Ovarian Vein Embolization Research Articles

Comparison of embolization using coil versus coil and ethylene vinyl alcohol copolymer in pelvic venous disorders

Endovascular treatments are frequently applied in pelvic venous disorders(PeVDs) with guidelines recommendations. There is no clear answer as to which of the embolization methods applied with endovascular treatments is superior. In this study, we aimed to compare the outcomes and symptom relief of patients with PeVDs treated using coils alone versus those treated with both coils and ethylene vinyl alcohol copolymer, as well as to evaluate the material usage and safety and efficacy of these treatments. Patients with PeVDs who underwent embolization of ovarian veins with coil and/or ethylene vinyl alcohol copolymer between January 2022 and April 2024 were included in the study. These patients were divided into two groups: patients who underwent coil embolization only (Group I) and patients who used ethylene vinyl alcohol copolymer together with coils (Group II). These patients were followed up at 1st ,3rd 6st and 12st months postoperatively. Symptoms were evaluated with an examination and a visual analog scale (VAS). Between January 2022 and April 2024, 90 patients with PeVDs who underwent endovascular treatment of their ovarian and pelvic veins were included in our study. 31 patients underwent coil embolization only (Group I), while 59 received both coil embolization and a ethylene vinyl alcohol copolymer (Group II). The mean age was 37.5 ± 7.9 and 40.4 ± 7.9 for Groups I and II, respectively. In group I, When pelvic pain was evaluated with VAS, there was a significant decrease in VAS scores between the preoperative period and at the 1st(VAS: 5.3±0.9) , 3rd(VAS:3.9±1.2), 6th(VAS: 3.5±1.5) , and 12th(VAS: 3.6±1.5) months postoperatively (p = 0.011, <0.001, <0.001, <0.001, respectively). In Group II, When pelvic pain was evaluated with VAS, there was a similarly significant decrease in VAS scores between the preoperative period and the 1st(VAS: 5.3±1.4), 3rd(VAS: 3.3±1.7) , 6th(VAS: 2.8±1.8) , and 12th(VAS:2.5±2.1) months postoperatively (p = 0.002, <0.001, <0.001, <0.001, respectively). Group II demonstrated significantly lower VAS scores at the 3rd, 6th, and 12th months compared to Group I. When examining the clinical symptoms of the patients individually, no significant differences were observed between the preoperative and 1st-month VAS scores for any specific symptom. However, at the 3rd, 6th, and 12th months, while there were no significant differences between Group I and Group II in terms of menstrual pain, Group II exhibited significantly lower scores for standing abdominal pain, sitting abdominal pain, and dyspareunia. In our study, The use of ethylene vinyl alcohol copolymer and coils in the embolization of PeVDs is considered an effective and safe procedure with a higher clinical efficacy rate compared to other embolization techniques. Additionally, the use of ethylene vinyl alcohol copolymer reduces the need for coils, providing a cost-effective advantage.

Long-term follow-up for the treatment of symptomatic pelvic venous insufficiency secondary to combined iliac vein stenosis and ovarian vein reflux treated with iliac vein stenting alone

