Procedure Guides
Women's and Men's Health

Pelvic Congestion Syndrome

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Guide

Anatomy

  • FOUR interconnected venous systems in the pelvis and lower extremities:

    • Left renal and bilateral ovarian

    • Common and internal iliac

    • Saphenofemoral junction

    • Superficial veins of the lower extremities

  • Connected to THREE venous reservoirs

    • Left renal hilum and kidney

    • Para-uterine veins

    • Superficial veins of the lower extremity

  • Pelvic venous escape points

    • Major: perineal/pudendal and inguinal/iliac

    • Minor: gluteal and obturator 

  • Pathology = reflux and/or obstruction which can be compensated via collateral reflux or uncompensated via pressure in reservoir

    • Ovarian venous reflux 

      • Compensated -> pelvic escape points with varices

      • Uncompensated -> primary pelvic symptoms

    • Internal iliac reflux

      • Compensated -> pelvic escape points

      • Uncompensated -> primary pelvic symptoms

    • Left renal vein obstruction

      • Compensated -> left ovarian reflux and pelvic symptoms

      • Uncompensated -> left flank/abdominal pain, hematuria, proteinuria, POTS

    • Left common iliac obstruction

      • Compensated -> pressurize periuterine plexus and pelvic symptoms

      • Uncompensated -> left leg swelling and pain

Indications

  • Pelvic venous congestion syndrome (PVCS, multiple other debated names)

    • Postcoital pain + ovarian point tenderness is 94/77% sensitive/specific. More common than pelvic pain/heaviness.

    • However, symptoms vary. Common examples include non-cyclic lower abdominal/pelvic pain for >6 months exacerbated by standing, coitus, menstruation, or pregnancy. Other have dysmenorrhea, dyspareunia, urinary urgency, varicose veins.

    • Affects an estimated ~27% of women and can be nulliparous.

    • Lower extremity pain/discomfort common, up to 83% of those with pelvic venous insufficiency.

  • Pelvic/vulvar varicose veins and dilated pelvic veins

    • Ultrasound: tortuous pelvic veins >6 mm in diameter, slowed (<= 3 cm/sec) or reversed flow in ovarian veins, dilated arcuate veins across myometrium, associated polycystic ovaries in 50%

    • CT/MR: at least 4 ipsilateral parauterine veins with at least 1 >4 mm in diameter or ovarian vein >8 mm in diameter

    • Can be associated with pregnancy, nutcracker syndrome, May-Thurner, genetics, congenital vascular malformation, hormonal dysfunction

Contraindications

  • Active infection

  • Contrast allergy

  • Uncorrected coagulopathy (INR >2.0, Plts <50K)

Efficacy and alternatives

  • Gonadal vein embolization: 47-98% success across studies

  • Often persistent symptoms due to not assessing for other associated lesions such as May-Thurner, nutcracker, etc.

    • Study showed incidence of iliac vein obstruction is far higher than reported (80%)

  • Embolization material used

    • Coils vs plugs RCT showed that coils required more fluoro time but were cheaper with similar outcomes; overall 90% clinical success

    • Systemic review showed better clinical improvement with coils, sclerosis, or sclerosis + coil rather than glue + lipiodol

  • Meds (e.g. medroxyprogesterone, Goserelin) plus psychotherapy can also help or serve as a /bridge to menopause when symptoms usually improve

  • Surgery such as ovarian vein ligation, hysterectomy/oophorectomy can be effective but more invasive. Also, this RCT showed endovascular therapy to result in more efficient pain reduction and reduction in estradiol levels at 3 months.

Pre-procedure Care

  • Important to counsel patients and set expectations.

    • Sometimes symptom relief takes a few months and multiple treatments.

    • Some insurers do not cover these procedure while others will with appeals.

  • Pre-procedural imaging is not strictly required but often helpful to have good quality CTV or MRV for treatment planning.

  • Ask about coexisting lower extremity venous insufficiency which is common.

Procedures

  • Internal jugular, greater saphenous, or common femoral vein access.

  • (Optional) cavagram in reverse Trendelenburg position or with Valsalva looking for reflux

  • Catheterize left renal vein with injection near hilum looking for ovarian vein reflux and renal venous outflow.

    • Degree of difficulty selecting the left renal vein can suggest significant compression.

    • Stenting is debated even in the setting of true nutcracker syndrome. If done, should be at least 6 cm long to reduce risk of stent migration.

  • Select the left gonadal vein cannulation (C2, MPA, Berstein) and gain access distally to the level of the pelvic brim. May need microcatheter (e.g. 2.7 Fr ProGreat).

  • Venography to assess for reflux.

  • Embolize to the proximal vein

    • Lots of variation in terms of embolization materials. There is data suggesting gelfoam or sclerosant (STS) alone is less effective than combining with coils or plugs. Many will sandwich injecting sclerosant followed by a coil or plug, then more sclerosant and so on.

    • Some suggest anchoring coil or plug deep within tortuous venous collaterals.

    • Some will use a balloon occlusion catheter (e.g. Python or Fogarty) for safer sclerosant and embolization.

    • Sclerosant mixtures vary. Some will use STS foam alone using CO2 DSA to visualize during injection. Others mix STS, air, contrast or lipiodol, +/- gelfoam.

  • Repeat above with the right gonadal vein. Some historically only treated the left but more recent data suggest treating both is most effective.

    • NOTE right gonadal vein may arise from IVC or right renal vein and can take a tortuous course laterally around the kidney

  • Should perform pelvic venography +/- IVUS to assess for significant iliac vein compression.

    • Should also select the internal iliacs for venography to assess for reflux and additional varices. Some suggest doing this with a balloon occlusion catheter especially if being done for persistent or recurrent symptoms after previous treatment.

    • Consider stenting if significant common iliac stenosis and evidence of reflux. If persistent internal iliac reflux and varices after stenting or without iliac vein compression, consider sclerosis.

Complications

Transient pain and low grade fever from thrombophlebitis (10%).

Other complications are rare such as coil/plug migration (1-6%), vein perforation, bleeding, infection.

Post-procedure care and follow up

  • Monitor ~4hrs post-procedure

  • Ice pack/pad + NSAID for pain/swelling or back pain. Some have patients take scheduled Naprosyn 500 mg BID for 3 days after.

  • Wear spanks or other compression garment for next 1-2 weeks, particularly after treatment of vulvar varicosities.

  • No lifting >20 lbs for 48 hrs post-procedure

  • F/U clinic visit in 2-4 weeks