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REVIEW ARTICLERichard P. Cambria, MD, Section Editor
FromMEnSy
AuthRepVcoM
Theshre
2213Cophttp
96
Diagnosis and treatment of the pelvic congestionsyndromeMarlene
T. O’Brien, MD, PhD,a and David L. Gillespie, MD,b Rochester, NY;
and Fall River, Mass
Background: Chronic pelvic pain accounts for up to 30%
ofoutpatient gynecologic visits in the United States,
potentiallyaffecting up to 40% of the female population during
theirlifetime. Pelvic congestion syndrome (PCS) is defined
aschronic pelvic pain resulting from reflux or obstruction of
thegonadal, gluteal, or periuterine veins, sometimes associatedwith
perineal or vulvar varices. It can also be caused bycompression of
the left renal vein (LRV) between the superiormesenteric artery and
the aorta, also known as the nutcrackersyndrome. Whereas PCS
accounts for up to 30% of patientspresenting with chronic pelvic
pain, it is frequently under-diagnosed. We reviewed the literature
to investigate the cur-rent state of the diagnosis and treatment of
this disorder.Methods: An online database search was performed
withMEDLINE. MeSH headings included PCS, chronic pelvicpain,
ovarian vein reflux, nutcracker syndrome, renal veinobstruction,
pelvic varicosities, labial varicosities, emboliza-tion, treatment,
and therapies.Results: Our MEDLINE search revealed more than 3756
ref-erences to chronic pelvic pain. Specific references to
PCS,pelvic chronic pain, ovarian vein reflux, nutcracker
syndrome,
the Division of Vascular Surgery, University of Rochester School
ofedicine and Dentistry, Rochestera; and the Division of Vascular
anddovascular Surgery, Heart and Vascular Center, Southcoast
Healthcarestem, Charlton Hospital, Fall River.b
or conflict of interest: none.rint requests: David L. Gillespie,
MD, RVT, FACS, Chief, Division ofascular and Endovascular Surgery,
Heart and Vascular Center, South-ast Health System, Charlton
Hospital, 363 Highland Ave, Fall River,A 02720 (e-mail:
[email protected]).editors and reviewers of this article
have no relevant financial relation-ips to disclose per the Journal
policy that requires reviewers to declineview of any manuscript for
which they may have a conflict of interest.-333Xyright � 2015 by
the Society for Vascular
Surgery.://dx.doi.org/10.1016/j.jvsv.2014.05.007
renal vein obstruction, pelvic varicosities, labial
varicosities,embolization, treatment, and therapies, however,
includedonly 260 references. Thirty-seven references were small
seriesincluding fewer than 50 patients or individual case
reportsdocumenting medical, surgical, or endovascular treatment
ofPCS. The majority of these papers demonstrated
successfultreatment of symptoms from PCS with embolization of one
orboth ovarian veins in addition to treatment of refluxing
in-ternal iliac vein branches. In addition, open surgery and,
morerecently, endovascular stenting of LRV obstruction haveshown
some promise in alleviating symptoms attributed tonutcracker
syndrome.Conclusions: Diagnosis of PCS requires a careful
history,physical examination, and noninvasive imaging. Several
largecase series have demonstrated the efficacy of embolotherapy
inthe reduction of pelvic pain; thus, it is the most
favoredtreatment option for patients with PCS. For patients
withoutflow obstruction due to nutcracker syndrome, a limitednumber
of studies have demonstrated remission of symptomswith stenting of
the LRV as an alternative to open surgery. (JVasc Surg: Venous and
Lym Dis 2015;3:96-106.)
Chronic pelvic pain is described as the presence oflower
abdominal or pelvic pain for longer than 6 months.Chronic pelvic
pain accounts for up to 30% of outpatientgynecologic visits in the
United States, potentially affectingup to 40% of the female
population during their lifetime.1,2
Pelvic congestion syndrome (PCS) is defined as chronicpelvic
pain often associated with perineal or vulvar varicesresulting from
reflux or obstruction of the gonadal, gluteal,or periuterine veins.
First described clinically by Richet in
1857, the existence of pelvic varicosities was documentedin 1949
by Taylor. PCS accounts for up to 30% of patientspresenting with
chronic pelvic pain and is characterized bysymptoms of
dysmenorrhea, dysuria, and dyspareunia.1 Itcan often be found in
conjunction with vulvar and pelvicvarices in women and with
varicoceles in men. In additionto causing a fair amount of physical
pain and discomfort,PCS also carries a psychological burden and is
often foundin conjunction with increased levels of anxiety, stress,
anddepression. Patients with PCS are primarily premenopausaland
range in age from 20 to 45 years, although most pre-sent in their
second and third decades of life. Genetic orethnic predilections
are unclear; however, a family historyand multiparity are both risk
factors. Venous outflowobstruction resulting from left renal vein
(LRV) compres-sion due to either the superior mesenteric artery
(SMA)in nutcracker syndrome or uterine malposition is also
animportant although less common factor in the develop-ment of PCS.