BackgroundWe previously reported that in women with symptomatic pelvic venous insufficiency secondary to combined iliac vein stenosis (IVS) and ovarian vein reflux (OVR), treated with iliac vein stenting alone that 78% reported complete symptom resolution up to 6 months. The purpose of this investigation was to determine the long-term effectiveness of this treatment strategy, the poststent reintervention rate and the incidence of poststent ovarian vein embolization (OVE) for residual symptoms. MethodsA retrospective review of prospectively collected data at the Center for Vascular Medicine was performed. We investigated women with pelvic pain or dyspareunia secondary to combined IVS and OVR who were treated with stenting alone. Patients whose primary complaint was dysmenorrhea and/or leg symptoms were excluded from the analysis. Assessments and interventions consisted of an evaluation for other causes of pelvic venous disorder by a gynecologist, documentation of preintervention and 3-, 6-, 12-, 24-, and 36-month visual analog scale pain scores; transabdominal duplex ultrasound examination; stent type, diameter, and length; vein territory covered; and reintervention rates. All patients underwent diagnostic venography of their pelvic, left ovarian veins, and pelvic reservoirs, and intravascular ultrasound examination of their iliac veins. ResultsFrom February 2018 to January 2023, 141 women with a pelvic venous disorder secondary to IVS and OVR were identified. The average age was 44.7 ± 10.5 years with 3.18 ± 1.82 pregnancies. The average follow-up time for the entire cohort was 12.0 ± 12.1 months (median, 10.65 months). Types of stents were Venovo 48 (34%), Wallstent 14 (10%), and Abre 79 (56%). The most common diameter and stent lengths used were 14 and 16 mm and 140 and 150 mm, respectively. The most common vein territories covered were the inferior vena cava to the left external iliac vein in 83% and inferior vena cava to right external iliac vein in 13%. Pelvic and dyspareunia VAS scores before the intervention and at 3, 6, 12, 24, and 36 months after the intervention were as follows: 6.4 ± 73 (n = 141), 2.6 ± 3.3 (n = 98), 1.71 ± 2.83 (n = 77), 2.04 ± 3.5 (n = 76), 2.4 ± 3.7 (n = 30), and 1.15 ± 3 (n = 13) (P ≤ .001). Of the entire cohort no patients required OVE and pelvic reservoir embolization. Pelvic reservoirs were present in 113 of 141 patients (83%). Stent reinterventions were required in 19 of 141 patients (13%). ConclusionsThe majority of women with pelvic pain secondary to combined IVS and OVR achieved near complete symptom resolution with iliac vein stenting alone, despite the presence of a pelvic reservoir in 83% of patients. Although most women complained of some minimal residual pelvic pain or dyspareunia, the majority were satisfied with their outcomes and did not require further intervention. In this patient population, iliac vein stenting should be considered the primary treatment modality. OVE should be reserved for patients with persistent or recurrent pelvic pain unresolved with stenting.

Effects of Venoactive Drug Therapy and Ovarian Vein Interventions on Vasoactive Neuropeptide and Cytokine Levels in Patients with Pelvic Venous Disorders

To study and compare the effects of venoactive drug (VAD) therapy and ovarian vein embolization or resection (OVE or OVR, accordingly) on the levels of vasoactive peptides and cytokines in patients with pelvic venous disorders (PeVDs). The study included 70 consecutive female patients with PeVD symptoms, such as chronic pelvic pain (CPP), dyspareunia, dysuria, and vulvar varicosities. Based on the results of clinical examination and duplex ultrasound of the pelvic veins, the patients were allocated to the VAD therapy (n=38) or OVE/OVR (n=32). Additionally, the enzyme-linked immunosorbent assay tests were performed to determine levels of calcitonin gene-related peptide (CGRP), substance P (SP), interleukins 6 and 8 (IL-6, IL-8) and monocyte chemotactic protein-1 (MCP-1) after a 2-month course of VAD therapy and at 3months after OVE/OVR. The VAD therapy was associated with a significant decrease in CPP in 84% of patients with PeVD and isolated lesions of the parametrial veins (PVs) and uterine veins (UVs). VAD had no significant effect on the pelvic venous reflux. No changes in the CGRP, SP, IL-6, IL-8, and MCP-1 levels were detected after treatment. At 3months after OVE or OVR, all patients with PeVD and combined lesions of the ovarian veins (OVs), PVs and UVs reported almost complete relief of CPP. Along with elimination of reflux in ovarian veins, the disappearance of reflux in PVs and UVs was noted. A decrease in the CGRP and SP levels was observed (0.7±0.1ng/mL and 0.12±0.02ng/mL before treatment; 0.5±0.12ng/mL and 0.09±0.06ng/mL after treatment, respectively; all P<0.05). No changes in cytokine levels were revealed. Treatment with VAD is associated with the CPP relief, but has no significant effect on the CGRP, SP, IL-6, IL-8, and MCP-1 levels. OVE/OVR results in the CPP relief, elimination of the pelvic venous reflux and a significant decrease in the CGRP and SP levels, but does not change cytokine levels.

Chronic Pelvic Pain in Congestion Pelvic Syndrome: Clinical Impact and Electromyography Pelvic Floor Activity Prior to and after Endovascular Treatment.

