectomies Balloon occlusion sclerotherapy Can combine with coils Lower Extremities Outcomes High initial technical success (98%) for ovarian coiling What to do with lower extremity symptoms/VVE’s? 58.5% total relief; 10% variable relief Leg complaints incidental or very proximal No differences if unilat or bilat presentation/tx - Maluex, et al. J Vasc Interv Rad. 2000 . Duplex useful Treat primary complaint first Most overlap with thigh issues 67 pts ovarian vein coiling May need lower extremity tx S/P 82% with pain reduction -Kwon et al. Cardiovasc and IR. 2007. coiling, etc… 106 patients RCT - Chung et al. J Exp Med, 2003. 6
Conclusions - PCS Diagnosis requires understanding the presentations -varices? locations? leg involvement Always be mindful of venous communications -ovarian, hypogastric, femoral (saphenous) Diagnosis: pattern of sx, U/S and venography Tx options: -Embolization of ovarian veins -Sclero of hypogastrics -Foam sclero (U/S) of varices with occasional stabs -lower extremity veins/reflux Chung et al. J Exp Med, 2003. ULCA Division of Vascular Surgery David Geffen School of Medicine at UCLA UCLA Ronald Reagan Medical Center Thank You 7
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