Abstract No. 652 - Endovascular techniques for pelvic congestion syndrome: a review of traditional and novel approaches

Abstract

1. Recognize the multi-factorial nature of pelvic congestion syndrome (PCS) and how a variety of anatomical and physiological processes can cause PCS. 2. Understand traditional endovascular options for treatment, including; embolization and sclerotherapy of gonadal and internal iliac veins. 3. Be aware of novel approaches to PCS treatment, including the role of venous stenting in May-Thurner syndrome (MTS), recently described as an etiology for PCS. PCS is often caused by pelvic venous insufficiency (PVI) from incompetent valves in gonadal and pelvic veins. As such, endovascular treatment of PCS is focused on embolization and sclerotherapy of these two distinct, yet overlapping, venous territories. Venous compression syndromes, such as Nutcracker syndrome, have also been implicated in PCS. Recently, MTS has also been recognized to contribute to PCS. In these cases, venous stenting, not embolization, has provided symptomatic relief of PCS symptoms. Treatment techniques for PCS include targeted embolization of select refluxing veins, often the gonadal and/or internal iliac veins. Treatment of gonadal veins can be unilateral or bilateral, and staged treatments are also performed with internal iliac vein embolization based on symptom relief. Common embolization agents include coils and sclerosants. Obliteration of the refluxing vein to within 1 cm of its confluence helps prevent recurrence. Risks include non-target embolization, and worsened pain from embolization related inflammation. Recently MTS has been described as an etiology for PCS, secondary to pelvic venous hypertension. In these cases, left common iliac vein angioplasty/stenting has been successful at treating PCS symptoms. Endovascular treatment of PCS requires an in-depth understanding of PVI in order to provide the most effective approach, most commonly embolization of the refluxing gonadal and/or internal iliac veins. An awareness that iliac vein compression, as seen in MTS, can also be a factor in PCS will help the interventionist provide additional treatments, such as venous angioplasty/stenting.