Abstract
Purpose
Pelvic venous insuffiency (PVI) can be responsible for pelvic congestion syndrome (PCS) and also lower limb varicose veins.
Material and methods
Charts of all women who had pelvic venography for PVI from September 2013 to August 2014 were reviewed. The procedure was performed under local anesthesia through left femoral approach. In case of reflux without associated obstructive lesions, embolization with coils and polidocanol foam was performed during the same procedure.
Results
119 women, with median age 39 years were explored (86 with PCS and 102 with lower limb venous disease). Of these, 78 had an isolated reflux and were embolized and 41 had an obstructive disease (29 iliocaval obstructive lesions (ICOL), 4 nutcracker syndrome (NCS), and 8 with an association of both). Median follow-up was 4 months. Of the 12 NCS, 5 had surgical treatment and 7 had stenting of the left iliac vein without embolization. All patients with ICOL without NCS were treated by stenting in 28 and by a Palma procedure in 1 (failure to recanalize). Primary and secondary patency rates were 97% at 12 months. Embolization led to improvement of PCS in 91% (60% without any pain) and of lower limb varicose veins in 51% by itself. If 82% need an additional treatment of lower limb varicose veins, embolization allowed a switch of strategy from surgery to sclerosis.
Conclusion
PVI can cause lower limb symptoms. In most cases, it is due to reflux and can be treated under local anesthesia by embolization. This technique is safe and efficient. Obstructive lesions must be recognized and treated.
Keywords
Pelvic venous insufficiency (PVI) is due to the development of varicose veins in the pelvis. According to Greiner and Gilling-Smith,
1
the etiology of pelvic varicose veins has the following three origins:
Type 1: due to a pathology of the venous wall (valvular insuffiency, valvular agenesis, venous malformations) Type 2: due to obstructive disease as nutcracker syndrome (NCS), May–Thurner syndrome (MTS), postthrombotic disease (PTS) Type 3: secondary to a local cause (endometriosis, tumor mass)
Pelvic varicose veins are found in 10% of women. Although first described in 1857 by Richet, 2 and given its name in 1949 by Taylor, 3 this pathology was only recently recognized as being a frequent cause of chronic pelvic pain. It can be responsible for disabling symptoms, mainly in women at child-bearing age, and these symptoms are known as pelvic congestion syndrome (PCS). It can also cause lower limb varicose vein, mainly in women.
We will report our experience and discuss the published literature.
Material and methods
We reviewed the charts of all women who had iliocavography and pelvic vein phlebography for PVI performed by the author in the North University hospital of Marseille from 1 September 2013 to 31 August 2014.
All patients had a clinical examination, duplex scan (pelvic color duplex scan performed after 3 days of a no residue diet and on an empty stomach with transparietal 5 MHz and transvaginal probes and lower limb duplex scan), and abdomino-pelvic CT venography or MR venography.
Phlebography was performed under local anesthesia through echo-guided left common femoral vein or femoral vein approach. Iliocavography was performed. Then after selective catheterization of the left renal vein, phlebography was performed in order to search for nutcracker syndrome (NCS) and/or left ovarian vein reflux (Figure 1). In case of suspected NCS, pullback reno-caval gradient was measured. The right ovarian vein was catheterized only when it was >4 mm in diameter on preoperative CT scan. Internal iliac veins were selectively catheterized for phlebography when iliocaval obstructive lesions were absent.
Incompetence of the left ovarian vein: (a) phlebography after selective catheterization of the left ovarian vein with a Cobra 2 catheter by left common femoral vein approach; (b) distal catheterization with a Progreat microcatheter; (c) result of distal embolization using 0.018 coils and foam; (d) final phlebography after embolization of the left ovarian vein with foam and 0.035 pushable coils.
In case of pelvic vein reflux without obstructive lesions, incompetent pelvic veins were treated by embolization during the same procedure according to the sandwich technique using pushable coils and 3% polidocanol foam. In some cases an Amplatzer vascular plug (St Jude Medical) was used (Figure 2). These patients were discharged 1 hour after the end of the procedure with only a prescription of paracetamol if needed.
Incompetence of the right inferior gluteal vein: (a) phlebography after selective catheterization of the right internal iliac vein with a Cobra 2 catheter by left common femoral vein approach; (b) result after embolization using 6 mL of 3% polidocanol foam and an Amplatzer vascular plug.
Patients with obstructive lesions were treated during the same procedure or on another day.
Follow-up
Clinical examination and duplex scanning were scheduled at 1, 3, 6, and 12 months and then annually. In case of clinical recurrence of the symptoms or of restenosis at color Doppler ultrasonography (>50% of in-stent restenosis with inflow obstruction was considered significant), transfemoral venography was performed.
Statistical analysis
Primary, assisted-primary and secondary patency rates were calculated by using survival analysis with the life table method.
Results
During this period, 119 women, with median age 39 years (range 17–74), were admitted for ilio-cavography and pelvic vein phlebography for PVI.
Of these, 86 were suffering from PCS and 102 lower limbs showed a chronic venous insufficiency, 69 (58%) with symptoms of both conditions.