This study aims to characterize the clinical impact of endovascular treatment in Chronic Pelvic Pain (CPP) patients due to Pelvic Congestion Syndrome (PCS) and to assess the diagnostic value of surface electromyography (sEMG) studies of pelvic floor musculature (PFM) in PCS patients pre- and post-endovascular treatment. Between January 2019 and July 2023, we studied consecutive patients who were referred for interventional radiology assessment and treatment to a tertiary trauma care hospital, had evidence of non-obstructive PCS from Magnetic Resonance Imaging (MRI), had sEMG of PFM and who had undergone endovascular treatment. The primary outcome was clinical, defined as a change in symptom severity after endovascular treatment. The secondary outcome was a difference in the sEMG values pre- and post-endovascular therapy. We included 32 women (mean age 38 years). CPP was the leading symptom in 100% patients, followed by dysmenorrhea (75%) and post-coital pain (68.7%). Endovascular therapy included ovarian vein embolization in 28 patients (87.5%) and internal iliac vein embolization in only 2 patients (6.2%). After a median of 8 (range 6-10) months from endovascular treatment, 29 (90%) of patients reported an improvement of the main symptoms, and 15 (46%) were symptom-free. The sEMG values did not show a statistical difference pre- and post-PCS endovascular treatment. Endovascular treatment appeared to be highly effective in CPP due to PCS and was associated with a low rate of complication. sEMG study could be useful in revealing alterations of PFM electrophysiology, but a difference pre- and post-embolization in PCS patients was not demonstrated.

Role of interventional radiology in obstetrics and gynaecology: a clinical review of an experience in a quaternary care centre.

The study aims to equip both Obstetricians and Gynaecologists with the knowledge of clinical conditions that will benefit from interventional radiology, equipment and materials that are commonly used, benefits, complications and the side effects of these techniques. It was a single-centre, retrospective cohort study with examples from hospital practice during the period of 2015 to 2021, acquired through computerised database including all obstetrics and gynecological cases in which interventional radiology techniques were used. No statistical analysis of data was applicable as it was a single-centre retrospective analysis of cases. We had a total of 35 cases, including but not limited to placenta accreta spectrum disorders, fibroid, pelvic congestion syndrome and arteriovenous malformation who underwent various interventional radiological procedures ranging from embolization of uterine artery, peripheral angiography, embolization, and internal iliac artery balloon placement to ovarian vein embolization and coil insertion. Increased collaborative efforts between interventional radiology and gynaecology would allow patients to be fully informed on the complete spectrum of surgical and nonsurgical treatment options available to them.

Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review.

Pelvic venous disorders (PeVD), previously known by various imprecise terms including pelvic congestion syndrome, have historically been underdiagnosed as a cause of chronic pelvic pain (CPP), a significant health problem associated with reduced quality of life. However, progress in the field has helped to provide heightened clarity with respect to definitions relating to PeVD, and evolution in algorithms for PeVD workup and treatment has been accompanied by new insights into the causes of a pelvic venous reservoir and associated symptoms. Ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for PeVD. Both treatments have been shown to be safe and effective for patients with CPP of venous origin, regardless of age. Current therapeutic protocols for PeVD exhibit significant heterogeneity owing to limited prospective randomized data and evolving understanding of the factors driving successful outcomes; forthcoming clinical trials are anticipated to improve understanding of CPP of venous origin as well as algorithms for PeVD management. This Expert Panel Narrative Review provides a contemporary update relating to PeVD, summarizing the entity's current classification, diagnostic workup, endovascular treatments, management of persistent or recurrent symptoms, and future research directions.

Techniques for Embolization of the Ovarian Vein and Pelvic Reservoir

Pelvic venous disorders are a common and under diagnosed cause of chronic pelvic pain in women, presenting with chronic, noncyclical pelvic pain for greater than 6 months and the presence of pelvic varicosities. Pelvic varices and ovarian vein reflux are a strong indicator of venous origin chronic pelvic and may benefit from embolization. This most commonly occurs in multiparous, premenopausal women with symptoms of gravity dependent pelvic pain and postcoital pain. Additional causes of pelvic venous disorders include iliac vein compression, internal iliac vein reflux, and renal vein compression, however for the purposes of this article we will focus on ovarian vein insufficiency. The mainstay of treatment for pelvic venous insufficiency is Ovarian Vein Embolization and embolization of the pelvic venous reservoir. This article will focus on the patient presentation and workup, followed by a detailed summary of how to perform this procedure, current research to support treatment, possible technical challenges and complications, and finally future research priorities.

