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PELVIC CONGESTION SYNDROME

What Is It?

� “Chronic Pelvic Pain arising from

dilated and refluxing incompetent

pelvic veins. This is often described as

a constant dull ache, often aggravated

by standing.

� There are no uniform, generally

accepted clinical criteria for the

diagnosis of PCS.

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Who Gets It?

Multiparous women of reproductive age, suggesting both mechanical and hormonal mechanisms.

Etiology?

Largely unclear.

May or may not be related to venous dysfunction elsewhere.

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Anatomy

Anatomy

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How Is The

Diagnosis Made?

MR

Abdominal US

TransVaginal US

CT

Catheter Venogram

MRI

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MRI

Abdominal US

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TransVaginal US

CT

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Therapy

Hormonal HysterectomyPelvic vein

ligation/transpositionPelvic vein

embolization

Interventional Therapy

� Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC

� Embolotherapy for Pelvic Congestion Syndrome

� J Vasc Interv Radiol. 2006; 17:289-297.

� Average follow up of 48 months

� 83% of patients with resolution of substantial improvement in symptoms

� KEY: Address all refluxing components at the time of venography

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Pelvic

Vein

Embolization

� In 2017, open surgery for PCS is a thing of the

past

� Morbidity, expense, blood loss and recovery are

much reduced by endovascular techniques

� Embolization can take several forms….

Embolotherapy

TechniquesCoils

11

Glue

22

Foam

33

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Deployment

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Venous Coils

Embolization

Case

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Male PCS?

Nutcracker

Syndrome

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Presentation

� Compression of L RV, leading to GV hypertension

and large varices

� Left flank pain, hematuria

� NO medical therapy

� Intervention is the preferred method of

management

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Diagnosis

� CT Venogram

� Abdominal CT

� MRI/A

Nutcracker Endovascular Therapy

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Issues

� Conceptually simple (very good)

� Quick, outpatient therapy (good)

� Unknown long term outcomes (maybe

bad)

� Known consequences of stent

compression (possibly bad)

� Potential for stent embolization to

heart (that’s really bad)

An Alternative?

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� Journal of Vascular Surgery: Venous and Lymphatic Disorders

� Volume 4, Issue 1, January 2016, Pages 114–118

� Venous and Endovenous Techniques

� Left ovarian to left external iliac vein transposition for the treatment of

nutcracker syndrome

• John V. White, MDa Connie Ryjewski, APN, CNS

• Richard N. Messersmith, MD Lewis B. Schwartz, MD

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An Alternative?

Iliac Vein Transposition

� Long term results are not yet know, but similar operations performed

elsewhere have excellent long term outcomes….

� …and no intravascular metal…

� …being compressed extrinsically

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Vamos a Ver

(We’ll See)

InternalIliac Vein

Incompetence?

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Bibliography

� Daniels JP, Champaneria R, Shah L, et al. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol 2016: 1478-1486

� White JV, Ryjewski C, Messersmith RN, Sbrana f, Schwartz Lewis. Left ovarian to left external iliac vein transposition for the treatment of nutcracker syndrome. J Vasc Surg: Venous and Lym Dis 2016; 4: 114-8

� The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technology Assessment, National Institute for Health Research (UK): Vol 20, Issue 5, Jan 2016