Pelvic Congestion Syndrome: Systematic Review of Treatment Success

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.

Analysis of the Clinical Efficacy of Interlock Detachable Coil Interventional Embolization on Pelvic Congestion Syndrome and Ovarian Reserve Function: A Retrospective Study

Objective

This study aimed to examine the effects and the efficacy of a combination of interventional embolization and endocrine hormone therapy for Pelvic congestion syndrome (PCS).

Methods

We retrospectively analyzed 132 patients diagnosed with PCS, and divided them into three groups based on their therapeutic schedule. The visual analog scale (VAS), pelvic venous blood flow parameters, and serum hormone levels of the three groups were compared before and after treatment. Moreover, the clinical efficacy and long-term changes in ovarian reserve functions were analyzed. For the comparison of measurement data before and after treatment within the group, paired - sample t - test was used for analysis. For the comparison between groups, one - way analysis of variance was applied. A P - value less than 0.05 indicated a statistically significant difference.

Results

Patients in the study group had significantly lower pain degrees than in the control group I and the control group II at 24 h and the first month after the operation (p < 0.05). The degree of pain in patients in the study group was significantly lower than that in the control group I at the third and 6 months following the treatment (p < 0.05). The parameters of venous blood flow and ovarian reserve in patients treated with the combined endocrine hormone therapy were significantly better than those in patients not treated with endocrine hormone therapy (p < 0.05). The total effective rate of the study group was significantly higher than that of the control groups (p < 0.05).

Conclusion

A combination of precise interventional embolization and endocrine hormone therapy can rapidly and effectively relieve pain in patients with PCS. Compared with free coil embolization, this combination can effectively increase vascular tension, reduce congestion, inhibit ovarian function, reduce pelvic congestion, and relieve symptoms.

Characterizing the description of pelvic congestion syndrome pain: A latent class analysis

ObjectivesChronic pelvic pain from pelvic congestion syndrome (PCS) is a complex condition disproportionately affecting women. PCS pain has been described as dull and achy, but emerging research indicates variances in the historical pain depictions. We aimed to identify the groups of pain characteristics experienced by women living with PCS using a latent class analysis and examine their predictive validity on quality of life, pain intensity, and pain management indicators.MethodsA secondary data analysis of cross-sectional survey data collected from 160 participants on a Facebook PCS support group was conducted. After evaluating the original 86 unique pain descriptors endorsed on the McGill Pain Questionnaire, descriptors endorsed by more than 30 participants were retained for analysis (n = 34).ResultsResults from the latent class analysis identified two latent classes: mild but consistent (44.4%) and intense and debilitating (55.6%). Between the two latent classes, there were clear patterns of pain endorsement to indicate that women in the two groups experience PCS pain differently. Compared to the second latent class (intense and debilitating), women in the first latent class (mild but consistent) experienced milder PCS associated pain and reported a significantly higher quality of life, satisfaction with their health, and less interference with sleep quality and sexual desire. Unfortunately, everyday activities (i.e., exercising, urinating, moving, standing, and working) were more likely to increase pain for women in the second latent class.ConclusionsDiagnosis and treatment of pelvic venous disorders are hindered by outdated evidence on the expected pain depictions. A comprehensive pain profile of PCS is needed to establish the effect on women's lifestyles, quality of life, and mental health.

Coil occlusion combined with sclerotherapy versus N-butyl-2-cyanoacrylate embolization in patients with pelvic venous disorders: a single-center retrospective study

BACKGROUND

Pelvic venous disorder (PeVD) is increasingly diagnosed with different modalities of treatment.

METHODS

This is a retrospective study in which we compared using metallic coil combined with sclerosant foam and N-butyl-2-cyanoacrylate in female patients with PeVD in terms of clinical and technical success as well as safety. Adult patients with symptoms suggestive of primary PeVD and confirmed with Doppler ultrasound examination and/or venography were eligible for the study. Secondary PeVD and lost follow-up were excluded.

RESULTS

This study included 167 patients who were treated with coil and sclerotherapy (n = 87; group I) or N-butyl-2-cyanoacrylate (n = 80; group II) embolization. Immediate postoperative veins' closure was achieved in all patients in the two groups. At the 6-month follow-up, there was a statistically significantly higher occlusion rate in group I (100% compared with 93.8% in group II, P = .018) with five new cases of recanalization. The 6-month visual analog scale score was lower in group I (median of 1 and mean of 1.14 ± 0.904) than group II (median of 2 and mean of 1.7 ± 1.32), with a statistically significant difference (P = .005).

CONCLUSIONS

The study emphasizes the potential advantages of the sclerosant foam and metallic coil combination in achieving favorable outcomes for patients with PeVD.