Patients were divided in two groups: those with isolated pelvic reflux and those with iliocaval obstructive lesions (ICOL) and/or NCS.
Demographic data and lower limbs lesions are described in Table 1.
Regarding the 12 patients with NCS, 5 were operated (including one with associated MTS) with embolization of the incompetent left ovarian vein. The seven remaining patients had treatment of the associated ICOL by stenting without embolization of the LOV reflux and are under surveillance.
Of the 29 patients with ICOL without NCS, 28 were treated by stenting (including 10 recanalizations) and embolization of the LOV reflux. In one case, recanalization failed and a Palma procedure was performed.
Venous claudication disappeared in all cases and edema was improved in all patients with ICOL (no edema in 12 patients). One patient had thrombosis of her left femoro-iliac recanalization at 1.5 months due to severe hemoptysis treated by reversion of oral anticoagulation (subsequent thrombolysis was contra-indicated). Primary and secondary patency rates of the venous reconstructions are 97% at 1 and 12 months.
Regarding patients with isolated reflux, treatment was performed by embolization in all cases. Treated veins were LOV in 68 cases (87%), right ovarian vein in 3 (3.8%), branches of the left internal iliac vein in 34 (43%), and of the right internal iliac vein in 27 (34%). In these patients, PCS was improved in 55 patients (91%) including 36 (60%), which had no more signs of PCS. In this group, a mild or moderate improvement on varicose veins was found in 31 patients (51%), measured as a decrease of symptoms or of the volume and extent of the varicose veins. None had a real significant improvement. An additional treatment of varicose veins is needed in 50 patients (82%) but, due to improvement, the planned surgical treatment could be changed for foam therapy in eight cases.
Discussion
Atypical varicose veins located on the posterior and lateral aspect of the thigh are quite pathognomonic for PVI. PVI can also cause non-sapheno-femoral reflux in the groin. Jiang et al. 4 reported that non-sapheno-femoral reflux in the groin were due to PVI in 1.3% of the patients with primary varicose veins. Garcia-Gimeno et al. 5 found that reflux was due to PVI in 48% of patients with reflux in the great saphenous vein and 26% of those with reflux in the anterior accessory great saphenous vein in 2036 patients.
PVI can also cause recurrent varicose veins on the lower limbs. 4 According to the REVAS study, 6 16.6% of the recurrences were due to PVI. Jiang et al. reported that for recurrent varicose veins, 6.3% of non-sapheno-femoral reflux in the groin, were due to PVI.
Greiner treated 24 women who had varicose vein recurrence after surgery and PVI. Embolization was performed on 74 incompetent pelvic veins before iterative surgical procedure on lower limbs. At 4 years, pelvic phlebography found the absence of incompetence on treated veins in 77% of the cases and an improvement of the initial lesions in 23%. Two patients had new incompetent veins: one asymptomatic and one that was forsaken during the initial procedure while located on the asymptomatic limb. Clinical examination and duplex scan of the lower limbs showed no improvement of C1 lesions but no more C2 lesions in 22 patients (91%).
Asciutto et al. 7 reported on 71 women with signs of PVI on selective phlebography. Of these, 35 had embolization and 36 had conservative treatment. Patients embolized for isolated ovarian vein had a significant improvement. Patients embolized for internal iliac vein incompetence also improved but not significantly. In patients with combined lesions, those who had ovarian vein embolization only were not improved while those who had coiling of all lesions were improved but again not significantly. In all cases, untreated patients did not improve.
Creton et al. 8 reported on 24 women with non-saphenous perineal varicose veins and PCS treated by embolization. At 3 years follow-up, 10 had no varicose veins, 7 had a good result, 3 had less varicose veins, and 2 had at least the same amount that before the procedure. Improvement of the global symptoms score was obtained in 76%.
In our experience, results were good too but the follow-up is too short to make any conclusions. But although the literature is sparse on the results of embolization of pelvic vein to treat lower limb varicose veins, it confirms that this treatment is safe and efficient but that all incompetent pelvic veins need to be embolized. If this treatment does not totally cure lower limb varicose veins by itself, it must be part of a global strategy in order to optimize the result and avoid recurrences. It might also reduce the invasiveness of the lower limb varicose veins treatment linked with PVI.
It must be emphasized that PVI can also be caused by obstructive lesions (NCS or ICOL). These lesions must be searched by imaging techniques and confirmed by phlebography. In case of ICOL, treatment must be performed by stenting as first-line strategy to improve PCS and avoid recurrence of lower limb varicose veins. In case of NCS, indication of treatment relies on the severity of the symptoms. In case of moderate and non-disabling symptoms, treatment can be omitted but patients must be informed that they are at higher risk of varicose vein recurrence.
Conclusion
Demographic data and lower limbs lesions.
ICOL: iliocaval obstructive lesion; NCS: nutcracker syndrome; LOV: left ovarian vein.
Median follow-up was 4 months (1–12).
Footnotes
Conflict of interest
Workshops on pelvic vein embolization for Boston Scientific, Cook, Cordis, and Covidien.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.