pelvic congestion syndrome: when to treat and how · 2020-02-14 · pevd and iliac vein stenosis...
TRANSCRIPT
Pelvic Congestion Syndrome: When to Treat and How
Gloria Salazar, MDMassachussets General Hospital
Boston, MA
Faculty Disclosures
Gloria Salazar: Consultant – Medtronic Vascular
Dr. Gloria Salazar has disclosed that the off-label use of Wallstentfor vein stenting will be discussed.
Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.
When to Treat?Checklist• Clinical history: 3Ps (postural, post-coital,
and pelvic pain)• Obstruction vs Reflux (US, MRV)
• Associated conditions: Vulvar varices, Escape points, Hematuria, Back pain
• Non-saphenous varicosities in the leg?
• Trial of ovarian suppression
Rule out• Endometriosis• Fibroids
• Malignancy• Pelvic infection• Mass–effect
• Neurological dx
Where?
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Internal iliac
veins Left
Renal vein
Ovarian veins
Gonadal vein refluxPelvic VaricesMay-Thurner Syndrome
Escape points
Nutcracker Syndrome
Journal of Vascular and Interventional Radiology 2019 30, 781-789DOI: (10.1016/j.jvir.2018.10.008) Copyright © 2018 SIR Terms and Conditions
Research Priorities in Pelvic Venous Disorders (PeVD) in Women: Recommendations from a Multidisciplinary Research
Consensus Panel
US Deep Veins Protocol
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Vein diameter >5 mm crossing the uterine body Specificity of 91%(95% CI;77-98%)
Reversed caudal flow ovarian vein sensitivity 100% (95% CI; 84-100%)Ovarian vein diameter > 5 or > 6 mm PPV 71.2% or 83.3%
Pelvic varicoceles: sensitivity/ specificity of 100% (95% CI; 89-100%) and 83-100%(95% CI; 66-93%)
PSV differential between LRV at point of compression & hilum Ratio >5.0 (80%/94% S/S)
>50% stenosis + post stenotic to prestenotic peak vein velocity ratio of 2.5.
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. Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg. 2007 Jul;46(1):101-7Steenbeck MP, et al. Noninvasive diagnostic tools for Pelvic Congestion Syndrome: A systematic review.Acta Obstet Gynecol Scand. 2018;97(7):776-786.Kim SH, Cho SW, Kim HD, Chung JW, Park JH, Han MC. Nutcracker syndrome: diagnosis with Doppler US. Radiology. 1996 Jan;198(1):93-7.
MRV versus another diagnostic modality (invasive venography and IVUS)
• 100 % sensitive (proximal venous obstruction)
• Specificity (22.8 %) • False-positive rate: 41.5 %
Time-resolved contrast-enhanced MR
• Dynamic assessment of the direction of flow in the ovarian veins
Massenburg BB, et al. Ann Vasc Surg. 2015;29(8):1619-1624. Yang DM, et al. Br J Radiol. 2012;85(1014):e117-e122.
How?Treatment Options PeVD
• Medical (NSAIDS/Medroxyprogesterone acetate): suppress ovarian function
• Ovarian vein ligation: open or laparoscopic
• Hysterectomy: 33% residual pain
Interventional procedures: Ovarian vein embo+/-Sclerotherapy vulvar varices +/- internal iliac veins and
stenting (vein compression)
Farquhar CM, Rogers V, Franks S, Pearce S, Wadsworth J, Beard RW. A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J Obstet Gynaecol 1989;96:1153–62Chung MH, Huh CY. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med 2003;201:131–8.Gargiulo T, Mais V, Brokaj L, Cossu E, Melis GB. Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome. J Am Assoc Gynecol Laparosc 2003;10:501–4.Beard RW, Kennedy RG, Gangar KF, Stones RW, Rogers V, Reginald PW, et al. Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelviccongestion. Br J Obstet Gynaecol 1991;98:988–92
Systematic Review of Embolization for PeVD
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2003 2002-2006 2008
2016
N=1308 (mostly reproductive age)
Champaneria R, Shah L, Moss J, Gupta JK, Birch J, Middleton LJ, Daniels JP. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess 2016;20(5).
Systematic Review of Embolization for PeVD1. No high-quality studies
2. Effectiveness: presumed prospective case series
3. N=1308 (reproductive age and parous)
4. 1/3 cases: bilateral embolization (coil placement being the dominant technique)
10Champaneria R, Shah L, Moss J, Gupta JK, Birch J, Middleton LJ, Daniels JP. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess 2016;20(5).
Not All the Same!
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Not All the Same!
1. Classic: multiparous women
2. Compression syndromes
3. Escape Points: Vulvar varices + leg
varicosities
4. Anatomical variant
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Classic PresentationGuidelines SVS/AVF
Coil embolization, plugs, or transcatheter sclerotherapy as
standard treatments,
with a grade 2B level of evidence
13Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practiceguidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53(5 suppl):2S–48S
Embolization
Ovarian vein embolization
• Combination of coils/sclerosant
• Coils alone • Sclerosants alone
Internal iliac vein embolization
• Prefer sclerosants; less nontarget embolization risk
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Venography: IVC/left renal /ovarian/common/internal iliac
Embolization of OV• Select OV distally inject liquid
embolic material: – 5% Sodium morrhuate/3 % STS mixed
with gelfoam slurry – Gelfoam slurry volume
– 3 % STS mixed with air at 1:4 ratio, inject performing Valsalva maneuver
AND /OR
• Coil embolization distal to 2-3 cm from the origin
• 100% technical success
15Daniels JP, Champaneria R, Shah L, Gupta JK, Birch J, Moss JG. Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review. J Vasc Interv Radiol. 2016 Oct;27(10):1478-1486.
