Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel

Pelvic vein thrombosis in patients with pelvic venous disorders

OBJECTIVE

To assess the incidence of pelvic vein thrombosis (PVT) and outcomes of anticoagulant therapy for PVT in patients with pelvic venous disorders (PeVDs).

METHODS

This prospective cohort study included 588 female patients with PeVDs underwent clinical examination followed by duplex ultrasound of the pelvic veins in 2021-2023. Patients with PVT were administered with anticoagulant therapy in an outpatient setting using low molecular weight heparins at a therapeutic dose.

RESULTS

PVT was detected in 7.6% of patients with PeVDs and was symptomatic in 28.8% of them. The majority of asymptomatic patients had thrombosis in only one of the parametrial veins (90.6%). Anticoagulant therapy resulted in the PVT symptoms relief in all patients within 10 days and recanalization of the pelvic veins in 1-3 months.

CONCLUSION

In our study, PVT was diagnosed in 7.6% of patients with PeVDs. Anticoagulant therapy is effective and safe in resolving PVT symptoms.

A scoping review of scores or grading systems for pelvic venous disorders

BACKGROUND

Pelvic venous disorders (PeVD) encompass a variety of conditions linked to chronic pelvic pain in women. However, PeVD remain underdiagnosed due to the absence of universally accepted diagnostic criteria. The complexity of PeVD classifications across specialties leads to delays in treatment. This scoping review aims to fill a gap in PeVD diagnosis and management by identifying all existing scoring or grading systems to lay the foundation for standardized clinical scoring tools for PeVD.

METHODS

This scoping review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews. Online databases were searched up to April 2023. Studies implementing a scoring or grading system for patients with confirmed or suspected PeVD were included. Scores or grading systems were classified into four main categories based on their use in the study: screening, diagnosis, measure of disease severity, and measure of response to treatment.

RESULTS

Of the 2976 unique records identified, 82 were reviewed in full, and 20 were included in this study. The publication dates ranged from 1984 to 2023 (median, 2018; interquartile range, 2003-2022). A total of 21 scores and/or grading systems were identified. Of these 21 scores, 10 (47.6%) were clinical scores, and 10 (47.6%) were scores based on radiological findings; one study included a score that used both clinical and radiological findings. The identified scores were used in various settings. Of the 21 scores, 2 (9.52%) were used for screening in a tertiary care setting; 3 (14.3%) were used to establish the PeVD diagnosis; 8 (38.1%) were used to assess disease severity; and 8 (38.1%) were used as measures of response to treatment. Of the eight scores assessing disease severity, four (50.0%) assessed the degree of dilatation of pelvic veins and four (50%) assessed the severity of reflux. Only three of the scores were validated.

CONCLUSIONS

This scoping review identified a range of scoring and grading systems for PeVD. We note a lack of a validated scoring system, both clinical and radiological, for screening and assessment of disease severity. This is an important first step in developing validated disease-specific scoring systems for patient screening, appropriate referral, assessment of symptom severity, and assessment of the response to treatment.

Relationships Among Pelvic Congestion Syndrome Pain, Daily Activities, and Quality of Life

OBJECTIVE

To examine women's experiences of pelvic congestion syndrome (PCS) pain.

DESIGN

Descriptive, cross-sectional.

SETTING

Online questionnaires in a Facebook PCS support group.

PARTICIPANTS

Convenience sample of 143 women who self-identified as being diagnosed with PCS.

METHODS

We recruited women through a social media support group and invited them to participate in a self-reported questionnaire. We collected demographic information and used the McGill Pain Questionnaire to elicit responses related to pain quality, pain intensity, quality of life, and satisfaction with health care. We analyzed data using descriptive statistics and correlation coefficients.

RESULTS

Respondents characterized their PCS pain as exhausting, stabbing, sharp, shooting, and tender. Respondents indicated that 19 of 24 daily activities increased PCS pain, whereas only 5 reduced PCS pain. Pain intensity was negatively related to the quality of life, health satisfaction, sleep, and sexual relationships.

CONCLUSION

Chronic pelvic pain from PCS severely affected quality of life among respondents. These findings suggest a difference in the presentation of PCS from historical pain depictions and further highlight the need to identify pain profiles to increase timely and precise diagnosis. Further research is needed to evaluate interventions to increase the quality of life for women with PCS.

Improvement in chronic pelvic pain, orthostatic intolerance and interstitial cystitis symptoms after treatment of pelvic vein insufficiency

OBJECTIVES

Comorbidities associated with venous origin chronic pelvic pain (VO-CPP) were evaluated pre and post venous treatment to assess change.

MATERIALS AND METHODS

45 women with VO-CPP were treated with venous stenting and/or embolization. Four surveys assessed symptoms pre- and post-treatment: IPPS (chronic pelvic pain), PUF (interstitial cystitis), OHQ (dysautonomia), and modified ROME III (IBS). Prevalence of joint hypermobility was investigated.

RESULTS

Ages were 18-65. Pretreatment, 64% and 49% of women were in the severe range for PUF and OHQ, respectively. 40% and 56% met criteria for IBS and Ehlers-Danlos syndrome/Hypermobility Spectrum Disorder (EDS/HSD), respectively. 17eceived an iliac stent, 5 pelvic embolization, and 23 both. Post-treatment, average scores improved: IPPS (by 55%), PUF (34%), and OHQ (49%). Rome III improved only slightly.

CONCLUSION

Pelvic pain, interstitial cystitis, and dysautonomia were frequently found with VO-CPP and improved after venous treatment. EDS/HSD and IBS were common in these women.

Identification of outcomes in clinical studies for pelvic venous disorders

OBJECTIVE

There is increasing recognition that health systems need to measure and improve the value of patient care by measuring outcomes. Chronic pelvic pain secondary to pelvic venous insufficiency can have a significant impact on the quality of life (QOL) of women affected. Despite growing recognition, pelvic venous disorders (PeVDs), an important cause of chronic pelvic pain, remain underdiagnosed. Developing a core outcome set (COS) for benchmarking care delivery enhances the standardization of care. However, there is no consensus regarding a standardized minimum set of outcomes for PeVD. We aimed to generate a list of outcomes reported in previous PeVD treatment studies to lay the foundation for developing a COS for PeVD.

METHODS

This scoping review was undertaken according to the PRISMA-ScR guidelines. Initially, screening, full-text review and extraction was conducted on studies published between 2018 and 2023. Subsequently, the search was expanded using 1-year intervals, until, over a 1-year interval, no new outcomes were recorded. Closely related outcomes were classified into domains, and domains into three core areas: disease-specific, treatment-related, and QOL-related outcomes.

RESULTS

Of the 1579 records identified, 51 publications were included. From these studies, 108 different outcomes were identified. The median number of outcomes per study was 8 (interquartile range, 6-13). Closely related outcomes were organized into 42 outcome domains, which were then categorized into 3 core outcome areas; 47.6% (20/42) were disease specific, 35.7% (15/42) treatment related, and 16.7% (7/42) were QOL related. Of the 51 included studies, disease-specific outcomes were identified in 96.1% of the studies (49/51), treatment-related outcomes in 94.1% (48/51), and QOL outcomes in only 13.7% (7/51).

