Pelvic vein incompetence: clinical perspectives

Detection and Coil Embolisation of Pelvic Vein Incompetence for Chronic Pain in the Female Pelvis: A Development Phase Economic Analysis

OBJECTIVE

Unexplained chronic pain in the female pelvis (CPFP) affects 7% of people of female sex in the UK. Evidence suggests that pelvic vein incompetence (PVI) could explain CPFP and that coil embolisation could provide relief. The aims of this study were to indicate (1) the cost effectiveness of detecting and treating PVI in people experiencing unexplained CPFP, and (2) the maximum value of further research, suggesting suitable areas.

METHODS

A decision tree compared standard care (regular prescribed analgesia) with an intervention comprising transvaginal duplex ultrasound to screen for PVI, venography to confirm the diagnosis, and coil embolisation treatment. The population included those experiencing unexplained CPFP. A UK National Health Service perspective and 2021 - 22 price year were used. Ten years of health costs and health related quality of life (HRQoL) effects for eligible 40 year olds were simulated. Evidence reviews informed diagnostic accuracy, health service usage, and unit costs. A single centre randomised controlled trial informed all other parameters. Probabilistic analysis incorporated parameter uncertainty in cost effectiveness estimates. Deterministic sensitivity analysis indicated drivers of uncertainty. Value of information methods measured the value of eliminating all relevant uncertainties, given uptake predictions. The main outcome measures were incremental cost and quality adjusted life years (QALYs) for the intervention compared with analgesia, the incremental cost effectiveness ratio (ICER), and expected value of perfect information.

RESULTS

The mean ICER for the intervention was £4 558 per QALY gained, and the probability that the ICER was within the UK cost effectiveness threshold (£20 000/QALY gained) was 90%. The expected value of perfect information about all model parameters was £46m. All deterministic sensitivity analysis scenarios met the threshold, except the smallest plausible HRQoL effect of (resolving) CPFP.

CONCLUSION

Detecting and treating PVI causing CPFP appears cost effective, but more primary research would be valuable to reduce decision uncertainty. Uncertainty in the HRQoL estimate for unexplained CPFP appeared to contribute most to decision uncertainty.

Analysis of the efficacy of endovascular treatment with foam sclerotherapy for pelvic congestion syndrome with ultrasound assessment

Background

Pelvic Congestion Syndrome is an important cause of pelvic pain in adult women, leading to reduced quality of life, absenteeism from work, anxiety, depression, and sexual disorders.

Objectives

To evaluate the response to endovascular treatment for pelvic varicose veins using foam sclerotherapy and outline the profile of patients with this diagnosis followed up at the Hospital das Clínicas Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Brazil.

Methods

Based on review of medical records, this retrospective descriptive study analyzes the profile and response of patients undergoing endovascular treatment for pelvic varicose veins by foam sclerotherapy. The variables analyzed include age, weight, height, body mass index, parity, pelvic pain complaints, ultrasound criteria comparing the diameter of pelvic vessels before and after the procedure, and presence of venous reflux on transvaginal Doppler ultrasound.

Results

The sample of patients analyzed had an average age of 43.3 years old, a mean of 2.95 gestations, and a mean BMI of 25.37kg/m2. Ultrasound assessment after the intervention indicated a statistically significant reduction (p-value < 0.005) in the caliber of the parauterine vessels, with mean diameters of 6.34 mm on the right and 7.26 mm on the left before the procedure and 4.37 mm and 4.56 mm respectively afterwards.

Conclusions

Foam sclerotherapy reduced the caliber of pelvic varicose veins in the study sample. The results were similar to those of other endovascular treatment methods for this comorbidity. Further prospective studies to assess the response to this intervention are necessary to establish it as an effective option for treatment of pelvic congestion syndrome.

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.

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.