A potentially dangerous complication of ovarian vein embolization for pelvic congestion syndrome treatment

A potentially dangerous complication of ovarian vein embolization for pelvic congestion syndrome treatment

Ovarian vein surgical ablation versus endovascular technique for treatment of pelvic vein incompetence

ObjectiveChronic pelvic pain in women is a disorder brought on by pelvic vein incompetence (PVI). In this prospective, randomized study, the effects of percutaneous coil embolization and surgical ovarian vein ligation and division combined with retrograde sclerotherapy were compared with regard to ovarian vein occlusion, improvement of pelvic congestion symptoms, and their influence on estradiol level after intervention. MethodsA total of 50 patients with PVI were enrolled, with a mean age of 31.9 ± 4.7 years and a pain score of 9 (range, 0-10; from 0 [no pain] to 10 [the highest level of pain]). Both percutaneous coil embolization of ovarian veins (endovascular group) and surgical ovarian vein ablation with retrograde sclerotherapy were offered to the patients at random. ResultsIn the open group, the pain level decreased to 2, whereas in the endovascular group, it decreased to 1 (range, 0-10). Estradiol levels were 224 (range, 9-612) in the open group and 478 (range, 18-613) in the endovascular group before the intervention, with no significant change (P = .1120). After 1 week of intervention, estradiol levels in the open group were 89 (range, 18-243) and 124 (range, 22-298) in the endovascular group, respectively, with statistical insignificance (P = .225). After 1 month of intervention, the endovascular group's estradiol level was 101 (range, 20-196) and the open group's was 89 (range, 15-190) (P = .382). After 3 months of intervention, the open group's estradiol level was 78 (range, 12-132) and the endovascular group's was 65 (range, 18-110) (P = .045). ConclusionsIn addressing PVI, both methods seemed to have promising results. Nevertheless, endovascular management was more effective at decreasing estrogen levels and relieving discomfort. Three months should be the time at which estradiol levels are measured, because this is when they are at their lowest. In both the open and endovascular groups as well as in the pooled data, there was a significant association between estradiol level from before the intervention and improvement in pain scores (P = .005). Because it was linked to a lower pain score, the high preoperative estradiol level can be used to predict postintervention improvement.

Venous Thromboembolism After Interventions on the Ovarian Veins in Patients With Pelvic Venous Disorder

Ovarian vein resection (OVR) and ovarian vein embolization (OVE) are effective options for treating patients with pelvic venous disorder (PeVD). However, due to in an abrupt cessation of blood flow in the ovarian veins (OVs), these interventions can be complicated by pelvic vein thrombosis (PVT). The aim of this study was to assess venous thromboembolism (VTE) rates after OVR and OVE in patients with PeVD. This retrospective cohort study included 272 patients with PeVD who underwent OVR (n=122) or OVE with coils (n=150). The rates and clinical manifestations of VTE were assessed in each group on days 1 and 3 after the intervention using duplex ultrasonography. Vein patency, blood flow velocity, and localization of thrombi in the pelvic (parametrial, uterine, and ovarian), iliac, superficial, and deep veins of the lower extremities were examined. PVT was defined as the formation of blood clots in nontarget (i.e. not intended to intervention) veins of the pelvis (parametrial, uterine veins, or tributaries of the internal iliac veins). VTE after OVR and OVE was identified in 52 (19%) out of 272 patients. In the OVR group, PVT and calf deep vein thrombosis were detected in 9% and 1% of patients, accordingly, while in the OVE group their rates were almost three times higher (24% and 3%; both P=0.001). In both groups, the most common VTE was PVT. The odds ratio for developing VTE with coils was 10 times higher (95% confidence interval: 2.35-56.43) after OVE than after OVR. Clinical manifestations of PVT were observed in 2.5% of patients, and the rest patients were asymptomatic. No cases of pulmonary embolism occurred. VTE after interventions of the ovarian vein in patients with PeVD occurs in every fifth patient. OVE is associated with a higher incidence of PVT.

