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Background to Pelvic Venous Congestion | Pelvic Congestion Syndrome
Background to Pelvic Venous Congestion | Pelvic Congestion Syndrome
chapterchroniccliniccongestiondiagnoseddiagnosisdifferentialinsufficiencypainpatientspelvicscenarioscenariossymptomssyndromeveinvenousworkup
Symptoms | Pelvic Congestion Syndrome
Symptoms | Pelvic Congestion Syndrome
chaptercongestionincompetentinsufficiencylevelpelvicpelvispoolingrefluxsensationsymptomstreatvaricesvaricosevaricose veinsveinsvenous
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
chaptercompressibleevidenceflowgonadalgrayiliacincompetentinsufficiencypelvicpelvissecondarysequelaeultrasoundvalsalvavalvevalvesvaricosevaricose veinsvaricositiesveinveinsvenous
Diagnosis | Pelvic Congestion Syndrome
Diagnosis | Pelvic Congestion Syndrome
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Treatment Options | Pelvic Congestion Syndrome
Treatment Options | Pelvic Congestion Syndrome
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Algorithm for Treatment | Pelvic Congestion Syndrome
Algorithm for Treatment | Pelvic Congestion Syndrome
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Treatment Case 2 | Pelvic Congestion Syndrome
Treatment Case 2 | Pelvic Congestion Syndrome
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Case- May Thurner Syndrome | Pelvic Congestion Syndrome
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
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Results | Pelvic Congestion Syndrome
Results | Pelvic Congestion Syndrome
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Does Embolic Material Matter | Pelvic Congestion Syndrome
Does Embolic Material Matter | Pelvic Congestion Syndrome
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Transcript

thanks everyone thanks for having me appreciate being here certainly as the title suggests here public congestion syndrome is probably something that you've heard of it's a little bit of a misnomer we don't really call it pelvic congestion syndrome anymore but I'll get

into that a little bit certainly have time for questions afterwards but if there's something that I want to talk about as we go I'm certainly happy to do that too no disclosures unfortunately for me so I'll do a little bit of a

background give some historical perspective and then I'll I'll basically just talk about the clinical symptoms and what type of workup that I go through and then how I do procedures for patients that have pelvic venous

insufficiency and then talk a little bit about outcomes so background you know chronic it's it's basically this spectrum of chronic pelvic pain which we'll get into a little bit but pelvic venous venous insufficiency for chronic

pelvic pain is really poorly understood and it's it's under-diagnosed oftentimes the patients that come to clinic to see me have been through a lot of different scenarios to try and find a source for their symptoms that's that's sort of the

most common scenario the second scenario that I find patients coming to me is through our vein clinic when they have symptoms of varicose veins in their legs and then we start talking a little bit further getting into their symptoms a

little bit more it starts to become clear that maybe there's a problem a little higher up than in the legs and so those are sort of the two scenarios but it's certainly under diagnosed at least as a portion or at least as a

contributor to chronic pelvic pain in women by definition it's intermittent or constant pain lasting three to six months duration and it's localized in the abdomen or pelvis not limited to two menstrual cycle and it's not associated

with pregnancy necessarily and like I mentioned a bit ago it's really part of this constellation of symptoms in chronic pelvic pain which there is a really big differential diagnosis for most of the time the patients

that have the significant symptoms range between eighteen and fifty and it's pretty big age range but like I said lengthy differential diagnosis so this is not number one on the list for foreign OB kind doctor to think about oh

yeah maybe this is pelvic venous insufficiency causing their pain and so that's why it goes under diagnosed and I mentioned the term pelvic congestion syndrome but really really what this is is we're talking about pelvic vein

insufficiency that's causing chronic pelvic pain so that's that's really what we're talking about

so again pelvic pain lasting three to six months the general symptoms are a lot like varicose veins and a leg so a

dull ache may be heavy sensation symptoms most severe at the end of the day and you can imagine as you're standing as I'll show you on a few slides coming up that that's that's what really makes the the symptoms worse

because the what vein insufficiency is is leaky valves and as you're standing gravity is working against you and so that blood is pooling in the incompetent veins which causes the heavy sensation leads to pain and can also lead to to

