2. DIAGNOSIS & ENDOASCULAR MANAGEMENT OF PELVIC CONGESTION SYNDROMEBy
M. Akram Khan, MD, FACC FSCAI
Interventional Cardiologist
Cardiac Center of Texas P.A.
4201 Medical Center Drive
Suite 380 McKinney, TX 75069
Baylor Heart Hospital of Plano
Plano, TX

3. PELVIC CONGESTION SYNDROME (PCS)
PCS commonly recognized as persistence of non cyclic Chronic Pelvic Pain (CPP) for longer than 6 months in the absence of known pelvic pathology.
Pelvic venous incompetence with pelvic venous hypertension is underlying etiology of PCS.

4. SYMPTOMS
On prolonged standing, lower back & pelvic area pain and heaviness.
Dyspareunia
Dysmenorrhea
Dysuria, increased frequency and urgency
Valvular congestion with or without vulvar varicosities.

5. ETIOLOGIES Ovarian Vein Reflux (predominantly left)
Internal Iliac Vein Reflex
Nutcracker Syndrome
May-Thurner Syndrome
It is a disease of child bearing age and most common in multiparous women and patients with polycystic ovarian disorders or hormonal dysfunctions.

6. OBSTRUCTIVE ETIOLOGY OF PCS
Nutcracker Syndrome May-Thurner Syndrome

7. CHRONIC PELVIC PAIN (CPP)
40% of all OBGYN outpatients visits leads to un necessary hysterectomies and laparoscopic exploratory surgeries.
Common causes of CPP:
Endometriosis
Fribroid
Ovarian Cyst
Adhesions
IBS
Pelvic Inflammatory Disease
40% of CPP are due to PCS which remain under diagnosed & under appreciated.

8. HISTORY, QUESTIONS THAT YOU NEED TO ASK
Do You have pelvic pain, heaviness, bloating?
When do you get symptoms?
How often do you have the symptoms?
Is it present throughout your cycle?
How long have you had the symptoms?
What makes it worse? What makes it better?
Are you sexually active?
Do you have pain/pressure with intercourse? During and/or after
Any urinary symptoms?
Frequency?
Pain with urination?
How many children?
When did symptoms develop in relation to last pregnancy?
Did you notice any vulvar varices during your last pregnancy?
History of hemorrhoids?
Any leg varicosities or leg symptoms of heaviness/throbbing with standing?

9. PAST MEDICAL HISTORY
14. Any history of gynecologic problems; Endometriosis, ovarian cysts, ectopic pregnancies?
Any history of IUD use, pelvic infections, pelvic surgery
Irregular vaginal bleeding?
Unexpected weight loss?
Bleeding after intercourse?
15. Other history: Abdominal surgeries, interstitial cystitis, irritable bowel syndrome, inflammatory bowel disease, back problems.
History of mental health illness/depression

10. Atypical Leg Varicose Veins
CLINICAL EXAMINATION
Atypical Leg Varicose Veins
Obturator br. of external/internal Iliac Veins
Ext. & Internal Pudendal Veins Communicators
Recanalization of vein of round ligament

11. DIAGNOSTIC IMAGING
Transabdominal US of ovarian & iliac vein (Antonios Gasparis M.D. Storybooks) – easier, feasible & practice
This is first, diagnostic test done in our institution.
Thansvaginal US.
Gold Standard in some institutions
MR Venography
CT Venography
Venography
Still Gold Standard

12. NORMAL ANATOMY

13. VENOUS ANGIOGRAM IMAGES SHOWING SIGNIFICANT REFLUX

14. VENOUS ANGIOGRAM SHOWING NO REFLUX

15. DIAGNOSTIC ANGIOGRAPHY
Access:
IJ, Branchial, femoral using 6 – 7 French Sheaths.
Catheters:
C-2, DRC Femoral Catheter for L. Ovarian Vein
Simmons Catheter for R. Ovarian Vein
Branchial / IJ MP Catheter
We prefer Femoral Access.
Images:
IVC Angiography
Selective L & R Ovarian Vein Angiography
Selective R & L Internal Iliac Vein Angiography with or without occlusive balloon – 11.5mm non-compliant balloon

16. OVARIAN VEIN EMBOLIZATION
First described by Edward et al in 1993
Sclerosing Agents – Most Common STS
Coils – We use Azur from Terumo but others available from Cook & Boston
Glue
Common Practice is to use foam sclerosing agents at the most distal segment in smaller branches followed by coil embolization for Main Trunk. Usual coil sizes are 10-20mm depending on size of ovarian vein.
(Do not do Compact Packing)
Post procedure every patient should be given NSAIDs due to thrombophlebitis

17. FOAM FOR PELVIC VEIN EMBOLIZATION
Use 3%Use 3% STS
Dilute with contrast
2cc 3% STS + 2cc contrast
Have 1.5% STS liquid
STS
Take 1cc 1.5% STS and mix with 3-4cc air using Tessari Method

18. FOAM PREP. GRAPHIC PRESENTATION

19. COIL EMBOLIZATION

20. INTERNAL ILIAC VEIN TREATMENT
Selective catheterization
Obturator
Internal Pudendal
Gluteal
Balloon Occlusion Venography
Balloon Occlusion Sclerotherapy
Coil Embolization - Avoid

21. COMPLICATIONS Thrombophlebitis Groin site complications
Pulmonary Embolism

22. DATA
Treatment of PCS
Chung MH et al; Tohoku J Exp Med Nov;201(3):131-8.
106 women with PCS
Randomized to:
Ovarian Vein Embolization (N=52)
Hysterectomy / BSO / HRT (n=32)
Hysterectomy /USO (n=34)

23. M. Akram Khan MD (214) 208-1827 arhum2000@gmail.com
Thank You!
M. Akram Khan MD (214)