CONCLUSIONS

There was significant heterogeneity in outcomes reported in PeVD studies. Most PeVD treatment studies evaluated disease-specific and treatment-related outcomes of PeVD, but few reported outcomes that measured the impact on QOL. These findings will inform the next steps in developing a COS for PeVD.

Role of interventional radiology in obstetrics and gynaecology: a clinical review of an experience in a quaternary care centre

OBJECTIVE

The study aims to equip both Obstetricians and Gynaecologists with the knowledge of clinical conditions that will benefit from interventional radiology, equipment and materials that are commonly used, benefits, complications and the side effects of these techniques.

METHODS

It was a single-centre, retrospective cohort study with examples from hospital practice during the period of 2015 to 2021, acquired through computerised database including all obstetrics and gynecological cases in which interventional radiology techniques were used. No statistical analysis of data was applicable as it was a single-centre retrospective analysis of cases.

RESULTS

We had a total of 35 cases, including but not limited to placenta accreta spectrum disorders, fibroid, pelvic congestion syndrome and arteriovenous malformation who underwent various interventional radiological procedures ranging from embolization of uterine artery, peripheral angiography, embolization, and internal iliac artery balloon placement to ovarian vein embolization and coil insertion.

CONCLUSION

Increased collaborative efforts between interventional radiology and gynaecology would allow patients to be fully informed on the complete spectrum of surgical and nonsurgical treatment options available to them.

Balancing evidence-based care with patient-centered individualized care

Weak evidence, when manifested in clinical guidelines, can translate into biased vascular care. In vascular surgery, we have few randomized controlled trials with appropriate representation of females and persons of color, so generalizability of trial results can be problematic. Physicians are required to balance evidenced-based care (which is only as good as the underlying evidence) with personalized treatment recommendations that are often based on demographics, social circumstances, and/or existing therapeutic relationships. Biases, whether implicit or explicit, have an oversized effect on treatment decisions, and patient outcomes. In this commentary, we propose three principles to strengthen the vascular surgery evidence foundation and patient-centered decision-making going forward: (1) generating evidence designed for individualized care, (2) constructing clinical guidelines that are context specific and complexity aware, and (3) strengthening the training and support for surgeons to deliver patient-centered individualized care.

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review

Pelvic venous disorders (PeVD), previously known by various imprecise terms including pelvic congestion syndrome, have historically been underdiagnosed as a cause of chronic pelvic pain (CPP), a significant health problem associated with reduced quality of life. However, progress in the field has helped to provide heightened clarity with respect to definitions relating to PeVD, and evolution in algorithms for PeVD workup and treatment has been accompanied by new insights into the causes of a pelvic venous reservoir and associated symptoms. Ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for PeVD. Both treatments have been shown to be safe and effective for patients with CPP of venous origin, regardless of age. Current therapeutic protocols for PeVD exhibit significant heterogeneity owing to limited prospective randomized data and evolving understanding of the factors driving successful outcomes; forthcoming clinical trials are anticipated to improve understanding of CPP of venous origin as well as algorithms for PeVD management. This Expert Panel Narrative Review provides a contemporary update relating to PeVD, summarizing the entity's current classification, diagnostic workup, endovascular treatments, management of persistent or recurrent symptoms, and future research directions.

Pelvic vein incompetence and chronic pelvic pain: a case-control study

OBJECTIVE

To investigate the association between chronic pelvic pain (CPP) and pelvic vein incompetence (PVI) or pelvic varices.

DESIGN

Case-control study.

SETTING

Gynaecology and vascular surgery services in two teaching hospitals in north-west England.

SAMPLE

A total of 328 premenopausal women (aged 18-54 years), comprising 164 women with CPP and 164 matched controls with no history of CPP.

METHODS

Symptom and quality-of-life questionnaires and transvaginal duplex ultrasound for PVI and pelvic varices.

MAIN OUTCOME MEASURES

Venous reflux of >0.7 s in the ovarian or internal iliac veins (primary outcome) and presence of pelvic varices (secondary outcome). Statistical analysis compared the prevalence of PVI between women with and without CPP using the two-sided chi-square test. Logistic regression was used to compare the odds of having PVI and pelvic varices between women with and without CPP.

RESULTS

Pelvic vein incompetence was found on transvaginal duplex ultrasound in 101/162 (62%) women with CPP, compared with 30/164 (19%) asymptomatic controls (OR 6.79, 95% CI 4.11-11.47, p < 0.001). Forty-three of 164 (27%) women with CPP had pelvic varices compared with three of 164 (2%) asymptomatic women (OR 18.9, 95% CI 5.73-62.7, p < 0.001).

CONCLUSIONS

There was a significant association between PVI, as detected by transvaginal duplex imaging, and CPP. Pelvic varices were strongly associated with CPP and were infrequently seen in control patients. These results justify further evaluation of PVI and its treatment in well-designed research.

Surgical and endovascular treatment of pelvic venous disorder: Results of a multicentre retrospective cohort study

OBJECTIVE

In the present study, we investigated the clinical outcomes after gonadal vein resection (GVR) and gonadal vein embolization (GVE) with coils in patients with pelvic venous disorder (PeVD). We also assessed the rates of procedural complications and disease recurrence.

METHODS

Our multicenter retrospective cohort study included 361 female patients with PeVD-related chronic pelvic pain (CPP) and gonadal vein reflux who underwent GVR (n = 184) or GVE with coils (n = 177) from 1999 to 2020. The clinical outcomes (ie, presence and severity of CPP, procedural complications, disease recurrence) were assessed at 1 month and 1, 3, and 5 years after intervention. The pain intensity before and after treatment was assessed using a visual analog scale. All the patients underwent duplex ultrasound after GVR and GVE, and those with persistent CPP and suspected perforation of the gonadal vein by the coils were also evaluated by multiplanar pelvic venography.

RESULTS

GVR and GVE was associated with the reduction or elimination of CPP at 1 month after treatment in 100% and 74% of patients and postprocedural complications in 14% and 37% of patients, respectively (Р < 0.01 for both). The most common complication after either GVR or GVE was pelvic vein thrombosis (11% and 22% patients, respectively; P < .01 between groups). GVE was associated with postembolization syndrome in 20%, coil protrusion in 6%, and coil migration in 1% of patients. The long-term recurrence rate after GVR and GVE was 6% and 16%, respectively (P < .01).

CONCLUSIONS

Both GVR and GVE were found to be effective in treating patients with PeVD. However, GVR was associated with better efficacy in the relief of CPP and lower rates of procedural complications and disease recurrence.

A Comparative Study of a Small Series of Patients (50 Patients) with Pelvic Varicose Veins Treated with Plugs Alone or Plugs and Polidocanol

LEVEL OF EVIDENCE

Level 2.

