Pelvic congestion syndrome

Sonographic View of Pelvic Congestion Syndrome

A particular pelvic pathology that may not be recognized, and is easily missed, is pelvic congestion syndrome. There is limited understanding about this condition, and many sonographers may have limited to no knowledge of this disorder. This article is to bring an awareness of this condition and the sonographic images necessary to obtain, so that further testing and possible treatment could relieve the patient of symptoms. Since a pelvic sonogram is generally the first modality of choice when an assessment of the pelvic organs is ordered, detailed imaging of all the pelvic region should be evaluated, including the vessels within this area. When evaluating a patient with chronic pelvic pain and visualizing any dilated vessels during a transabdominal or transvaginal sonogram, further imaging and documentation are essential. With this additional information, further testing with computed tomography or magnetic resonance imaging, along with a venogram, may result in a definitive diagnosis of pelvic congestion syndrome to facilitate treatment.

Nutcracker syndrome: A rare cause of left flank pain that can also manifest as unexplained pelvic pain

Nutcracker syndrome (NCS) is symptomatic unilateral renal venous hypertension due to compression of the left renal vein between the superior mesenteric artery and aorta (anterior NCS) or between the aorta and spine (posterior NCS). The left ovarian or spermatic vein empties into the left renal vein and is an additional site of venostasis in about half the cases of NCS. The presenting symptom of NCS in about half the cases is atypical left flank pain suggesting a disorder of the lower ribs or thoracolumbar spinal junction, particularly as the pain worsens with standing and increased lumbar lordosis. NCS may be suggested by any combination of the following manifestations: hematuria, which is often only microscopic; orthostatic proteinuria; varicocele and infertility; dyspareunia and other gynecological symptoms; varicose veins in the pelvis, buttocks, or upper thighs; orthostatic hypotension and fatigue; and abdominal pain. Narrowing of the left renal vein on imaging studies is required but far from sufficient to establish the diagnosis. Several converging clinical findings and a marked pressure gradient between the left renal vein and inferior vena cava must be present also. Urological procedures and vascular surgery are being superseded by endovascular stenting with or without simultaneous treatment of the acquired gonadal vein insufficiency by embolization.

Evaluation of Effectiveness of Embolization in Pelvic Congestion Syndrome with the New Vascular Occlusion Device (ArtVentive EOS™): Preliminary Results

Purpose

This study aimed to collect confirmatory data in support of the safety and efficiency of the ArtVentive EOS™ for the treatment of the pelvic congestion syndrome (PCS). This study was based on the OCCLUDE 1 Study Protocol approved by the Local Ethics Committee.

Materials and Methods

A prospective study carried out in June and July 2014 included 12 women aged 21–48 years (mean 31 years) scheduled for PCS embolization using the ArtVentive EOS™. The inclusion criteria were clinical symptoms of PCS documented by transvaginal Doppler ultrasound and pelvic MRI. The pelvic pain was assessed by VAS score from 0 to 10 (0 represents lack of pain and 10 unbearable pain). A decrease in pelvic pain intensity based on the VAS was considered a clinical success.

Results

Successful embolization procedures with ArtVentive EOS™ were performed in 11 out of 12 patients. Nine patients underwent unilateral embolization of the left ovarian vein, and two had bilateral embolization of the ovarian veins. Complete ovarian vein occlusion confirmed by post deployment venography was achieved in all 11 patients. Procedures lasted from 19 to 45 min (average 28 min). Pain intensity decrease was observed in all 11 patients—a decrease of 5.6 points—from 7.3 pre-procedure to 1.6 post-embolization (standard deviation: 0.67). In one case, the left ovarian vein was injured by guide wire manipulation with contrast extravasation—not clinically significant.

Conclusions

The use of ArtVentive EOS™ for occlusion of the ovarian veins in PCS patients is safe and effective.

Embolization is not essential in the treatment of leg varices due to pelvic venous insufficiency

AIM

To consider if it is essential to perform embolization in the treatment of leg varices due to pelvic venous insufficiency.

METHODS

Review of the current literature concerning treatment options of leg varicose veins of pelvic origin.

RESULTS

Pelvic venous insufficiency, vulvar and pudendal varicose veins as well as pelvic congestive syndrome are under diagnosed entities. Embolization of ovarian and pelvic veins is well established in patients with pelvic congestive syndrome. In varicose veins of pelvic origin but without pelvic congestive syndrome, comparative studies comparing the outcome of embolization or treatment of varicose veins by sclerotherapy or phlebectomy alone are missing. Foam sclerotherapy or phlebectomy shows good results in patients with varicose veins of pelvic origin.

CONCLUSIONS

Embolization is not essential in the treatment of leg varices of pelvic origin without pelvic congestive syndrome. Foam sclerotherapy or phlebectomy shows good results in patients with vulvar or pudendal varicose veins. Randomized comparative studies using embolization of incompetent pelvic veins or sclerotherapy of varicose veins with pelvic origin should be performed.