evolve our pernil varices which is one one of the indicators of someone having pelvic venous insufficiency it's definitely been implicated as the cause of of what we used to term pelvic congestion syndrome and so the

congestion is really that pooling of blood in those incompetent veins are really varicose veins in your in your pelvis and the the mainstay of treating varicose veins whether it's in your leg or pelvis is that you treat the the

problem at the highest level or the closest level to the heart as possible because of all the issues with veins then transmit them further away from the heart if that makes sense so you treat at the highest level of reflux to give

yourself the best chance to make a difference with symptoms there we go

so what what venous insufficiency is is really leaky valves so if you want to hit the play on that so that's all venous insufficiency that's what we

talked about it's it's leaky valves and so you can see this the valve leaflets there which are paper-thin is allowing blood to go the wrong way if you want to hit play on that one when we looked for valve

insufficiency for sure in the legs we use ultrasound and there's a bunch of different things that we look at an ultrasound you first look if you can augment blood flow so that was that first part we see if it's compressible

to make sure there's not a clot in it that's this part you can see the vein winking at you and then finally we look at valsalva or some type of way to determine if the valves are competent or incompetent and what this figure is

showing is that when a patient valsalva Zoar tenses up their abdominal muscles you see the gray line for the ultrasound crossing the access and going the opposite way all that means is it's got opposite directional flow which you

should not be able to do if your valves work so if your valves work you would not see that ultrasound picture crossing the line here it would just continue right there or would just stop and then flow would start again once you stop fel

salving so that's how we check in a leg but for pelvic venous insufficiency that's kind of hard to ultrasound the deep pelvic veins I could certainly look for varicosities with a an ultrasound of the pelvis but you can't really find the

source of an usually the source veins are the internal iliac veins or the gun at Elaine's and those are tough to ultrasound so secondary evidence of incompetence or leaky valves in those systems is varicosities

and so in the case of pelvic venous insufficiency those varicosities are in the pelvis and you see on the slide here you got varicose veins deep in the pelvis here and here and see some larger ones in that same

area on that CT scan so that'll tell us varicose veins that doesn't necessarily tell you whether the issue is with a gonadal vein or an internal iliac vein it just tells you that there are sequelae of varicosities much like in

the leg you might have varicose veins in the ankle but the problem is really higher up in the leg at this afterno femoral Junction so that gives us secondary evidence but it hasn't really told us the cause of the varicose veins

this is just a CT image that it also may show a large gonadal vein right here so you normally should not see it that big it's right there also secondary evidence that the valve is incompetent but it doesn't really test the valve itself

it's it just gives you the idea that veins enlarge and the valves gonna be leaky this is a cartoon schematic of the

pelvic veins and in the most common scenarios it's the left go nate'll Baine and that's the vein that's circled there

and so when we're evaluating someone for leaky valves in their pelvic venous system you do that through catheter vena Graham and I'll show you exactly how we do it but really there's four pathways at least for the four main ones that you

have to look at and that's the both side gonad all veins for right and left gonna handle vein which are imaged there and then the internal iliac veins on both sides so those are sort of the four pathways that you start with evaluating

on a catheter vena Graham the first sign that there is a leaky valve is by doing a vena Graham in the renal vein so the left gonadal vein communicates with the left renal vein if you want to hit play on that video the if I do a left renal

vena Graham you should not even see the gonna dull vein but if you see reflux down the gonadal vein you'll see it here so renal vein looks great but you should not see any blood flow going against against the

grain there so that's clearly venous insufficiency I think this is just another video showing the same you want to hit the play on that one a different patient again renal vena Graham showing a huge go nate'll Baine so that clearly

has valves that don't work that's how you can specifically test for venous insufficiency on this one you'll hit the play on this video this shows us what a normal renal vena Graham would look like and you're not seeing any part of the

gonadal vein so what are the general

treatment options once you've sort of isolated that there are leaky valves and the patient has typical symptoms that there are some surgical options but really embolization and catheter

directed treatment are really the mainstays of treatment both because it's an outpatient procedure you get to go home the same day and the recoveries fairly easy the factors that we consider when you embolize or block these

varicose veins are listed here you want to you want desired duration you want it to be closed forever you can't replace valves it would be nice to be able to do that but there's not a valve replacement so much like in the leg when you're