Treatment of PCS consists of hormone ther-apy, embolotherapy,
sclerotherapy, and endovascular andopen surgery. Although no
randomized prospective trialshave studied the efficacy of such
therapies, several studiesfrom single institutions have
demonstrated efficacy for
mailto:[email protected]://dx.doi.org/10.1016/j.jvsv.2014.05.007http://crossmark.crossref.org/dialog/?doi=10.1016/j.jvsv.2014.05.007&domain=pdf
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Fig 1. Pelvic venous anatomy. CIV, Common iliac veins;
IIV,internal iliac veins; IVC, inferior vena cava; LOP, left
ovarianplexus; LOV, left ovarian vein; LRV, left renal vein; LUP,
leftuterine plexus;ROP, right ovarian plexus;ROV, right ovarian
vein;RUP, right uterine plexus. (Modified with permission. �
2014Intermountain Vein Center.)
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC
DISORDERSVolume 3, Number 1 O’Brien and Gillespie 97
interventions that have alleviated symptoms related to
thedisease.
ANATOMY
The ovaries and uterus are drained by both the internaliliac and
gonadal veins (Fig 1). The internal iliac vein passesslightly
medial and posterior to the internal iliac artery,joining the
external iliac to form the common iliac vein.Its tributaries are
divided into parietal and visceral. Parietaltributaries are the
superior and inferior gluteal, sciatic, sacral,ascending lumbar,
and obturator veins. Visceral tributariesare the internal pudendal,
middle hemorrhoidal, and vesico-prostatic plexuses in men and the
uterine, gonadal, and ves-icovaginal plexuses in women. In 27% of
cases, the internaliliac vein drains by means of two separated
trunks. Rarely, itcan drain directly into the inferior vena cava
(IVC). Valvesare found infrequently on the internal iliac veins
(10% ofcases on the main trunk and 9% on its tributaries).3
Ovarian veins provide drainage of the parametrium,cervix,
mesosalpinx, and pampiniform plexus, forming arich anastomotic
venous plexus with the paraovarian, uter-ine, vesical, rectal, and
vulvar plexuses (Fig 1). Two orthree trunks form a single ovarian
vein at L4, with theleft ovarian vein draining into the LRV and the
rightovarian vein draining directly into the IVC in the majorityof
women. In up to 10% of women, the right ovarian veinmay also drain
into the right renal vein instead of the IVC.Studies have shown
that normal ovarian veins have anaverage diameter of less than 5
mm.3 Valves are presentin these veins, mainly in the distal third.
Ahlberg et al3
found no ovarian vein valves on the left side in 15% andnone on
the right side in 6%. In those in whom valvesare present, they are
incompetent in 40% on the left andin 35% on the right. Ovarian vein
reflux has been reportedin 10% of female renal transplant donors,
up to 60% ofwhom develop PCS.4 Up to 47% of asymptomatic
parouswomen have left ovarian reflux and enlarged mean
ovariandiameters ranging from 7 to 12 mm on computed tomog-raphy
(CT) scan.5 Thus, because of variation in anatomyand the
variability of correlation between both anatomicand functional
imaging and clinical symptoms, the diag-nosis of PCS is primarily a
clinical one that is often deducedfrom a process of elimination in
conjunction with imagingsuggestive of venous incompetence or
obstruction. On thebasis of clinical presentation and hemodynamic
pathophys-iologic findings, four main types of pelvic venous
circula-tion disorders have been recognized: vulvar variceswithout
accompanying symptoms of pelvic congestion(although vulvar varices
may be seen with any type of pelviccongestion), isolated
insufficiency of the hypogastric veinand its tributaries, gonadal
vein reflux, and obstruction ofthe gonadal outflow by mesoaortic
compression of theLRV (nutcracker syndrome).2,6 The most common
ofthese is gonadal vein reflux due to incompetent valves.2,7
PATHOPHYSIOLOGY
Because of the paucity of functioning valves and theproximity of
the pelvic veins to several structures, pelvic
varicosities can develop by two mechanisms, reflux causedby
incompetent valves and obstruction. The cause ofvalvular
incompetence is unknown, although hormonalfactors are thought to
play a significant role. During preg-nancy, estradiol inhibits
vasoconstriction and induces uter-ine enlargement with selective
dilation of the ovarian anduterine veins, placing more stress on
the valves. Multipa-rous women are more likely to develop pelvic
venousincompetence. Conversely, vasoconstrictors have shownsome
efficacy in alleviating the symptoms of PCS byimproving venous
return through compression of thevein. In women diagnosed with PCS,
the injection of dihy-droergotamine produces a 35% reduction in
diameter ofthe pelvic veins and a decrease in pain.8
PCS may also result from obstruction of ovarian veinoutflow. The
most common cause of obstruction is thecompression of the LRV
between the SMA and the aorta,also known as the nutcracker syndrome
(Fig 2).9 Distalobstruction can lead to increased venous pressure
and sub-sequent venodilation, valvular incompetence, and
tortuos-ity of the ovarian vein, resulting in the development of
anelevated pressure gradient between the LRV and the venacava, a
finding that is normally absent. The presence ofan elevated LRV-IVC
pressure gradient may be suggestive
-
Fig 3. Patient with disfiguring vulval varices of intrapelvic
origin.(Reprinted from Scultetus AH, Villavicencio JL, Gillespie
DL, KaoTC, Rich NM. The pelvic venous syndromes: analysis of
ourexperience with 57 patients. J Vasc Surg 2002;36:881-8,
withpermission from Elsevier.)