Pelvic Varicose Veins in Women. Russian Experts Consensus

Pelvic Varicose Veins in Women. Russian Experts Consensus.

Medical treatment for pelvic congestion syndrome with flavonoid: A pilot study

OBJECTIVE

To investigate the efficacy of medical management by flavonoid in women with pelvic congestion syndrome (PCS) by comparison of the changes in venous size and quality of life (QoL) before and after treatment.

MATERIALS AND METHODS

Eleven women who met the diagnostic criteria of PCS were enrolled in the study. Flavonoid 500 mg twice or 1000 mg once daily was prescribed. Objective outcome was evaluated by measurement of ovarian vein diameter via transvaginal ultrasound in each case before and after 3-6 months of the treatment. PCS related symptoms were evaluated by Pelvic Varicose Vein Questionnaire (PVVQ), and Visual Analog Scale (VAS) as subjective outcomes. Wilcoxon signed rank test was used to compare the differences pre- and post-treatment. Data analysis was performed using SPSS 22.0. Statistical significance was defined as P value < 0.05.

RESULTS

From January 2022 to September 2023, 11 women met the criteria and were diagnosed with pelvic congestion syndrome. The age ranged from 40 to 72 years old with mean of 57 y/o. 90.9 % of the subjects (10/11) reported significant decreases in VAS (mean = 5.9 pre-vs. 2.5 post-treatment, p = 0.005) and PVVQ (mean = 51.6 pre-vs. 30.5 post-treatment, p = 0.005). Transvaginal ultrasound also showed significant decreases in ovarian vein diameter, from 8.1 mm to 6.2 mm (p = 0.016).

CONCLUSION

Our study demonstrated that medical treatment with flavonoids significantly reduced of ovarian venous diameter in patients with pelvic congestion syndrome. Additionally, the impaired quality of life was markedly improved proven by the significant decreases of PVVQ and VAS scores following treatment. Based on these findings, we suggest that flavonoids may be considered as first-line treatment for patients with pelvic congestion syndrome in routine clinical practice.

An Unusual Case of Pelvic Congestion Syndrome: A Case Report

This manuscript presents a case of a 35-year-old nulligravida premenopausal woman who presented with acute abdominal pain due to pelvic congestion syndrome (PCS). PCS is characterized by multiple pathophysiological mechanisms and various clinical presentations. Our patient was nulliparous with no history of abdominal surgery. However, diagnostic laparoscopy revealed endometriosis lesions on the uterovesical fold. Reporting this unusual case, we focus on the presenting symptoms, the imaging findings, and the final approach by diagnostic laparoscopy.

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.

Pelvic Congestion Syndrome Related Vaginal Bleeding and the Efficacy of Transcatheter Foam Sclerotherapy in Managing This Condition: Two Case Reports

Pelvic congestion syndrome (PCS) is a chronic condition primarily characterized by pelvic pain and heaviness, with vaginal bleeding being a rare but significant symptom. We present two cases of PCS-related vaginal bleeding, emphasizing the necessity of considering PCS in differential diagnoses for abnormal vaginal bleeding. A 28-year-old Chinese woman presented with abnormal vaginal bleeding exacerbated by abdominal pressure during activities like squatting or defecation. Imaging revealed a dilated right ovarian vein, and transcatheter venography confirmed Nutcracker syndrome. After undergoing transcatheter foam sclerotherapy, her symptoms resolved. The second case involves a 29-year-old Chinese woman with similar symptoms; imaging and venography identified a dilated left ovarian vein. Following sclerotherapy, her symptoms also alleviated. These cases underscore the importance of recognizing PCS as a potential cause of abnormal vaginal bleeding and demonstrate the efficacy of transcatheter foam sclerotherapy in managing this condition. Integrating clinical presentation with imaging findings is crucial for timely diagnosis and effective treatment, ultimately improving patient outcomes.

Effectiveness and safety of coils plus glue in slope embankment technology versus coils plus sclerosant in embolization therapy for reflux-type pelvic venous disorders

OBJECTIVE

This study aimed to evaluate the effectiveness and safety of coils plus glue (CPG) in slope embankment technology vs coils plus sclerosant (CPS) in treating reflux-type pelvic venous disorders.

METHODS

The analysis included patients diagnosed with reflux-type pelvic venous disorders who were treated with CPG or CPS from 2019 to 2021. The inclusion criteria were noncyclic pain lasting more than 6 months, atypical varicose, and transvaginal Doppler ultrasound (TVDUS) and computed tomographic venography confirming the diagnosis and excluding compression factors and other diseases. Propensity score matching was performed at a 1:1.1 ratio based on the following covariates: age, pregnancy, body mass index, pretreatment visual analog scale (VAS), dysmenorrhea, dyspareunia, urinary urgency, tenesmus, low back pain, vulvar varicosities, vaginal varicosities, and lower limb varices. The pain was relieved by embolizing the target lesions with different embolic materials. The efficacy and safety of the different embolization materials were compared by VAS and TVDUS examinations at 1, 3, 6, 12, 24, and 36 months.