CELLULAR AND HUMORAL IMMUNE PARAMETERS IN THE PERIPHERAL AND LOCAL BLOOD FLOW IN PATIENTS WITH PRIMARY PELVIC VARICOSE

Pelviс varicose veins (PVV) in women is of extremely high relevance due to a close relationship with reproductive disorders and disease relapse. Despite on research in the field, the results of the analysis on immune reactivity in PVV are rather contradictory, and mainly relate to general mechanisms. The study of cell-mediated and humoral arms of adaptive immunity will allow us to assess an intensity and dynamics of PVV progression as well as a potential for using immune status parameters to optimize diagnosis and immunological correction. The aim of this study was to assess characteristics of cellular and humoral immunity in peripheral (ulnar) and local (ovarian) venous pools in women with mild and moderate PVV. The study involved 142 women of reproductive age (mean age - 37.27.1 years) with diagnosed PVV - mild (Group 1) (n=79) and moderate (Group 2) (n=63) forms. Data from 30 apparently healthy women (mean age 33.56.3 years) were in control group. Flow cytometry was used to identify lymphocyte subsets. The functional state of the humoral immunity was assessed by measuring concentration of immunoglobulins IgA, IgG, IgM by using radial immunodiffusion in the gel. According to our data obtained, patients in group 1 had changes found only in the local blood flow such as prominent lymphocytopenia (decreased level of CD3+ and CD4+ lymphocytes). Patients in group 2 were featured with more pronounced changes: increased lymphocyte level, CD3+, CD4+/CD8+, IgA and lower levels of IgM, IgG in peripheral blood; high average leukocyte and lymphocyte count, IgA and reduced levels of CD3+, CD4+, CD4+/CD8+, IgM and IgG in the local area. It can be concluded that altered parameters in the local blood flow are of primary origin in mild PVV being characterized by disturbed cellular immune arm. Along with increasing disease severity, the host compensatory capabilities decline, which is manifested by pronounced combined immunodeficiency at the level of local blood flow less evident at peripheral level. These results may contribute to a more accurate assessment of intensity and dynamics of PVV progression to optimize diagnostics and immunological correction.

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.

Impact of ovarian vein embolization in recurrent varicose veins of the lower extremity

Summary: Background: The treatment success of catheter-based ovarian vein embolization due to peripheral varicose veins and ovarian vein reflux (OVR) should be investigated in this clinical investagtion. Patients and methods: For this study, 95 female patients were identified over a 5-year period (beginning of 2006 to end of 2011) after catheter-based coil (+/- chemical) embolization of the ovarian vein due to peripheral primary or recurrent varicose veins and proven reflux in the ovarian vein. Treatment success was retrospectively assessed in 2014 by means of a structured telephone interview (n=60), clinical examination (n=56), duplex ultrasound (n=56) and magnetic resonance imaging (n=51) in patients who were willing to participate in the study. Results: After an average of 51.9 months, 95.2% of the 60 included patients were diagnosed with recurrent varicose veins by duplex sonography and 88.1% by clinical examination. In 15.2%, a new intervention was required due to clinical symptoms. The median recurrence-free time was 47.0±5.5 months. A significant improvement by therapy was reported for all subjective symptoms in both pelvis and legs. No significant correlation between radiological findings and complaints or between radiological findings and clinical recurrence was found. Conclusions: The medical history of female patients with peripheral varicose veins should obligatorily include the question of symptoms in the pelvis. An appropriate diagnostic should follow in order to prevent a possible overlook of a pelvic leak point. Only then an individually adapted therapy for symptom relief is possible. Catheter-based ovarian vein embolization is one optional safe procedure that leads to significant improvement of subjective symptoms but does not necessarily prevent recurrent varicose veins.

Respiratory changes in biometry of suprarenal inferior vena cava in patients with varicose veins of lower extremities

AIM

This study examines respiratory biometry of inferior vena cava in patients with varicose veins of lower extremities.

MATERIAL AND METHODS

We performed retrospective analysis of clinical and ultrasound data of 67 patients with primary varicose veins.

