Embolization of pelvic varicose veins - what do we know after over 30 years of experience?

Ovarian vein embolization in recurrent varicose veins - how invasive should varicose treatment be?

The aim of our investigation was a comprehensive clinical and instrumental assessment of efficacy of endovascular embolization in women with pelvic varicose veins. Our single-centre study included a total of 29 female patients presenting with pelvic varicose veins and undergoing embolization of ovarian veins using microcoils, in 5 cases the procedure was supplemented with injecting a foam sclerosant. The technical success of endovascular occlusion of ovarian veins amounted to 100%. Two women immediately after the operation were subjected to a redo intervention: in one case - resection of the ovarian vein and in the second case - repositioning of the microcoils. In the remote period, one patient due to recurrent relapses underwent repeat embolization followed by retroperitoneal resection of the ovarian vein. The findings of the clinical methods of examination demonstrated a decrease in the intensity of manifestations of pelvic varicose veins according to the pelvic venous clinical severity score and visual analogue scale, as well as improvement of the women's quality of life. Endovascular occlusion of ovarian veins is a highly effective, minimally invasive, and safe method of treatment of female patients with incompetent ovarian veins. Endovascular treatment may be regarded as a method of choice in management of the primary form of pelvic varicose veins.

Objective – to improve the selection criteria and the algorithm for examining patients with chro-nic pelvic pain syndrome caused by varicose pelvis veins. Optimize the technique of embolization of ovarian veins and veins of the pelvic venous plexus, to improve the results of endovascular treatment and prevent possible complications that may arise during the embolization procedure.Materials and methods. The analysis of 24 sources of scientific and medical literature on the problem of etiology, pathogenesis, diagnostic and endovascular treatment of chronic pelvic pain syndrome in women by embolization of ovarian veins and veins of the pelvic venous plexus. The authors present their own results of endovascular treatment of 31 patients with varicose veins of the small pelvis and ovarian veins.Results. The improved patient selection criteria based on careful history taking, preoperative confirmation of ovarian and pelvic varicose veins. The technique of phlebographic examination, embolization of ovarian veins and veins of the pelvic venous plexus was optimized. The causes of complications that arise during the embolization procedure have been analyzed. Practical recommendations for endovascular surgeons are given for the prevention of such complications in the future.Conclusions. The failure of the ovarian and pelvic veins underlies the etiology of pelvis veins varicose. Pain syndrome against the background of pelvis veins varicose is the main reason for referring to gynecologists in 10–30 % of cases. Selective phlebography of the ovarian and pelvic veins has become the gold standard in the diagnosis of venous pelvic insufficiency, since only this technique is most likely to show the connection between the incompetent ovarian and internal iliac veins. Conservative therapy of pelvic congestion syndrome often turns out to be ineffective, and surgical approaches do not exclude organ loss. Endovascular surgery showed a disappearing or decrease in the clinical manifestations of chronic pelvic pain syndrome by up to 94 %, while maintaining a positive treatment result for up to 12–36 months. The main complication during embolization is the migration of the coils to the right heart and pulmonary artery. Careful adherence to the embolization technique, the correct selection of the length and diameter of the coil can minimize the occurrence of embolic complications and improve the results of treatment of chronic pelvic pain syndrome.

The study objective is to investigate the pathogenesis of the development of pelvic symptoms in patients with pelvic varicose veins.Materials and methods. From 2015 to 2022, 145 men with pelvic varicose veins were examined. The examination included questioning of patients using questionnaires (scales) and instrumental methods: 1) ultrasound examination of the scrotum with color Doppler mapping; 2) transrectal ultrasound examination of the prostate and veins of the periprostatic plexus; 3) magnetic resonance imaging of the inferior vena cava and pelvic vessels or computer (multispiral) tomography of the abdominal organs with contrast; 4) phlebography of the renocaval and ileocaval segments.Results. The variant anatomy of fibrous and fibro-osseous canals (tunnels) can explain the fact that with equally pronounced expansion of the pelvic veins, some patients have pelvic symptoms due to nerve compression, while the other part does not. This concept is supported by the fact that in those patients who had complaints of pain, dysuria and erectile dysfunction, after surgical treatment of pelvic varicose veins, in most cases they disappeared or decreased.Conclusion. Pain syndrome (56.6 % of cases), erectile dysfunction (51 % of cases) and dysuria (17.9 % of cases) were noted as clinical manifestations in patients with pelvic varicose veins. Analysis of data after examination and treatment of patients with pelvic varicose veins allowed us to identify “venous compression neuropathy syndrome” as a probable cause of the development of pelvic symptoms in patients with pelvic varicose veins. Depending on the level of localization of nerve compression by varicose veins, we proposed to distinguish three forms of this syndrome: 1) thoracic, 2) lumbar, and 3) sacral form.