PURPOSE

To compare the safety and efficacy of vascular plug (VP) and vascular plug and polidocanol foam (VPPF) treatments for embolization in pelvic congestion syndrome (PCS).

MATERIALS AND METHODS

A comparative, prospective, two-center study enrolled 50 women with PCS from January 2019 to January 2020. The patients were divided into two groups, and embolization was performed with VP (n = 25) and VPPF (n = 25) treatments. The mean age of the patients was 45.6 years ± 6.9. Three clinical parameters were assessed: abdominal pain, dyspareunia, and lower limb pain. The primary outcome (clinical success at 1 yr using a VAS), number of devices, procedure and fluoroscopy times, radiation doses, costs, and complications were compared. The participants were followed-up at 1, 3, 6, and 12 months.

RESULTS

At the 1-year follow-up, clinical success did not significantly differ between the two groups (VP vs. VPPF) regarding the improvement of the symptoms analyzed (pelvic pain, dyspareunia, lower extremity pain, and other symptoms (p < 0.05)). The mean number of devices per case was 4 ± 1.1 for the VP group and 2 ± 0.31 for the VPPF group (p < 0.001). No major complications were recorded in either group. The VPPF group had a significantly longer fluoroscopy time (42.8 min ± 14.2 vs. 25.4 min ± 7) and longer radiation dose (VPPF air kerma 839.4 ± 513 vs. VP air kerma 658.4 mGy ± 355 (all p < 0.001)).

CONCLUSIONS

Embolization for PCS resulted in pain relief in 90% of patients; the use of polidocanol did not demonstrate changes in the clinical outcome. The use of a VP alone was associated with decreased fluoroscopy time and radiation dose.

Pelvic Venous Disorders: An Update in Terminology, Diagnosis, and Treatment

Pelvic venous disorder (PeVD) is a term that encompasses all the interrelated causes of chronic pelvic pain (CPP) and perineal/lower extremity varicose veins of pelvic venous origin historically known as nutcracker syndrome, pelvic congestion syndrome, and May-Thurner syndrome, resulting in a more precise diagnosis that accounts for the underlying pathophysiology and anatomy. PeVD manifests as CPP with associated vulvar and lower-extremity varicosities, left flank pain and hematuria, and lower extremity pain and swelling secondary to obstruction or reflux in the left renal, ovarian, or iliac veins. This article will focus specifically on the most current nomenclature, evaluation, and management of CPP of venous origin.

Blood Cytokines of the Ovarian Vein Basin in Different Stages of Pelvic Varicose Veins

We analyzed the blood concentration of pro- and anti-inflammatory cytokines in the ovarian vein basin area in women of the reproductive age with primary pelvic varices. Increase in the disease severity was accompanied by a significant increase in proinflammatory cytokines (TNFα, IL-1β, IL-2, IL-6, and IL-8) and the proinflammatory index (IL-6/IL-10), whereas anti-inflammatory cytokine production changed ambiguously (increase of IL-4 at stage I, decrease of IL-10 at stage II, significant decrease of IL-4 and IL-10 at stage III). Control of these changes in female patients should probably be an important component of treatment measures and prevention of morphofunctional disorders occurring at disease progression, in particular at stage III of the disease.

Techniques for Embolization of the Ovarian Vein and Pelvic Reservoir

Pelvic venous disorders are a common and under diagnosed cause of chronic pelvic pain in women, presenting with chronic, noncyclical pelvic pain for greater than 6 months and the presence of pelvic varicosities. Pelvic varices and ovarian vein reflux are a strong indicator of venous origin chronic pelvic and may benefit from embolization. This most commonly occurs in multiparous, premenopausal women with symptoms of gravity dependent pelvic pain and postcoital pain. Additional causes of pelvic venous disorders include iliac vein compression, internal iliac vein reflux, and renal vein compression, however for the purposes of this article we will focus on ovarian vein insufficiency. The mainstay of treatment for pelvic venous insufficiency is Ovarian Vein Embolization and embolization of the pelvic venous reservoir. This article will focus on the patient presentation and workup, followed by a detailed summary of how to perform this procedure, current research to support treatment, possible technical challenges and complications, and finally future research priorities.

Venous Thromboembolism After Interventions on the Ovarian Veins in Patients With Pelvic Venous Disorder

BACKGROUND

Ovarian vein resection (OVR) and ovarian vein embolization (OVE) are effective options for treating patients with pelvic venous disorder (PeVD). However, due to in an abrupt cessation of blood flow in the ovarian veins (OVs), these interventions can be complicated by pelvic vein thrombosis (PVT). The aim of this study was to assess venous thromboembolism (VTE) rates after OVR and OVE in patients with PeVD.

METHODS

This retrospective cohort study included 272 patients with PeVD who underwent OVR (n = 122) or OVE with coils (n = 150). The rates and clinical manifestations of VTE were assessed in each group on days 1 and 3 after the intervention using duplex ultrasonography. Vein patency, blood flow velocity, and localization of thrombi in the pelvic (parametrial, uterine, and ovarian), iliac, superficial, and deep veins of the lower extremities were examined. PVT was defined as the formation of blood clots in nontarget (i.e. not intended to intervention) veins of the pelvis (parametrial, uterine veins, or tributaries of the internal iliac veins).

RESULTS

VTE after OVR and OVE was identified in 52 (19%) out of 272 patients. In the OVR group, PVT and calf deep vein thrombosis were detected in 9% and 1% of patients, accordingly, while in the OVE group their rates were almost three times higher (24% and 3%; both P = 0.001). In both groups, the most common VTE was PVT. The odds ratio for developing VTE with coils was 10 times higher (95% confidence interval: 2.35-56.43) after OVE than after OVR. Clinical manifestations of PVT were observed in 2.5% of patients, and the rest patients were asymptomatic. No cases of pulmonary embolism occurred.

CONCLUSIONS

VTE after interventions of the ovarian vein in patients with PeVD occurs in every fifth patient. OVE is associated with a higher incidence of PVT.

Retrospective Analysis of Complications After Gonadal Vein Interventions for Pelvic Venous Disorder

INTRODUCTION

To investigate and compare complications after gonadal vein embolization (GVE) with coils and gonadal vein resection (GVR) in patients with pelvic venous disorder (PeVD).

METHODS

This single-center retrospective cohort study included 277 female patients with PeVD who underwent GVE with coils (n = 150) or GVR (n = 122) in the period from 2000 to 2020. The participants were selected from a cohort of 4975 patients with chronic pelvic pain (CPP), of whom 1107 suffered from the PeVD-related CPP and 305 underwent surgical or endovascular intervention on the gonadal veins. The GVR technique was open retroperitoneal in 92, endoscopic transperitoneal in 18, and retroperitoneal in 12 patients. Clinical outcomes included 30-day complication rates and 3-year PeVD recurrence rates. The pain intensity was assessed before and after the procedure using a visual analogue scale. All patients underwent duplex ultrasound after the procedure, and those with persisting pain and suspected gonadal vein perforation with coil were also examined using computed tomographic venography.

