A systematic review on isolated coil embolization for pelvic venous reflux

Management of Extra-Pelvic Varicose Veins of Pelvic Origin in Female Patients

Extra-pelvic varicose veins (VVs), originating from incompetent pelvic veins, present a significant clinical challenge, due to their complex anatomy, etiology, and symptomatology. This review aims at providing a comprehensive overview of the diagnostic and therapeutic strategies for these cases and emphasizes the importance of a tailored, evidence-based approach to the effective management of these varicosities, particularly regarding the interplay between the pelvic and extra-pelvic venous systems. Diagnostic workup should be multifaceted, incorporating patient-reported symptoms, physical examinations, and duplex ultrasound imaging. Specific diagnostic assessments include evaluation of the pelvic escape points and the transvaginal and transabdominal ultrasonography, to analyze venous hemodynamics and identify anatomical abnormalities in the pelvic floor and pelvis. In patients presenting with additional pelvic venous insufficiency (PVI)-related pelvic symptoms, advanced diagnostic techniques, such as cross-sectional imaging, venography, and intravascular ultrasound can be valuable to confirm and establish the appropriate treatment strategy. Since most patients with extra-pelvic VVs of pelvic origin do not report pelvic symptoms, minimally invasive procedures, using the "bottom-up" approach, such as ultrasound-guided foam sclerotherapy of the pelvic escape points and extra-pelvic VVs, or surgical ligation and miniphlebectomy for these incompetent veins, are usually sufficient. There are several advantages of these local procedures: they are simple, radiation exposure and injection contrast agents are avoided, they are convenient for the patient since they are performed on an outpatient basis, and they can be easily repeated, if required. When the "bottom-up" treatment fails and the extra-pelvic VVs recur quickly or the patient develops pelvic symptoms, management of the pelvic veins including embolization of the ovarian veins or stenting of the iliac veins should be considered. Careful patient selection is essential to avoid overtreatment and achieve optimal clinical outcomes.

Pelvic Varicose Veins in Women. Russian Experts Consensus

Pelvic Varicose Veins in Women. Russian Experts Consensus.

Pelvic Venous Disorders in Women: 5-Year Update from a Society of Interventional Radiology Foundation-Sponsored Research Consensus Panel

Pelvic venous disorders (PeVDs) are rarely considered as a cause of chronic pelvic pain in women being evaluated by nonvascular specialists. A Society of Interventional Radiology (SIR) Foundation-sponsored Research Consensus Panel addressing this issue identified multiple gaps in the literature and made recommendations to enhance the evidence. Since publication of these recommendations in 2019, significant progress has been made in developing the necessary tools to improve the ability to conduct rigorous clinical studies and advance the evidence supporting the diagnosis and treatment of PeVD. This report summarizes the 5-year impact of the panel's recommendations. The investment made by SIR Foundation to host a Research Consensus Panel on PeVD has facilitated enduring academic productivity related to this clinical issue.

Diagnosis and Management of Pelvic Venous Disorders in Women

Pelvic venous reflux and obstruction can lead to chronic pelvic pain and extra-pelvic varicosities. This paper will discuss the contemporary understanding of this pathophysiology and its clinical manifestations. It will review evidence-based clinical and imaging criteria of pelvic venous disorders, data supporting benefit from venous interventions, criticisms of the available data and highlight evidence research gaps that exist. Finally, it will argue that comparative outcomes research utilizing standardized patient selection for embolization and stenting, embolization treatment strategies that eliminate the pelvic varices (at least to start), and clinically relevant outcome measures are necessary to establish the benefit of vascular treatments.

Effects of Venoactive Drug Therapy and Ovarian Vein Interventions on Vasoactive Neuropeptide and Cytokine Levels in Patients with Pelvic Venous Disorders

BACKGROUND

To study and compare the effects of venoactive drug (VAD) therapy and ovarian vein embolization or resection (OVE or OVR, accordingly) on the levels of vasoactive peptides and cytokines in patients with pelvic venous disorders (PeVDs).

METHODS

The study included 70 consecutive female patients with PeVD symptoms, such as chronic pelvic pain (CPP), dyspareunia, dysuria, and vulvar varicosities. Based on the results of clinical examination and duplex ultrasound of the pelvic veins, the patients were allocated to the VAD therapy (n = 38) or OVE/OVR (n = 32). Additionally, the enzyme-linked immunosorbent assay tests were performed to determine levels of calcitonin gene-related peptide (CGRP), substance P (SP), interleukins 6 and 8 (IL-6, IL-8) and monocyte chemotactic protein-1 (MCP-1) after a 2-month course of VAD therapy and at 3 months after OVE/OVR.

RESULTS

The VAD therapy was associated with a significant decrease in CPP in 84% of patients with PeVD and isolated lesions of the parametrial veins (PVs) and uterine veins (UVs). VAD had no significant effect on the pelvic venous reflux. No changes in the CGRP, SP, IL-6, IL-8, and MCP-1 levels were detected after treatment. At 3 months after OVE or OVR, all patients with PeVD and combined lesions of the ovarian veins (OVs), PVs and UVs reported almost complete relief of CPP. Along with elimination of reflux in ovarian veins, the disappearance of reflux in PVs and UVs was noted. A decrease in the CGRP and SP levels was observed (0.7 ± 0.1 ng/mL and 0.12 ± 0.02 ng/mL before treatment; 0.5 ± 0.12 ng/mL and 0.09 ± 0.06 ng/mL after treatment, respectively; all P < 0.05). No changes in cytokine levels were revealed.