Coils Alone Author/ Year N Procedure Outcomes
Chung and Huh 2003
106 OV or IIV embo (52) Vs. Hysterectomy (54)
Significant decrease in VAS (12 mo), more effective than hysterectomy
Creton et al.2007
24 OV or IIV embo VAS significantly decreased (dysmenorrhea/dyspareunia/ venous pain)
Kwon et al.2007
67 LOV (96%) 82% total or significant pain reduction (2 coil migrations)
Ratnam et al. 2008
218 OV or IIV embo + VV surgery
Repeat TVUS (n=193) up to 13% reflux
Asciutto et al. 2009
35 OV , IIV embo or both VAS improved/ 47% sustained improvement (45 mo)
D’Archambeauet al. 2010
193 Bilateral OV (4.7%)LOV (94.3%)ROV ( 1%)
89.2% improvement on VAS 5.7% re-embolized (3 mo – 6 years)
Sclerosants Alone
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Author/ Year N Procedure Outcomes
Pieri et al.2003
33 OV foam sclero (64% bilateral)
61% improvement of pain(1mo)7 pts transient flank pain
Gandini et al.2008
67 Bilateral OV foam sclero(3% STSF)
VAS significantly decreased(12 mo) (dysmenorrhea/dyspareunia/ urinary urgency)
Tropeano et al. 2008
20 OV foam sclero (15% bilateral)
85% women reported marked improvement (6 mo)
Tinelli et al. 2012
28 OV foam sclero (29% bilaterally)
100% technical success/need for analgesics in 21% patients
Van der Vleuten et al. 2012
21 Bilateral OV sclero or unilateral
76.2% moderate / obvious improvement (2mo survey), 42% second embo
Coils and Sclerosant
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Author/ Year N Procedure Outcomes
Venbrux et al.2002
56 Bilateral OV coil+foamsclero (Gelfoam-Morrhuate) 85% IIV coils
VAS significantly decreased(12 mo)No significant change is cycle length
Kim et al.2006
127 Bilateral OV coil+foamsclero85% IIV sclero
VAS significantly decreased(45 mo)80% significant improvement (two coil migrations)
Leal Monedero et al. 2006
239 OV/ IIV coil +/- foam sclero
50.2% women reported complete resolution 36.8% partial resolution (6 mo)
Meneses et al. 2013
10 Combined OV/ IIV Sclero + Sodium morrhuate +coil
VAS significantly decreasedVCSS significantly decreased (3 months)
Results
Daniels JP, Champaneria R, Shah L, Gupta JK, Birch J, Moss JG. Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review. J Vasc Interv Radiol. 2016 Oct;27(10):1478-1486.
• No predictors for clinical improvement
• Best results in multiparous women
• Coils alone (89% and 100%) of clinical improvement vs sclerosants (75%)
• Short-term pain and fevers are common with sclerosants vs. coils
Variant 2- Compression Syndromes Iliac Vein Compression
• Stenting
• More data available
Renal Vein Compression
• IR– Stenting
– Embolization
• Surgical – LRV/SMA transposition/Gonadocaval bypass
Reed NR, Kalra M, Bower TC, Vrtiska TJ, Ricotta JJ 2nd, Gloviczki P. Left renal vein transposition for nutcracker syndrome. J Vasc Surg. 2009 Feb;49(2):386-93
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PeVD and Iliac Vein Stenosis
Santoshi RKN, Lakhanpal S, Satwah V, Lakhanpal G, Malone M, Pappas PJ. Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2018 Mar;6(2):202-211. doi: 10.1016/j.jvsv.2017.09.007. Epub 2017 Dec 29.
• 80% pts (significant iliac vein stenosis)
22Santoshi RKN, Lakhanpal S, Satwah V, Lakhanpal G, Malone M, Pappas PJ. Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2018 Mar;6(2):202-211. doi: 10.1016/j.jvsv.2017.09.007. Epub 2017 Dec 29.
Variant 3 – Escape Points 55
Gluteal vein Vulvar veinsPosterolateralthigh perforator
vein
Sciatic nerve vein
Popliteal fossavein
Knee perforator
vein
Lowerposterior thigh vein
Fig. 4.4 Non-saphenous vein refl ux patterns (Used with permission) [ 5 ]
4 Refl ux Management
Phlebology, Vein Surgery and Ultrasonography
Eric Mowatt-Larssen • Sapan S. Desai Anahita Dua • Cynthia E.K. Shortell Editors © Springer International Publishing Switzerland 2014
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Variant 4- Anatomical Variant
Conclusion and Key Learning Points
• Heterogeneity of studies BUT proper diagnosis and patient selection is key
• Ovarian vein and internal iliac vein embolization minimally invasive, low risk, outpatient treatment: 70-98% positive clinical response to treatment
• Stenting is also indicated in the setting of PeVD but more studies are needed
• Renal vein compression still controversial • Look for escape points veins and anatomical variants
But most importantly …
It has truly been life changing. You have taken away so much
unbearable pain. Some of my symptoms have gone away completely and others have improved substantially.
Thank you so much for understanding and validating my pain, and providing me with a treatment option.
Thank you so much Dr. Salazar you have made an immense difference in my life. I hope you can help many, many other women with
this pain and more importantly spread your expertise and knowledge of PCS in the medical community.
Gloria Salazar MD @Gsalazar_MD
Thank You