Pelvic Venous Disorders (PeVD).

Pelvic venous disorders (PeVDs) have replaced the concept of pelvic congestion syndrome encompassing venous origin chronic pelvic pain (VO-CPP) in women. The evaluation of women with VO-CPP includes the assessment for other causes of pelvic pain as well as imaging evaluation for pelvic varicosities measuring greater than 5 mm diameter, ovarian vein diameter, and flow direction, as well as iliac vein diameter and signs of compression. Proper identification of these patients can lead to high degrees of success eliminating chronic pelvic pain following ovarian vein embolization and/or iliac vein stenting. Strong encouragement is provided to use the symptoms, varices, pathophysiology classification for these patients and upcoming research studies on the specific symptoms of patients with VO-CPP will help elucidate patient selection for intervention. Additional future randomized controlled trials are also upcoming to evaluate for outcomes of ovarian vein embolization and iliac vein.

Impact of ovarian vein embolization in recurrent varicose veins of the lower extremity.

Background: The treatment success of catheter-based ovarian vein embolization due to peripheral varicose veins and ovarian vein reflux (OVR) should be investigated in this clinical investagtion. Patients and methods: For this study, 95 female patients were identified over a 5-year period (beginning of 2006 to end of 2011) after catheter-based coil (+/- chemical) embolization of the ovarian vein due to peripheral primary or recurrent varicose veins and proven reflux in the ovarian vein. Treatment success was retrospectively assessed in 2014 by means of a structured telephone interview (n=60), clinical examination (n=56), duplex ultrasound (n=56) and magnetic resonance imaging (n=51) in patients who were willing to participate in the study. Results: After an average of 51.9 months, 95.2% of the 60 included patients were diagnosed with recurrent varicose veins by duplex sonography and 88.1% by clinical examination. In 15.2%, a new intervention was required due to clinical symptoms. The median recurrence-free time was 47.0±5.5 months. A significant improvement by therapy was reported for all subjective symptoms in both pelvis and legs. No significant correlation between radiological findings and complaints or between radiological findings and clinical recurrence was found. Conclusions: The medical history of female patients with peripheral varicose veins should obligatorily include the question of symptoms in the pelvis. An appropriate diagnostic should follow in order to prevent a possible overlook of a pelvic leak point. Only then an individually adapted therapy for symptom relief is possible. Catheter-based ovarian vein embolization is one optional safe procedure that leads to significant improvement of subjective symptoms but does not necessarily prevent recurrent varicose veins.

A novel management strategy for treatment of pelvic venous disorders utilizing a clinical screening score and non-invasive imaging.

Background: Treatment of pelvic venous disorders (PVD) including pelvic congestion syndrome (PCS) are often delayed due to its varying clinical manifestations. Patients and methods: Patient referral was based on a literature- and personal experience-derived clinical "PCS screening score" (higher score points indicate greater likelihood with a maximum score of 10 points). We studied consecutive women who were (i) referred for vascular assessment and treatment to the University Hospital Zurich (2017-2021), (ii) had a PCS score ≥3 points, (iii) had evidence of obstructive or non-obstructive PVD by duplex sonography or cross-sectional imaging, and (iv) underwent endovascular therapy. The primary outcome was change in symptom severity after endovascular therapy: (i) freedom from symptoms, (ii) improvement with residual symptoms, (iii) no improvement. Results: We included 43 women (mean age 36 years): 81% had previous pregnancy, 19% endometriosis. The median PCS score was 7 (IQR 5-9) points. Chronic lower-abdominal pain was the leading symptom in 86% patients, followed by recurrent leg (9%) and vulvar (5%) varicosities. The main PVD pathologies were ovarian vein insufficiency (61%), internal iliac vein insufficiency (9%), or a combination of both (30%), whereas 42% had a deep venous obstruction of the inferior vena cava, common iliac or left renal veins. Endovascular therapy included ovarian vein embolization (86%), internal iliac vein embolization (9%), and venous stent placement (35%). After a median of 4 (IQR 1-8) months from endovascular treatment, 40 (93%) patients reported improvement of the leading symptom, and 14 (33%) were symptom-free. Complications included re-intervention for stent stenosis (13%, all post-thrombotic), coil-migration into the left renal vein (7%, all retrieved), and transient pelvic sclerotherapy-induced thrombophlebitis (2%). Conclusions: Endovascular therapy following a diagnostic approach, which included a PCS screening tool and non-invasive imaging, appeared to be highly effective and was associated with a low rate of complications.