CONCLUSIONS

Treatment with VAD is associated with the CPP relief, but has no significant effect on the CGRP, SP, IL-6, IL-8, and MCP-1 levels. OVE/OVR results in the CPP relief, elimination of the pelvic venous reflux and a significant decrease in the CGRP and SP levels, but does not change cytokine levels.

Efficacy of embolotherapy for the treatment of pelvic congestion syndrome: A systematic review

Pelvic congestion syndrome (PCS) poses a significant health, diagnostic, and economic challenges. Transcatheter embolisation has emerged as a promising treatment for PCS. A systematic review was performed in order to assess the safety and efficacy of transcatheter embolisation in the treatment of PCS. A systematic search of electronic databases was performed using 'PubMed', 'Embase', 'Medline (OVID)', and 'Web of Science', for articles pertaining to efficacy of embolotherapy for the treatment of pelvic congestion syndrome. A total of 25 studies were included in this systematic review with a combined total of 2038 patients. All patients included were female with a mean average age of 37.65 (31-51). Of the 25 studies, 18/25 studies reported pre- and post-procedural pelvic pain outcomes using a visual analogue scale (VAS). All studies showed a reduction in VAS post-procedure. Transcatheter embolisation had a high technical success rate (94%) and an overall complication rate of 9.0%, of which 10.4% were major and 89.6% were minor. Fifteen out of 19 (78.9%) major complications required a subsequent intervention. Transcatheter embolisation using various techniques is effective and safe in treating PCS. A low quality of evidence limits the currently available literature; however, embolisation has shown to improve symptoms in the majority of patients with low complication rates and recurrence rates.

The role of iliac vein stent placement in pelvic venous disorder management

Pelvic venous disease (PeVD) has historically been challenging to diagnose and treat. This paper describes a comprehensive approach to the diagnosis of PeVD and reviews the role of iliac vein stent placement in treatment. Patient selection is vital for non-thrombotic iliac vein lesions (NIVLs) as only a small subset of patients with an NIVL will benefit from stent placement. There is limited, inconclusive data on optimal treatment for patients with both primary ovarian vein reflux and an NIVL. Patients with chronic post-thrombotic outflow obstruction typically have a more favorable risk/benefit ratio for intervention but require anticoagulation and close follow-up due to poorer long-term stent patency. Intravascular ultrasound is a useful tool for identifying obstructive lesions, sizing stents, and planning landing zones. More research is needed to characterize underlying pathophysiology, validate thresholds for intervention, develop reliable methods for outcomes assessment, and determine treatment response. Until this data is produced, an individualized treatment approach is warranted.

Nickel-related hypersensitivity reactions following endovascular interventions: A review of current evidence

INTRODUCTION

Nickel is a principal alloying agent in the production of vascular endoprostheses, despite persisting as the most habitually identified allergen. Variable nickel-related hypersensitivity manifestations following endovascular intervention were reported, challenging established paradigms in treatment and accuracy of prognostic assessments. The objective of this review is to critically evaluate current metrics to maximise patient-related outcomes.

METHODS

A literature review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement. Patients indicative of nickel hypersensitivity reaction following endovascular intervention were discerned. A positive reaction was defined by patch testing, histological analysis, or anamnesis indicative of nickel hypersensitivity. Morphology of implicating prostheses, adverse events and postoperative complications, clinical course, diagnostic and therapeutic strategies alongside patient prognosis were recorded.

RESULTS

Nickel-related hypersensitivity reactions following endovascular repair were identified in 36 patients with a median age of 44.5 years. 20 patients received nitinol-containing intervention. 28 (77.8%) patients are female. Multi-organ adverse reactions occurred in 21 (58.3%) patients with variable latency. 14 (38.9%) patients were presented with neurological adverse reactions manifesting mainly as unilateral hemiparesis. Dermatological reactions implicated 16 (44.4%) patients. Miscellaneous manifestations include suicidal ideation. 13 (36.1%) patients displayed previous metal intolerance and 32 (88.9%) patients had positive patch testing for nickel. Histological analysis of lesions and prostheses indicated lymphocytic infiltration. 5 (13.9%) patients experienced device-specific reactions as in-stent restenosis or auxiliary distal vessel stenosis. 11 (30.1%) patients received solely medical therapy and 5 (13.9%) patients received solely surgical therapy. 19 (52.7%) patients underwent both medical (oral corticosteroid) and surgical therapy (device retrieval). 26 (77.1%) patients achieved symptomatic cessation, 6 (16.7%) patients exhibited symptomatic persistence and 0 patients died.

CONCLUSION

Prophylactic pre-assessment for a history of metal allergy and consideration of prostheses alternatives is recommended to minimise reaction risk and severity. Despite nickel's predominant usage, information paucity urges additional studies to emphasise its implications and maximise patient outcomes.

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.

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.

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.