Stratification of pelvic venous reflux in patients with pelvic varicose veins

Basilic vein access as an effective alternative for endovascular embolization of pelvic varicose veins: A retrospective-cohort based population study.

A large number of individuals develop venous thromboembolism (VTE) every year.1 Each patient’s episode of DVT or PE is, naturally, unique. To highlight a variety of aspects about VTE a compilation case is presented that is composed of clinical data and images from several real patients. ### History of Present Illness A 36-year-old woman presents to the Emergency Department with severe shortness of breath and moderately intense anterior chest pain, worse on deep inspiration, which had started suddenly that morning. She also reports a 6-wk history of mild shortness of breath, for which she had been seen 4 wk earlier by her primary care physician who diagnosed her with “asthma.” Bronchodilators and steroids were prescribed but led to no significant improvement in her symptoms. She also gives a history of mild left calf pain that had started about 2 months earlier without preceding trauma, immobilization, or surgery. Her primary care physician had seen her and prescribed Ibuprofen for a “pulled muscle.” However, in the 1 week before her present presentation her leg symptoms worsened, and she had increased diffuse leg pain and swelling and slightly bluish discoloration of the whole leg. Her past medical history is only significant for an appendectomy at age 16. She has never been pregnant. She is on no medications, except for an estrogen and progestin-containing oral contraceptive, started 10 months earlier. She does not smoke. There is no family history of venous thromboembolism, although the patient reports that her paternal grandmother had a “swollen leg for many years” until she died in her 70’s, but no further details are known of the patient. ### Physical Examination The patient’s weight is 86 kg and her height 165 cm, calculating to a body mass index (weight divided by [height in meters]2) of 31.6 kg/m2, ie, she has grade 1 obesity. Her …

Aim. Evaluation of the results of venography and efficacy of gonadal veins embolization in female patients with pelvic congestive syndrome and concomittant genital pathology. 
 Methods. The study included 61 patients with pelvic varicosities diagnosed on the basis of ultrasound and Doppler studies of the veins with obligatory use of Valsalva test. The average age of the patients was 34.11±0.98 years. Patients were divided into groups according to the presence or absence of concomitant genital pathology: group A - 16 patients with pelvic varicose veins without concomitant genital pathology; group B - 20 patients with pelvic varicose veins and endometriosis; group C - 25 patients with pelvic varicose veins and other genital pathology. All patients underwent selective pelvic vein embolization by the combined method with the use of coils and sclerosants. The variants of anatomical structure of venous system in patients from three groups were clarified according to the results of venography. Efficacy of the method was assessed by the change in pelvic pain intensity according to Visual Analogue Scale before and after embolization. 
 Results. Bilateral pelvic varicose veins in all groups was the most prevalent variant diagnosed in venography. In groups A and C 87.5 and 84% of patients, respectively, noted improvement. In group B 35% of patients reported improvement, while 65% maintained pain after embolization. However, even while maintaining pain, decrease of its intensity was reported by 35% of patients, but in 6 (30%) of cases it required surgical organ-resecting treatment. 
 Conclusion. Venograghy in pelvic congestive syndrome in women is characterized by stagnation of venous blood in the venous system of pelvis with the reflux and valvular incompetence; endovascular method confirmed its high efficiency for relieving pelvic pain syndrome; we had no complications during the study.