RESULTS

From a total of 495 patients, 88 patients were selected from the CPG group and 77 patients from the CPS group by propensity score matching. The patients were followed up for 36 months. The preoperative VAS score of the CPG group was 8 (range, 6-8), and the CPS score was 8 (range, 7-8; P = .64). The postembolization VAS score of the CPG group was 2.05 ± 0.37, and the CPS score was 2.14 ± 0.35 (P = .55). A total of 28 cases (16.9%) showed complications, most of which were transient pain after embolization. No serious complications such as coil embolization to the lungs occurred. In addition, the CPG group used fewer coils than the CPS group by using the slope embankment technique. The mean coil length of the CPG group was 77.18 ± 33.82 cm, and the CPS group was 105.29 ± 71 cm (P = .001). The CPG group had an average operative time of 44.49 ± 5.72 minutes, whereas the CPS group took 43.45 ± 4.18 minutes on average (P = .19). The radiation dose in the CPG group was 398.40 ± 76.16 mGy, and the radiation dose in the CPS group was 388 ± 44.23 mGy (P = .30). The median recurrence-free survival in the CPG group was 34.23 months (95% confidence interval, 33.2-35.2), and the median recurrence-free survival in the CPS group was 30.39 months (95% confidence interval, 28.2-32.6; log rank P = .018).

CONCLUSIONS

Embolization therapy for refluxing PeVD was safe and effective, and proficient use of slope embankment technique with CPG increased efficacy and reduced complications.

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.

A Retrospective Cohort Study of Patient Risk Factors and Pelvic Venous Reflux Patterns on Treatment Outcomes With Pelvic Vein Embolisation

OBJECTIVE

To identify the effects of patient risk factors and pelvic venous reflux (PVR) patterns on treatment outcomes of Pelvic Vein Embolisation (PVE) for Pelvic Venous Disorder (PeVD).

METHODS

We performed a retrospective cohort review assessing population, intervention, comparison, and outcomes (PICO) for women undergoing PVE for PVR January 2017-January 2021. We identified 190 patients who had completed both questionnaires and who had given consent for their information to be used for research (Median age 46, IQR 40-52). The distribution of pathological pelvic venous reflux found on transvaginal duplex ultrasound (TVDUS) was analysed for all patients. Pre- and post-procedure symptom burden scores were studied using a standardised questionnaire protocol. We used inferential univariate non-parametric statistics to describe our data.

RESULTS

190 cases were reviewed; 62.6% (119/190) premenopausal, 11.1% (21/190) perimenopausal, 25.3% (48/190) postmenopausal and menopausal status not documented 1% (2/190). 10.1% (19/188) were nulliparous (average age 34 years; range 20-55 years). There was a statistically significant improvement in all symptoms and in the appearance of varicosities on TVDUS post-PVE (P < 0.05) of the ovarian vein plexus, uterus plexus, arcuate veins, vaginal wall, peri-urethral, peri-anal, haemorrhoids, labial and proximal thigh. The locations of veins requiring embolisation having demonstrated reflux were analysed; 82.8% (154/186) underwent embolisation of at least one internal iliac vein tributary and ovarian vein embolisation. Age, parity, menopausal status and previous laparoscopy did not affect symptom improvement (P > 0.05). No significant complications such as coil migration were observed.

CONCLUSIONS

PVE is an effective treatment for pelvic pain due to PeVD and its diagnosis should not be limited to multiparous women of childbearing age, as a significant proportion of patients who benefited from PVE were either nulliparous and/or postmenopausal.

Interventional Therapy of Pelvic Venous Disorders (PeVD)

BACKGROUND

Pelvic venous disorders (PeVD) are an underdiagnosed cause of chronic pelvic pain in women. They are caused by venous insufficiency of the pelvic or ovarian veins, leading to the development of mainly periuterine and periovarian varices. It is a progressive disease if left untreated and can cause swelling, dyspareunia, dysmenorrhea, and other symptoms, some non-specific, that affect the patient's quality of life. Interventional therapies are a central component of the treatment of PeVD, with a variety of techniques available for both diagnosis and treatment.

METHOD

This review provides an overview of the pathophysiologic background, diagnosis, and, most importantly, interventional treatment options for PeVD.

RESULTS

There is a lack of standardized nomenclature and internationally accepted diagnostic criteria for PeVD as well as randomized controlled trials demonstrating clinical success. However, in clinical trials, endovascular therapy for PeVD has been shown to be safe and effective. This review presents the various interventional techniques for the treatment of PeVD, including embolization, stenting, and sclerotherapy.

