Pelvic Congestion Syndrome Diagnosis and Treatment Hadjipolycarpou Andreas Vascular Surgery Clinic, Nicosia General Hospital Director Dr Ch.

Transcription

1 Pelvic Congestion Syndrome Diagnosis and Treatment Hadjipolycarpou Andreas Vascular Surgery Clinic, Nicosia General Hospital Director Dr Ch. Bekos Vascular Surgical Society of LIVE Patra, 2018

2 Incidence Pelvic VV present in 10% women 15% women ages years suffer chronic pelvic pain Pelvic VV >60% --> explain symptoms Differential Diagnosis Endometriosis, uterine fibroma, pelvic cancer OBGyn exam mandatory even if pelvic vv are present PCS can cause atypical or recurrence of lower limb vv Mathias SD, et al: Chronic pelvic pain: prevalence. Obstet Gynecol 87: ,1996

3 Clinical Findings Mainly young women (late 20s to early 30s) Multiparous Symptoms disappear after menopause Rare in men (venous obstructive disease, varicocele)

4 Clinical Findings Chronic pelvic pain (6 months) Heaviness increases during the day, relieved by lying down Dyspareunia, Dysmenorrhea, urinary and rectal symptoms Symptoms predominantly unilateral, can be bilateral

5 Diagnosis Non Invasive Duplex scanning (transabdominal and tranvaginal) 3 days no residue diet, empty stomach Pelvic VV: dilated tubular structures around uterus and ovaries with diameter >5mm Internal iliac v and genital v: reflux using Valsalva m. Positive predictive value of 6mm ovarian v for PCS is 83.3% Common Iliac v, IVC, and Renal v checked for obstruction Lower limb duplex for secondary vv Park SJ, et al: Diagnosis of pcs using tranabdominal and tranvaginal sonography. AJR Am J Roentgenol 182: , 2004

6 Search for other causes, mainly endometriosis, venous obstructive disease Severely underestimate venous disease, performed supine Rozenblit AM, et al: Incompetent and dilated ovarian veins: a common CT finding. AJR AM J Roentgenol , 2001 Diagnosis Non Invasive CTV and MRV CTV evaluate portal, genital and renal veins, separate imaging later for pelvic and iliocaval veins Ovarian vein Incompetent : completely opacified during arterial phase Dilated : >7mm at greatest diameter

7 Diagnosis Left ovarian vein

8 Diagnosis Phlebography Gold standard Common femoral v or Jugular v approach Urinary catheter Image both Internal iliac v and Gonadal v with/without Valsalva m. 4F or 5F Cobra 2 catheter, Simmons for right gonadal v Study of Iliac v, IVC and LRV for obstructive disease

9 Diagnosis

10 Chung M, et al:comparison of treatments for pcs. Tohoku J Exp Med 201: , 2003 Phlebographic criteria Beard and colleagues and Chung and Huh (values 1 to 3, >5 -> PCS) Ovarian vein >5mm Contrast retention >20s Congestion in the pelvic venous plexus or opacifation of the Internal iliac v (contra/ipsilateral) Filling of vulvovaginal and thigh varicosities

11 Medical Treatment Medroxyprogestorone acetate (progestin) 30mg OD for 6 months 73% report >50% pain improvement (33% placebo) Not maintained 9 months after discontinuation Goserelin acetate (GNRH agonist) 3.6mg OM for 6 months (statistically significant better results) Daflon 500mg BD for 6 months Statistical improvement Soysal ME, et al: A randomized control trial of goserelin and medroxyprogesterone in the treatment of pcs Hum Reprod 16: ,2001

12 Surgical Treatment Conventional and Laparoscopic surgery Ovarian and/or internal iliac vein ligation Ovarian and uterine artery and vein ligation Oophorectomy uni/bilateral, hormone replacement therapy Total hysterectomy

13 Series Rundquist et al Surgical Treatment No of patients Technique Follow up (Mo) Asympto matic (%) 15 LOV restriction Beard et al 36 Hysterectomy+ bilat OO +HRT Impr oved (%) Richardson et al 67 OV resection ns 87 Belenky et al 13 Lt nephrectomy+ LOV ligation ns Tourne et al 8 OV resection Scultetus et al 12 5 OV resection IITD Chung and Huh Hysterectomy+ bilat OO +HRT Hysterectomy+ unilat OO Improv. No improv. Gargiulo et al 23 Bilat OV ligation

14 Endovascular treatment Coil embolisation and/or Foam sclerotherapy Some rules : Whole internal iliac v must NOT be embolised (balloon occlusion, avoid main trunk embolization) Embolisation of gonadic v proximal to last collateral (prevent recurrences)

15 Endovascular treatment Coils.035 for 4F/5F Vascular plugs (Amplatzer) Foam Before coiling Sandwich techique (coil plus 2% polidocanol) greater improvement rate

16 Endovascular treatment Complications <4% Hematoma access site Extravasation of contrast Coil/glue embolization DVT Pulmonary embolism Transient cardiac arrhythmia

17 Series Endovascular treatment No of patients Veins Technique Follow up(mo) Kim et al 127 OV Gelfoam+sodium morrhuate+coils Chung and Huh Impr oved (%) OV Coils 26.6 Stat. impr. Kwon et al 67 OV Coils Maleux et al 41 OV Enbucrilate+coils Pieri et al 33 OV 3% STS 9 61 Creton et al 24 OV+IIVT Coils Machan et al 23 OV Coils Richardson and Driver 28 OV Coils + foam 22.2 Stat. impr.

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22 Thank you for your attention!