Servier – Phlebolymphology

XXII. Diagnostics and treatment of
the chronic pelvic vein disease and
varicose veins of pelvic origin

Not all pelvic vein disease cases and varicose veins of pelvic origin are related to the same pathology
(doubts and difficulties)
Małgorzata Mielnik (Poland)
Transvaginal and abdominal duplex ultrasound scanning can be used in diagnosing pelvic vein disorders, but, in most cases, transvaginal duplex ultrasound scanning is not mandatory to make the diagnosis. So far, we have been strongly focused on transvaginal scanning, but not all patients with abnormal transvaginal duplex ultrasound scanning are symptomatic. Ultrasound examination has many limitations; there are no strict criteria for assessing reflux, some portion of the vessels are invisible on duplex ultrasound scanning and many phenomena are functional (ie, depend on the body’s position). Duplex ultrasound scanning still plays an important role assuming that a comprehensive assessment of a venous system is performed.

Transvaginal duplex ultrasound scanning is offered to women whose lower limb duplex results suggest a pelvic venous reflux and/or compression (in cases of pelvic congestion syndrome symptoms, recurrent/atypical varicose veins) or women who are referred by gynecologists with a suspicion of pelvic vein abnormalities with or without concomitant lower extremity varicose veins, symptomatic or asymptomatic. The examination is performed after the patient has been fasting overnight, with the patient in a supine position with the head elevated 45 degrees (semi-upright position), and with the use of a wide bandwidth (transvaginal, valvular L10-5, and convex C9-3).

Perhaps it is evident, but sometimes we forget that the venous vascular bed of the pelvis and abdominal cavity should be treated together as one unit because what we see in the pelvis is very often the result of what happens above the pelvis. During transvaginal duplex ultrasound scanning, we have to search for varicose veins in the uterine area, examine the distal part of the gonadal vein, and examine visible tertiary tributaries. During transabdominal duplex ultrasound scanning, we have to examine the inferior vena cava, search for anatomic and hemodynamic criteria of left renal vein compression, and examine the iliac vessels (flow direction in tertiary tributaries deserves attention).

When performing duplex ultrasound scanning in patients with pelvic congestion syndrome/pelvic congestion incompetence, we are looking for vein pathology, as well as all abdominal and pelvic structure variants/abnormalities contributing to symptoms of the disease. Comprehensive pelvic and abdominal venous vascular bed assessments must be performed because proximal abnormalities have an effect on distal vascular segments. Before the diagnosis of primary pelvic venous insufficiency is established, a careful evaluation of potential compression sources is necessary, including pelvic angleinclination, abnormalities, and arterial variants (eg, aorta transposition, right renal artery ostial angle and increased diaphragm ligament tension) as sources of potential “venous entrapment.” Assessment of venous compression points is difficult and time consuming due to the temporary and functional nature of signs, often depending on the body’s position. Mechanisms responsible for clinical symptoms are probably not due to compression and occlusion of the veins, but due to their functional, temporal compression. The fact that we do not see compression does not mean that it does not exist.

Pelvic vein disease with reflux and/or obstruction? VS diagnostic approach
Nicos Labropoulos (US)
Nicos Labropoulos introduced a standardized diagnostic approach for pelvic congestion syndrome. Pelvic congestion syndrome is one of the many causes of chronic pelvic pain and is often diagnosed based on exclusion of other pathologies. Over the past decades, pelvic congestion syndrome was recognized to be a more common cause of chronic pelvic pain. Multiple diagnostic modalities, including pelvic duplex ultrasonography, transvaginal ultrasonography, computed tomography, and magnetic resonance, were studied. In the current literature, selective ovarian venography, an invasive imaging approach, is believed to be the gold standard for diagnosing pelvic congestion syndrome. The described transabdominal technique takes all potential pathologies that can contribute to pelvic congestion syndrome into account and, in experienced hands, it can consistently identify the ovarian veins, as well as document their diameter and possible reflux. If successful, the patient can potentially avoid other expensive and time-consuming imaging modalities that may require ionizing radiation or intravenous contrast and undergo venography and coil embolization. Other tests, such as computed tomographic venography and magnetic resonance venography, may be useful when there is suboptimal imaging or limited experience with ultrasound.

How to decide when pelvic vein reflux is clinically relevant to the varicose vein and pelvic congestion syndrome occurrence?
Neil Khilnani (US)
Today, there is a need to review the medical nomenclature and use the term pelvic congestion disorder instead of the term pelvic congestion syndrome. It is logical because the term “syndrome” stands for a group of symptoms, when the underlying cause does not figure in, while “disorder” means distinguishing symptoms and signs, with an understood cause. The main indication is to treat the pelvic source: quality of life affecting pelvic pain due to abnormal pelvic venous physiology when alternative diagnoses are unlikely. There are no pathognomonic symptoms for pelvic congestion disorders. The rate of sensitivity/specificity of the most frequent symptoms in patients with chronic venous pain are not high: 71%/32% for increased pain while standing, 84%/26% for dysmenorrhea, 75%/21% for deep dyspareunia, and 79%/41% for postcoital pain. As the causes of pelvic pain are often due to different diseases, multidisciplinary care is important (with gynecology, psychiatry, physical therapy, pain management, urology, and vascular specialists) due to the secondary responses to chronic pain. In particular, conditions, such as depression, occur in 86% of women with pelvic pain and only 38% without it. Central sensitization (maladaptive pain perception secondary to CNS processing issue) often occurs and there may be irreversible pain, even when the cause of the pain is eliminated.

Of the women with pelvic congestion disorders, 51% had lower extremity varicose veins, but only 9% were related to escape point reflux. Therefore, lower extremity veins and symptoms can be successfully treated in most patients without a pelvic vein intervention.

