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Syndrome
Durham JD, Machan L
Semin Intervent Radiol.
2013;30:372380
Presentan: Daniel N. Aji
Desember 2014
Epidemiology
Chronic pelvic pain in women 18-50 yo: 15%
(USA)
60% women with chronic pelvic pain the
cause remains undiscovered
Chronic pelvic pain pelvic congestion
syndrome (PCS)
PCS: 31% in symptomatic population
Belenkey et al (2002): ovarian varices
prevalence 9.9% (27/273); mostly reported
chronic pelvic pain
Definition
Chronic pelvic pain: noncyclic pelvic
pain of more than 6 months duration
Pelvic congestion syndrome: chronic
pelvic pain secondary to PVI and
associated pelvic venous distension
Pelvic venous insufficiency:
retrograde flow through incompetent
gonadal and pelvic veins
Black CM, Thorpe K, Venrbux A, et al. Research reporting standards for endovascular
treatment of pelvic venous insufficiency. J Vasc Interv Radiol 2010;21:796 803
Anatomy
Lower uterus & Vagina
uterine vein internal iliac
vein
Left ovarian plexus left
ovarian vein left renal
vein
Right ovarian plexus
inferior vena cava
Patophysiology
PCS: ovarian vein reflux and/or pelvic
varicosities (Ovarian vein diameter >5 mm)
Primary: congenital / aqcuired ovarian vein
absence/incompetence (nonobstructive)
Secondary: nutcracker syndrome, May-Thurner
syndrome
Venkatachalam S, Bumpus K, Kapadia SR, Gray B, Lyden S, Shishehbor MH. The nutcracker
syndrome. Ann Vasc Surg 2011;25(8): 11541164
Diagnosis
PCS: clinical syndrome + anatomic findings
chronic pelvic pain of greater than 6 months
duration secondary to PVI and associated pelvic
venous distention
Symptoms:
Noncyclical, positional lower back, pelvic, and upper
thigh pain
Pain is exacerbated before or during menses and
may be associated with dyspareunia and prolonged
postcoital discomfort
most severe at the end of the day, exacerbated by
standing or heavy activity, and are diminished with
supine positioning.
Diagnosis (2)
Pelvic examination: cervical motion and
ovarian point tenderness.
Postcoital ache + ovarian point tenderness
94% sensitive and 77% specific for PVI
Patients undergoing evaluation for PCS and
PVI fall into:
incidentally found pelvic varices
unusual vulvar or upper thigh varices that
complicate lower extremity insufficiency with or
without pelvic pain
painful pelvic varicosities secondary to PVI
Jung SC, Lee W, Chung JW, et al. Unusual causes of varicose veins in the lower
extremities: CT venographic and Doppler US findings. Radiographics 2009;29(2):525
536
Jung SC, Lee W, Chung JW, et al. Unusual causes of varicose veins in the lower
extremities: CT venographic and Doppler US findings. Radiographics 2009;29(2):525
536
Imaging Evaluation
Exclude common causes of intrinsic pelvic
pathology (endometriosis, PID,
postoperative adhesions, adenomyosis or
leiomyoma)
Transabdominal + transvaginal US
pelvic varices and ovarian venous reflux
Sonographic findings: enlarged ovarian
veins greater than 6 mm in diameter with
reversed bloodflow; pelvic varicocele (>5
mm); dilated (>5 mm) arcuate veins
crossing the uterine myometrium
between pelvic varicoceles
Park SJ, Lim JW, Ko YT, et al. Diagnosis of pelvic congestion syndrome using
transabdominal and transvaginal sonography. AJR Am J Roentgenol 2004;182(3):683
688
Park SJ, Lim JW, Ko YT, et al. Diagnosis of pelvic congestion syndrome using transabdominal and
transvaginal sonography. AJR Am J Roentgenol 2004;182(3):683688
Treatment
Coil embolization of the ovarian vein,
unilaterally or bilaterally, has been the
most common approach to eradicate
ovarian vein reflux
Partial or significant relief of symptoms in
70 to 100% patients
Improvement in 82% with coil embolization
alone (Kwon 2007)
Improvement of VAS in 94% patients
(Laborda 2013)
Kwon SH, Oh JH, Ko KR, Park HC, Huh JY. Transcatheter ovarian vein embolization using coils
for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol
2007;30(4):655661
Treatment (2)
Direct sclerosing of abnormal
pelvic vein was introduced by
Venbrux (2002) using 5% sodium
morrhuate mixed with gelfoam
Significant & partial response in 96%
subject
Decrease of pain level
Treatment (3)
Combination of multiple sclerosant
& ovarian vein mechanical
occlusion
Gandini (2008): 3% sodium tetradecyl
sulfate (STS) foam
Foam was injected until venous stasis
Volume of sclerosant required typically
ranges from 2.5 to 12.5 cc per ovarian
vein
Treatment (4)
Treatmant of PVI secondary to
nutcracker or May-Thurner syndrome
limited data/ experience
Surgical approach better than
endovascular?
Self expanding stent?
Treatment (5)
Ovarian suppression with
medroxyprogesterone or goserelin, or
Surgical ovarian suppression with
bilateral salpingo-oophorectomy
Surgical VS endovascular :
embolization more effective at
reducing pelvic pain
Complication
Preprocedure Care
Not related to menstrual or pain
cycle
Patient should be restricted to clear
fluids after midnight for a morning
appointment, and clear fluids after
breakfast for an afternoon
appointment.
Admission to day care
CASE 1
Approach
Before venography, patient was
sedated (5 mg of versed and 200 g
of fentanyl)
A sheath was introduced into the right
internal jugular vein
Multipurpose catheter was directed
into the left renal vein and a
diagnostic renal venogram performed
during Valsalva maneuver
3 months later
Pain improved
Dyspareunia had not resolved
Transvaginal US: residual paraovarian
veins, with normal Valsalva
CASE 2
CASE 3
CONCLUSION
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