Efficacy of the endovascular ovarian vein embolization technique in pelvic venous congestion syndrome.

PurposePelvic pain, either related or unrelated to menstruation, is especially common in women of reproductive age. Thirty-nine per cent of all women suffer from chronic pelvic pain at some point in their lives, and pelvic venous congestion syndrome (PVCS) is the cause of this pain in 30% of cases. The aim of this study was to determine factors affecting the success of endovascular venous embolization used in the treatment of PVCS, and to present the long-term treatment results.Material and methodsThe data of 144 female patients who underwent endovascular ovarian vein embolization for PVCS between January 2012 and July 2020 were retrospectively analysed.ResultsPain management was determined to be very successful in 37 (25.6%) patients, successful in 55 (38.1%), and unsuccessful in 52 (35.3%). Treatments using a coil alone were significantly more successful in pain management than those involving the use of different materials in addition to the coil (p = 0.036). In addition, patients with unilateral insufficiency before the procedure were found to have more successful pain management than those with bilateral insufficiency (p = 0.041). Reproductive/postmenopausal state and parity did not have a statistically significant effect on treatment efficacy (p = 0.250 and p = 0.573, respectively).ConclusionsEndovascular pelvic venous embolization is an important option in the treatment of PVCS due its less invasive and reproducible nature.

Ovarian Vein Embolization With N-butyl-2 Cyanoacrylate Glubran-2® for the Treatment of Pelvic Venous Disorder.

Background: There are few reports in the literature on the use of Glubran-2 for the embolization of ovarian veins in patients with pelvic venous disorder (PeVD). In addition, a consensus on the efficacy and safety of Glubran-2 has not been reached.Purpose: To investigate the safety and efficacy of ovarian vein embolization (OVE) with N-butyl-2 cyanoacrylate (NBCA) Glubran-2 for the treatment of PeVD.Material and Methods: Between January 2013 and January 2020, 21 women (mean age, 43.9 ± 13.3 years) with PeVD who underwent OVE with Glubran-2 were evaluated. Of those patients, ovarian vein or pelvic venous plexus insufficiency was verified by duplex ultrasound and/or multislice computer tomography (MSCT). The symptoms and signs of PeVD included chronic pelvic pain (CPP) (21/21; 100%), dyspareunia (12/21; 57.1%), dysmenorrhea (10/21; 47.6%), and vulvar varices (3/21; 14.3%). The medical data were retrospectively reviewed.Results: Glubran-2 was employed as the sole embolic material in 18 cases (85.7%) and used to perform rescue embolization in 3 cases (14.3%) due to CPP recurrence 1 month after initial embolization using microcoils. Technically successful embolization was achieved using Glubran-2 in all patients. No Glubran-2 related complications were noted. Neither persistent nor recurrent CPP was observed during follow-up, for which the mean was 62 ± 38 months (range, 12–102 months). Clinical efficacy was evaluated, and all patients exhibited complete or slight improvement of CPP after embolization. The visual analog scale (VAS) score significantly decreased from pre-intervention to post-intervention (p < 0.001). Six patients (28.6%) gave birth to healthy babies during follow-up after embolization with Glubran-2.Conclusions: Ovarian vein embolization with Glubran-2 is a feasible and safe treatment for CPP secondary to PeVD. This treatment may represent a potential and attractive alternative when patients desire symptom relief and want to continue reproducing. Larger studies are warranted to confirm the findings of this study.