CONCLUSION

The importance of PeVD is receiving growing recognition. Recent advances, such as the development of the Symptoms-Varices-Pathophysiology (SVP) classification, provide an impetus to standardize nomenclature and are the first step toward systematizing disease management. Interventional therapies provide a safe and tailored minimally invasive treatment option for patients with PeVD.

KEY POINTS

· Pelvic venous disorders are an underdiagnosed condition with frequently delayed diagnosis and debilitating symptoms.. · Until now, the PeVD nomenclature has been imprecise, with terms like May-Thurner syndrome/Nutcracker syndrome.. · Interventional approaches are effective and play a central role in PeVD treatment..

CITATION FORMAT

· Dewald CL, Becker LS, Meyer BC. Interventional Therapy of Pelvic Venous Disorders (PeVD). Fortschr Röntgenstr 2024; 196: 921 - 927.

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.

Chronic Pelvic Pain in Congestion Pelvic Syndrome: Clinical Impact and Electromyography Pelvic Floor Activity Prior to and after Endovascular Treatment

BACKGROUND

This study aims to characterize the clinical impact of endovascular treatment in Chronic Pelvic Pain (CPP) patients due to Pelvic Congestion Syndrome (PCS) and to assess the diagnostic value of surface electromyography (sEMG) studies of pelvic floor musculature (PFM) in PCS patients pre- and post-endovascular treatment. Between January 2019 and July 2023, we studied consecutive patients who were referred for interventional radiology assessment and treatment to a tertiary trauma care hospital, had evidence of non-obstructive PCS from Magnetic Resonance Imaging (MRI), had sEMG of PFM and who had undergone endovascular treatment. The primary outcome was clinical, defined as a change in symptom severity after endovascular treatment. The secondary outcome was a difference in the sEMG values pre- and post-endovascular therapy.

RESULTS

We included 32 women (mean age 38 years). CPP was the leading symptom in 100% patients, followed by dysmenorrhea (75%) and post-coital pain (68.7%). Endovascular therapy included ovarian vein embolization in 28 patients (87.5%) and internal iliac vein embolization in only 2 patients (6.2%). After a median of 8 (range 6-10) months from endovascular treatment, 29 (90%) of patients reported an improvement of the main symptoms, and 15 (46%) were symptom-free. The sEMG values did not show a statistical difference pre- and post-PCS endovascular treatment.

CONCLUSIONS

Endovascular treatment appeared to be highly effective in CPP due to PCS and was associated with a low rate of complication. sEMG study could be useful in revealing alterations of PFM electrophysiology, but a difference pre- and post-embolization in PCS patients was not demonstrated.

Endovascular Treatment of Pelvic Venous Congestion Syndrome in Nulliparous Patients-Preliminary Results of 10 Years of Experience

PURPOSE

The aim of this article is to present our experience with minimally-invasive treatment for nulliparous patients with pelvic venous congestion syndrome (PVCS) with special attention to anatomical considerations, procedural and clinical outcome.

MATERIALS AND METHODS

In this retrospective, monocentric study, 21 patients with PVCS treated from January 2014 to June 2023 were included. The preprocedural imaging evaluation of PVCS was based on color Doppler ultrasound, contrast-enhanced CT and/or MRI. In all cases insufficient ovarian veins and/or internal iliac branches were occluded with coils and sclerosant. Procedural and clinical outcomes were measured 30 and 90 days after the procedure.

RESULTS

Average duration of pelvic pain was 44.8 ± 54.2 months (from 6 to 200) with the mean VAS-recorded pain intensity of 8.5 ± 1.1 (range from 7 to 10 where 0 was "no pain" and 10 "worst pain possible"). Most common symptoms included dysmenorrhea, dyspareunia and dysuria. Complete embolization was observed in in all cases. Targeted vessels included left ovarian vein (13/21, 62%), both ovarian veins (7/21, 33%) and left pudendal with left ovarian (1/21, 5%). Residual PVCS was noted in 1 patient. Mean VAS at 90-days after the procedure was 2.4 ± 1.4 (range from 0 to 6, p < 0.001). Nineteen patients (90%) were satisfied with the clinical outcome (13 "very satisfied", 6 "satisfied") and reported improvement in quality of life. Two patients (9.5%) reported to be "neutral" as the VAS reduction was less than 50%.

CONCLUSION

Our study confirms that endovascular coil embolization is safe and effective in treatment of nulliparous patients with PVCS that provides very high rate of clinical success and overall satisfaction.

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.

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.

Vascular Diseases in Women: Do Women Suffer from Them Differently?