RESULTS

A substantial pelvic pain relief was achieved within 30 d after GVE and GVR in 73% and 100% patients, accordingly (Р = 0.001). Complications after GVE were identified in 85 (56%) patients. The major complications included pelvic vein thrombosis (PVT) and calf deep vein thrombosis (24%), postembolization syndrome (22%), and coil protrusion (5.3%). Complications after GVR occurred in 14 (11%) patients and consisted of PVT (10%) and ileus (1.6%). The 3-year recurrence rates after GVE and GVR were 11% and 5%, accordingly (P = 0.04).

CONCLUSIONS

In patients with PeVD, the gonadal vein embolization with coils is associated with a high complication rate, which can be reduced with further development of the GVE technique, the use of new embolic agents, and the selection of a treatment method based on the patient's body composition.

Interventional Radiology in Obstetrics and Gynecology: Updates in Women's Health

Interventional radiology has had an expanding role in women's health over the past few decades, with recent accelerated growth and development. Interventional radiology is fundamental in the treatment of multiple conditions that affect women, including pelvic venous disease, uterine fibroids, and adenomyosis, and in postpartum management. Patient workup, classification, and treatment techniques have continued to evolve as interventional radiology has become more prevalent in the treatment of patients affected by these conditions. The authors provide a review of the pathophysiology of, patient workup for, and treatment of pelvic venous disease and uterine artery embolization for various disease processes. The authors also highlight updates from the past 5-10 years in diagnosis, classification, and treatment strategies. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Efficacy of endovascular treatment of pelvic varicose veins: A single-center retrospective observational study

OBJECTIVE

To evaluate the efficacy of endovascular embolization of pelvic varicose veins in the treatment of pelvic venous disorders (PeVD).

METHODS

A single-center retrospective study was performed, including 156 women referred to the Erasmus University Medical Center between January 2011 and October 2020 for an evaluation of PeVD. Data on presenting symptoms, clinical workup, treatment, and clinical outcomes were collected. The primary end point was resolution of symptoms after treatment. Secondary outcomes were correlation between symptoms at presentation and relief of symptoms after treatment, minor or major procedural complications, recurrences, and additional treatments needed.

RESULTS

Ninety patients underwent a pelvic phlebography, of which 75 received embolization of pelvic varicose veins. Median follow-up after phlebography was 13.2 months (interquartile range, 6.0-40.1 months). Of the treated patients, 53 (70.7%) had partial or complete relief of symptoms. Forty-six women (61.3%) who received embolization of pelvic varicose veins required additional treatments for leg and/or vulvar varicose veins.

CONCLUSIONS

This study found that endovascular embolization of pelvic varicose veins can be an effective treatment for PeVDs. However, additional treatments are often required for leg and/or vulvar varicose veins.

Insights into pelvic venous disorders

Pelvic venous disorders (PeVD), sometimes referred to as pelvic congestion syndrome (PCS), widely impact affected patients-mainly young women's quality of life, causing puzzling, uncomfortable symptoms sometimes requiring months or years to get an explanation, while simply remaining undiagnosed in other cases. Because pelvic pain is a non-specific symptom, an appropriate diagnosis requires a careful patient workup, including a correlation between history and non-invasive imaging. Invasive imaging is frequently required to confirm the diagnosis and plan treatment. Current therapeutic approaches principally rely on minimally invasive techniques delivered through endovascular access. However, while comprehensive descriptive classifications such as the symptoms-varices-pathophysiology (SVP) classification exist, universally accepted guidelines regarding therapy to apply for each SVP category are still lacking. This review strongly focuses on PeVD imaging and discusses available therapeutic approaches with regard to pathophysiological mechanisms. It proposes a new classification scheme assisting clinical decision-making about endovascular management to help standardize the link between imaging findings and treatment.

Pelvic Venous Insufficiency: Input of Short Tau Inversion Recovery Sequence

Objectives: To evaluate indirect criteria of pelvic venous insufficiency (PVI) of a short tau inversion recovery (STIR) sequence retrospectively compared with phlebographic findings. Methods: Between 2008 and 2018, 164 women who had received MRI and phlebography for pelvic congestion syndrome (60), varicose veins in the lower limbs (45), both (43), or other symptoms (16) were included. The presence of periuterine varicosities and perivaginal varicosities were compared to the findings of phlebography: grading of left ovarian vein reflux and presence of internal pudendal or obturator leak. Results: There was a correlation between the grading of LOV reflux on phlebography and the diameter of periuterine varicosities on STIR sequence (p = 0.008, rho = 0.206, CIrho [0.0549 to 0.349]). Periuterine varicosities had a positive predictive value of 93% for left ovarian reflux (95% CI [88.84% to 95.50%]). Obturator or internal pudendal leaks were found for 118 women (72%) and iliac insufficiency for 120 women (73%). Conclusions: Non-injected MRI offers a satisfactory exploration of PVI with STIR sequence. STIR sequences alone enabled the detection of left ovarian and iliac insufficiency.

Comprehensive overview of the venous disorder known as pelvic congestion syndrome

Pelvic venous disorders (PeVD) also known as Pelvic Congestion Syndrome (PCS) affect a great number of women worldwide and often remain undiagnosed. Gynecological symptoms caused by vascular background demand a holistic approach for appropriate diagnosis. This is a relevant cause of chronic pelvic pain and atypical varicose veins. The diagnosis is based on imaging studies and their correlation with clinical presentation. Although the aetiology of PCS still remains unclear, it may result from a combination of factors including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension and dilatation. The following paper describes an in-depth overview of anatomy, pathophysiology, symptoms, diagnosis and treatment of PCS. In recent years, minimally invasive interventions have become the method of first choice for the treatment of this condition. The efficacy of a percutaneous approach is high and it is rarely associated with serious complications.Key MessagesPelvic venous disorders demand a holistic approach for appropriate diagnosis.This article takes an in-depth look at existing therapies of Pelvic Congestion Syndrome and pathophysiology of this condition.Embolisation is an effective and safe treatment option.

Pelvic Venous Disorders (PeVD)

Pelvic venous disorders (PeVDs) have replaced the concept of pelvic congestion syndrome encompassing venous origin chronic pelvic pain (VO-CPP) in women. The evaluation of women with VO-CPP includes the assessment for other causes of pelvic pain as well as imaging evaluation for pelvic varicosities measuring greater than 5 mm diameter, ovarian vein diameter, and flow direction, as well as iliac vein diameter and signs of compression. Proper identification of these patients can lead to high degrees of success eliminating chronic pelvic pain following ovarian vein embolization and/or iliac vein stenting. Strong encouragement is provided to use the symptoms, varices, pathophysiology classification for these patients and upcoming research studies on the specific symptoms of patients with VO-CPP will help elucidate patient selection for intervention. Additional future randomized controlled trials are also upcoming to evaluate for outcomes of ovarian vein embolization and iliac vein.

