Hypersensitivity to nickel in a patient treated with coil embolization for pelvic congestion syndrome

Nickel-related hypersensitivity reactions following endovascular interventions: A review of current evidence

INTRODUCTION

Nickel is a principal alloying agent in the production of vascular endoprostheses, despite persisting as the most habitually identified allergen. Variable nickel-related hypersensitivity manifestations following endovascular intervention were reported, challenging established paradigms in treatment and accuracy of prognostic assessments. The objective of this review is to critically evaluate current metrics to maximise patient-related outcomes.

METHODS

A literature review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement. Patients indicative of nickel hypersensitivity reaction following endovascular intervention were discerned. A positive reaction was defined by patch testing, histological analysis, or anamnesis indicative of nickel hypersensitivity. Morphology of implicating prostheses, adverse events and postoperative complications, clinical course, diagnostic and therapeutic strategies alongside patient prognosis were recorded.

RESULTS

Nickel-related hypersensitivity reactions following endovascular repair were identified in 36 patients with a median age of 44.5 years. 20 patients received nitinol-containing intervention. 28 (77.8%) patients are female. Multi-organ adverse reactions occurred in 21 (58.3%) patients with variable latency. 14 (38.9%) patients were presented with neurological adverse reactions manifesting mainly as unilateral hemiparesis. Dermatological reactions implicated 16 (44.4%) patients. Miscellaneous manifestations include suicidal ideation. 13 (36.1%) patients displayed previous metal intolerance and 32 (88.9%) patients had positive patch testing for nickel. Histological analysis of lesions and prostheses indicated lymphocytic infiltration. 5 (13.9%) patients experienced device-specific reactions as in-stent restenosis or auxiliary distal vessel stenosis. 11 (30.1%) patients received solely medical therapy and 5 (13.9%) patients received solely surgical therapy. 19 (52.7%) patients underwent both medical (oral corticosteroid) and surgical therapy (device retrieval). 26 (77.1%) patients achieved symptomatic cessation, 6 (16.7%) patients exhibited symptomatic persistence and 0 patients died.

CONCLUSION

Prophylactic pre-assessment for a history of metal allergy and consideration of prostheses alternatives is recommended to minimise reaction risk and severity. Despite nickel's predominant usage, information paucity urges additional studies to emphasise its implications and maximise patient outcomes.

Surgical and endovascular treatment of pelvic venous disorder: Results of a multicentre retrospective cohort study

OBJECTIVE

In the present study, we investigated the clinical outcomes after gonadal vein resection (GVR) and gonadal vein embolization (GVE) with coils in patients with pelvic venous disorder (PeVD). We also assessed the rates of procedural complications and disease recurrence.

METHODS

Our multicenter retrospective cohort study included 361 female patients with PeVD-related chronic pelvic pain (CPP) and gonadal vein reflux who underwent GVR (n = 184) or GVE with coils (n = 177) from 1999 to 2020. The clinical outcomes (ie, presence and severity of CPP, procedural complications, disease recurrence) were assessed at 1 month and 1, 3, and 5 years after intervention. The pain intensity before and after treatment was assessed using a visual analog scale. All the patients underwent duplex ultrasound after GVR and GVE, and those with persistent CPP and suspected perforation of the gonadal vein by the coils were also evaluated by multiplanar pelvic venography.

RESULTS

GVR and GVE was associated with the reduction or elimination of CPP at 1 month after treatment in 100% and 74% of patients and postprocedural complications in 14% and 37% of patients, respectively (Р < 0.01 for both). The most common complication after either GVR or GVE was pelvic vein thrombosis (11% and 22% patients, respectively; P < .01 between groups). GVE was associated with postembolization syndrome in 20%, coil protrusion in 6%, and coil migration in 1% of patients. The long-term recurrence rate after GVR and GVE was 6% and 16%, respectively (P < .01).

CONCLUSIONS

Both GVR and GVE were found to be effective in treating patients with PeVD. However, GVR was associated with better efficacy in the relief of CPP and lower rates of procedural complications and disease recurrence.

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.

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.

Nickel hypersensitivity and endovascular devices: a systematic review and meta-analysis

OBJECTIVE

Nickel allergy is common; endovascular specialists are often confronted with nickel allergic patients ahead of the implantation of endovascular devices, many of which are nickel-containing. Our aim was to elucidate whether nickel hypersensitivity is significantly associated with worse or adverse outcomes after placement of a nickel-containing endovascular device.

METHODS

Inclusion criteria were: endovascular and transcatheter procedures for coronary, structural heart, neurovascular and peripheral vascular pathology involving nickel-allergic patients. All adverse outcomes were included as defined by included studies. A systematic review and meta-analysis were undertaken using a random-effects model. Searches of MEDLINE and EMBASE were conducted for articles published 1947-2019.

RESULTS

190 records were identified, 78 articles were included for qualitative synthesis and 15 met criteria for meta-analysis. Patch-test confirmed nickel allergy was associated with an increased risk of adverse outcomes following implantation of a nickel-containing endovascular device (n=14 articles, 1740 patients; OR 2.61, 95% CI 1.41 to 4.85). This finding further was observed in coronary (n=12 articles, 1624 patients; OR 1.94, 95% CI 1.16 to 3.23) and structural heart subgroups (n=2 articles, 83 patients; OR 52.28, 95% CI 1.31 to 2079.14), but not in the neurovascular subgroup (n=1 article, 33 patients; OR 3.04, 95% CI 0.59 to 15.72) or with a patient-reported history of nickel allergy (n=2 articles, 207 patients; OR 2.14, 95% CI 0.23 to 19.70).