Fig 2. Ovarian vein obstruction (nutcracker syndrome).
Duplex(A), computed tomography (CT) scan (B), and angiographic
(C)views of the nutcracker syndrome. (Reprinted from Hartung
O,Grisoli D, Boufi M, Marani I, Hakam Z, Barthelemy P, et
al.Endovascular stenting in the treatment of pelvic vein
congestioncaused by nutcracker syndrome: lessons learned from the
first fivecases. J Vasc Surg 2005;42:275-80, with permission
fromElsevier.)
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS98
O’Brien and Gillespie January 2015
of nutcracker syndrome, but not in isolation without symp-toms
or evidence of varicosities, as will be further discussed.Uterine
malposition with ovarian kinking is anotheralthough less common
cause of outflow obstruction alongwith May-Thurner syndrome, a
condition in which the leftcommon iliac vein is compressed by the
right common iliac
artery. This compression can sometimes lead to deepvenous
thrombosis. Regardless of the etiology, the endresult of ovarian
vein outflow obstruction is the develop-ment of numerous refluxing
varicosities, cross-pelvicvenous collaterals, and painful venous
congestion of theperineal vasculature (Fig 3).
PRESENTATION
Patients with PCS have usually seen primary care andgynecologic
specialists before being referred to a vascularspecialist. Many
patients will present with chronic, dull,lower abdominal pain often
accompanied by dyspareuniaand bladder irritability and urgency.1
The pain is typicallyrelieved by lying down and exacerbated by
standing upor increased intra-abdominal pressure, such as during
preg-nancy and the premenstrual period. Pain during inter-course or
during the postcoital period is not uncommon.Other symptoms of
pelvic congestion are nonspecific andvariable in intensity.
Affected women may have fullness inthe legs, generalized lethargy,
depression, abdominal orpelvic tenderness, vaginal discharge,
dysmenorrhea,swollen vulva, lumbosacral neuropathy, rectal
discomfort,and nonspecific gastrointestinal symptoms.2
Differentialdiagnosis in these patients is lengthy and includes
pelvic in-flammatory disease, endometriosis, pelvic tumors,
intersti-tial cystitis, and inflammatory bowel disease.
Clinical examination often reveals vulvar varicosities(Fig 3)
together with an engorged cervix and pain on
-
Fig 4. Algorithm for workup of pelvic congestion syndrome(PCS).
Patients present to primary care physicians with complaintsof
chronic pelvic pain and possibly dysmenorrhea, dysuria,
anddyspareunia. A thorough physical and pelvic examination shouldbe
conducted, looking for perineal, vulvar, and lower extremityvarices
and ovarian point tenderness. The patient should then bereferred to
a vascular laboratory for pelvic and lower extremity(LE) duplex
ultrasound (US) examination, performed preferablywhile standing. If
US demonstrates an ovarian vein of more than6 mm, dilated tortuous
arcuate veins in the myometrium thatcommunicate with bilateral
pelvic varicose veins, slow blood flow(6 mm,16 although 7 mm has
also been sug-gested as a cutoff.5,14 Park et al16 found the
positive pre-dictive value of a 6-mm-diameter ovarian vein for
thediagnosis of PCS caused by the ovarian vein to be 83.3%,and this
number has been widely accepted since. In truth,whereas an ovarian
vein size criterion is one component ofPCS, its diagnosis is
favored on the basis of a combination
of ovarian vein dilation, clinical symptoms, and these
veno-graphic findings: dilated tortuous arcuate veins in the
myo-metrium that communicate with bilateral pelvic varicoseveins,
slow blood flow (
-
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS100
O’Brien and Gillespie January 2015
Both the internal iliac and the genital veins should beimaged to
look for dilation and reflux, including imagingwith the Valsalva
maneuver. The obturator, sciatic, and in-ternal pudendal veins
should also be imaged. Collateralpathways can be found in patients
with PCS. In addition,duplex scanning should evaluate the common
iliac veins,IVC, and renal veins to search for venous
obstruction.The authors think that all patients suspected of
havingPCS should also undergo lower extremity duplex scanlooking
for common femoral vein reflux into the perineumthrough tributary
veins even in the absence of lower ex-tremity symptoms, given that
the absence of lower extrem-ity varicosities does not necessarily
preclude the diagnosisof PCS.6,11,12
If pelvic US with color duplex imaging is highly sug-gestive of
PCS, proceeding to venography and potentialintervention is not
unreasonable. However, in patientswith normal or nondiagnostic
findings on pelvic US andpersistent symptoms, MDCT venography and
MRVshould be considered as they have a higher sensitivity forlower
pelvic varices and also yield more discriminating in-formation
about the surrounding anatomy. First describedas tools for the
diagnosis of pelvic varicosities in 1999,traditional CT venography
and MRV provide usefulanatomic data in the diagnosis of PCS,
particularly if thecause is compressive, as with May-Thurner or
nutcrackersyndrome.17 The abrupt narrowing of the LRV with anacute
angle (beak sign) has been shown to have 91.7%sensitivity and 88.9%
specificity in diagnosis of nutcrackersyndrome.17 The limitations
to traditional CT and mag-netic resonance imaging (MRI) are that
static images pro-vide few data about the direction of flow within
pelvicveins. These studies are normally conducted while the
pa-tient is lying down, so they may underestimate the extentof
collateral networks or ovarian vein enlargement. Theemergence of
MDCT and time-resolved MRV (TR-MRV), however, has bridged the gap
between staticanatomic and dynamic functional imaging.