An online survey of pelvic congestion support group members regarding comorbid symptoms and syndromes

Objectives

Patients with pelvic congestion syndrome (PCS) often report overlapping somatic symptoms and syndromes. The objective of this study was to explore the prevalence of co-existing symptoms and self-reported syndrome diagnoses among women with PCS and to inform future research hypotheses.

Methods

A brief online survey was offered to members of a PCS support group website. Responses were assessed for self-reported co-existing symptoms and formal diagnoses, including: chronic fatigue syndrome, fibromyalgia, postural tachycardia syndrome, irritable bowel syndrome, migraines, interstitial cystitis, and temporomandibular joint dysfunction.

Results

Of a total of 6000 members, there were 398 respondents; 232 (59%) had not yet been treated for PCS. Among these, the most prevalent co-existing symptoms were as follows: severe fatigue (72%), dizziness (63%), IBS symptoms (61%), brain fog (33%), migraines (49%), polyuria or dysuria (41%), excessive sweating (31%), TMJ pain (31%), and loose skin or lax joints (18%). These are much higher than reported for the general female population. The most commonly self-reported comorbid syndrome diagnoses for the overall group of 398 were: irritable bowel syndrome (29%), fibromyalgia (13%), spinal nerve problems (18%), interstitial cystitis (10%), postural tachycardia syndrome (9%), hypertension (11%), chronic fatigue syndrome (10%), and Ehlers-Danlos syndrome (6%). Other than with hypertension, these rates are variably higher than in the general population.

Conclusion

Several self-reported co-existing symptoms and syndromes are more prevalent in members of a PCS support group relative to the reported prevalence in the general population. More formal investigation is warranted to evaluate this finding and to investigate potential etiologic links. Ehlers-Danlos Syndrome appears to be common in self identifying PCS women.

Venous Anatomy and Collateral Pathways of the Pelvis: An Angiographic Review

The pelvic venous system is complex, with the potential for numerous pathways of collateralization. Owing to stenosis or occlusion, both thrombotic and nonthrombotic entities in the pelvis may necessitate alternate routes of venous return. Although the pelvic venous anatomy and collateral pathways may demonstrate structural variability, a number of predictable paths often can be demonstrated on the basis of the given disease and the level of obstruction. Several general categories of collateral pathways have been described. These pathway categories include the deep pathway, which is composed of the lumbar and sacral veins and vertebral venous plexuses; the superficial pathway, which is composed of the circumflex and epigastric vessels; various iliofemoral collateral pathways; the intermediate pathway, which is composed of the gonadal veins and the ovarian and uterine plexuses; and portosystemic pathways. The pelvic venous anatomy has been described in detail in cadaveric and anatomic studies, with the aforementioned collateral pathways depicted on CT and MR images in several imaging studies. A comprehensive review of the native pelvic venous anatomy and collateralized pelvic venous anatomy based on angiographic features has yet to be provided. Knowledge of the diseases involving a number of specific pelvic veins is of clinical importance to interventional and diagnostic radiologists and surgeons. The ability to accurately identify common collateral patterns by using multiple imaging modalities, with accurate anatomic descriptions, may assist in delineating underlying obstructive hemodynamics and diagnosing specific occlusive disease entities. ^©RSNA, 2022.

The Clinical Problem of Pelvic Venous Disorders

Pelvic venous disorders are inter-related pathologic conditions caused by reflux and obstruction in the pelvic veins. It can present a spectrum of clinical features based on the route of transmission of venous hypertension to either distal or caudal venous reservoirs. Imaging can help to visualize pelvic vascular and visceral structures to rule out other gynecologic, gastrointestinal, and urologic diseases. Endovascular treatment, owing to its low invasive nature and high success rate, has become the mainstay in the management of pelvic venous disorders. This article reviews the pathophysiology, clinical presentations, and diagnostic and therapeutic approaches to pelvic venous disorders.

Embolization in pelvic venous disorders using ethylene vinyl alcohol copolymer (Onyx®) and Aetoxysclerol: a prospective evaluation of safety and long-term efficacy

OBJECTIVES

To prospectively evaluate the safety and efficacy of embolization using ethylene vinyl alcohol copolymer (Onyx^®) and Aetoxysclerol for treatment of pelvic venous disorders (PeVD).

METHODS

This prospective study was approved by the institutional ethics review board. Ten clinical parameters were retained for evaluation of PeVD (pelvic pain, dyspareunia, post-coital pain, menstruation pain, lower limbs pain, difficulty walking, aesthetic discomfort, impact on daily working life, psychological impact and impact on daily life), measured on a visual analogue scale (VAS) between 0 and 10, and a global score out of 100 was noted before embolization, after 3 months during the imaging follow-up, and at the end of follow-up by phone call. The main criterion was clinical efficacy of embolization defined by an impairment score < 40/100 and a 50% decrease in overall score. Complications were recorded. Visualization of Onyx^® on MRI 3 months after embolization was noted.

RESULTS

Between July 2017 and May 2019, 73 consecutive women (mean age ± SD [range]: 41 ± 11 years [25-77]) treated by embolization with Onyx^® and Aetoxysclerol were included. The median follow-up was 28 months [Q1-Q3: 24.0-29.2] (range: 18.1-34.5). The median initial VAS impairment score was 39/100 [29.75-48.50] (12-58). Clinical efficacy was obtained for 70 patients (70/73, 95.9%), and the median VAS impairment score at the end of follow-up was significantly lower at 3 [0.00-7.25] (0-73) (p < 0.0001). Four minor complications occurred. Onyx^® was visualized on DIXON sequence of MRI for all patients.

CONCLUSION

Embolization using Onyx^® and Aetoxysclerol for PeVD is safe and effective.

KEY POINTS

• Embolization using Onyx^® and Aetoxysclerol for pelvic venous disorders is safe and effective. • Imaging follow-up is facilitated by visualization of Onyx^® on MRI DIXON sequences.