Spontaneous rupture of the ovarian vein in association with nutcracker syndrome: a case report

BackgroundNutcracker syndrome is a condition in which the left renal vein is pinched between the abdominal aorta and the superior mesenteric artery, resulting in an increase in renal vein pressure and certain symptoms. We report a very rare case of retroperitoneal hematoma caused by the rupture of varicose veins of the left ovary.Case presentationA 77-year-old Japanese woman, para 7, experienced sudden left lower abdominal pain. She had no history of trauma or treatment complications. Computed tomography revealed a left retroperitoneal hematoma, but her abdominal pain subsided quickly; thus, urgent treatment was not required. We then scheduled her for an assessment regarding the cause of her bleeding. However, 6 days after the pain onset, abdominal pain symptoms recurred, confirming hematoma regrowth. Magnetic resonance imaging and three-dimensional computed tomography revealed an abnormal vascular network from the left side of the uterus to the left adnexa. Subsequent angiography revealed that the retroperitoneal bleeding originated from rupture of the distended left ovarian vein, which caused blood reflux from the left renal vein to the left ovarian vein. Although angiography confirmed a passage between the left renal vein and inferior vena cava, computed tomography showed obvious stenosis in the left renal vein. In accordance with these findings, we diagnosed the cause of the distention and rupture of the left ovarian vein as nutcracker syndrome. She underwent embolization of the left ovarian vein as hemostasis treatment, and had a good course thereafter.ConclusionsThis is the first report of a spontaneous rupture of the left ovarian vein caused by nutcracker syndrome. Nutcracker syndrome is not yet well known to clinicians and should be considered as part of the differential diagnosis when an abnormal vascular network in the pelvis is found.

Successful Ovarian Vein Embolization of a Multiparous Woman with Pelvic Congestion Syndrome

AbstractPelvic congestion syndrome (PCS) is a clinical syndrome supported by specific findings, such as ovarian vein's dilatation, that cause pelvic vein congestion. Although many theories are explaining the pathophysiologies of this condition, the underlying cause remains unknown. The clinical manifestations of PCS are various including chronic pelvic pain (CPP), voiding disturbances, or ureteral obstruction. Imaging modality, such as ultrasonography, computed tomography (CT scan), magnetic resonance imaging (MRI), and venography, are needed to confirm and exclude the differential diagnosis. Currently, American venous forum guidelines recommended endovascular therapy which is percutaneous embolization as the first option therapy of PCS. Here, we reported a 35-year-old woman with PCS who underwent successful percutaneous embolization therapy.

Pelvic congestion syndrome and May-Thurner syndrome as causes for chronic pelvic pain syndrome: neuropelveological diagnosis and corresponding therapeutic options.

To report on diagnosis and management of pelvic congestion including the May-Thurner syndrome (MTS) as potential etiologies for intractable pelvic neuropathic pain. Retrospective study of women presented with intractable pelvic neuropathic pain, who had left sided venous uterine plexus above 6mm with reversed and slow flow on Doppler, with dilated arcuate veins passing through the uterine muscle. Those with suspicion of MTS underwent further radiological investigations and if applicable, endovascular interventions. Tertiary referral unit specialized in advanced gynaecological surgery and neuropelveology. 61 consecutive patients were included. 14 with visceral pain presumed to be caused by Pelvic Congestion Syndrome were treated by ovarian vein embolization. An improvement of pain was observed in all patients - mean pain reduction of 3.93 points, from 7.21 (±1.42; 4-10) to 3.28 pts (±1.54; 1-6) over 6 months (p<0.01). 47 presented with pelvic somatic neuropathic pain; 19 underwent endovascular intervention (angioplasty, stenting) and finally all of them a laparoscopic exploration/decompression of the sacral plexus and the endopelvic portion of the pudendal nerves, with an overall VAS reduction from 8.56 (±1.1712;7-10) to 2.63 (±1.53; 0-6) at one-year-follow-up (p<0.01). Laparoscopic exploration/decompression of the nerves seems to be effective in a carefully selected group of patients. Endovascular interventions for pelvic somatic neuropathies may not be an effective treatment. We recommend that Doppler studies of the uterine vessels are performed as an extension to gynaecological examination in women with intractable pelvic pain.