According to the World Health Organization, cardiovascular disease (CVD) is the leading cause of death among women worldwide, yet its magnitude is often underestimated. Biological and gender differences affect health, diagnosis, and healthcare in numerous ways. The lack of sex and gender awareness in health research and healthcare is an ongoing issue that affects not only research but also treatment and outcomes. The importance of recognizing the impacts of both sex and gender on health and of knowing the differences between the two in healthcare is beginning to gain ground. There is more appreciation of the roles that biological differences (sex) and sociocultural power structures (gender) have, and both sex and gender affect health behavior, the development of diseases, their diagnosis, management, and the long-term effects of an illness. An important issue is the knowledge and awareness of women about vascular diseases. The risk of cardiovascular events is drastically underestimated by women themselves, as well as by those around them. The purpose of this review is to draw attention to improving the medical care and treatment of women with vascular diseases.

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.

A review of the pathophysiology and evidence-based management of varicoceles and pelvic congestion syndrome

Pelvic congestion syndrome (PCS) in females and varicoceles in males may be regarded as closely related conditions since the main pathophysiological cause for both processes is pelvic venous insufficiency. Varicoceles are more prevalent amongst sub-fertile males, with an approximate incidence of 15% in the general male population. PCS is commonly diagnosed amongst premenopausal multiparous women, representing one of the leading causes of chronic pelvic pain. Both conditions appear to be predominantly left-sided and are associated with oxidative stress and pro-inflammatory cascades with subsequent effects on fertility. Clinical examination and pelvic ultrasonography play an essential role in the assessment of varicoceles, PCS and chronic pelvic pain. Venography is generally considered as a gold-standard procedure for both conditions. There is still much debate on how these conditions should be managed. This review article provides a comparative analysis of the underlying pathophysiological mechanisms of both PCS and varicoceles, their impact on fertility, as well as their clinical management.

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.

Female Gonadal Venous Insufficiency in a Clinical Presentation Which Suggested an Acute Abdomen-A Case Report and Literature Review

Pelvic venous insufficiency (PVI) is frequently associated with symptoms of abdominal pain or discomfort that is overlooked or under-diagnosed in women. Despite the fact that pelvic venous insufficiency in men is very well documented, its occurrence in women needs to be further studied. Patients with pelvic varicose veins undergo a long and inconclusive diagnostic work-up before the exact cause of the symptoms is identified. Gonadal venous insufficiency (GVI) is a condition that can present acutely, leading to diagnostic challenges. We present a case report of a 47-year-old female with acute abdominal pain and GVI, where endovascular embolization was used for successful treatment. The patient was diagnosed with GVI based on imaging findings of an enlarged left ovarian vein with retrograde flow and dilated pelvic veins seen on magnetic resonance imaging (MRI) with contrast material. Due to the severity of her symptoms and imaging findings, endovascular embolization was chosen as the treatment modality. The embolization was successful, and the patient's symptoms resolved completely. This case highlights the challenge of diagnosing GVI with acute clinical expression and the potential benefits of endovascular embolization as a treatment option. Further studies are needed to determine the optimal management strategies for acute GVI, but endovascular embolization should be considered a safe and effective option. At the same time, we present a short review of the recent literature data related to this topic.

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.

Proximal coil occlusion preceding distal sclerotherapy in patients with pelvic congestion syndrome: A multicenter, retrospective study

OBJECTIVE

We investigated the efficacy, feasibility, and safety of proximal coil occlusion preceding distal sclerotherapy (PCODS) for patients with pelvic congestion syndrome (PCS).

METHODS

We performed a multicenter, retrospective cohort study of 94 patients with PCS who had undergone PCODS and 53 patients who had undergone standard endovascular embolization (control group) between June 2014 and April 2020. The primary end point was the clinical remission rate and the secondary end points were the operative time, total fluoroscopy time, radiation dose, overall length of coils used per case, and adverse events. The patients were followed up at 1, 3, 6, and 12 months.

RESULTS

PCODS was successfully performed in 94 patients (100%). The clinical remission rates were significantly higher in the PCODS group than in the control group at 1, 6, and 12 months (P = .036, P = .032, and P = .032). The operative time and total fluoroscopy time were shorter for the PCODS group than for the control group (48.3 ± 5.2 minutes and 37.7 ± 4.4 minutes vs 53.9 ± 4.8 minutes and 42.6 ± 4.1 minutes, respectively; P < .001 for both). The radiation dose was significantly lower in the PCODS group than in the control group (362,634.69 ± 41,533.13 mGy·cm² vs 421,578.30 ± 49,517.93 mGy·cm²; P < .001). The overall length of coils used per case was 19.8 ± 6.0 cm in the PCODS group and 31.7 ± 8.5 cm in the control group (P < .001). Migration of n-butyl cyanoacrylate to the renal vein occurred in two patients in the control group.