An interventional treatment of the pelvic vein disease – tactics, practical advices, tips and tricks
Antonios Gasparis (US)
Treatment of pelvic vein disease should focus on the patient’s clinical symptoms (pelvic pain, heaviness, dyspareunia, dysuria). There are two patterns of disease reflux (reflux in ovarian veins or internal iliac vein reflux due to testicular varices or a nonsaphenous vein) and obstruction. For the treatment of a nonsaphenous varicose vein, microphlebectomy, ultrasound-guided sclerotherapy, and especially fluoroscopy-guided sclerotherapy gives good results. Fluoroscopy-guided sclerotherapy delivers large volumes of sclerosant and reaches the periuretine venous plexus. For the treatment of ovarian vein reflux, Antonios Gasparis prefers a combined procedure. For the first step, he uses embolization of pelvic varicosities with a mixed solution of 3% sodium tetradecyl sulfate and contrast in a 1:1 ratio, sometimes using a 11.5 mm balloon. After that, he performs a coil embolization of the ovarian vein. For the left ovarian vein, he prefers the right common femoral vein access, and, for the right ovarian vein, the right internal jugular veins. He performs the same procedure for the internal iliac vein treatment (selective catheterization, balloonocclusion sclerotherapy, and coil embolization).

Endovascular treatment: staged or simultaneous reflux ablation?
Radoslaw Pietura (Poland)
Radoslaw Pietura discussed how isolated embolization of the left ovarian vein alone is not enough to treat pelvic congestion syndrome, and, in many cases, 3 to 4 main veins in the pelvis need embolization as well, especially with combined damage to the veins of the pelvis and the lower extremities. He described his own experience where 100 patients were followed up for up to 4 years after embolization of the left ovarian vein (100%), right ovarian vein (91%), left internal iliac vein (98%) and right internal iliac vein (97%). In 39% of the patients, the treatment was done over 1 session and, in 61%, it was done over 2 sessions. The pain score was reduced from 7.2 to 1.2 in 43 patients (93%). Neck hematomas occurred in 4 patients, coil migration occurred in 1 patient, and small neck abscesses occurred in 8 patients. He advocated using a simultaneous approach where doctors try to embolize as much as possible because it is cheaper, faster, and more comfortable for patients than a staged procedure.

Pelvic vein incompetence, unknown aspects & challenging situation and technical difficulties
Louay Altarazi (Syria)
Louay Altarazi presented some complicated cases of pelvic congestion syndrome treatment, including Nutcracker syndrome, anatomy variations and ovarian vein anomalies, dangerous anatomy (close disposition of pelvic varicose veins and magistral trunk, such as the iliac vein), urinary tract compression, reanalyzed sciatic vein, huge veins, ovarian veins thrombosis, male pelvic congestion, and even a case with the worst technical complications.

Sclerotherapy of the pelvic origin varicose veins without embolization of the pelvic vein – does make sense?
Eberhard Rabe (Germany)
Atypical varicose veins without saphenofemoral or saphenopopliteal reflux may develop in the vulvar or pudendal area in women. Reflux in these varices may be connected to insufficient pelvic veins. In the most of the cases, the left ovarian vein or the hypogastric veins are involved. Venous obstruction or a local pathology is another (rare) reason for this condition. Many of the affected women are multiparous and such veins develop during pregnancy and are located only in the genital, pudendal, or proximal thigh area. Only a few case reports and case control series have been published concerning the treatment of vulvar or pudendal atypical varicose veins and no prospective randomized studies comparing different treatment options are available. The benefit of embolization of pelvic veins in patients without pelvic congestion syndrome was not demonstrated in randomized control trials comparing the results with atypical varicose vein treatment by phlebectomy or sclerotherapy alone. Therefore, embolization should only be used in a well-established indication. Embolization should be recommended in pelvic congestion syndrome due to ovarian or pelvic vein reflux with or without vulvar, pudendal, or leg atypical varicose veins. Foam sclerotherapy or phlebectomy without embolization of the ovarian vein shows good results in patients with atypical varicose veins of pelvic origin. Embolization should be considered in symptomatic cases with recurrent varicose veins after treatment even if no pelvic congestion syndrome is present. Randomized comparative studies comparing embolization on incompetent pelvic veins and sclerotherapy of atypical varicose veinswith pelvic origin should be performed.

Sclerotherapy can be enough for varicose veins of pelvic origin
Lorenzo Tessari (Italy)
According to Lorenzo Tessari, at least 45% of varicose veins of the great saphenous vein do not originate from the saphenofemoral junction. In spite of a complete saphenofemoral junction and great saphenous vein truncular continence, other kinds of reflux coming from the groin or from the perineal and/or gluteal region can occur. The frequency of pelvic reflux is consistently increased from 5%, 20%, 45%, 65%, and 80% for no pregnancy, 1, 2, 3, and 4+ pregnancies, respectively. According the Franceschi classification, there are 6 points of pelvic reflux: (i) point I (groin) – round ligament vein origin; (ii) suprapubic origin (spontaneous “Palma”); (iii) point P (perineal) – internal pudendal vein origin; (iv) obturator vein origin; (v) ischiatic vein/inferior gluteal vein origin; and (vi) clitoral vein origin. The frequency of reflux is 12% for point I, 1% for suprapubic veins, 13% for obturator veins, 24% for ischiatic vein/inferior gluteal vein, 2% for the clitoral vein, and 48% for point P. It is possible to use foam sclerotherapy to treat each reflux variant (Lorenzo Tessari prefers 2% and 3% sodium tetradecyl sulfate) with good long-term results (88% complete obliteration after 13 years).