Right Ovarian Embolisation not the usual Amr Abdel Rahim, MD

The development of varicose veins in the pelvis with symptoms i The development of varicose veins in the pelvis with symptoms i.e pelvic congestion syndrome(PCS) although first described in 1857 by Richet & given its name in 1949 by Taylor, this pathologic process was recognized only recently.

Incidence Pelvic varicose veins are found in 10% of women, and 15% of women between the ages of 18 and 50 years suffer from pelvic pain. Ovarian varicose veins were found in 9.9% of the general female population, with 59% of them having PCS. Other pelvic diseases (endometriosis, uterine fibroma, pelvic cancer) may cause pelvic pain so it’s mandatory to be ruled out even in presence of pelvic varicose veins.

Anatomy of the Pelvic Venous System Pelvic structures are drained by both the internal iliac and genital veins. In 27% of cases, the internal iliac vein drains by two separated trunks. In exceptional cases, it can drain directly into the IVC. Valves are found in 10% of cases on the main trunk and 9% on its tributaries.

The ovarian veins form a plexus in the broad ligament & communicate with the uterine plexus. They end on the right side in the IVC at an acute angle and on the left side in the LRV at a right angle. In the middle third, only 60% on the left side and 70% on the right side have one trunk; the rest are multiple. As many as six trunks can be found in the lower third.

According to Stancati and coauthors, valves are present in these veins, mainly in the distal third. Ahlberg and collaborators found no ovarian vein valves on the left side in 15% and none on the right side in 6%.

Reflux pattern Asciutto ,et al (2009) Number of patients (% of studygroup) Left ovarian vein 57.7% Right internal iliac vein 57.7% Left internal iliac vein 49.2% Right ovarian vein 4.2% Combined reflux 53.5%

Pathophysiology Type 1: Reflux secondary to pelvic vein incompetence. Most frequent etiology and its cause is uncertain, hormonal factors contribute; pregnancy,cystic ovaries. Type 2: Secondary to an obstruction of the outflow. May- Thurner syndrome, nutcracker syndrome and LRV thrombosis, postthrombotic disease involving the common iliac veins or the IVC (or both), and Budd- Chiari syndrome.

Type 3: Secondary to a local extravenous phenomenon. The main cause is endometriosis, but it can also be due to tumors (benign or malignant) & posttraumatic lesions.

Clinical Findings Mainly in young women (late 20s to early 30s) who are generally multiparous & usually disappears after menopause. Rare in men, except in cases of varicocele and are often due to venous obstructive disease.

The syndrome can be described as chronic (up to 6 months) pelvic pain (heaviness that increases mostly on sitting or standing and can be relieved by lying down), dyspareunia, dysmenorrhea, and urinary (dysuria ,pollakiuria, bladder urgency) and rectal (constipation) symptoms. Predominantly on one side but can be bilateral.

Clinical examination: Cervical, uterine, and ovarian tenderness; uterine enlargement; and uterine retroversion. Perineal (mainly vulvar) varicose veins can be the sole reason for consultation. Superficial venous insufficiency, atypical varicose veins, and recurrence after surgery for varicose veins.

Diagnosis Duplex Scanning: Multiple dilated tubular structures around the uterus and ovary with a diameter larger than 5 mm. Both the internal iliac and the genital veins should be imaged to look for dilatation and reflux (reversed caudad flow), including imaging with the Valsalva maneuver.

The common iliac veins, IVC, and renal veins are seen to search for venous obstruction. A lower limb duplex scan should be obtained to search for varicose veins, which can be secondary to pelvic varicose veins.

Computed Tomographic and Magnetic Resonance Venography. Dilated, tortuous, enhanced tubular structures around the uterus and ovary . Other causes of the symptoms, mainly endometriosis and for venous obstructive disease. Because they are performed supine, however, they can underestimate venous disease.

Phlebography This imaging technique is the “gold standard” for diagnosis. Under local anesthesia through the common femoral or humeral vein with a urinary catheter inserted . Image the four veins responsible for venous return from the pelvis with and without a Valsalva maneuver.

Criteria used of PCS caused by the ovarian vein: Ovarian vein larger than 5 mm in diameter, Retention of contrast medium for longer than 20 seconds, Opacification of the internal iliac vein and filling of vulvovaginal and thigh varicosities.

Treatment Medical Treatment Medroxyprogesterone acetate (Provera), 30 mg/day for 6 months. Its positive effect, however, was not maintained 9 months after discontinuation of treatment. Micronized purified flavonoid fraction 500 mg twice a day for 6 months.

Conventional and Laparoscopic Surgery Ovarian or internal iliac vein ligation (or both). Ovarian and uterine artery and vein ligation. Oophorectomy, and even total hysterectomy with bilateral salpingo-oophorectomy.

Endovascular Treatment Coil(or vascular plug) embolization alone or in conjunction with foam sclerotherapy under local anesthesia after placement of a urinary catheter. Better results with coils and the sandwich technique than with the use of coils alone (95.6% rate of improvement vs 76% at 6 months)

A whole internal iliac vein must not be embolized; and regarding the gonadic veins, embolization must be performed proximal to the last collateral to prevent recurrences. In treating the internal iliac vein, Kim and coauthors recommended use of balloon occlusion and avoidance of embolization of the main trunk.

Complications are rare and include: hematoma at the access site, extravasation of contrast material,coil or glue embolization, DVT and pulmonary embolism, and transient cardiac arrhythmia. PCS linked to iliocaval obstructive disease should be treated by stenting.

Take home message Pelvic congestion syndrome is still underestimated It should not only addressed from the gynecological point of view However,even in presence of pelvic varicosities, gynecological causes must be ruled out Endovascular intervention is the best and the left ovarian vein is the most targeted.