Pelvic congestion syndrome (PCS) as a pathology of postmenopausal women: a case report with literature review

BackgroundDue to the scarcity of adequately powered, randomized controlled trials and internationally standardized diagnostic criteria, evidence on the diagnosis and treatment of pelvic congestion syndrome (PCS) is limited. Earlier epidemiologic observations led to the attribution of PCS to the premenopausal state, and a remission of symptoms after menopause is frequently described a hallmark of the pathology. This concept has currently been challenged by radiological studies reporting a notable prevalence of ovarian venous congestion in adult female patients of advanced age. PCS as a pathology of postmenopausal women, however, has not been acknowledged by systematic research to date, impeding appropriate diagnostics and therapy for affected patients.Case presentationA 69-year-old postmenopausal patient presented with newly diagnosed dilated and insufficient pelvic veins in combination with characteristic pain anamnesis, thereby fulfilling the diagnostic criteria of PCS. Interventional coil embolization of both ovarian veins as a standard treatment previously described for premenopausal patients was successfully performed, resulting in prompt alleviation of symptoms. The patient remained symptom-free at the 18-month follow-up visit.ConclusionsGiven this first systematically documented case of a patient with postmenopausal symptomatic PCS in the light of recently published data on the prevalence of ovarian venous congestion in patients of advanced age, it may be assumed that PCS is not to be considered a pathology strictly limited to premenopausal state. Further clinical studies expanding the diagnostic scope beyond menopause may help to substantiate evidence and subsequently define standardized therapeutic approaches for affected postmenopausal patients.

Pelvic venous insufficiency secondary to iliac vein stenosis and ovarian vein reflux treated with iliac vein stenting alone

BackgroundWe have previously reported that in women with a pelvic venous disorder secondary to pelvic venous insufficiency, 56% will present with an iliac vein stenosis (IVS) and ovarian vein reflux (OVR). The purpose of the present investigation was to determine whether women with combined disease can be treated using iliac vein stenting alone. MethodsA retrospective review of prospectively collected data at the Center for Vascular Medicine was performed. We investigated women with pelvic pain or dyspareunia secondary to combined IVS and OVR who had undergone stenting alone. The patient demographics, pre- and 6-month postoperative visual analog scale (VAS) for pain scores, stent type, stent diameter, stent length, and ovarian vein diameters were assessed. All patients had undergone diagnostic venography of their pelvic veins, left ovarian veins, and pelvic reservoirs and intravascular ultrasonography of their iliac veins. ResultsFrom May 2016 to October 2019, 82 patients with a pelvic venous disorder secondary to IVS and OVR were identified. The present data analysis focused on 38 patients with complete pre- and postoperative VAS scores and duplex scan stent patency data at 6 months. The pelvic and dyspareunia VAS scores at the initial and 6-month follow-up visits were as follows: 6.83 ± 3.19 and 4.24 ± 2.65 and 1.72 ± 2.01 and 0.05 ± 2.0, respectively (P ≤ .001). At 6 months, 29 of the 38 women (76%) reported complete resolution of all symptoms, 26 of 28 (93%) reported complete resolution of their dyspareunia, 5 of 38 (13%) reported significant improvement, and 4 of 38 (10%) reported no improvement. The average ovarian vein diameter was 6.7 ± 2.5 mm. The average stent size and length was 18.20 ± 1.6 mm and 92.41 ± 18.5 mm, with 25 placed in the left common iliac, 2 in the right common iliac vein, and 3 bilaterally. Of the 38 patients, 7 required reintervention (18%). An untreated pelvic reservoir was observed in 17 of the 38 patients (44%). One of the two with no response and six of the patients with improvement had OVR and an untreated pelvic reservoir. The remaining 10 patients with a pelvic reservoir had experienced complete resolution of their symptoms with stenting alone. ConclusionsOf the 38 women with pelvic pain secondary to combined IVS and OVR, 76% achieved complete symptom resolution with iliac vein stenting alone. Most of the women with a pelvic reservoir were asymptomatic and reported full symptom resolution after stenting alone. However, these data suggest that in some women, a relationship might exist between the presence of a pelvic reservoir and the persistence of symptoms. Therefore, for women with combined IVS and OVR, we recommend iliac vein stenting alone and staged ovarian vein embolization only for women with persistent symptoms.