Evaluation and Management of Pelvic Venous Disorders

Transcription

1 Evaluation and Management of Pelvic Venous Disorders Mark H. Meissner, MD Peter Gloviczki Professor of Venous & Lymphatic Disorders University of Washington School of Medicine Seattle, WA

2 Mark H. Meissner, MD I Have No Disclosures Relevant To This Presentation

3 Primary Pelvic Venous Disorders Chronic Pelvic Pain Pain Dysparunia Dysuria Pelvic Congestion Syndrome Pelvic Varices Gluteal Perineal Vulvar Four Reflux Clinical Obstruction Presentations Two Patterns of Reflux Leg Symptoms Pain Swelling Chronic Pelvic Venous Disorders Ovarian Vein Reflux Renal Symptoms Flank Pain Hematuria Iliac Vein Obstruction Internal Iliac Nutcracker Syndrome Reflux

4 The Female Pelvic Circulation Four Interconnected Venous Systems Internal iliac tributaries The gateway to the leg SEV Superfical External Pudendal Great Saphenous Deep External Pudendal Exactly analogous to perforating veins, connecting The deep veins of the pelvis The superficial veins of the leg

5 Uncompensated Obstruction L Renal Vein L Common Iliac Vein Compensated Obstruction L Renal Vein L Common Iliac Vein Uncompensated Reflux L Ovarian Vein L Internal Iliac Vein L Renal Vein Renal Reservoir L Ovarian Vein L Internal Iliac Vein Compensated Reflux L Ovarian Vein L Internal Iliac Vein Pelvic Escape Points Pelvic Reservoir Leg Reservoir Pelvic Floor

6 Chronic Pelvic Venous Disorders I. History II. Imaging III.Treatment

7 Classification of Pelvic Venous Disorders Identify the 1º underlying etiology Primary gonadal / internal illiac reflux Primary L renal vein compression Iliac venous obstruction Compression Post-thrombotic syndrome

8 I. The History Key Elements Pregnancy history Gynecologic history Symptom response to hormonal therapy DVT history Leg symptoms (swelling, claudication) Left flank symptoms Hematuria Body habitus Axial (GSV, SSV)varices Pelvic origin varices Other vascular (e.g capillary) lesions Edema, skin changes History 1º reflux uncommon in nulliparous women 1º reflux uncommon in post-menopausal women??? Consider iliac obstruction Consider iliac obstruction Consider L renal vein compression Consider L renal vein compression Physical Exam Compressive lesions common in aesthenic pts Is there a type II (competent) junction Labial, perineal, gluteal distribution Consider venous malformation Consider iliac obstruction

9 The Pathophysiology of Pelvic Venous Disorders Villavicencio et al 42 women with pelvic varices Mean age 31.9 (20-45) yrs Mean onset after 2nd pregnancy Associated pathology Vulvar varices - 31 (74%) Leg varices - 18 (43%) Pelvic pain - 11 (26%) Mesoaortic compression - 3 (7%)

10 II. Imaging Studies Lower Extremity Venous Duplex Cross-sectional imaging CT venography MR venography Ultrasonography Transvaginal Transabdominal Direct Puncture Varicography Retrograde Ovarian / Internal Iliac Venography

11 MR / CT Venography Coakley et al; J Comput Assist Tomogr tortuous parauterine veins Parauterine veins > 4 mm Ovarian vein > 8 mm Adjunct findings L renal vein compression Common iliac compression

12 Transvaginal Ultrasound Advantages Visualization of peri-uterine varices Evaluation of other pelvic pathology Incomplete pelvic venous evaluation Iliac / renal vein compression Flow direction in ovarian veins

13 Transabdominal Ultrasound Step 1 Exclude Abdominal-Pelvic Venous Obstruction Exclude iliac venous compression Diminished CFV respiratory variation Velocity ratio > 2.5 Iliac venous diameters (B mode) Exclude aortomesenteric renal vein compression PSV ratio (hilum to Ao-SMA angle) > 5.0 Diameter ratio (hilum to Ao-SMA) > 5.0 Aortomesenteric angle < 23 35º Hilar varies & renal vein collaterals

