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2 DIAGNOSIS & ENDOASCULAR MANAGEMENT OF PELVIC CONGESTION SYNDROMEBy M. Akram Khan, MD, FACC FSCAI Interventional Cardiologist Cardiac Center of Texas P.A. 4201 Medical Center Drive Suite 380 McKinney, TX 75069 Baylor Heart Hospital of Plano Plano, TX

3 PELVIC CONGESTION SYNDROME (PCS)PCS commonly recognized as persistence of non cyclic Chronic Pelvic Pain (CPP) for longer than 6 months in the absence of known pelvic pathology. Pelvic venous incompetence with pelvic venous hypertension is underlying etiology of PCS.

4 SYMPTOMS On prolonged standing, lower back & pelvic area pain and heaviness. Dyspareunia Dysmenorrhea Dysuria, increased frequency and urgency Valvular congestion with or without vulvar varicosities.

5 ETIOLOGIES Ovarian Vein Reflux (predominantly left)Internal Iliac Vein Reflex Nutcracker Syndrome May-Thurner Syndrome It is a disease of child bearing age and most common in multiparous women and patients with polycystic ovarian disorders or hormonal dysfunctions.

6 OBSTRUCTIVE ETIOLOGY OF PCSNutcracker Syndrome May-Thurner Syndrome

7 CHRONIC PELVIC PAIN (CPP)40% of all OBGYN outpatients visits leads to un necessary hysterectomies and laparoscopic exploratory surgeries. Common causes of CPP: Endometriosis Fribroid Ovarian Cyst Adhesions IBS Pelvic Inflammatory Disease 40% of CPP are due to PCS which remain under diagnosed & under appreciated.

8 HISTORY, QUESTIONS THAT YOU NEED TO ASKDo You have pelvic pain, heaviness, bloating? When do you get symptoms? How often do you have the symptoms? Is it present throughout your cycle? How long have you had the symptoms? What makes it worse? What makes it better? Are you sexually active? Do you have pain/pressure with intercourse? During and/or after Any urinary symptoms? Frequency? Pain with urination? How many children? When did symptoms develop in relation to last pregnancy? Did you notice any vulvar varices during your last pregnancy? History of hemorrhoids? Any leg varicosities or leg symptoms of heaviness/throbbing with standing?

9 PAST MEDICAL HISTORY 14. Any history of gynecologic problems; Endometriosis, ovarian cysts, ectopic pregnancies? Any history of IUD use, pelvic infections, pelvic surgery Irregular vaginal bleeding? Unexpected weight loss? Bleeding after intercourse? 15. Other history: Abdominal surgeries, interstitial cystitis, irritable bowel syndrome, inflammatory bowel disease, back problems. History of mental health illness/depression

10 Atypical Leg Varicose VeinsCLINICAL EXAMINATION Atypical Leg Varicose Veins Obturator br. of external/internal Iliac Veins Ext. & Internal Pudendal Veins Communicators Recanalization of vein of round ligament

11 DIAGNOSTIC IMAGING Transabdominal US of ovarian & iliac vein (Antonios Gasparis M.D. Storybooks) – easier, feasible & practice This is first, diagnostic test done in our institution. Thansvaginal US. Gold Standard in some institutions MR Venography CT Venography Venography Still Gold Standard

12 NORMAL ANATOMY

13 VENOUS ANGIOGRAM IMAGES SHOWING SIGNIFICANT REFLUX

14 VENOUS ANGIOGRAM SHOWING NO REFLUX

15 DIAGNOSTIC ANGIOGRAPHYAccess: IJ, Branchial, femoral using 6 – 7 French Sheaths. Catheters: C-2, DRC Femoral Catheter for L. Ovarian Vein Simmons Catheter for R. Ovarian Vein Branchial / IJ MP Catheter We prefer Femoral Access. Images: IVC Angiography Selective L & R Ovarian Vein Angiography Selective R & L Internal Iliac Vein Angiography with or without occlusive balloon – 11.5mm non-compliant balloon

16 OVARIAN VEIN EMBOLIZATIONFirst described by Edward et al in 1993 Sclerosing Agents – Most Common STS Coils – We use Azur from Terumo but others available from Cook & Boston Glue Common Practice is to use foam sclerosing agents at the most distal segment in smaller branches followed by coil embolization for Main Trunk. Usual coil sizes are 10-20mm depending on size of ovarian vein. (Do not do Compact Packing) Post procedure every patient should be given NSAIDs due to thrombophlebitis

17 FOAM FOR PELVIC VEIN EMBOLIZATIONUse 3%Use 3% STS Dilute with contrast 2cc 3% STS + 2cc contrast Have 1.5% STS liquid STS Take 1cc 1.5% STS and mix with 3-4cc air using Tessari Method

18 FOAM PREP. GRAPHIC PRESENTATION

19 COIL EMBOLIZATION

20 INTERNAL ILIAC VEIN TREATMENTSelective catheterization Obturator Internal Pudendal Gluteal Balloon Occlusion Venography Balloon Occlusion Sclerotherapy Coil Embolization - Avoid

21 COMPLICATIONS Thrombophlebitis Groin site complicationsPulmonary Embolism

22 DATA Treatment of PCS Chung MH et al; Tohoku J Exp Med Nov;201(3):131-8. 106 women with PCS Randomized to: Ovarian Vein Embolization (N=52) Hysterectomy / BSO / HRT (n=32) Hysterectomy /USO (n=34)

23 M. Akram Khan MD (214) 208-1827 [email protected]Thank You! M. Akram Khan MD (214)