CONCLUSIONS

We found PCODS was feasible with a higher clinical remission rate and mild adverse effects in patients with PCS.

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.

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.

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.

Ovarian Vein Embolization With N-butyl-2 Cyanoacrylate Glubran-2® for the Treatment of Pelvic Venous Disorder

Background: There are few reports in the literature on the use of Glubran-2 for the embolization of ovarian veins in patients with pelvic venous disorder (PeVD). In addition, a consensus on the efficacy and safety of Glubran-2 has not been reached. Purpose: To investigate the safety and efficacy of ovarian vein embolization (OVE) with N-butyl-2 cyanoacrylate (NBCA) Glubran-2 for the treatment of PeVD. Material and Methods: Between January 2013 and January 2020, 21 women (mean age, 43.9 ± 13.3 years) with PeVD who underwent OVE with Glubran-2 were evaluated. Of those patients, ovarian vein or pelvic venous plexus insufficiency was verified by duplex ultrasound and/or multislice computer tomography (MSCT). The symptoms and signs of PeVD included chronic pelvic pain (CPP) (21/21; 100%), dyspareunia (12/21; 57.1%), dysmenorrhea (10/21; 47.6%), and vulvar varices (3/21; 14.3%). The medical data were retrospectively reviewed. Results: Glubran-2 was employed as the sole embolic material in 18 cases (85.7%) and used to perform rescue embolization in 3 cases (14.3%) due to CPP recurrence 1 month after initial embolization using microcoils. Technically successful embolization was achieved using Glubran-2 in all patients. No Glubran-2 related complications were noted. Neither persistent nor recurrent CPP was observed during follow-up, for which the mean was 62 ± 38 months (range, 12-102 months). Clinical efficacy was evaluated, and all patients exhibited complete or slight improvement of CPP after embolization. The visual analog scale (VAS) score significantly decreased from pre-intervention to post-intervention (p < 0.001). Six patients (28.6%) gave birth to healthy babies during follow-up after embolization with Glubran-2. Conclusions: Ovarian vein embolization with Glubran-2 is a feasible and safe treatment for CPP secondary to PeVD. This treatment may represent a potential and attractive alternative when patients desire symptom relief and want to continue reproducing. Larger studies are warranted to confirm the findings of this study.

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.

Advances of Laparoscopy for the Diagnosis of Pelvic Congestion Syndrome

The objective of this review is to describe the effectiveness of laparoscopy in the diagnosis and treatment of pelvic congestion syndrome (PCS). PCS is a cause of chronic pelvic pain (CPP) and is associated with dysfunction of the pelvic venous system. PCS is more common in women of reproductive age, and hormonal changes are associated with its development along with other reasons (e.g., working and living habits). There is an urgent need to establish an effective algorithm for the diagnosis and treatment of CPP, which could have a dramatic effect in patients' everyday life. This algorithm should be able to overcome known issues that lead to the underdiagnosis of PCS, such as the overlap of its symptoms with other diseases. Here, we present our findings from literature articles about the methods used in practice today for the diagnosis of this syndrome. We also compare the methods to propose the most promising technique for providing a diagnosis with high accuracy. In our understanding, laparoscopy is superior when compared to other methods. It can provide a diagnosis of PCS while excluding or identifying other comorbidities and can also lead toward the next steps for the treatment of PCS.

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.

Broad ligament pregnancy with pelvic congestion syndrome: A case report

We present the first case that describes a right broad ligament pregnancy patient complicated with pelvic congestion syndrome. A 23-year-old female referred to the gynecological emergency room with pelvic pain and amenorrhea. Serum beta-human chorionic gonadotropin (β-hCG) test of the patient was positive, and ultrasonography indicated that there were mixed mass signals and a large number of blood flow signals in the right parauterine area. Considering the possibility of a diagnosis of ectopic pregnancy, we performed laparoscopic exploration for this patient. According to the intraoperative situation, we formally diagnosed the right broad ligament pregnancy. Although the intraoperative hemorrhage was fierce, we still successfully completed the resection of the lesion and performed the ipsilateral salpingectomy. We performed three-dimensional CT vascular reconstruction on the patient after surgery, and diagnosed right pelvic congestion syndrome combined with the patient's usual chronic pelvic pain symptoms.

Poorly Understood Pelvic Venous Disorders Require a Multidisciplinary Approach

Pelvic venous diseases encompasses all chronic pathologies of pelvic veins caused by venous hypertension and retrograde flow in pelvic veins. It is commonly unexplained and often underdiagnosed cause of chronic pelvic pain in women of productive age. Pelvic venous pathologies are a part of multidisciplinary problem that should be considered in a holistic approach. Newly offered SVP classification may help correctly classifying patients and using the same nomenclature. Endovascular treatment options are highly effective with good long-term results. Patients with inconclusive gynecologists examinations should be referred to a specialist for the investigation of pelvic venous disorders.

