Female Pelvic Vein Embolization: Indications, Techniques, and Outcomes

Anthony James Lopez, Anthony James Lopez

Abstract

Until recently, the main indication for pelvic vein embolization (PVE) in women was to treat pelvic venous congestion syndrome (PVC) but increasingly, patients with refluxing pelvic veins associated with leg varicosities are also being treated. A more unusual reason for PVE is to treat pelvic venous malformations, although such lesions may be treated with sclerotherapy alone. Embolotherapy for treating PVC has been performed for many years with several published studies included in this review, whilst an emerging indication for PVE is to treat lower limb varicosities associated with pelvic vein reflux. Neither group, however, has been subjected to an adequate randomized, controlled trial. Consequently, some of the information presented in this review should be considered anecdotal (level III evidence) at this stage, and a satisfactory 'proof' of clinical efficacy remains deficient until higher-level evidence is presented. Furthermore, a wide range of techniques not accepted by all are used, and some standardization will be required based on future mandatory prospective studies. Large studies have also clearly shown an unacceptably high recurrence rate of leg varicose veins following venous surgery. Furthermore, minimally or non-invasive imaging is now revealing that there is a refluxing pelvic venous source in a significant percentage of women with de novo leg varicose veins, and many more with recurrent varicosities. Considering that just over half the world's population is female and a significant number of women not only have pelvic venous reflux, but also have associated leg varicosities, minimally invasive treatment of pelvic venous incompetence will become a common procedure.

Figures

Fig. 1
Fig. 1
Refuxing internal iliac venous branches with vulval (A) and lower limb varicosities (B)
Fig. 2
Fig. 2
A and B Duplicated left ovarian vein before and after embolization
Fig. 3
Fig. 3
Obturator veins draining into both internal (catheter in situ) and external iliac veins (right side)
Fig. 4
Fig. 4
A–C Abdominal ‘nutcracker’ phenomenon—despite completely embolizing the enlarged left ovarian vein, the ‘compressed’ left renal vein still fills poorly on direct injection
Fig. 5
Fig. 5
A and B Refluxing right and left ovarian veins
Fig. 6
Fig. 6
A and B Refluxing right and left obturator veins
Fig. 7
Fig. 7
Non-refuxing ‘large’ right ovarian vein. Note ‘competent’ valve along main trunk and aberrant retroperitoneal branches
Fig. 8
Fig. 8
A and B Aberrant retroperitoneal veins before and after embolization
Fig. 9
Fig. 9
Persisting ovarian vein reflux following incomplete coil embolization (A) re-treated with ‘distal’ foam sclerotherapy and ‘completion’ coil embolization (B)
Fig. 10
Fig. 10
Foam sclerotherapy of right ovarian vein
Fig. 11
Fig. 11
A and B Vulval varices treated with foam sclerotherapy and coil embolization
Fig. 12
Fig. 12
A and B Cross embolization of right ovarian vein from left vein
Fig. 13
Fig. 13
A and B Cross embolization of right vulval veins from left internal iliac vein
Fig. 14
Fig. 14
Pudendal and broad ligament venous embolization
Fig. 15
Fig. 15
A and B Inadvertent pulmonary coil embolization (before and after removal)

References

    1. Nascimento AB, Mitchell DG, Holland G. Ovarian veins: magnetic resonance imaging findings in an asymptomatic population. J Magn Reson Imaging. 2002;15:551–556. doi: 10.1002/jmri.10098.
    1. Rozenblit A, Ricci Z, Tuvia J, Amis ES. Incompetent and dilated ovarian vein: a common CT finding in asymptomatic parous women. Am J Roentgenol. 2001;176:119–122. doi: 10.2214/ajr.176.1.1760119.
    1. Ganeshan A, Upponi S, Hon LQ, Uthappa MC, Warakaulle DR, Uberoi R. Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology. Cardiovasc Interv Radiol. 2007;30(6):1105–1111. doi: 10.1007/s00270-007-9160-0.
