Pelvic Congestion Syndrome David Rigberg, M.D. Clinical Professor - - PowerPoint PPT Presentation

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Pelvic Congestion Syndrome

David Rigberg, M.D.

Clinical Professor of Surgery Division of Vascular Surgery University of California Los Angeles

Disclosures: none

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Common problem

– Noncyclic pain > 6 months – 40% of women at some point – Multiple specialties evaluate primary care Ob/Gyn ER GI Surgeons Pain docs

Pelvic Pain Pelvic Pain

• Multiple Causes
• endometriosis
• cysts
• PID
• interstitial cystitits
• IBS
• urologic issues
• Inflammatory bowel syndrome
• urologic issues
• Much pathology to exclude!

Pelvic Venous Disorders

Two Syndromes

Pelvic Congestion Syndrome pain dyspareunia dysuria Pelvic Varices gluteal perineal vulvar Ovarian reflux Hypogastric reflux Nutcracker Syndrome

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Pelvic Venous Disorders

Need to understand venous anatomy 3 connections:

• ovarian
• hypograstric
• femoral

All interconnected Also cross pelvic drainage Ovarian: parametrium, cervix, mesosalpinx, pampiniform Trunks combine at ≈ L4 (R IVC, L LRV) 2-3 valves, reflux common!

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Hypogastric Anatomy

Clinical Presentation: Pelvic Venous Insufficiency Pelvic Congestion Syndrome

• Pain
• Pressure

Pelvic Varices

• Gluteal
• Perineal
• Labial

Combined pelvic and LE sx

Dx of Pelvic Venous Disorders

H & P

• Post-coital pain
• Ovarian tenderness
• Varices with an unusual distribution

Duplex Exam

• transvaginal/abdominal
• Ovarian vein reflux with vein > 6 mm
• Pelvic VVE with reflux and > 5 mm
• Large uterine crossing veins

CT/MRV Venography

Dx of Pelvic Venous Disorders

Venography should include

• IVC, L renal vein, bilateral ovarian veins, bilateral

hypogastric veins Femoral access usually ok; may be difficult for R ovarian vein Diagnostic Criteria

• Ovarian vein/uterine veins > 6 mm
• Free reflux in ovarian vein
• contralateral reflux across the midline
• visualization of thigh/vulvar varicosities
• Stagnation of contrast

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Diagnosis

Laborda et al. 2013

Diagnosis Whom to treat?

Patients usually have undergone exhaustive w/u Relatively safe procedures

• venous access site
• coil migration
• paradoxical embolism
• inadvertent sclerosant placement (paravert/mesenteric)

R/O other pathology first!

Ovarian Vein Sclero/Embo

Right CFV or IJV 7 Fr RDC or 6F Raabe 5 Fr selective cath

• Cobra-2, Sos Omni, VS2

Micro cath through selective

• Renegade STC 0.018

Sclerotherapy

• Compliant balloon
• 1:1 Ethiodol: 3% STS
• Liquid or foam

Coiling

• Place coils to upper ½ of SI joint
• 5-15 mm, 0.035 or 0.018 coils (Interlock)

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IHypogastric Vein Treatment

Controversial – may stage (see how patient does with

• varian treatment first)

Selective branch catheterization

• Obturator
• Int Pudendal branches
• Gluteals

Balloon occlusion imaging Balloon occlusion sclerotherapy Can combine with coils

Treatment of Varicosities

Associated VVE’s of labial/vulvar regions Typically, can puncture directly “Map” the VVE’s with venography Inject foam based on venography Try to limit cranial extension

• f sclerosant

Can do phlebectomies

Lower Extremities

What to do with lower extremity symptoms/VVE’s? Leg complaints incidental or very proximal Duplex useful Treat primary complaint first Most overlap with thigh issues May need lower extremity tx S/P coiling, etc…

Outcomes

High initial technical success (98%) for ovarian coiling 58.5% total relief; 10% variable relief No differences if unilat or bilat presentation/tx

• Maluex, et al. J Vasc Interv Rad. 2000.

67 pts ovarian vein coiling 82% with pain reduction

• Kwon et al. Cardiovasc and IR. 2007.

106 patients RCT

• Chung et al. J Exp Med, 2003.

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Chung et al. J Exp Med, 2003.

Conclusions - PCS

Diagnosis requires understanding the presentations

• varices? locations? leg involvement

Always be mindful of venous communications

• ovarian, hypogastric, femoral (saphenous)

Diagnosis: pattern of sx, U/S and venography Tx options:

• Embolization of ovarian veins
• Sclero of hypogastrics
• Foam sclero (U/S) of varices with occasional stabs
• lower extremity veins/reflux

UCLA Ronald Reagan Medical Center ULCA Division of Vascular Surgery David Geffen School of Medicine at UCLA

Thank You