Relationships of Pelvic Vein Diameter and Reflux with Clinical Manifestations of Pelvic Venous Disorder

The causes of chronic pelvic pain (CPP) in patients with pelvic venous disorder (PeVD) are not completely understood. Various authors consider dilation of pelvic veins (PeVs) and pelvic venous reflux (PVR) as the main mechanisms underlying symptomatic forms of PeVD. The aim of this study was to assess relationships of pelvic vein dilation and PVR with clinical manifestations of PeVD. This non-randomized comparative cohort study included 80 female patients with PeVD who were allocated into two groups with symptomatic (n = 42) and asymptomatic (n = 38) forms of the disease. All patients underwent duplex scanning and single-photon emission computed tomography (SPECT) of PeVs with in vivo labeled red blood cells (RBCs). The PeV diameters, the presence, duration and pattern of PVR in the pelvic veins, as well as the coefficient of pelvic venous congestion (C_PVC) were assessed. Two groups did not differ significantly in pelvic vein diameters (gonadal veins (GVs): 7.7 ± 1.3 vs. 8.5 ± 0.5 mm; parametrial veins (PVs): 9.8 ± 0.9 vs. 9.5 ± 0.9 mm; and uterine veins (UVs): 5.6 ± 0.2 vs. 5.5 ± 0.6 mm). Despite this, C_PVC was significantly higher in symptomatic versus asymptomatic patients (1.9 ± 0.4 vs. 0.7 ± 0.2, respectively; p = 0.008). Symptomatic patients had type II or III PVR, while asymptomatic patients had type I PVR. The reflux duration was found to be significantly greater in symptomatic versus asymptomatic patients (median and interquartile range: 4.0 [3.0; 5.0] vs. 1.0 [0; 2.0] s for GVs, p = 0.008; 4.0 [3.0; 5.0] vs. 1.1 [1.0; 2.0] s for PVs, p = 0.007; and 2.0 [2.0; 3.0] vs. 1.0 [1.0; 2.0] s for UVs, p = 0.04). Linear correlation analysis revealed a strong positive relationship (Pearson's r = 0.78; p = 0.007) of CPP with the PVR duration but not with vein diameter. The grade of PeV dilation may not be a determining factor in CPP development in patients with PeVD. The presence and duration of reflux in the pelvic veins were found to be predictors of the development of symptomatic PeVD.

Predicting pelvic congestion syndrome: Concomitant pelvic pain diagnoses do not affect venography or embolization outcomes

Objectives

Pelvic congestion syndrome (PCS) is a challenging diagnosis to make secondary to nonspecific presenting symptoms and imaging findings. This retrospective review aims to discern predictive factors which can guide the decision to perform catheter-based venography and prognosticate outcomes.

Material and Methods

A retrospective analysis of patients who underwent catheter venography for PCS between January 2014 and December 2019 was performed. Multiple factors, including patient demographics, clinical history, pre-procedural imaging, venographic findings, and treatment outcomes 180 days post-procedure, were included in the analysis. Venographic findings were used to separate patients into two groups (positive or negative), with these factors compared across groups. Regression analysis controlled for the confounding effects of age and body mass index (BMI). Treated subjects were separated based on outcome (partial, no response, complete response, or technical failure), and comparisons were performed.

Results

Eighty patients were included in the initial analysis. Two patients were excluded due to prior embolization or portal hypertension. Seventy-eight patients were included in the final analysis. Sixty-two patients had positive findings, and 16 had no venographic findings to suggest PCS. A history of prior pregnancy was a significant predictor of positive venographic results (odds ratio = 5.99, P = 0.007). BMI was significantly lower in those with positive venographic results (P = 0.047). Presence of concomitant diagnoses did not affect venographic findings or treatment outcomes. No factors predicted treatment outcomes. Five of the treated patients had subsequent successful pregnancies.

Conclusion

A lower BMI supports the decision to perform venography for suspected PCS. In addition, patients who carried concomitant potentially confounding diagnoses for chronic pelvic pain were found to have similar rates of venographic findings suggesting PCS, as well as similar treatment outcomes.

Sonographic Evaluation of Pelvic Venous Disorders

ABSTRACT

Pelvic venous disorders are a group of interrelated conditions characterized by venous incompetence. These conditions often manifest with nonspecific symptoms that overlap with many gynecological, gastrointestinal, and urologic diseases. Clinical diagnosis can be difficult, and imaging can play a vital role in differentiating etiology. Sonographic evaluation is often the first step in evaluating these symptoms. Special attention to possible underlying pelvic venous disorders can reveal characteristic findings, support diagnosis, and guide treatment. Here we review pelvic congestion syndrome, nutcracker syndrome, May-Thurner syndrome, and other venous disorders, with a specific focus on sonographic findings and considerations.

A systematic review on isolated coil embolization for pelvic venous reflux

OBJECTIVE

Pelvic venous reflux (PVR) can present with symptoms such as chronic pelvic pain, dysmenorrhea, and dyspareunia, resulting in a decreased quality of life among those affected. Percutaneous coil embolization (CE) is a common intervention for PVR; however, the efficacy and safety of its use in isolation has yet to be reviewed.

METHODS

The MEDLINE and EMBASE databases were systematically searched from 1990 to July 20, 2020, for studies reporting on adult patients undergoing isolated CE for PVR. Articles not in English, case reports, studies reporting on pediatric patients, and studies not performing isolated CE were excluded. Search, review, and data extraction were performed by two independent reviewers (S.S. and M.T.). Changes in pain before and after CE was evaluated through a pooled analysis of visual analogue scale scores in seven studies.

RESULTS

A total of 970 patients (range, 3-218, 100% female) undergoing isolated ovarian vein or mixed veins embolization from 20 studies were included. Pooled analysis revealed mean improvements of 5.47 points (95% CI, 4.77-6.16) on the visual analogue scale. Common symptoms such as urinary urgency and dyspareunia reported significant improvements of 78-100% and 60-89.5% respectively. Complications were rare, with coil migration (n = 19) being the most common. Recurrence rates differed based on the varying symptoms and studies, with recurrence in pain 1-2 years after CE ranging from 5.9-25%. Two randomized controlled trials revealed improved clinical outcomes with CE as compared with vascular plugs and hysterectomy.

CONCLUSIONS

The current data suggests that isolated CE is technically effective and can result in clinical improvement among patients with PVR. However, further trials are required to ascertain its long-term effects.

Choosing the Most Appropriate Treatment Option for Pelvic Venous Disease: Stenting versus Embolization

Pelvic venous disease (PeVD) in women encompasses a wide variety of entities all resulting in pelvic pain and varices. Successful treatment with percutaneous interventions is dependent on identifying underlying factors contributing to the disease and addressing them with either embolization of incompetent veins or stenting for venous stenoses. There are a multitude of embolization methods with marked practice heterogeneity. Moreover, with the ongoing development of dedicated venous stents in the treatment of chronic venous disease, there are more opportunities to consider this modality for the treatment of PeVD, as many patients present with combined vein reflux and central venous stenosis. The necessity to address both and the order of interventions in these patients is still to be elucidated. Here, we describe when to choose stenting or embolization for PeVD, their limitations, and our practice and identify further areas of research in this field.

Clinical Presentation, Patient Assessment, Anatomy, Pathophysiology, and Imaging of Pelvic Venous Disease

Pelvic venous disorders (PeVDs) can result in several different clinical presentations, but can be challenging to distinguish from other etiologies of chronic pelvic pain (CPP). Clinical evaluation of CPP patients optimally should be performed in a multidisciplinary fashion and patients who may have PeVD should be referred for consultation with a vascular interventionalist whose evaluation would utilize an imaging workup to search for pelvic varices. Additionally, it is critical to quantify the quality-of-life effects of all CPP to determine the impact on the patient's overall health. Diagnostic imaging, including transabdominal and transvaginal ultrasound, computed tomography, magnetic resonance imaging, and venography, can be utilized to identify pelvic varices, as well as venous reflux and obstruction leading to CPP. The use of the SVP tool is important to classify PeVD patients based on their clinical symptoms, varicose veins, and pathophysiology for precise clinical communication and for reporting clinical research. The goal of this publication is to delineate the clinical presentation, anatomy, pathophysiology, and imaging evaluation of patients with CPP suspected of having PeVD.