    1. Meneses L, Fava M, Diaz P, Andia M, Tejos C, Irarrazabal P, Uribe S. Embolization of incompetent pelvic veins for the treatment of recurrent varicose veins in lower limbs and pelvic congestion syndrome. Cardiovasc Interv Radiol. 2013;36:128–132. doi: 10.1007/s00270-012-0389-x.
    1. Marsh P, Holdsock J, Harrison C, Smith C, Price BA, Whiteley MS. Pelvic vein reflux in female patients with varicose veins: comparison of incidence between a specialist private vein clinic and the vascular department of a National Health Service District General Hospital. Phlebology. 2009;24(3):108–113. doi: 10.1258/phleb.2008.008041.
    1. Francheschi C, Bahnini A. Treatment of lower extremity venous insufficiency due to pelvic leak points in women. Ann Vasc Surg. 2005;19(2):284–288. doi: 10.1007/s10016-004-0180-9.
    1. Hobbs JT. The pelvic congestion syndrome. Br J Hosp Med. 1990;43:200–206.
    1. Taylor HC. Vascular congestion and hyperemia; their effects on structure and function in the female reproductive system. Am J Obstet Gynecol. 1949;57:637–653.
    1. Kölbel T, Lindh M, Akesson M, Wassèlius J, Gottsäter A, Ivancev K. Chronic iliac vein occlusion: midterm results of endovascular recanalization. J Endovasc Ther. 2009;16:483–491. doi: 10.1583/09-2719.1.
    1. Scott TE, LaMorte WW, Gorin DR, Menzoian JO. Risk factors for chronic venous insufficiency: a dual case-control study. J Vasc Surg. 1995;22:622–628. doi: 10.1016/S0741-5214(95)70050-1.
    1. Khan SR, Ginsberg JS. Relationship between deep venous thrombosis and the postthrombotic syndrome. Arch Intern Med. 2004;164:17–26. doi: 10.1001/archinte.164.1.17.
    1. Whiteley AM, Taylor DC, Whiteley MS. Pelvic venous reflux is a major contributory cause of recurrent varicose veins in more than a quarter of women. J Vasc Surg. 2013;1:100–101.
    1. Perrin MR, Labropoulos N, Leon LR., Jr Presentation of the patient with recurrent varices after surgery (REVAS) J Vasc Surg. 2006;43:327–334. doi: 10.1016/j.jvs.2005.10.053.
    1. Barber B, Horton A, Patel U. Anatomy of the origin of the gonadal veins on CT. Anatomy of the origin of the gonadal veins on CT. J Vasc Interv Radiol. 2012;23(2):211–215. doi: 10.1016/j.jvir.2011.10.013.
    1. Ahlberg NE, Bartley O, Chidekel N. Right and left gonadal veins: an anatomical and statistical study. Acta Radiol Diagn. 1966;4:593–601. doi: 10.1177/028418516600400601.
    1. Edwards RD, Robertson IR, MacLean AB, Hemmingway AP. Case report: pelvic pain syndrome—successful treatment of a case by ovarian vein embolization. Clin Radiol. 1993;47:429–431. doi: 10.1016/S0009-9260(05)81067-0.
    1. Kennedy A, Hemmingway A. Radiology of ovarian varices. Br J Hosp Med. 1990;44:38–43.
    1. Raju S, Neglen P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg. 2006;44(1):136–143. doi: 10.1016/j.jvs.2006.02.065.
    1. Scultetus AH, Villavicencio JL, Gillespie DL. The nutcracker syndrome: its role in the pelvic venous disorders. J Vasc Surg. 2001;34:812–819. doi: 10.1067/mva.2001.118802.
    1. Hartung O, Grisoli D, Boufi M, Marani I, Hakam Z, Barthelemy P, Alimi YS. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome: lessons learned from the first five cases. J Vasc Surg. 2005;42(2):275–280. doi: 10.1016/j.jvs.2005.03.052.
    1. Asciutto G, Asciutto KC, Mumme A, Geier B. Pelvic venous incompetence: reflux patterns and treatment results. Eur J Vasc Endovasc Surg. 2009;38:381–386. doi: 10.1016/j.ejvs.2009.05.023.