CT venography with three-dimensional reconstructionhas been
shown to be an effective road map before varicosevein surgery and
in the visualization of venous webs, suchas those found in
May-Thurner syndrome.17 The proce-dure should be timed for
evaluation of the portal, genital,and renal veins, and separate
imaging should be performedlater for evaluation of the pelvic and
iliocaval veins. Pelvicvarices are imaged as dilated, tortuous,
enhanced tubularstructures around the uterus and ovary, with
possibleextension into the broad ligament and pelvic side wall.They
can also involve the paravaginal venous plexus. Anovarian vein is
considered incompetent if it is completelyopacified during the
arterial phase of CT angiography.5
Time-resolved MRA (TR-MRA) is particularly helpfulfor the
detection of PCS because of its ability to accuratelydetermine
whether anterograde or retrograde flow in theovarian vein is
present. Patients are placed in the supine po-sition with their
arms at the side. Kim et al describe a pro-tocol for single-pulse
TR-MRA whereby imaging of thepelvis is performed in the coronal
plane at rapid 2- to 5-
second intervals for 1 to 3 minutes after peripheral
intrave-nous injection of 0.1 mmol/kg body weight of
nondilutedgadopentetate dimeglumine or gadobenate dimeglumineat a
rate of 2 mL/s. This is followed by a saline bolus of20 mL at 2
mL/s. Maximum intensity projections ofeach three-dimensional data
set are generated in both thecoronal and sagittal planes. Compared
with T2/T2-weighted MRI, TR-MRV has a better image conspicuityto
discriminate ovarian vein reflux. Most recently, the sensi-tivity,
specificity, and accuracy of TR-MRA were comparedwith those of
conventional venography, with resultsdemonstrating excellent
agreement and the implicationthat TR-MRA is the best noninvasive
means for diagnosisof pelvic venous reflux and PCS in symptomatic
patients.14
One caveat to MRI, however, is that follow-up imagingwith
magnetic resonance can be limited because of the arti-factual
effects of embolization coils placed endovascularly.
Venography is the “gold standard” for diagnosis ofPCS; however,
it should be reserved for concomitant inter-vention or if
noninvasive imaging is equivocal (Fig 5). It isperformed under
local anesthesia through the commonfemoral or basilic vein
approach.11 Patients should havea urinary catheter inserted to
prevent the bladder fromfilling with contrast medium and obscuring
visualizationof the pelvic venous drainage. It should image the
fourveins responsible for venous return from the pelvis: both
in-ternal iliac veins and both gonadal veins. The study shouldbe
performed with and without a Valsalva maneuver andpreferably with a
tilt table in reverse Trendelenburg.1Venography should not be used
as the primary imagingmode for diagnosis of PCS but rather reserved
for patientswho have suspected PCS necessitating intervention
basedon prior noninvasive imaging or in patients whose noninva-sive
imaging is equivocal (Fig 4).
NONSURGICAL TREATMENT
Reports have varied in the literature over the decadeson
nonsurgical treatment of PCS, including progestins,danazol,
phlebotonics, gonadotropin-releasing hormone(GnRH) receptor
agonists with hormone replacement ther-apy, dihydroergotamine,
nonsteroidal anti-inflammatorydrugs, and psychotherapy. Whereas
psychotherapy hasbeen used in conjunction with ovarian suppression
to treatthe symptoms of PCS,18 there are no studies to show
thatpatients who have been diagnosed with PCS will benefitfrom
psychotherapy in isolation. For women with chronicpelvic pain of
unknown etiology, the benefits of a multidis-ciplinary approach
have been described, yet the utility of psy-chological intervention
to alleviate pain is unclear.19
With medical therapy, the primary goal is either to sup-press
ovarian function or to cause vasoconstriction ofdilated veins.
Medroxyprogesterone acetate (MPA) andthe GnRH analogue goserelin
have been used with limitedeffects (Table I). MPA may be given
orally 30 mg/day for6 months. Goserelin acetate is dosed as an
injection of3.6 mg monthly during a 6-month period.20 As
chemicalovarian ligation has numerous side effects,
estrogenreplacement therapy is frequently required as well.
-
Fig 5. Ovarian vein reflux. A, Selective left ovarian vein
injectionshows free reflux into broad ligament. Maximum left
ovarian veindiameter is 12 mm. B, Left ovarian vein is successfully
embolized
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC
DISORDERSVolume 3, Number 1 O’Brien and Gillespie 101
Although these therapies provide some relief, their effectsare
transient, particularly those of MPA. Results fromstudies using
daily oral administration of MPA demonstratevisual analog scale for
pain score improvements whilereceiving therapy, but stable results
9 months after treat-ment were obtained only when psychotherapy was
coadmi-nistered with MPA.18 This result reinforces
earlyobservations on the close relationship between the
psycho-logical and somatic symptoms of PCS. When GnRH ago-nists
were compared with daily MPA, both showedefficacy, with GnRH
agonists showing more improvementsin pain symptoms, depressive
symptoms, and sexual func-tion 12 months after completion of
treatment. Side effectsfrom progestins principally included
bloating and anaverage 5-pound weight gain during 4 to 6
months;GnRH agonists were associated with hot flashes, nightsweats,
vaginal dryness, and mood changes.8,18,20 Becauseof these side
effects, combined with limited efficacy, med-ical therapy is not
favored for long-term treatment ofPCS. Medical treatment also often
diminishes fertility.On the other hand, for patients with mild to
moderatesymptoms who would like to delay endovascular or
surgicaltreatment, medical therapy is not an unreasonable choice.A
discussion with the patient about the positives and neg-atives of
medical therapy vs intervention with potentialadjuvant
psychotherapy should be a part of treatment,addressing the side
effects and benefits of these options.
