Clinical results after coil embolization of the ovarian vein in patients with primary and recurrent lower-limb varices with respect to vulval varices
Castenmiller PH, de Leurk, de Jong Team, van der Loan L.,
Phlebology. 2013;28:234-238.
Reviewed by: Javier Leal MONEDERO Madrid, Spain
This article presents an evaluation of the effects of insufficient ovarian veins embolization in the prevalence of lower limb and vulvar varices. It presents a follow-up of a series of patients treated with ovarian veins embolization in order to study the effects on the recurrence of varicose veins in the lower limb and vulva. They use as a diagnosis method.
However, it presents a series of flaws concerning the experimental and clinical design. The main objective and purpose of the article is not clear. The introduction and overview of the insufficiency of ovarian veins (IOV) is not comprehensive enough, using only 10 references; and is out of date, referring to articles until 2009. It fails to focus on the problem to be solved, making it difficult to follow if they are going to focus on ovarian vein insufficiency or on varicose veins. It presents a series of erratic facts, for example, a recurrence intervals in a span of 5% to 49% or a different number of total patients in different points of the study.
It is not clear what the inclusion/exclusion criteria was for select the patients, which criteria are poorly presented and summarized. We were not able to understand the experimental design of use. For example, it is not necessary to mention that all patients were females, because the interest is focused on the ovarian vein, however, even as they mention that pregnancy is an important issue in IOV, they do not present the pregnancy medical record. It’s also difficult to follow the study, presenting results as a part of the methods. Also, it lacks of some data that we consider necessary, such as what happened to nonembolized patients.
The results, again, we found a mix of data that would have been necessary in the methods and, therefore, redundant in this section. Also, it is quite redundant to present the same data in the text and tables. Only one follow-up after three months is a short time, it would have been very interesting to see a continuous follow-up, with Duplex ultrasound studies in order to investigate the permeabilization state and the recurrence of the varicose veins. In other terms, giving the influence of iliac vein leaks in lower limbs in the presence of pelvic and lower limb varicose veins, it would have been important to study the incompetence of iliac veins in all cases.
Finally, in the discussion of this work, the authors do not add any other reference to discuss his conclusions. Besides, it is not all clear if they consider their results as an improvement or advance in the field. A more detailed discussion and comparison with other results should have been provided, such as present in previous studies (1-4).
The authors mention the limitations of their study, that would have been easily avoided with a better working procedure and experimental design.
From an endovascular point of view, in our experience, we recommend to perform a selective phlebography of gonadal veins by puncturing in the brachial vein, accessing from the flexure in the elbow, or, if it is not possible, from the jugular vein. Using this approach is a more accurate way to selectively and distally canalize both gonadal veins, especially in the case of right gonadal vein. In addition, it is also possible to canalize the tributary branches of the internal iliac veins, which are also a common cause of refluxes and leaks in lower limbs. An approach from the femoral vein, as performed in the present article, would be difficult to canalize and access gonadal veins, mainly due to a pronounced angulation that would disturb the catheter manipulation.
In other terms, we prefer to perform a bilateral occlusion, using a “sandwich” technique, using controlled-release coils, as a desirable choice in the proximal side, and 2% etoxisclerol foam in the distal portion of the vein. Using this strategy, we consider that a better occlusion of vessels is obtained, minimizing the apparition of recidivism or repermeabilizations.
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