Purpose: To evaluate medium-term clinical outcomes of transcatheter embolization and stenting in women with several pelvic venous disorders responsible for chronic pelvic pain and varicose veins of the lower limbs.Materials and Methods: The study population included 327 consecutively recruited patients referred to the interventional radiology unit from January 2014 to December 2019 due to chronic pelvic congestion (91; 27.83%), lower limb varices (15; 4.59%), or a combination of both the symptoms (221; 67.58%). Preprocedural pelvic, transvaginal Doppler ultrasound (US), and MRI were conducted in all the patients and revealed anatomical varicosities and incompetent pelvic veins in 312 patients. In all the patients, selective catheterization demonstrated uterine venous engorgement, ovarian plexus congestion, or pelvic vein filling. Retrograde flow was detected on catheter venography in the left ovarian vein (250; 78%), the right ovarian vein (85; 26%), the left internal iliac vein (222; 68%), and the right internal iliac vein (185; 57%). Patients were followed-up at 1, 6, and 12 months, and years thereafter systematically by the referring angiologist and the interventional radiologist of center. They were contacted by telephone in November and December 2020 to assess pain perception and quality of life by using the visual analog scales from 0 to 10 with assessments made at the baseline and last follow-up. Of the 327 patients (mean age, 42 ± 12 years), 312 patients were suffering from pelvic congestion syndrome and 236 patients was suffering from lower limb varices. All underwent embolization by using ethylene vinyl alcohol copolymer (Onyx®). Eighty-five right ovarian veins, 249 left ovarian veins, 510 tributaries of the right internal iliac vein, and 624 tributaries of the left internal iliac vein were embolized. A cohort of patients also underwent nutcracker syndrome angioplasty (6.7%) and May–Thurner syndrome angioplasty (14%) with a stent placement.Results: The initial technical success rate was 80.9% for embolization of pathological veins and 100% for stenting of stenoses. Overall, 307 patients attended 12-month follow-up visits and 288 (82%) patients completed the telephone survey at mean 39 (±18)-month postintervention. Main pelvic pain significantly improved from 6.9 (±2.4) pre- to 2.0 (±2.4) postembolization (p < 0.001), as did specific symptoms in each category. Improvement or disappearance of pain was achieved in 266/288 (92.36%) patients with improved quality of life in 276/288 (95.8%) patients. There were 16 minor and 4 major adverse events reported on the follow-up.Conclusion: Pelvic vein embolization (Onyx®) is an effective and safe procedure with high clinical success and quality of life improvement rates.

This study was undertaken to investigate the effect of pelvic venous reflux (PVR) and the activity of vasoactive neuropeptides on the development of chronic pelvic pain (CPP) in patients with pelvic venous disease (PeVD). Our prospective cohort study sequentially included 110 patients with PeVD and 20 volunteers (healthy women). Amongst patients with PeDV, 70 had a symptomatic form of the disease (i. e., there were complaints of CPP, hypogastric discomfort, dyspareunia) and 40 had an asymptomatic form (i. e., with no clinical manifestations of PeVD). Patients underwent a clinical examination, duplex ultrasound scanning (DUS) of pelvic and lower-limb veins, as well as single-photon emission computed tomography (SPECT) of pelvic veins with in vivo labelled red blood cells. The frequency of reflux in pelvic veins, its duration and the degree of blood deposition in the varicose veins of the pelvis were assessed. Volunteers underwent only a clinical examination and DUS. All the 130 participants underwent enzyme immunoassay of blood plasma to determine the levels of calcitonin-gene-related peptide (CGRP) and substance P (SР). According to DUS, reflux in the gonadal veins (GVs) was found in 45.7% of patients with symptomatic PeVD, and only in 10% of asymptomatic patients (p=0.001). Reflux duration in GVs in symptomatic patients was 4.1±1.7 s and in asymptomatic patients - 1.4±0.3 s (p=0.002). There were no statistically significant differences in the diameters of GVs with reflux among patients with symptomatic and asymptomatic PeVD. Similar data were obtained by comparing the duration of reflux in parametrial veins (PVs) and their diameters. Reflux in GVs for more than 2 s was found in 41.4% of symptomatic patients and only in 5% with asymptomatic PeVD (p=0.001). In patients with CPP, reflux in the GVs, PVs and uterine veins (UVs) was detected in 24.2%, in the GVs and PVs in 45.7%. In 90% of patients without CPP, reflux was detected only in the PVs. Pronounced pelvic venous congestion was found in 95.7% of patients with CPP and in 15% of patients without CPP (p=0.001) according to SPECT. CGRP and SP levels in symptomatic patients significantly exceeded those in asymptomatic patients (CGRP - 0.48±0.06 ng/ml vs 0.19±0.02 ng/ml, respectively, p=0.001; SP - 0.38±0.08 ng/ml vs 0.13±0.03 ng/ml, respectively, p=0.001). Reflux in the pelvic veins for more than 2 s, involvement of more than 1 pelvic venous collector in the pathological process, combined with an increase in the levels of CGRP and SP in blood plasma, can be considered as hemodynamic and neurobiological factors in the development of CPP in patients with PeVD.