    1. Scultetus AH, Villavicencio JL, Gillespie DL, Kao TC, Rich NM. The pelvic venous syndromes: analysis of our experience with 57 patients. J Vasc Surg. 2002;36:881–888. doi: 10.1067/mva.2002.129114.
    1. Creton D, Hennequin L, Kohler F, Allaert FA. Embolisation of symptomatic pelvic veins in women presenting with non-saphenous varicose veins of pelvic origin—three year follow-up. Eur J Vasc Endovasc Surg. 2007;34:112–117. doi: 10.1016/j.ejvs.2007.01.005.
    1. Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006;17:289–297. doi: 10.1097/01.RVI.0000194870.11980.F8.
    1. Laborda A, Medrano J, de Blas I, Urtiaga I, Carnevale FC, de Gregorio MA. Endovascular treatment of pelvic congestion syndrome: visual analogue scale (VAS) long-term follow up clinical evaluation in 202 patients. Cardiovasc Interv Radiol. 2013;36(4):1006–1014. doi: 10.1007/s00270-013-0586-2.
    1. Monedero JL, Zubicoa Ezpeleta S, Castro Castro J, Calderon Ortiz M, Sellars Fernandez G. Embolization treatment of recurrent varices of pelvic origin. Phlebology. 2006;21(1):3–11. doi: 10.1258/026835506775971108.
    1. Ratnam LA, Marsh P, Holdstock JW, Harrison CS, Hussain FF, Whiteley MS, Lopez AJ. Pelvic vein embolisation in the management of varicose veins. Cardiovasc Interv Radiol. 2008;31(6):1159–1164. doi: 10.1007/s00270-008-9402-9.
    1. Moyano CJL, Teba del Pino F, Arellano GR, Romero TJC, Albacete AP, Ruiz ZC, Pereira SI. The ovarian vein syndrome. Its treatment by percutaneous embolisation and a review of the same. Arch Esp Urol. 1993;46:802–806.
    1. Capasso P, Simons C, Trotteur G, Donderlinger RF, Henroteaux D, Gaspard U. Treatment of symptomatic pelvic varices by ovarian vein embolisation. Cardiovasc Interv Radiol. 1997;20:107–111. doi: 10.1007/s002709900116.
    1. Cordts PR, Eclavea A, Buckley PJ, De Moiorilius CA, Cockerill ML, Yeager TD. Pelvic congestion syndrome: early clinical results after transcatheter ovarian vein embolisation. J Vasc Surg. 1998;28:862–868. doi: 10.1016/S0741-5214(98)70062-X.
    1. Maleux G, Stockx L, Wilms G, Marchal G. Ovarian vein embolisation for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J Vasc Interv Radiol. 2000;11(7):859–864. doi: 10.1016/S1051-0443(07)61801-6.
    1. Lopez AJ, Holdstock J, Harrison C, Price B, Whiteley MS (2012) Transjugular pelvic vein embolization in the management of lower limb varicosities: experience gained in 1000 patients. Abstracts from Global Embolization Symposium and Technologies (May 3–6).
    1. Mathis BV, Miller JS, Lukens ML, Paluzzi MW. Pelvic congestion syndrome: a new approach to an unusual problem. Am Surg. 1995;61:1016–1018.
    1. Boersma D, van Eekeren RR, Werson DA, van der Waal RI, Reijnen MM, de Vries JP. Mechanochemical endovenous ablation of small saphenous vein insufficiency using the Clarivein® device: one year results of a prospective series. Eur J Vasc Endovasc Surg. 2013;45(3):299–303. doi: 10.1016/j.ejvs.2012.12.004.
    1. Lawson J, Gauw S, van Vlijmen C, Pronk P, Gaastra M, Mooij M, Wittens CH. Sapheon: the solution? Phlebology. 2013;28(Suppl 1):2–9. doi: 10.1177/0268355513475970.
    1. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg. 2001;27(1):58–60.
    1. Wang CL, Cohan RH, Ellis JH, Caoili EM, Wang G, Francis IR. Frequency, outcome and appropriateness of treatment of non-ionic iodinated contrast media reactions. Am J Roentgenol. 2008;191(2):409–415. doi: 10.2214/AJR.07.3421.
