MRI associated factors of clinical efficacy of embolization in patients with pelvic venous insufficiency

Identification of outcomes in clinical studies for pelvic venous disorders

OBJECTIVE

There is increasing recognition that health systems need to measure and improve the value of patient care by measuring outcomes. Chronic pelvic pain secondary to pelvic venous insufficiency can have a significant impact on the quality of life (QOL) of women affected. Despite growing recognition, pelvic venous disorders (PeVDs), an important cause of chronic pelvic pain, remain underdiagnosed. Developing a core outcome set (COS) for benchmarking care delivery enhances the standardization of care. However, there is no consensus regarding a standardized minimum set of outcomes for PeVD. We aimed to generate a list of outcomes reported in previous PeVD treatment studies to lay the foundation for developing a COS for PeVD.

METHODS

This scoping review was undertaken according to the PRISMA-ScR guidelines. Initially, screening, full-text review and extraction was conducted on studies published between 2018 and 2023. Subsequently, the search was expanded using 1-year intervals, until, over a 1-year interval, no new outcomes were recorded. Closely related outcomes were classified into domains, and domains into three core areas: disease-specific, treatment-related, and QOL-related outcomes.

RESULTS

Of the 1579 records identified, 51 publications were included. From these studies, 108 different outcomes were identified. The median number of outcomes per study was 8 (interquartile range, 6-13). Closely related outcomes were organized into 42 outcome domains, which were then categorized into 3 core outcome areas; 47.6% (20/42) were disease specific, 35.7% (15/42) treatment related, and 16.7% (7/42) were QOL related. Of the 51 included studies, disease-specific outcomes were identified in 96.1% of the studies (49/51), treatment-related outcomes in 94.1% (48/51), and QOL outcomes in only 13.7% (7/51).

CONCLUSIONS

There was significant heterogeneity in outcomes reported in PeVD studies. Most PeVD treatment studies evaluated disease-specific and treatment-related outcomes of PeVD, but few reported outcomes that measured the impact on QOL. These findings will inform the next steps in developing a COS for PeVD.

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.

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.

Diagnosis and Management of Pelvic Venous Disorders in Females

Pelvic venous pathologies in females are responsible for chronic symptoms grouped under the term pelvic congestion syndrome, which includes chronic pelvic pain, perineal heaviness, urgency, and postcoital pain, along with vulvar, perineal, and lower limb varicose veins. These conditions are also associated with ovarian and pelvic venous reflux and venous obstruction. This review aimed to explore the clinical and imaging modalities for diagnosing pelvic congestion syndrome, pelvic venous pathologies, their therapeutic management, and their outcomes.

Embolization in pelvic venous disorders using ethylene vinyl alcohol copolymer (Onyx®) and Aetoxysclerol: a prospective evaluation of safety and long-term efficacy

OBJECTIVES

To prospectively evaluate the safety and efficacy of embolization using ethylene vinyl alcohol copolymer (Onyx^®) and Aetoxysclerol for treatment of pelvic venous disorders (PeVD).

METHODS

This prospective study was approved by the institutional ethics review board. Ten clinical parameters were retained for evaluation of PeVD (pelvic pain, dyspareunia, post-coital pain, menstruation pain, lower limbs pain, difficulty walking, aesthetic discomfort, impact on daily working life, psychological impact and impact on daily life), measured on a visual analogue scale (VAS) between 0 and 10, and a global score out of 100 was noted before embolization, after 3 months during the imaging follow-up, and at the end of follow-up by phone call. The main criterion was clinical efficacy of embolization defined by an impairment score < 40/100 and a 50% decrease in overall score. Complications were recorded. Visualization of Onyx^® on MRI 3 months after embolization was noted.

RESULTS

Between July 2017 and May 2019, 73 consecutive women (mean age ± SD [range]: 41 ± 11 years [25-77]) treated by embolization with Onyx^® and Aetoxysclerol were included. The median follow-up was 28 months [Q1-Q3: 24.0-29.2] (range: 18.1-34.5). The median initial VAS impairment score was 39/100 [29.75-48.50] (12-58). Clinical efficacy was obtained for 70 patients (70/73, 95.9%), and the median VAS impairment score at the end of follow-up was significantly lower at 3 [0.00-7.25] (0-73) (p < 0.0001). Four minor complications occurred. Onyx^® was visualized on DIXON sequence of MRI for all patients.

CONCLUSION

Embolization using Onyx^® and Aetoxysclerol for PeVD is safe and effective.

KEY POINTS

• Embolization using Onyx^® and Aetoxysclerol for pelvic venous disorders is safe and effective. • Imaging follow-up is facilitated by visualization of Onyx^® on MRI DIXON sequences.