Stratification of pelvic venous reflux in patients with pelvic varicose veins

OBJECTIVE

We investigated the association between the pattern and duration of pelvic venous reflux (PVR) and pelvic pain severity in patients with pelvic varicose veins (PVVs).

METHODS

The present retrospective study included 600 female patients with PVVs. Of the 600 patients, 453 had had PVVs and pelvic congestion syndrome (group 1) and 147 had had an asymptomatic disease course (group 2). Pelvic venous pain (PVP) was assessed using a visual analog scale. All the patients had undergone duplex ultrasound of the left and right renal veins, external, internal, and common iliac veins, and parametrial, uterine, gonadal, and vulvar veins (PV, UV, GV, and VV, respectively), with an assessment of their patency and diameter and the presence and duration of reflux. Reflux in the pelvic veins was considered pathologic if it lasted for >1 second.

RESULTS

In group 1, PVR type I (1-2 seconds), II (3-5 seconds), and III (>5 seconds or spontaneous reflux in the absence of a loading test) was found in 31%, 58%, and 11% of the patients, respectively. Moderate and severe reflux (types II and III) was associated with severe PVP (mean score, 8.3 ± 0.5) in 69% of the group 1 patients. A combination of reflux in the GV, PV, UV, and internal iliac vein was associated with severe PVP (mean score, 8.1 ± 0.3) in 51% of these patients. A combination of reflux in the PVs, UVs, and VVs was associated with moderate pain (mean score, 5.3 ± 0.2) in 49.2% of group 1. In group 2, PVR type I, II, and III was present in 95%, 4%, and 1% of the patients, respectively, and was observed in the PV only in patients with type I; in the GVs, PVs, UVs, and internal iliac veins in those with type II; and in the PVs and GVs in the patients with type III reflux. Reflux in the GVs and UVs was significantly more prevalent in group 1 than in group 2 (GVs, 51% vs 6%; P = .0001; UVs, 57% vs 7%; P = .0001). A combination of reflux in the GVs and UVs was a predictor of severe PVVs (odds ratio, 19.7; 95% confidence interval, 11.3-34.6).

CONCLUSIONS

In patients with PVVs, the presence and severity of pelvic pain will be determined by the type of PVR and its distribution in the pelvic veins. The combination of moderate to severe reflux (types II and III) in the PVs, UVs, and GVs was a predictor of severe PVP. Patients with asymptomatic PVVs were characterized by mild reflux (type I) in the PVs, with rare involvement of the GVs and UVs.

Clinical Presentation and Evaluation of Pelvic Venous Disorders in Women

The term pelvic venous disorders (PeVD) describes a group of related clinical entities with overlapping clinical presentations that were previously characterized by separate imprecise syndromic terminology. The clinical manifestations of PeVD may variously include chronic pelvic pain; pelvic origin extrapelvic lower extremity and genital varices; lower extremity pain and swelling; and left flank pain and hematuria. This manuscript focuses on the primary manifestations of PeVD in women - chronic pelvic pain and pelvic origin lower extremity and vulvar varices - and will review the underlying pathophysiology and related complicating factors (such as maladaptive pain responses) to explain the variety of clinical presentations.

Imaging of Pelvic Venous Disorders (PeVD); Should Every Patient Get an MRI?

Pelvic venous disease (PeVD) is part of the broad differential diagnosis of chronic pelvic pain with a challenging diagnosis and clinical workup to identify those patients that are most likely to benefit from intervention. Ultrasound, MRI, CT, venography, and intravascular ultrasound can all provide information to aid in the diagnostic algorithm. The purpose of this article is to review imaging as a component of the outpatient workup of patients with chronic pelvic pain to guide appropriate understanding and use of imaging modalities to accurately identify patients suffering from PeVD. A favored approach is to begin with transabdominal sonography with selective use of MRI/MRV in specific patient populations.

Iliac Vein Stenosis: Is the Data Strong Enough for Stenting in the Young Pelvic Venous Disorders (PeVD) Population?

Iliac vein stenosis is a clinical condition resulting from external compression of the iliocaval venous unit with the consequent remodeling of the vascular wall, hemodynamic alterations, and predisposition to venous thrombosis. As such, the most common indications for percutaneous endovascular iliac vein stenting supported by the literature, include the management of thrombotic and non-thrombotic iliac venous lesions associated with advanced chronic venous disease (CVD). However, its clinical presentation is variable, and it may also include features associated with PeVD such as chronic pelvic pain, perineal heaviness, urinary urgency, postcoital pain, and vulvar or superficial non-saphenous veins varicosities. In this setting, the management revolves around the relieving venous obstruction and restoring normal blood flow through the compressed vein with percutaneous endovascular iliac vein stenting, that can be augmented with ovarian vein embolization (OVE) or direct embolization of the superficial varices. Given the heterogeneity of PeVD presentation and the lack of high-level quality data in outcomes for iliac vein stenosis stenting, this review will discuss the current evidence available for this intervention and clinical issues to consider when evaluating these patients.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355521999559] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.12.084]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal’s style. The contribution has been published under a Attribution-Non Commercial 4.0 International (CC BY-NC 4.0), (https://creativecommons.org/licenses/by-nc/4.0/)

With the support of the American College of Obstetricians and Gynecologists, the American Vein & Lymphatic Society, the American Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and Interventional Radiology Society of Europe, the European Venous Forum, the International Pelvic Pain Society, the International Union of Phlebology, the Korean Society of Interventional Radiology, the Society of Interventional Radiology, and the Society for Vascular Surgery

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology (“SVP”) classification for PeVD, includes three domains—Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient’s disease. An individual patient’s classification is designated as SVP_A,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Vulvar Varicosities in an Adolescent Girl with Morbid Obesity: A Case Report

Vulvar varicosities in nonpregnant females, either isolated or as a part of the pelvic congestion syndrome, are rare. We present a case of an adolescent girl with morbid obesity with bilateral bluish protrusions on the labia minora, as an incidental finding, that coincided with her excessive weight gain. The adolescent underwent thorough clinical examination, doppler ultrasound, contrast venography and varicography, and magnetic resonance angiography to rule out alternative diagnoses. Imaging results confirmed the presence of large venous lakes. Venous drainage to the internal iliac vein and connections with the long saphenous vein were delineated. Incompetence, dilatation, or reflux of ovarian or internal iliac veins, or their main tributaries, were not noted. Since the adolescent was asymptomatic and other pathologies, such as vascular malformations or hemangiomas were excluded, she was managed conservatively with counseling about lifestyle modification and weight reduction. This is only the third reported case of vulvar venous varicosities in adolescents. Female sex, along with obesity, are known risk factors for varicose vein formation; however, the pathogenesis is not fully understood. Additional research is needed to elucidate the role of excess adipose tissue in the pathophysiology of vulvar varicose veins and to optimize diagnostic workup and management in adolescence.