To investigate the effectiveness of transvenous occlusion of incompetent pelvic veins in women presenting with chronic pelvic pain (CPP) in improving symptoms and quality of life. Patient-blinded randomised controlled trial with objective outcome measures. Results were analysed on an intention-to-treat basis. Gynaecology and Vascular Surgery Services of two teaching hospitals in northwest England. Sixty women aged 18-54 years presenting with CPP after exclusion of other pathology, and who were found to have pelvic vein incompetence. Participants were randomised and assigned to contrast venography alone or contrast venography plus transvenous occlusion of the incompetent pelvic veins. The primary outcome was change in pain score measured using the short-form McGill Pain Score (SF-MPQ) and the Visual Analogue Score (VAS) recorded at 12 months post-randomisation. Secondary outcomes included quality of life using the EQ-5D instrument, symptomatic improvement and procedure-related complications. Sixty participants were randomised to transvenous occlusion of incompetent pelvic veins or venography only. At 12 months, median pain scored 2 (3-10) in the intervention group versus 9 (5-22) in controls (p = 0.016). Pain on the VAS scored 15 (0-3) versus 53 (20-71), respectively (p = 0.002). Median EQ-5D improved after intervention from 0.79 (0.74-0.84) to 0.84 (0.79-1.00; p = 0.008) over 12 months. No major complications were reported. Transvenous occlusion of pelvic vein incompetence reduced pain scores, improved quality of life and diminished symptom burden with no major reported complications. ISRCTN 15091500.

Using assessment scales in clinical and research practice is one of fundamental reference methods of evaluation in human pathological states. Pelvic vein varicosity is an independent nosological entity within the framework of chronic vein diseases. Currently, the clinical methods of assessment in the aspect of a patient-oriented approach in this type of disease are largely understudied and still not duly defined. The study was aimed at analyzing clinical outcomes of surgical treatment in the form of resection of the ovarian vein in female patients with pelvic varicose veins, based on the developed specialized scale of clinical assessment of disease severity. We carried out an open prospective study of efficacy of resection of the ovarian vein in 37 women with pelvic varicose veins. The main criterion for assessment was a clinical method of determining manifestations of the disease by means of the Pelvic Venous Clinical Severity Score. According to the Pelvic Venous Clinical Severity Score, improvement of the condition was observed in 36 (97.3%) operated female patients and 1 (2.7%) woman turned out to have negative dynamics. The median of the composite score of the severity scale decreased form 11.78±5.06 points to 5.22±3.19 (p<0.05). The total positive gradient of the score amounted to 6.57±3 .65 points. A significant decrease in manifestations of severity was observed for 9 of the 10 clinical descriptors of the disease. The use of the suggested scale in practical assessment of the results made it possible to prove high efficacy of resection of the ovarian vein in women with pelvic varicose veins in the form of decreased intensity of the disease's symptomatology. The VCSS is an easy-to-fill-in tool, taking up little time, ensuring no influence of the physician's personality on the answers, presenting quantitative expression of therapeutic results.

Journal of Vascular Surgery: Venous and Lymphatic Disorders – November 2021 Audiovisual Summary

To determine the relation between pelvic varicose veins and lower extremity venous insufficiency in women with chronic pelvic pain. This study was done in Yuzuncu Yil University Faculty of Medicine, Department of Radiology, with patients who were referred for abdominal and pelvic imaging between January 2007 and April 2008. A total of 1029 women with pelvic imaging study were included in the study. The presence of venous dilatations (diameter > 5 mm) in parauterine and paraovarian localizations were accepted as pelvic varicose veins. In all patients, endometrial thickness was measured and lower extremity venous system was examined with Doppler ultrasonography to assess possible associated venous insufficiency. All patients were undergone questionnaire for frequency of delivery, age, and chronic pelvic pain. Pelvic varicose veins were discovered with transabdominal ultrasound and computerized tomography in 56 of 1029 patients. Various degrees of associated lower extremity venous insufficiency were also discovered in 44 of 56 patients (78,6%) with pelvic venous dilatation. Of the 44 patients with lower extremity venous insufficiency, 21 were bilateral, 9 were right-sided, and 14 were left-sided. Endometrial thickness was significantly increased in patients with pelvic venous dilatation. The presence of pelvic varicose veins is significantly associated with lower extremity venous insufficiency. Since the diagnosis of lower extremity venous insufficiency plays an important role in deciding the course of treatment, lower extremity Doppler ultrasonography examination would be useful to include in the evaluation of pelvic varicose veins.

Pelvic congestion syndrome: Outcome after embolization with coils