SURGICAL TREATMENT
Surgical treatment of PCS is still an accepted therapyfor a
select group of patients who have debilitating symp-toms, are
acceptable surgical candidates, and are refractoryto medical or
endovascular therapy. Surgery for ovarianreflux can provide
symptomatic relief for patients, withthe drawbacks of scarring,
morbidity, prolonged hospitalstay, and extended healing time (Table
I). Extraperitonealresection of the left ovarian vein to treat PCS
was first re-ported by Rundqvist et al21 in 1984. In properly
selectedpatients, this operative method was shown to
providesymptomatic improvement in two thirds of patients withPCS.10
In 2003, Gargiulo et al22 published the largest se-ries of
laparoscopic transperitoneal ovarian vein ligation in23 women with
a 1-year follow up. They reported com-plete resolution of the
patient’s symptoms with this tech-nique. This technique involves
accessing the right ovarianvein by incising the posterior
peritoneum below the mesen-tericoparietal fossa and accessing the
left ovarian vein byreflecting medially the left colon and incising
the posteriorperitoneum covering the aorta below the inferior
duodenal
to proximal aspect. Note circumaortic left renal vein (LRV).
C,Right ovarian vein dilation and reflux shown on selective
injection.Note small distal parallel ovarian vein channels
(frequent finding).(Reprinted from Cordts PR, Eclavea A, Buckley
PJ, DeMaioribusCA, Cockerill ML, Yeager TD. Pelvic congestion
syndrome: earlyclinical results after transcatheter ovarian vein
embolization. J VascSurg 1998;28:862-8, with permission from
Elsevier.)
-
Table I. Summary of treatment modalities for pelvic congestion
syndrome (PCS)
Study (year) Patients Treatment Time, months Complications%
Clinicalimprovement
MedicalFarquhar et al (1989) 22 MPA vs MPA þ psychotherapy 9
Weight gain, bloating 73Reginald et al (1989) 84 MPA vs placebo 9
Weight gain, bloating 75Soysal et al (2001) 47 GnRH agonist 12 Hot
flashes, mood swings,
night sweats65
EmbolotherapyEdwards et al (1993) 1 Coils 12 None 100Sichlau et
al (1994) 3 Coils 22.8 1 recurrence 67Cordts et al (1998) 9 Coils,
coils and gelatin 13.4 2 recurrences 88.9Maleux et al (2000) 41
Sclerosing agents 19.9 Glue migration 4% 58.5Venbrux et al (2002)
56 Sclerosing agents 22.1 3.6% coil migration;
5.4% recurred65
Scultetus et al (2002) 57 Coils, sclerosing agents, excision
25-288 None 75.4Pieri et al (2003) 33 Sclerosing agent 6.5 None
61Kim et al (2006) 127 Sclerosing agent and coils 45 5% recurrence
83Kwon et al (2007) 67 Coils 48 None 82Creton et al (2007) 24 Coils
and phlebectomy 36 4.2% recurrence, 4.2%
coil migration76
Asciutto et al (2009) 35 Coils 45 None 47Castenmiller et al
(2013) 43 Coils None 88Hocquelet et al (2013) 33 Coils 26 1 failure
to catheterize 61Laborda et al (2013) 202 Coil 60 3% groin
hematoma, 2%
coil migration, 0.5%reaction to contrast material
93.8
SurgeryRundqvist et al (1984) 15 Extraperitoneal resection
of
left ovarian vein67.2 6.7% wound infection, 6.7%
bleeding73.3
Beard et al (1991) 36 Bilateral oophorectomy andhysterectomy
12 Infertility, morbidity, longhospital stay
67
Mathis et al (1995) 1 Transperitoneal laparoscopicligation of
ovarian vein
None 100
Gargiulo et al (2003) 23 Transperitoneal laparoscopicligation of
ovarian vein
12 Ileus, hematoma 74
GnRH, Gonadotropin-releasing hormone; MPA, medroxyprogesterone
acetate.
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS102
O’Brien and Gillespie January 2015
fold. The drawbacks to this procedure include higher sur-gical
morbidity and several complications, such as deepvenous thrombosis,
retroperitoneal hematoma, paralyticileus, and mechanical ileus
caused by intestinal adhesion.Hospital stay and recovery time are
also limiting factorswith surgical ovarian vein ligation.22 Surgery
should beconsidered in patients with lifestyle-limiting
symptomsthat have recurred despite embolotherapy.