    1. Marsh P, Holdstock JM, Bacon JL, Lopez AJ, Whiteley MS, Price BA. Coil protruding into the common femoral vein following pelvic venous embolization. Cardiovasc Interv Radiol. 2008;31(2):435–438. doi: 10.1007/s00270-007-9249-5.
    1. Venbrux AC, Chang AH, Kim HS, Montague BJ, Hebert JB, Arepally A, Rowe PC, Barron DF, Lambert D, Robinson JC. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 2002;13:171–178. doi: 10.1016/S1051-0443(07)61935-6.
    1. Sichlau MJ, Yao JS, Vogelzang RL. Transcatheter embolotherapy for the treatment of pelvic congestion syndrome. Obstet Gynecol. 1994;83:892–896.
    1. Tarazov PG, Prozorovskij KV, Ryzhkov VK. Pelvic pain syndrome caused by ovarian varices: treatment by transcatheter embolization. Acta Radiol. 1997;38:1023–1025.
    1. Bachar GN, Belenky A, Greif F, Atar E, Gat Y, Itkin M, Verstanding A. Initial experience with ovarian vein embolization for the treatment of chronic pelvic pain syndrome. Isr Med Assoc J. 2003;12:843–846.
    1. Pieri S, Agresti P, Morucci M, de’Medici L. Percutaneous treatment of pelvic congestion syndrome. Radiol Med (Torino) 2003;105:76–82.
    1. Kwon SH, Oh JH, Ko KR, Park HC, Huh JY. Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Interv Radiol. 2003;30:655–661. doi: 10.1007/s00270-007-9040-7.
    1. LePage PA, Villavicencio JL, Gomez ER, Sheridan MN, Rich NM. The valvular anatomy of the iliac venous system and its clinical implications. J Vasc Surg. 1991;14:678–683. doi: 10.1016/0741-5214(91)90193-X.
    1. Chung MH, Huh CY. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med. 2003;201:131–138. doi: 10.1620/tjem.201.131.
    1. Beard RW, Highman JH, Pearce S, Reginald PW. The diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet. 1984;2:946–949. doi: 10.1016/S0140-6736(84)91165-6.
    1. Scultetus AH, Villavicencio JL, Rich NM. The female pelvic venous syndrome—an overview. Phlebologie. 2003;32:37–42.
    1. Geier B, Barbera L, Mumme A, Koster O, Marpe B, Kaminsky C, Asciutto G. Reflux patterns in the ovarian and hypogastric veins in patients with varicose veins and signs of pelvic venous incompetence. Chir Ital. 2007;59(4):481–488.
    1. Myers KA, Ziegenbein RW, Zeng GH, Matthews PG. Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux. J Vasc Surg. 1995;21:605–612. doi: 10.1016/S0741-5214(95)70192-3.
    1. Perrin MR, Guex JJ, Ruckley CV, dePalma RG, Royle JP, Eklof B, Nicolini P, Jantet G. Recurrent varices after surgery (REVAS), a consensus document. Cardiovasc Surg. 2000;8:233–245. doi: 10.1016/S0967-2109(00)00019-3.
    1. Darke SG. The morphology of recurrent varicose veins. Eur J Vasc Surg. 1992;6:512–517. doi: 10.1016/S0950-821X(05)80626-7.
    1. Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularization is the principal cause of varicose vein recurrence; results of a randomized trial of stripping the long saphenous vein. Eur J Endovasc Surg. 1996;12:442–445. doi: 10.1016/S1078-5884(96)80011-6.
    1. Fischer R, Linde N, Duff C, Jeanneret C, Chandler JG, Seeber P. Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein. J Vasc Surg. 2001;34:236–240. doi: 10.1067/mva.2001.115802.
    1. Labropoulos N, Delis K, Nicolaides AN, Leon M, Ramaswami G. The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency. J Vasc Surg. 1996;23:504–510. doi: 10.1016/S0741-5214(96)80018-8.
    1. Moreau P. Neovascularisation is not a major cause of varicose vein recurrence. Int J Angiol. 2005;11:99–101. doi: 10.1007/BF01616375.