14 Transabdominal Ultrasound Step 2 Evaluate Reflux Evaluate ovarian reflux Ovarian vein diameter ( 6 mm) Flow direction +/-Valsalva Evaluate internal iliac reflux Vein diameter Flow direction +/-Valsalva Evaluate pelvic varices Transuterine crossing veins > 5 mm Change in waveform with Valsalva

15 Transabdominal / Transvaginal U/S Park et al; AJR 2004 PCS Controls U/S Feature n = 32 n = 35 L Ovarian Vein Diameter 0.79 ± 0.23 cm 0.49 ± 0.23 cm Ovarian Vein Reflux 100% 22% Pelvic Varies > 5 mm 100% 17% PPV L ovarian vein > 6 mm - 83%

16 Definitive Diagnosis The Complete Evaluation L renal vein evaluation Selective bilateral ovarian venography L iliocaval evaluation Bilateral internal iliac vein balloon occlusion venography Complete evaluation modified based on clinical evaluation and ultrasound

17 Step 1 - Left Renal Vein Evaluation Flush venography AP & 360º rotational views Signs of renal vein compression Contrast stagnation Contrast attenuation Renal hilar varices Collateral drainage pattern and rate Hemiazygous pathways Gonadal veins Intravascular ultrasound Pullback pressures

18 Step 2 Selective Bilateral Ovarian Venography Tilt table with 30º reverse Trendelenburg Selective imaging R & L ovarian veins Pelvic venous plexus 4 diagnostic criteria (Beard, 1984) Ovarian vein diameter 6 mm Contrast retention > 20 sec Pelvic venous congestion / Filling of IIV Filling of vulvar / thigh varicosities

19 Step 3 Evaluation for Iliac Obstruction Iliocaval venography Intravascular ultrasound (IVUS)

20 Step 4 Internal Iliac Venography Requires balloon occlusion (13.2 mm compliant Berenstein balloon) AP & LAO/RAO projections Selective catheterization of refluxing tributaries (Know the anatomy!!!)

21 Approach to Interventional Diagnosis Guided by Clinical Suspicion and Ultrasound Clinical Suspicion L Renal Venography L Renal IVUS Pullback Pressures L Ovarian Venography R Ovarian Venography L CIV Venography L CIV IVUS Internal Iliac Venograpy L Renal Vein Compression X X X X X X 1º Ovarian Incompetence X X X X X L Common Iliac Compression X X X

22 Approach to Interventional Diagnosis How I Do It R internal jugular access Ultrasound guided, micropuncture access Rosen wire 8 Fr X 35 cm braided, curved sheath to L1 L renal venography 65 cm Kumpe / glide wire Anchor in L ovarian vein if necessary Exchange for Rosen vs Amplatz wire 5 Fr pigatail (venography) Bilateral 8.2 Fr ovarian IVUS venography L Straight ovarian end-hole Kumpe catheter catheter (Pullback pressures) R ovarian Kumpe, C2, Simmons1, microcatheter 30º reverse trendelenberg Catheter in proximal ovarian vein and at SI joint

23 Approach to Interventional Diagnosis How I Do It Common iliac venography Pigtail catheter at femoral head AP and LAO / RAO projections IVUS over amplatz wire Internal iliac venography Requires thorough knowledge of pelvic anatomy Internal internal iliac selection in LAO / RAO projections Calibrate balloon to vein size Initial imaging with balloon at EIV / IIV confluence Progressive selection of varicose tributaries

