Pelvic venous insufficiency my best practice, warning and complications prevention
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1 Nice, June 1 st 2017 Pelvic venous insufficiency my best practice, warning and complications prevention O Hartung Dpt of Vascular Surgery CHU Nord, Marseille, FRANCE
2 Pelvic venous insufficiency All manifestations due to pelvic venous system dysfunction Mainly pelvic varicose veins Can cause Pelvic congestion syndrome Lower limb varicose veins Underdiagnosed and undertreated
3 3 mechanisms of pelvic VV (Greiner) Type 1 : reflux secondary to pelvic vein incompetence Type 2 : obstructive lesions of venous outflow Type 3 : secondary to a local extra venous phenomenon (endometriosis )
4 In which patients? Mainly premenopausal multiparous women Chronic pelvic pain without gynecologic cause Lower limb varicose veins Recurrence after GSV treatment Atypical varicose veins Vulvar and/or inguinal varicose veins +/- PCS
5 Strategy : Diagnosis Pelvic varicose veins : duplex scan +++ Presence of multiple dilated tubular structures into the pelvis with a venous blood Doppler signal and a diameter > 5 mm
6 Strategy : Diagnosis 2 different contexts : Isolated PCS => other causes? Gynecologic examination Pelvic echography, CT, MRI Lower limb varicose veins due to PVI => TRT
7 Strategy : Diagnosis Identification of pathologic veins DS, CTV, MRV Anatomic variations
8
9 Strategy : Diagnosis Identification of pathologic veins DS, CTV, MRV Anatomic variations Selective phlebography Brachial or femoral approach Local anesthesia without urinary drainage Both OV and both IIV + Iliocavography and LRV
10 Strategy : Diagnosis Exclude obstructive lesions DS, CTV, MRV, phlebography, IVUS Iliocaval (MTS +++)=> stenting Nutcracker syndrome => TRT if very disabled Contraindication to isolated LOV embolization
11
12
13 Strategy : Treatment Embolization During or secondary to diagnostic phlebography Methods : Coils + foam
14 Strategy : Treatment Embolization During or secondary to diagnostic phlebography Methods : Coils + foam Amplatzer Glue
15 Right ovarian vein
16 Right ovarian vein
17 Left ovarian vein
18 Left ovarian vein
19 Left ovarian vein
20 Left internal iliac vein
21 Left internal iliac vein
22 Left internal iliac vein
23 Strategy : Treatment Embolization Local anesthesia Poorly invasive Ambulatory Do not preclude from future pregnancies
24 Strategy : Treatment Other TRT Medical TRT : can improve symptoms but none resolved symptoms and PVI Surgical TRT: ovarian or internal iliac vein ligation ovariectomy total hysterectomy with bilateral salpingo-ovariectomy
25 Results Leal Monedero : 1186 embolizations coils + foam 95.6% improvement vs coils 76% at 6M and less coils Greiner : 24 p, 74 embolized veins with glue and coils Good clinical results without reflux recurrence on the treated veins
26 Series N Veins Technique FU Results (%) Improved Capasso 19 OV Enbucrilate and/or coils 15.4M 74% Tarazov 6 OV Coils 24M 100% Machan 23 OV Coils 15M 78% Cordts 9 OV Coils + gelatin 13.4M 100% Cotroneo 22 OV Coils 3M 60% Richardson 28 OV Coils + foam 22.2M SS Maleux 41 OV Enbucrilate + coils 19.9M 68.2% Bachar 6 OV Coils 7.7M 83% Pieri 33 OV 3% STS 9M 61% Chung 52 OV Coils 26.6M SS van der Vleuten 21 OV Coils 18M 62% Kim 127 OV Gelfoam + SM + coils 45M 83% Tropeano 22 OV Foam 15M 90% d Archembeau 48 OV Coils 43M 73% Gandini 38 OV 3% STS foam 12M 100% Kwon 67 OV Coils 40M 82% Scultetus 7 OV Coils 27M 43% 6 IIVT Coils 83% 12 IIVT + OVR Coils + OVR 83.4% Creton 24 OV +/- IIVT Coils 36M 76% Laborda 202 OV +/- IIVT Coils 89% 60M 93% Nasser 113 OV +/- IIVT Coils 12M 100% Lasry 30 OV +/- IIVT Coils 6M 90% Hocquelet 33 OV +/- IIVT Coils + foam 23M 93% Asciutto 35 OV / IIVT Coils 45M Embolisation >>> Monedero 215 OV / IIVT Coils + foam 6M 90% Venbrux 56 OV / IIVT Coils and foam 22M SI Ratnam 218 OV / IIVT Coils 0.9M 95% Hartung 78 OV / IIVT Coils + foam 4M 91%
27 Complications Rare Dye extravasation => No foam
28
29
30
31
32 Complications Rare Dye extravasation => No foam Coils or glue embolization
33 Coils embolization Leal Monedero : 1186 embolizations coils + foam : > results and less coils Less cephalic
34 Coil migration During the procedure Recapture or stock
35
36
37
38
39 Coil migration During the procedure Recapture or stock Late embolization
40 Complications Rare Dye extravasation => no foam Coils or glue embolization Foam Hematoma at access site DVT/PE : early walking, heparin? Transient arrhythmia
41 Iliocaval obstructive lesions
42 Iliocaval obstructive lesions
43 Iliocaval obstructive lesions
44 Nutcracker syndrome
45 Conclusion Disabling pathology Endovascular treatment for reflux : poorly invasive, sure, efficient and well tolerated Obstruction must be recognized and treated if indicated Quality of results relies on experience Patients selection Technique
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