EMBOLOTHERAPY
Since its introduction in 1993, transcatheter ovarian
veinembolization (Fig 5) has become the mainstay for treatmentof
PCS secondary to ovarian and pelvic venous incompe-tence.23 Several
embolic agents, including sclerosantfoam,24 glue,7 Amplatzer
plugs,25 and coils,2,11,26 havebeen described.Whereas a fairly
large body of data regardingtranscatheter ovarian vein embolization
exists, these studiesare limited to relatively small clinical
series and retrospectivereviews. The success rates for the
reduction of chronic pelvicpain in these studies range from 47% to
94% with averagefollow-ups of 12 to 36 months (Table I).
First described by Edwards et al23 in 1993 with a singlecase
report of bilateral ovarian vein embolization, the tech-nique has
grown and been used widely with relative
success. Sichlau et al27 reported on ovarian vein coil
embo-lization in 1994, citing success in three patients with
onerecurrence after 1 year. Cordts et al28 described ninewomen
undergoing ovarian vein embolization in 1998,89% of whom
demonstrated relief of symptoms with tworecurrences at 2 years of
follow-up. Interestingly, no pub-lished data demonstrate a
significant difference in out-comes between unilateral and
bilateral ovarian veinembolization. A study of 41 patients using
enbucrilateand lipiodized oil as embolic agents demonstrated a
nearly60% total symptomatic relief with no difference in
outcomebetween bilateral and unilateral ovarian vein
embolization.7
Investigators have most commonly employed the visualanalog pain
scale to measure severity of symptoms beforeand after
embolotherapy. A larger series of 56 patients in2002 demonstrated a
mean decrease in pain by 65% afterembolization.29 More recent
studies have reported successby pain reduction at a rate nearing
85%.26 Some studiessuggest that ovarian vein embolization, followed
by inter-nal iliac vein embolization at a later date, improves
out-comes and prevents recurrence.2,29 Kim et al30 found an83%
improvement in symptoms in 131 patients with amean follow-up of 45
months, of whom 85% received in-ternal iliac vein embolization.
Venbrux et al29 reported
-
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DISORDERSVolume 3, Number 1 O’Brien and Gillespie 103
similar results with ovarian vein embolization succeeded
byinternal iliac vein treatment and a follow-up of 38 months.Of
note, patients with isolated ovarian vein reflux had out-comes
superior to those of patients with isolated internaliliac vein
reflux or combined disease.1,2 Ovarian vein embo-lization did
result in a significant improvement of symp-toms for those with
isolated ovarian reflux, but theresults of embolization with
combined reflux did not reachstatistical significance.2
Patients with vulvar and lower extremity varicositieshave been
studied with regard to regression of varicoseveins after
embolotherapy for PCS. There has been moresuccess in the regression
of vulvar than of lower extremityvaricosities after ovarian vein
embolization.12,31 To date,there has been no large study that
demonstrates a signifi-cant change in clinical, etiologic,
anatomic, and pathologic(CEAP) classification after embolotherapy
for PCS,although several studies report >80% reduction in
vulvarvaricosities and symptoms after embolization for ovarianvein
insufficiency.
Right femoral vein access is the most commonapproach for
venography and embolization, althoughtransjugular, basilic, and
transbrachial approaches havebeen reported with technical success.
The average numberof coils per vein has been reported at six, with
spring coilsbeing the most common form of embolization.11
The technique of transcatheter embolotherapy forovarian and
pelvic varices is straightforward, although thereis some variation
in the literature. With a femoral or rightinternal jugular
approach, a 6F sheath is guided into thevena cava. For assessments
of the left or right ovarianvein, access is facilitated with a
Cobra or Sim 1 catheter.Once access is obtained, the sheath is
guided into the renalvein for coaxial support. Next, with use of a
glide wire andglide catheter, the ovarian vein is catheterized. An
injectionof 10 mL of contrast material with the patient in the
reverseTrendelenburg position is performed. Incompetent
ovarianveins will show venous dilation and reflux of contrast
mate-rial into the pelvis. The guidewire and catheter should thenbe
moved down the ovarian vein to just above the pelvicbrim. Another
injection confirms reflux of contrast materialinto the pelvic
veins, cross-pelvic collaterals, and any thighor vulvar
varicosities.
Modern embolotherapy of the main trunk of the ovarianvein or the
iliac veins is facilitated by a microcatheter systemand microcoils.
In general, framing coils are placed first, fol-lowed by gel coils
to promote venous thrombosis. Sclero-therapy of the hypogastric
veins can be used adjunctively.With a balloon occlusion technique,
sclerosants such as so-dium tetradecyl sulfate are injected (Fig
2).