treating varicose veins you're either blocking or taking veins out so the surgical options are to take the vein out or to ligate but and the vascular options would be to block it and so I would just thought I would cover just a

little bit of embolization materials I'm sure you're all very familiar with and as I'll mention a little bit later there's there's sort of not necessarily agreement on what type of things people use to embolize gonadal veins or pelvic

varicosities but i'll show you what i do but give you a background of just generalized embolization materials so I'm sure you've all seen gel foam supplied as a sheet you can make a slurry you soak it with contraire

so that you can see it as you're putting it in some people use glue and will glue the entire gonadal vein it solidifies when it's mixed with saline or blood usually mix it with acai it also you can see it as

you're injecting it and then the standard coils which there are multiple sizes shapes detachable non-detachable Amplatz or plugs all the mechanical devices that can be used to block blood vessels and then I put on Souter deck

all because there are some people that will sort of do the sandwich technique you may have heard we'd put a coil peripherally and a coil up by the renal vein and then in between the coils you can film a sclerosant and embolize that

way the other important factor for me is using the suture deck all on the actual varicosities I'm not just necessarily treating or blocking off the the blood supply to them you know and I'll mention that a little bit more during the case

here so go through a case patient with

typical symptoms if you want to hit the play on this I think this is one we've probably already seen but it's it's the the algorithm that I go through for treatment so we do my renal vena Graham

there we go it's classic definitely has reflux and so next I will selectively catheterize the gonadal vein and here you see very large pelvic varicosities and so my standard is to actually treat the varicose veins with a sclerostin

much like I would sclerosis a varicose vein in the leg and there's a few reasons that I do that and so here's how I do it I'll put an occlusion blown up you see the picture on the left of the screen has an occlusion balloon it's the

same occlusion balloon we use for a tips procedure and I'll temporarily block the gonadal vein and fill up the system or the varicosities with contrast so that I get a sense for the volume of sclerosis and I would use then the picture on the

right is a venogram after I've injected the sclerostin so I've evaluated the volume and then I've replaced all that contrast by forcing it through the system to drain out the pelvic veins and filling the varicosities with

soldier column I do that because I believe and there's no data to prove it that it helps prevent superficial phlebitis in those varicosities so if we're just gonna block off the gonna dull vein then we have stagnant blood in

all the pelvic varicosities and stating that blood wants to clot and when blood clots on its own it'll stretch and expand the vein and cause pain and so in my own personal experience that has created a little bit worse post

procedural symptoms for patients compared to the patients that I use so TRADOC all to actually treat the varicosities so that's what I start out with and then since I'm kind of an old-fashioned guy I still go with the

coils and so I coiled the whole going a ttle vein and you can use sort of whatever you want you know that's the simplest thing for me are using nester coiours coils and and fill it up some people use the long detachable shaping

coils kind of an expensive way to do it if it saves you radiation then then that's that's one of the reasons to do it but the point is in in the venous system you have to be able to and I show this slide because you can see a

collateral vein or at least a branch there a confluence point that we've coiled off too if you do not treat the entire length there's a there's a lot higher chance for recurrence and veins have a way to find their way around if

they can communicate back up then patient gets recurrent symptoms and that can happen in about ten percent of cases so in order to prevent that you treat the whole gun out of vein and that's sort of why I think some people like to

use liquid sclerosis because then they will be able to sort of profuse all those branch points that would have a chance for recurrence case number two

you see again renal Dena Graham you can see a hint of the gonad of Ain selective

vena Graham again showing us the large gonadal vein and that's my post so charcoal with the occlusion balloon and then treat I showed the cartoon slide before that we look at all four of those territories so I always start with the

left but then I'm gonna look at the right gonadal vein as well as the internal iliac veins on both sides in this case the right go Natalie was normal as were the internal iliac veins so not seeing any varicosities

normal venous outflow so this patient it was only treated with a left gonadal vein embolization

now other causes this is a little bit different different scenario here but it's not always just as simple as all

there's leaky valves in the gonadal vein that are causing these symptoms this is 38 year old Lafleur extremity swelling presented to our vein clinic has evolved our varicosities once you start to discuss other symptoms she does have

