Female Pelvic Vein Embolization: Indications, Techniques, and Outcomes.

Anthony James Lopez

doi:10.1007/s00270-015-1074-7

Abstract

Until recently, the main indication for pelvic vein embolization (PVE) in women was to treat pelvic venous congestion syndrome (PVC) but increasingly, patients with refluxing pelvic veins associated with leg varicosities are also being treated. A more unusual reason for PVE is to treat pelvic venous malformations, although such lesions may be treated with sclerotherapy alone. Embolotherapy for treating PVC has been performed for many years with several published studies included in this review, whilst an emerging indication for PVE is to treat lower limb varicosities associated with pelvic vein reflux. Neither group, however, has been subjected to an adequate randomized, controlled trial. Consequently, some of the information presented in this review should be considered anecdotal (level III evidence) at this stage, and a satisfactory ‘proof’ of clinical efficacy remains deficient until higher-level evidence is presented. Furthermore, a wide range of techniques not accepted by all are used, and some standardization will be required based on future mandatory prospective studies. Large studies have also clearly shown an unacceptably high recurrence rate of leg varicose veins following venous surgery. Furthermore, minimally or non-invasive imaging is now revealing that there is a refluxing pelvic venous source in a significant percentage of women with de novo leg varicose veins, and many more with recurrent varicosities. Considering that just over half the world’s population is female and a significant number of women not only have pelvic venous reflux, but also have associated leg varicosities, minimally invasive treatment of pelvic venous incompetence will become a common procedure.

Highlights

Ovarian and other pelvic varices are not an infrequent finding in adult women, and those who have previously had at least one pregnancy associated with a vaginal delivery or at least a significant trial of labour [1]
A number of studies have shown the incidence of refluxing left ovarian and bilateral internal iliac veins as fairly equal and together the commonest pattern [21,22,23,24,25,26, 27], and it does not appear to predispose to a particular pattern of symptoms compared to involvement of other pelvic veins, the importance of treating these veins is increasingly being recognized [21, 27]
Evidence remains poor for its efficacy, and initially anecdotal by way of case reports and small series, data is accumulating in larger series

Summary

Introduction

Ovarian and other pelvic varices (such as in the distribution of the internal iliac veins) are not an infrequent finding in adult women, and those who have previously had at least one pregnancy associated with a vaginal delivery or at least a significant trial of labour [1]. Pelvic venous incompetence is usually the underlying aetiology in the causation of pelvic varices and has been well known to be manifest as pelvic venous congestion syndrome [7] and usually reflects damage of pelvic vein valves during parturition [8], but it rarely results from congenital venous stenosis or webs such as in May– Thurner syndrome [9], or acquired venous stenosis perhaps associated with iatrogenic or other trauma [10], tumour or deep venous thrombosis [11] This well-recognized but poorly understood condition presents with a spectrum of symptoms including non-cyclic pelvic and sometimes abdominal pain for greater than six months duration, dyspareunia, dysmenorrhea, haemorrhoids, bladder irritability, and symptoms of irritable bowel syndrome there are several others [7]. The relationship between pelvic venous incompetence and both PVC and lower limb varicosities, remains intuitive and to some extent empirical clearly, requiring further evidence, and ideally should be subjected to a randomized controlled trial

Radiological Anatomy

Technical Considerations

Radiation Protection and Dosimetry

Delayed complications can include

Findings

Discussion