Venous overload choroidopathy: A hypothetical framework for central serous chorioretinopathy and allied disorders

In central serous chorioretinopathy (CSC), the macula is detached because of fluid leakage at the level of the retinal pigment epithelium. The fluid appears to originate from choroidal vascular hyperpermeability, but the etiology for the fluid is controversial. The choroidal vascular findings as elucidated by recent optical coherence tomography (OCT) and wide-field indocyanine green (ICG) angiographic evaluation show eyes with CSC have many of the same venous patterns that are found in eyes following occlusion of the vortex veins or carotid cavernous sinus fistulas (CCSF). The eyes show delayed choroidal filling, dilated veins, intervortex venous anastomoses, and choroidal vascular hyperpermeability. While patients with occlusion of the vortex veins or CCSF have extraocular abnormalities accounting for the venous outflow problems, eyes with CSC appear to have venous outflow abnormalities as an intrinsic phenomenon. Control of venous outflow from the eye involves a Starling resistor effect, which appears to be abnormal in CSC. Similar choroidal vascular abnormalities have been found in peripapillary pachychoroid syndrome. However, peripapillary pachychoroid syndrome has intervortex venous anastomoses located in the peripapillary region while in CSC these are seen to be located in the macular region. Spaceflight associated neuro-ocular syndrome appears to share many of the pathophysiologic problems of abnormal venous outflow from the choroid along with a host of associated abnormalities. These diseases vary according to their underlying etiologies but are linked by the venous decompensation in the choroid that leads to significant vision loss. Choroidal venous overload provides a unifying concept and theory for an improved understanding of the pathophysiology and classification of a group of diseases to a greater extent than previous proposals.

Pelvic congestion syndrome (PCS) as a pathology of postmenopausal women: a case report with literature review

Background

Due to the scarcity of adequately powered, randomized controlled trials and internationally standardized diagnostic criteria, evidence on the diagnosis and treatment of pelvic congestion syndrome (PCS) is limited. Earlier epidemiologic observations led to the attribution of PCS to the premenopausal state, and a remission of symptoms after menopause is frequently described a hallmark of the pathology. This concept has currently been challenged by radiological studies reporting a notable prevalence of ovarian venous congestion in adult female patients of advanced age. PCS as a pathology of postmenopausal women, however, has not been acknowledged by systematic research to date, impeding appropriate diagnostics and therapy for affected patients.

Case presentation

A 69-year-old postmenopausal patient presented with newly diagnosed dilated and insufficient pelvic veins in combination with characteristic pain anamnesis, thereby fulfilling the diagnostic criteria of PCS. Interventional coil embolization of both ovarian veins as a standard treatment previously described for premenopausal patients was successfully performed, resulting in prompt alleviation of symptoms. The patient remained symptom-free at the 18-month follow-up visit.

Conclusions

Given this first systematically documented case of a patient with postmenopausal symptomatic PCS in the light of recently published data on the prevalence of ovarian venous congestion in patients of advanced age, it may be assumed that PCS is not to be considered a pathology strictly limited to premenopausal state. Further clinical studies expanding the diagnostic scope beyond menopause may help to substantiate evidence and subsequently define standardized therapeutic approaches for affected postmenopausal patients.

Ovarian Vein Embolization: How and When Should It Be Done?

Pelvic Venous Disease (PeVD) is characterized by pelvic varicosities and chronic pelvic pain, defined as noncyclic pelvic pain that persists for more than 6 months. Pain and discomfort related to PeVD typically worsen with upright positioning and occur more frequently in multiparous and premenopausal women. The most common cause of PeVD is pelvic venous insufficiency (PVI) due to incompetent valves. Noninvasive imaging modalities such as ultrasound, computed tomography, or magnetic resonance imaging, and invasive catheter-based venography can help characterize varicosities and venous insufficiency, supporting the diagnosis of PeVD. In patients with PeVD, ovarian and/or internal iliac vein embolization demonstrate excellent technical and clinical success rates with relatively low complication rates and should be considered as standard management, in conjunction with medical therapy. Appropriate diagnostic work-up and patient selection are important prior to any intervention for achieving therapeutic success, as multiparous women have a higher success rate compared to patients with dyspareunia after embolization therapy. Post-procedure follow-up is critical for assessing symptom improvement and need for repeat intervention. However, further research is needed to identify additional predictors of successful outcomes after embolization therapy. This article aims to provide an overview of patient selection, interventional technique, challenges, and outcomes of ovarian vein embolization.