Efficacy of two micronized purified flavonoid fraction dosing regimens in the pelvic venous pain relief

BACKGROUND

The venoactive drug treatment regimen for pelvic venous disorders (PeVDs) is not finally established. The study aimed at assessing the efficacy of micronized purified flavonoid fraction (MPFF) in a standard or double dose in the pelvic venous pain (PVP) relief in PeVD.

METHODS

We analyzed the treatment efficacy in 125 female patients with PeVD, who were allocated to two groups with MPFF treatment in a regular dose of 1000 mg once daily (OD) for 2 months (N.=65; group 1) or double dose of 1000 mg twice daily for 1 month and then 1000 mg OD for 1 month (N.=60; group 2). Patients underwent clinical examination along with an assessment of the PVP severity using the visual analogue scale (VAS) ranged from 0 to 10 scores, transvaginal and transabdominal duplex ultrasound scanning (DUS), and single-photon emission computed tomography (SPECT) of the pelvic veins with in vivo-labelled red blood cells (RBCs). The groups were different at baseline in the PVP severity (3.4±1.2 vs. 7.3±0.5 scores in groups 1 and 2, accordingly; P=0.012). DUS and SPECT were used to evaluate diameters of gonadal, parametrial, and uterine veins, to assess the presence of reflux in them, to measure blood flow velocity in the internal iliac veins (V<inf>lin IIV</inf>), and to calculate the coefficient of pelvic venous congestion (C<inf>PVC</inf>).

RESULTS

The treatment was associated with a significant reduction in the PVP score from 3.4±1.2 to 1.2±0.2 (P=0.03) when using the standard dose for 2 months and from 7.3±0.5 to 0.8±0.1 (P=0.001) when using the double dose in the 1^st month. The PVP relief was achieved on average after 13.7±0.6 and 3.1±0.8 days in groups 1 and 2, accordingly (P=0.0001 between the groups). At month 2, the C<inf>PVC</inf> reduction was found to be significantly greater in group 2 compared to group 1 (46.6% vs. 25%; P=0.018). Side effects (gastralgia, flatulence) were reported by only 2 (3.3%) patients of group 2.

CONCLUSIONS

The venoactive drug therapy with MPFF is an effective and safe option for the PVP relief in female patients with PeVD. The use of double dose in the 1^st month seems to be appropriate in patients with greater PVP severity but is associated with an increased rate of side effects.

Hemodynamic and Radiological Classification of Ovarian Veins System Insufficiency

Ovarian veins system insufficiency is one of the most common reasons for pelvic venous insufficiency (PVI). PVI is a hemodynamic phenomenon responsible for the occurrence of venous insufficiency of the lower extremities and recurrent varicose veins in nulliparous and parous women, as well as for a set of symptoms described as pelvic congestion syndrome (PCS). In the years 2017–2019, 535 patients admitted to our center with symptoms of venous insufficiency of the lower extremities, underwent complete ultrasound diagnostics (color-duplex ultrasound) of the venous system of the abdomen, pelvis and lower limbs, as well as extended imaging diagnostics using computed tomography (CT) or magnetic resonance (MR) venography. On the basis of the obtained results, the authors proposed a 4-grade hemodynamic and radiological classification (grades I-IV) defining the stratification of ovarian veins insufficiency. Using the above mentioned classification approx. 32% patients were identified as Grade I and I/II, approximately 35% revealed morphological and hemodynamic changes corresponding to Grade II and II/III, approximately 25% were classified as Grade III, whereas the remaining 8% were assessed as Grade IV. The described classification allows for the grading of ovarian veins insufficiency based on transparent radiological criteria, making it easy to use in everyday clinical practice. According to the authors, the proposed classification could facilitate communication between diagnostic physicians, specialists dealing with the treatment of venous insufficiency and gynecologists, who admit patients with symptoms suggesting venous insufficiency of the pelvis.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVP_A,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Medicine and Phlebolymphology: Time to Change?

Biomedical science is undergoing a reappraisal of its scientific advancement process and of the related healthcare management. Progress in medicine should combine improvements of knowledge, efficacy, and safety of diagnostic/therapeutic procedures, with adequate cost-effectiveness profiles. This narrative review is aimed at assessing in medicine, more specifically in phlebology and lymphology: (a) scientific literature possible biases, (b) the level of evidence, comprehensiveness, and cost-effectiveness of the main therapeutic options, and (c) the possible contribution of integrative and translational medicine. Current medical research may have cognitive biases, or industry-tied influences, which impacts clinical practice. Some reductionism, with an increasing use of drugs and technology, often neglecting the understanding and care of the root causative pathways of the diseases, is affecting biomedical science as well. Aging brings a relevant burden of chronic degenerative diseases and disabilities, with relevant socio-economic repercussions; thus, a major attention to cost-effectiveness and appropriateness of healthcare is warranted. In this scenario, costly and innovative but relatively validated therapies may tend to be adopted in venous and lymphatic diseases, such as varicose veins, leg venous ulcer, post-thrombotic syndrome, pelvic congestion syndrome, and lymphedema. Conversely, a more comprehensive approach to the basic pathophysiology of chronic venous and lymphatic insufficiency and the inclusion of pharmacoeconomics analyses would benefit overall patients’ management. Erroneous lifestyle and nutrition, together with chronic stress-induced syndromes, significantly influence chronic degenerative phlebo-lymphatic diseases. The main active epigenetic socio-biologic factors are obesity, dysfunctions of musculo-respiratory-vascular pumps, pro-inflammatory nutrition, hyperactivation of stress axis, and sedentarism. An overall critical view of the scientific evidence and innovations in phebolymphology could be of help to improve efficacy, safety, and sustainability of current practice. Translational and integrative medicine may contribute to a patient-centered approach. Conversely, reductionism, eminence/reimbursement-based decisional processes, patients’ lack of education, industry-influenced science, and physician’s improvable awareness, may compromise efficacy, safety, appropriateness, and cost-effectiveness of future diagnostic and therapeutic patterns of phlebology and lymphology.

Activity of Antioxidant Enzymes in the Regional Blood Flow during Pelvic Venous Disorders in Women

Activity of some antioxidant enzymes (superoxide dismutase, catalase, and glutathionedependent enzymes), as well as the level of LPO products in the region regional blood flow (collateral branches of the main trunks of ovarian veins) in women with pelvic venous disorders were studied. A compensatory increase in activity of superoxide dismutase, catalase, and glutathione peroxidase during stage I of the disease was found; during stage II, superoxide dismutase activity decreased and glutathione peroxidase increased, while during stage III, pronounced decrease in activities of all studied enzymes was observed. The level of lipid peroxidation products in the regional blood flow increased as the disease progressed, with maximum values in the third stage.