One major drawback to coil embolization is undoubt-edly coil
migration into the pulmonary system, which hasbeen reported in 2%
of patients after coiling of the internaliliac vein.32 Larger
caliber veins (>12 mm) increase the riskof this complication. To
prevent coil migration to the pul-monary artery, the diameter of
the coils should be at least30% or 50% larger than the diameter of
the left internal iliacveins.32 Other complications include
perforation of the
ovarian vein, flank pain, postprocedural fevers, and
veni-puncture site hematomas.29,30
For male patients with varicocele or female patientswith mild
vulvar varices, sclerotherapy has proved to bean effective
treatment. Several groups in Europe use sclero-sants exclusively
for embolization of the spermatic vein inmen with varicocele.33 The
most frequently used sclero-sants are 3% to 5% sodium tetradecyl
sulfate (liquid orfoam) and polidocanol. A catheter is placed into
the reflux-ing segment of the spermatic vein and injected with 3
or4 mL of sclerosant during a Valsalva maneuver. Depositionof
sclerosant in the pelvic segment of the vein is more effec-tive
than at a lumbar level. The catheter is then left at theorifice of
the spermatic vein for 2 or 3 minutes to minimizeegress of the
sclerosant.1 Scultetus et al6 reported successwith local excision
and sclerotherapy for women withvulvar varices, whereas a paper
from Australia reports suc-cessful US-guided foam sclerotherapy of
vulvar varicositiessecondary to ovarian vein reflux.24
Ultimately, there remains an uncertainty as to theoptimal
technique for ovarian vein embolization, althougha combination of
coils and sclerosants has demonstratedclinical efficacy in a number
of studies described beforeand is the most common published
technique for ovarianvein embolization (Table I). There is
currently no evidenceto suggest a difference in symptomatic relief
with regard tounilateral vs bilateral ovarian vein
embolization.7,30 Kim et alreported 83% clinical improvement with
bilateral ovarianembolization followed by embolization of
varicosities fromthe internal iliac vein 4 to 6 weeks later. On the
basis ofthe current literature, the decision to treat one or
bothovarian veins should depend on the severity of symptoms,the
anatomy of the pelvic varicosities, and the degree ofreflux in each
ovarian vein. A patient with a high degreeof reflux bilaterally and
a number of bilateral varicositiesnetworking with the internal
iliac veins would likely benefitfrom bilateral embolization,
whereas a patient with left-sideddilation and reflux with moderate
varicosities may benefitfrom unilateral embolization. Clinical
judgment and experi-ence should be used to guide embolotherapy in
conjunctionwith symptoms, anatomy, and functional studies.
NUTCRACKER SYNDROME
For patients with PCS secondary outflow obstructionfrom
nutcracker syndrome, treatment should focus onrelieving anatomic
compression rather than embolizationof outflow tracts. Diagnosis of
nutcracker syndrome, asdescribed before, is based on a
constellation of factors,including symptoms of pelvic congestion as
well as flankpain, microhematuria, and suggestive imaging. An acute
nar-rowingof theLRV, termed the beak sign, has a high
sensitivityfor diagnosis of nutcracker syndrome.17 In addition, the
ratioof the LRV at its narrowed vs its dilated portion is often
usedas a diagnostic criterion, with the high end of normal
beingaround 4:1; one study demonstrated that a value>4.9
corre-lates strongly with the presence of LRV compression.17
Inaddition, there is conflicting evidence regarding the utilityof
LRV pressure gradients in the diagnosis of nutcracker
-
Table II. Summary of treatment modalities for nutcracker
syndrome
Study (year) Patients Treatment Time, months Complications%
Clinical
Improvement
EndovascularWei et al (2003) 1 Stent 3 None 100D’Archambeau et
al (2004) 40 Embolization N/A 4% failure to catheterize 75Hartung
et al (2005) 5 Stent 14.3 40% stent migration 40Kim et al (2005) 1
Stent 24 None 100Basile et al (2007) 3 Stent 16 None 100Zhang et al
(2007) 20 Stent 15 6.7% migration 100Cohen et al (2009) 1 Stent 12
In-stent restenosis Required bypassChen et al (2011) 61 Stent 66
3.2% stent migration,
1.6% maldeployment,1.6% IVC protrusion
96.7
Wang et al (2012) 30 Stent 36 6.7% migration 100Surgery
Thompson et al (1992) 1 SMA transposition 12 None 100Shokeir et
al (1994) 2 Autotransplantation 12 None 100Hohenfellner et al
(2002) 8 LRV transposition 66.4 8.3% hematoma, 8.3% DVT 87.5Shen et
al (2004) 2 LRV transposition 3 None 100Wang et al (2009) 7 LRV
transposition 42.6 14% ileus, 29% hematoma 85.7Viriyaroj et al
(2009) 1 Transperitoneal laparoscopic
gonadal vein ligation12 None 100
Marone et al (2011) 1 LRV anterior transposition 6 None 100Gong
et al (2012) 3 Left spermatic vein ligation,
iliac vein anastomosis3 None 100
Li et al (2012) 1 Abdominal aortic transposition 38 None 100Xu
et al (2013) 2 Laparoscopic inferior
mesentericegonadal vein bypass3 None 100
DVT, Deep venous thrombosis; IVC, inferior vena cava; LRV, left
renal vein; N/A, not applicable; SMA, superior mesenteric
artery.
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS104
O’Brien and Gillespie January 2015
syndrome as studies have classified it as compensated
ornoncompensated, with the compensated syndrome havingpressure
gradients within normal ranges and the noncompen-sated syndrome
being characterized by LRV hypertension.The normal pressure
gradient between the LRV and IVC is1 mm Hg or lower, and various
studies have identified LRVhypertension as a gradient >3 mm Hg.4
Therefore, whereasLRV hypertension is not diagnostic of nutcracker
syndrome,measuring the pressure gradient during venography
andstenting does provide a way to monitor the technical successof
the procedure and has utility in some cases.