RESULTS

The largest expiratory (mean 16.2 mm, p-value 0.09) and inspiratory (mean 8.2 mm, p-value 0.02) inferior vena cava diameters were in C3 Clinical Etiological Anatomical Pathophysiological clinical class; the smallest expiratory diameters (mean 13.1 mm, p-value 0.5) were in C6 class; the smallest inspiratory diameters (mean 4.6 mm, intercept) were in C2 class. C2 class was associated with highest inferior vena cava collapsibility index (mean 68.2%, intercept); C6 class was associated with lowest collapsibility index (mean 48.3%, p-value 0.04).Recurrent varices in comparison with previously untreated were associated with smaller inspiratory diameters of inferior vena cava (mean 4.4 mm, p-value 0.005), smaller expiratory diameters (mean 13.4 mm, p-value 0.06) and higher collapsibility index (mean 68.5%, p-value 0.005). Patients with recurrent and bilateral varicose veins had identical respiratory biometry of inferior vena cava.Older age was associated with smaller inferior vena cava diameters (p-value <0.01).

CONCLUSION

Clinical presentation of varicose veins is associated with different respiratory biometry of suprarenal inferior vena cava. C6 clinical class in comparison with C2 clinical class is associated with lower central venous compliance possible due to the narrowing of inferior vena cava. Smaller inferior vena cava diameters and higher collapsibility index in recurrent subgroup in comparison with previously untreated can be a sign of the significantly altered pressure gradient between the systemic capillaries and the right heart and impaired peripheral venous return. Narrowing of inferior vena cava with age can be a sign of more profound changes in systemic venous return with age in patients with varicose veins in comparison to those without chronic venous disease.

Recent developments on foaming mechanical and electronic techniques for the management of varicose veins

Introduction: Varicose veins are a common disease, causing significant impairment of quality of life to afflicted individuals. Conventional surgery has represented the traditional treatment for years, with significant post-operative complications. By the end of the 20^th century, novel approaches had been developed to induce biochemical sclerosis into the treated vein in order to exclude it from blood circulation.Areas covered: Foaming techniques for treatment of varicose veins, both clinically-approved methods and those under experimental studies. A brief description of cavitation, which is the basis of microbubbles formation, and an overview of foam properties have been also provided, including a discussion on clinical efficacy and safety profile.Expert commentary: Foam sclerotherapy has rapidly gained popularity since it represents the most minimally invasive and cost-effective procedure in the short term. Several different methods of foam preparation have been described in literature. In general, the foam generation method may affect characteristics such as stability and bubble size distribution, which in turn affect the therapeutic action of foam itself. Therefore, the selection of a suitable foaming technique is of importance for treatment success. Future developments on foaming techniques are expected to make sclerotherapy, already an effective treatment, even safer and more versatile therapeutic procedure.

Calcitonin Gene-Related Peptide and Substance P As Predictors of Venous Pelvic Pain

The purpose of this work was to study the contents of calcitonin gene-related peptide (CGRP) and substance P (SP) in the blood plasma of patients with pelvic varicose veins. Thirty women with pelvic varicosities and a reflux blood flow were investigated using duplex ultrasonography. Group 1 included 18 patients with clinical signs of the pelvic congestion syndrome (PCS), including venous pelvic pain (VPP). Group 2 consisted of 12 patients with pelvic varicosities with no clinical signs of PCS. Group 1. The score of VPP intensity ranged from 4 to 8; the mean score being 4.84 ± 0.43. The CGRP level in the studied group ranged from 0.39 to 1.01 ng/mL; the SP level ranged from 0.005 to 1.33 ng/mL. Group 2. The CGRP values were 0.15–0.32 ng/mL, and the SP range was 0.003–0.3 ng/mL. In this group, the levels of the studied peptides were 3–5 times lower than those for the patients with VPP. Group 3. The mean CGRP values were 0.06 ± 0.003 ng/mL, and the mean SP values were 0.03 ± 0.001 ng/mL. These values were considered as the reference parameters; a statistical analysis was performed for them. The correlation analysis revealed a strong relationship between the CGRP and VPP levels (r = 0.82) and a medium correlation between the SP level and pelvic pain in Group 1. The CGRP and SP levels in blood plasma highly correlate with the presence of pelvic venous pain.