CONCLUSIONS

Patch-tested nickel allergy is associated with an increased risk of adverse outcomes following endovascular device implantation and alternative treatment options should be considered. Specialists faced with patients' self-reporting nickel allergy should consider proceeding to diagnostic patch-testing.

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.

The Effect of Venoactive Drug Therapy on the Development and Severity of Post-Embolization Syndrome in Endovascular Interventions on the Gonadal Veins

Objective. To evaluate the incidence of post-embolization syndrome (PES) and the effect of venoactive therapy on its development, severity, and duration after endovascular embolization of gonadal veins (EEGV) with coils in patients with pelvic congestion syndrome (PCS). Materials and Methods. We analyzed the outcomes of EEGV with coils in 70 female patients who received (n = 38; group 1) or did not receive (n = 32; group 2) treatment with a venoactive drug (VAD) before and after the procedure. Assessments of the EEGV efficacy and for possible signs of PES were done on days 1, 5, 10, 15, 20, and 30 after the intervention. All patients underwent transvaginal and transabdominal duplex ultrasound scanning (DUS) after EEGV. In addition, patients with PES were examined using the computed tomography of the pelvic veins in the postprocedural period. Results. Technical success of EEGV was achieved in 100% of patients. Pelvic venous pain (PVP) reduction after EEGV was observed in 77.1% of patients. The PES was diagnosed in 18.6% of cases (10.5% in group 1 vs. 28.1% in group 2, p > 0.05). In three patients of group 1, the protrusion of coils was suspected and eventually verified during the resection of the left gonadal vein with coils. The group 1 patients had less severe post-embolization pain (6.2 ± 0.4 vs. 7.8 ± 0.3 scores in group 2; p = 0.009) and three times shorter duration of PES (5.0 ± 1.2 vs. 16.2 ± 2.7 days; p = 0.003). No significant differences in the diameters of gonadal veins, side of embolization, and number of coils were revealed between patients with and without PES. The rate of parametrium vein thrombosis was found to be significantly higher in patients with PES than in those without PES (30.7% vs. 18.5%, respectively; p < 0.05). Conclusion. The PES is a frequent complication of EEGV with coils and occurs in 18.6% of patients. Venoactive treatment does not effect the incidence of this complication but reduces the PES severity and duration.

Shape memory polymer ovarian vein embolisation in a patient with nickel allergy

Background

Ovarian vein embolization in pelvic varicocele is usually obtained using nitinol coils. These devices can not be used in patients with proven nickel allergy.

Case presentation

Shape memory polymer is a new embolic material available to interventionalists. A patient presented with pelvic congestion syndrome requiring embolisation of the left ovarian vein. The target vessel consisted of two twisted branches, each 5–6 mm in diameter. The patient also had a known allergy to nickel. Considering the anatomy and allergy status, embolisation with polyurethane shape memory polymer vascular plugs was considered a good case strategy. The embolisation procedure was technically successful with the deployment of two shape memory polymer plugs into each of the two left ovarian vein branches. Follow-up magnetic resonance imaging at 4 months showed sustained occlusion of the treated vessels and the patient showed no signs of allergy to the implanted material.

Conclusions

In conclusion, our case presented an opportunity to utilise a new embolic material and achieve a good outcome in a patient with an allergy that may have resulted in complications when using metallic implants.

Postembolization syndrome in endovascular interventions on the gonadal veins

OBJECTIVE

The present study evaluated the incidence of postembolization syndrome (PES) after endovascular coil embolization of the gonadal veins (EEGV) in patients with pelvic congestion syndrome and investigated the appropriate medical treatment.

METHODS

EEGV was performed in 70 female patients with pelvic congestion syndrome (left-sided in 58, right-sided in 3, and bilateral in 9 patients). For embolization, 0.035-in. coils with an 8- to 12-mm diameter and 10- to 20-cm length were used. Assessments of the EEGV results and possible PES symptoms were performed on days 1, 5, 10, 20, and 30 after the procedure and included transvaginal and transabdominal duplex ultrasound scanning of the pelvic veins and at the embolization site.

RESULTS

PES had manifested with increased pelvic pain, tenderness along the embolized vein, and hyperthermia ≤37.5°C to 37.8°C and had developed in 14 patients (20%). For PES treatment, a nonsteroidal anti-inflammatory drug (diclofenac, 75 mg daily for 3-7 days; mean, 4.2 ± 1.1 days) and a venoactive drug (micronized purified flavonoid fraction, 1000 mg daily for 2 months) were used. Medical treatment was associated with a significant reduction in PES symptoms in all patients within 14 days and complete resolution by day 30 after embolization. duplex ultrasound scanning revealed thrombosis of parametrial veins in 12 of 56 patients (21.4%) with successful EEGV and 3 of 14 patients (21.4%) with PES.

CONCLUSIONS

In patients who have undergone EEGV, increased pelvic pain, the occurrence of tenderness along the embolized vein, and the presence of hyperthermia should be considered as PES manifestations. In our study, PES occurred in 20% of the treated patients.