    1. Ndiaye A, Ndiaye A, Ndoye J, Diarra O, Diop M, Dia A, Ndiaye M, Sow ML. The arch of the great saphenous vein: anatomical bases for failures and recurrences after surgical treatment of varices in the pelvic limb. About 54 dissections. Surg Radiol Anat. 2006;28(1):18–24. doi: 10.1007/s00276-005-0046-z.
    1. Vin F, Chleir F. Echo Doppler classification of postoperative recurrence of varicose vein in the region of the internal saphenous vein. Presse Med. 1998;27(4):148–152.
    1. Massell TB, Heringman E, Greenstone SM. Lower extremity varicosis originating from the pelvis. Angiology. 1966;17:121–126. doi: 10.1177/000331976601700209.
    1. Labropoulos N, Kang SS, Mansour MA, Giannoukas AD, Buckman J, Baker WH. Primary superficial vein reflux with competent saphenous trunk. Eur J Vasc Endovasc Surg. 1999;18:201–206. doi: 10.1053/ejvs.1998.0794.
    1. Giannoukas AD, Dacie JE, Lumley JS. Recurrent varicose veins of both lower limbs due to bilateral ovarian vein incompetence. Ann Vasc Surg. 2000;14:397–400. doi: 10.1007/s100169910075.
    1. Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Mansour MA, Baker WH. Nonsaphenous superficial vein reflux. J Vasc Surg. 2001;34:872–877. doi: 10.1067/mva.2001.118813.
    1. Seidel AC, Miranda F, Jr, Juliano Y, Novo NF, dos Santos JH, de Souza DF. Prevalence of varicose veins and venous anatomy in patients without truncal saphenous reflux. Eur J Vasc Endovasc Surg. 2004;28:387–390. doi: 10.1016/j.ejvs.2004.06.014.
    1. Hobbs JT. Varicose veins arising from the pelvis due to ovarian vein incompetence. Int J Clin Pract. 2005;59:1195–1203. doi: 10.1111/j.1368-5031.2005.00631.x.
    1. Welch HJ, Faliakou EC, McLaughlin RL, Umphrey SE, Belkin M, O’Donnell TF., Jr Comparison of descending phlebography with quantitative plethysmography, and duplex quantitative valve closure time in assessing deep venous reflux. J Vasc Surg. 1992;16:913–919. doi: 10.1016/0741-5214(92)90054-C.
    1. Neglen P, Raju S. A comparison between descending phlebography and duplex Doppler investigation in the evaluation of reflux in chronic venous insufficiency: a challenge to phlebography as the “gold standard”. J Vasc Surg. 1992;16:687–693. doi: 10.1016/0741-5214(92)90222-T.
    1. Caggiati A, Ricci S, Laghi A, Luccichenti P, Ravone P. Three-dimensional contrastless varicography by spiral computed tomography. Eur J Vasc Endovasc Surg. 2001;21:374–376. doi: 10.1053/ejvs.2000.1263.
    1. Uhl JF, Verdeille S, Martin-Bouyer Y. Three dimensional spiral CT venography for the pre-operative assessment of varicose patients. Vasa. 2003;32:91–94. doi: 10.1024/0301-1526.32.2.91.
    1. Muller MA, Mayer D, Seifert B, Marincek B, Willmann JK. Recurrent lower limb varicose veins: effect of direct contrast-enhanced three dimensional MR venographic findings on diagnostic thinking and therapeutic decisions. Radiology. 2008;247(3):887–895. doi: 10.1148/radiol.2473070987.
    1. Asciutto G, Mumme A, Marpe B, Köster O, Asciutto KC, Geier B. MR venography in the detection of pelvic venous congestion. Eur J Endovasc Surg. 2008;36(4):491–496. doi: 10.1016/j.ejvs.2008.06.024.
    1. Dos Santos SJ, Holdstock JM, Harrison CC, Lopez AJ, Whiteley MS. Ovarian vein diameter cannot be used as an indicator of ovarian vein reflux. Eur J Vasc Endovasc Surg. 2014;49:90–94. doi: 10.1016/j.ejvs.2014.10.013.

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