Surgery for nutcracker syndrome has been reportedwidely (Table
II). For young patients in good health with se-vere pain and
persistent symptoms, open surgery has advan-tages of success and
durability. LRV transposition,34 SMAtransposition,35 abdominal
aortic transposition,36 and infe-rior mesenteric veinegonadal vein
bypass37 have all beendescribed with relative success, although in
small numbers(Table II). Surgical morbidity and renal ischemia time
areboth drawbacks to open surgery. More recently, severalstudies
have reported success in relieving the symptoms ofnutcracker
syndrome by stenting the LRV.
LRV stenting for treatment of nutcracker syndromeand PCS was
first described in 2005,38 and since then,studies primarily from
China have demonstrated the safetyand efficacy of the procedure,
particularly with self-expanding nitinol stents (Table II).9,39,40
Follow-up timeshave not exceeded 1 year. Although deployment of a
renalstent is less invasive than open surgery, the
postoperative
complications can include stent migration into the rightatrium,
stent protrusion into the IVC, and stent migrationinto the hilar
LRV.9,40 Wang et al recommended stentoversizing by 20% based on the
diameter of the LRV atthe hilum as measured on US and MRI. Smaller
stents,particularly 10- and 12-mm stents, are more likely
tomigrate, according to Hartung et al.38 Chen et al9 recom-mended a
stent length of 60 mm for stability within thefirst large branch of
the LRV, postulating that if migrationdoes occur, the proximal end
of the longer stent will prob-ably stay at the opposite wall of the
IVC with the distal endremaining at the stenotic segment of the LRV
to preventmigration into the heart.
The decision of open surgery vs endovascular treatmentfor
nutcracker syndrome is also undoubtedly based on anat-omy. With
anterior nutcracker syndrome, in which the LRVis compressed between
the SMA and aorta, stenting mayprove to be sufficient to relieve
symptoms. However, inthe case of posterior nutcracker syndrome, in
which theLRV is compressed between the aorta and a vertebralbody,
transposition may be necessary to relieve the obstruc-tion.4
Ultimately, surgery can provide a long-term solution.The outcomes
for endovascular treatment are encouraging;however, stents are not
permanent solutions, and for thisreason, in very young patients,
surgery may be preferred.
CONCLUSIONS
The diagnosis and management of PCS continue toevolve. PCS
remains an underdiagnosed cause of chronic
-
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC
DISORDERSVolume 3, Number 1 O’Brien and Gillespie 105
pelvic pain because of the difficulty in identifying
varicositiesand ovarian vein reflux in patients who are supine.
Thesymptoms of PCS are often lifestyle limiting, consisting
ofchronic lower abdominal pain exacerbated by sitting orstanding,
dyspareunia, dysuria, vulvar and lower extremityvaricosities, and
pelvic tenderness. Nutcracker syndromecan also be manifested with
hematuria and flank pain.Vascular surgeons in academic and
community settingscan improve the diagnosis of PCS by educating
primarycare physicians through in-service or continuing
educationseminars on the signs and symptoms of PCS. Because PCSis
frequently a diagnosis of exclusion, an awareness of itsprevalence
within the primary care patient population canultimately increase
the referral of appropriate patients tovascular specialists for
further workup. Diagnosis of PCS re-quires a careful history,
physical examination, and noninva-sive imaging with either
transvaginal or transabdominal USwith color duplex imaging to
visualize dilated and tortuousovarian veins. MDCT with
three-dimensional reconstruc-tion and time-resolved MR
angiographies are also usefulnoninvasive tests with the advantage
of providing informa-tion about the surrounding anatomy as well as
functionalinformation about retrograde flow. Once diagnosed,
pa-tients with PCS should be offered embolotherapy as a pri-mary
treatment option. Although conservative medicaltherapy with MPA or
GnRH agonists has been reported,its effects are limited. Whereas
the data in favor of embo-lotherapy are limited to a number of
clinical series, success-ful reduction in pelvic pain can be
achieved in 70% to 85%of patients who undergo embolization. Coil
embolizationof one or both ovarian veins with sclerosing therapy
ofbranching varicosities is the most widely reported andminimally
invasive technique for alleviation of the symp-toms of PCS due to
gonadal vein reflux. For patientswith outflow obstruction due to
nutcracker syndrome, alimited number of studies have demonstrated
remissionof symptoms with stenting of the LRV. Open
surgeryinvolving renal vein transposition carries high success
ratesbut should be reserved for patients who are young andsuitable
surgical candidates.
AUTHOR CONTRIBUTIONS
Conception and design: DGAnalysis and interpretation: DG, MOData
collection: DG, MOWriting the article: DG, MOCritical revision of
the article: DG, MOFinal approval of the article: DGStatistical
analysis: Not applicableObtained funding: Not applicableOverall
responsibility: DG
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2012;56:142-8.
Submitted Nov 4, 2013; accepted May 25, 2014.
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Diagnosis and treatment of the pelvic congestion
syndromeAnatomyPathophysiologyPresentationImagingNonsurgical
treatmentSurgical treatmentEmbolotherapyNutcracker
syndromeConclusionsAuthor contributionsReferences