Liquid and Solid Embolic Agents in Gonadal Veins

Male varicocele and pelvic congestion syndrome (PCS) are common pathologies with high predominance in young patients, having a high impact on the quality of life and infertility. Lately, the use of different endovascular embolization techniques, with various embolizing agents, shows good technical results and clinical outcomes. With the aim of presenting the "state of the art" of endovascular techniques for the treatment of male varicocele and PCS, and to discuss the performance of the different embolic agents proposed, we conducted an extensive analysis of the relevant literature and we reported and discussed the results of original studies and previous meta-analyses, providing an updated guide on this topic to clinicians and interventional radiologists. We have also underlined the technical aspects for the benefit of those who approach this type of interventional treatment. Our review suggests promising results in both the endovascular embolic treatment of male varicocele and PCS; for varicocele, a success rate of between 70% and 100% and a recurrence rate of up to 16% is reported, while for PCS it has been found that technical success is achieved in almost all cases of endovascular treatment, with a highly variable recurrence rate based on reports. Complications are overall rather rare and are represented by periprocedural pain, migration of embolic media and vascular perforations: severe adverse events have been reported very rarely.

Left renal vein transposition for posterior Nutcracker syndrome

Nutcracker syndrome (NCS) is a rare cause of pelvic venous congestion syndrome and is secondary to either compression of the left renal vein in its normal anatomic position by the superior mesenteric artery and aorta or less commonly when the left renal vein is in a retroaortic position, compressed between the aorta and the spine. We herein present a unique case of NCS in a female patient with a history of chronic pelvic pain and venous congestion. We also review the literature and discuss the diagnostic modalities, differential diagnosis, and various open surgical and endovascular options for NCS.

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 Analysis of Selected Morphological and Hemodynamic Parameters of the Venous System and Their Presumable Impact on the Risk of Recurrence after Varicose Vein Treatment

INTRODUCTION

The current treatment of venous disease is focused on reflux elimination in main venous trunks, especially in the saphenous vein. However, a high recurrence rate, independent of the method of treatment, suggests that the reason of low effectiveness may be due to a strategy focused on symptoms, without considering their origin.

METHOD

The aim of study was the comparison of retrospective data from 535 women with venous disease, either after treatment (n = 183) or not treated before (n = 352). The analysis concerned clinical symptoms and the results of the extended diagnostics, including the examination of the lower limb, pelvic and abdominal veins either using duplex-doppler ultrasound as well as venography with computed tomography or magnetic resonance.

RESULTS

The comparison of selected venous system parameters revealed more advanced disease progression in previously treated patients, compared to non-treated individuals (e.g., ipsi- or bilateral incompetence of sapheno-phemoral junction-29.5% vs. 20.4%, at P < 0.05 and 13.6% vs. 7.7% at P < 0.05, respectively). This difference could be explained by post-treatment alterations in the venous system, an older age and the higher number of pregnancies in the recurrence group. However, both groups did not differ in regards to the symptoms of pelvic venous insufficiency or the frequency of relevant variants/abnormalities in venous system.

CONCLUSIONS

Based on the aforementioned findings, we postulate the revision of treatment strategy, which should consider abdominal and pelvic veins as the source of reflux in many female subjects.

[Immediate and remote results of endovascular embolization of ovarian veins]

Presented in the article is a prospective study of endovascular embolization of ovarian veins in female patients suffering from primary pelvic varicose veins, with the assessment of the immediate and remote results, as well as a 1-year follow up.

AIM

The aim of our investigation was a comprehensive clinical and instrumental assessment of efficacy of endovascular embolization in women with pelvic varicose veins.

PATIENTS AND METHODS

Our single-centre study included a total of 29 female patients presenting with pelvic varicose veins and undergoing embolization of ovarian veins using microcoils, in 5 cases the procedure was supplemented with injecting a foam sclerosant.

RESULTS

The technical success of endovascular occlusion of ovarian veins amounted to 100%. Two women immediately after the operation were subjected to a redo intervention: in one case - resection of the ovarian vein and in the second case - repositioning of the microcoils. In the remote period, one patient due to recurrent relapses underwent repeat embolization followed by retroperitoneal resection of the ovarian vein. The findings of the clinical methods of examination demonstrated a decrease in the intensity of manifestations of pelvic varicose veins according to the pelvic venous clinical severity score and visual analogue scale, as well as improvement of the women's quality of life.

CONCLUSION

Endovascular occlusion of ovarian veins is a highly effective, minimally invasive, and safe method of treatment of female patients with incompetent ovarian veins. Endovascular treatment may be regarded as a method of choice in management of the primary form of pelvic varicose veins.