24 III. Treatment of Pelvic Venous Disorders Standard Gynecologic Approaches Ovarian suppression Short-term symptom relief Sustained improvement unlikely (Black CA, JVIR 2010) High incidence of side effects Medroxyprogesterone weight gain / bloating Goserelin Pseudomenopausal symptoms Hot flashes Bone loss Hysterectomy Non-physiologic approach Incompletely effective (Kim HS, JVIR 2006) Residual symptoms 33% Recurrent symptoms 20%

25 Keys to Treatment of 1º Pelvic Reflux Exclude any venous obstruction Complete Aortomesenteric evaluation L of renal axial vein pelvic compression trunks ( Nutcracker ) Complete Iliac Bilateral vein treatment ovarian compression of veins pelvic ( May venous Thurner ) reservoir Mechanical Bilateral Balloon occlusion internal iliac of all veins refluxing (balloon axial occlusion trunks venography) Liquid Coil embolization versus foam sclerosant Sandwich technique Alternating coils / sclerosant Contrast Hilar Varices Attenuation Gluteal Varices Collateral Drainage Occlusion Balloon Obturator Varices L Ovarian Vein Occlusion Balloon

26 Treatment of Pelvic Reflux Obstruction 1º obstruction accounts for < 10% of pelvic reflux However If present, it must be treated first Renal Vein Stent 1º Iliac Compression Iliac Vein Stent Nutcracker Syndrome Renal Vein Trasposition

27 Treatment of 1º Pelvic Reflux Pelvic Venous Embolization Selective catheterization Bilateral ovarian veins Internal iliac tributaries Obturator Internal pudendal tributaries Balloon occlusion sclerotherapy Superior & Inferior Gluteals 11.5 mm compliant OTW balloon Coil embolization 3:1 3% STS with Lipiodol foam Pushable coils (CHEAP!!!) Sandwich technique Occlusion Balloon L IIV

28 Treatment of Pelvic Venous Disorders Chung et al; Tohoku J Exp Med, women with PCS failing 4-6 months MPA Diagnosis confirmed by laparoscopy and venography Randomized to Ovarian vein embolization (n = 52) Hysterectomy / BSO / HRT (n = 32) Hysterectomy / USO (n = 34) * * *p < 0.05

29 Procedural Variability and Outcomes Embolization Techniques Author N Treatment Symptoms Resolved Symptoms Improved No Change / Worse Kim 97 Sclero + coils % Monedero 100 Sclero + coils 64% 29% 7% Hocquelet 33 Sclero + coils 61% 33% 6% Asciutto 71 Coils only % Laborda 179 Coils only % Nasser 100 Coils only 53% 47% 0% Capasso - Glue / coils 57.9% 15.8% 26.3% Maleux 41 Glue 58.5% 9.7% 31.8% Van der Vleuren Qualitative Symptom Improvement 21 Glue 14.3% 61.9% 23.8% Total % 15%

30 Procedural Variability and Outcomes Extent of Embolization Author N Left Ovarian Right Ovarian Left IIV Right IIV Asciutto % 4.2% 49.2% 57.7% Nasser % 72% 80% 46% Laborda % 95.5% 91.1% 73.8% Maleux 41 78% 22% - - Pieri 33 97% 67% - - Chung % 15.1% - - Capasso % 31.6% % failure rate if refluxing IIV left untreated * Improved results with bilateral ovarian embolization Tendency for recurrence in untreated veins * Asciutto G, Eur J Vasc Endovasc Surg 2009 Monedero JL, Phlebology 2012

31 Conclusions Initial clinical evaluation guides subsequent work-up 3 interconnected venous systems Trans-abdominal U/S is initial imaging test of choice Ovarian Venography (± IVUS) is the Internal definitive evaluation Veins Iliac Veins Requires excellent knowledge of pelvic venous anatomy Requires good selective catheter-guidewire techniques Treatment Treat obstruction first Saphenofem Junction Balloon occlusion foam sclerotherapy / coil embolization for tx of reflux Complete treatment of ALL refluxing trunks Complete treatment of pelvic venous plexus