pelvic pain happiness so we're concerned about about pelvic congestion and I'll mention here that if I hear someone with exactly the classic symptoms I won't necessarily get a CT scan or an MRI because again that'll give me secondary

evidence and it won't tell me whether the veins are actually incompetent or not and so you know I have a discussion with the patient and if they are deathly afraid of having a procedure and don't want to have a catheter that goes

through the heart to evaluate veins then we get cross-sectional imaging and we'll look for secondary evidence if we have the secondary evidence then sometimes those patients feel more comfortable going through a procedure some patients

on the other hand will say well if it's not really gonna tell me whether the veins incompetent or not why don't we just do the vena Graham and we'll get the the definite answer whether there's incompetence or not and you'll be able

to treat it at the same time so in this case we did get imaging she wanted to take a look and it was you know shame on me because it's it's a good thing we did because this is not the typical case for pelvic venous congestion what we found

is evidence of mather nur and so mather nur is compression of the left common iliac vein by the right common iliac artery and what that can do is cause back up of pressure you'll see her huge verax here and here for you guys

huge verax in that same spot and so this lady has symptoms of pelvic venous congestion but it's not because of valvular incompetence it's because of venous outflow obstruction so Mather 'nor like I mentioned is compression of

that left common iliac vein from the right common iliac artery as shown here and if you remember on the cartoon slide for pelvic congestion I'm showing a dilated gonna delve a non the left here but in this case we have obstruction of

the common iliac vein that's causing back up of pressure the blood wants to sort of decompress itself or flow elsewhere and so it backed up into the internal iliac veins and are causing her symptoms along with her of all of our

varicosities and just a slide describing everything i just said so i don't think we have to reiterate that the treatments could you go back one on that I think I did skip over that treatments from a thern er really are also endovascular

it's really basically treating that that compression portion and decompressing the the pelvic system and so here's our vena Graham you can see that huge verax down at the bottom and an occluded iliac vein so classic Mather nur but causing

that pelvic varicosity and the pelvic congestion see huge pelvic laterals in pelvic varicosities once we were able to catheterize through and stent you see no more varicosity because it doesn't have to flow that way it flows through the

way that that it was intended through the iliac vein once it's open she came back to clinic a week later significant improvement in symptoms did not treat any of the gonadal veins this was just a venous obstruction causing the increased

pressure and symptoms of pelvic vein congestion how good how good are we at

symptoms technical success rate is high so that means are we able to diagnose and treat what we're looking for and yes if we see in a incompetent gonadal vein

almost always we are able to embolize and treat but that doesn't always mean that their symptoms get better so even if you have the right symptoms and pelvic venous insufficiency and you got a gonad a vein the size of a three

car garage it doesn't always mean that the patient's give better and that's what this clinical success slide shows that looking through meta analyses of all the studies patients that have all those things the classic symptoms and

classic venous insufficiency their symptoms don't get better 100% of the times and so that's part of the the patient expectation and management and clinic and follow-up and looking for other causes chronic pelvic pain is

really complicated and venous insufficiency is part of it and you'd love to tell them that we're gonna do this procedure and it's gonna make you feel a hundred percent better but at least takes that element out of the the

scenario complications are our few range from 3 to 9 percent non-target embolization depending on what type of embolic you're using is certainly one thing that you always have to be concerned about but if done carefully

extremely rare there is a small risk of paradoxical emboli and stroke in the case of using a foam sclerostin recurrence as I mentioned earlier can happen in up to 10 percent of patients I think that can happen when you know the

vein wreak analyzes so successful embolization helps decrease that and that's the reason that you treat sort of the whole vein that's that's abnormal

does the embolic material matter I'm showing the picture of an amp lats are

here this was a patient that was treated with a few different things you see coils peripherally there there was sclerosant and then in Amplatz are up near the confluence with the renal vein doesn't matter

a little is the short answer looking at as many studies that are published which are few it looks like you get a little bit better result with coil and or mixed methods meaning sclerosis and with coil and gelfoam compared to glue oil or foam

sclerostin alone however you know with the paucity of data take that with a grain of salt i think if you get good at something and you can treat the entire length of the vein I think you're successful and you have the best

chance to improve symptoms I think that's where I'll end if anybody has questions I'm happy to answer great thank you

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