Interventional Therapy of Pelvic Venous Disorders (PeVD)

Abstract

Background Pelvic venous disorders (PeVD) are an underdiagnosed cause of chronic pelvic pain in women. They are caused by venous insufficiency of the pelvic or ovarian veins, leading to the development of mainly periuterine and periovarian varices. It is a progressive disease if left untreated and can cause swelling, dyspareunia, dysmenorrhea, and other symptoms, some non-specific, that affect the patient’s quality of life. Interventional therapies are a central component of the treatment of PeVD, with a variety of techniques available for both diagnosis and treatment.

Method This review provides an overview of the pathophysiologic background, diagnosis, and, most importantly, interventional treatment options for PeVD.

Results There is a lack of standardized nomenclature and internationally accepted diagnostic criteria for PeVD as well as randomized controlled trials demonstrating clinical success. However, in clinical trials, endovascular therapy for PeVD has been shown to be safe and effective. This review presents the various interventional techniques for the treatment of PeVD, including embolization, stenting, and sclerotherapy.

Conclusion The importance of PeVD is receiving growing recognition. Recent advances, such as the development of the Symptoms-Varices-Pathophysiology (SVP) classification, provide an impetus to standardize nomenclature and are the first step toward systematizing disease management. Interventional therapies provide a safe and tailored minimally invasive treatment option for patients with PeVD.

Key Points 

• Pelvic venous disorders are an underdiagnosed condition with frequently delayed diagnosis and debilitating symptoms.

• Until now, the PeVD nomenclature has been imprecise, with terms like May-Thurner syndrome/Nutcracker syndrome.

• Interventional approaches are effective and play a central role in PeVD treatment.

Citation Format

• Dewald CL, Becker LS, Meyer BC. Interventional Therapy of Pelvic Venous Disorders (PeVD). Fortschr Röntgenstr 2024; 196: 921 – 927

Keywords

pelvic venous disorders (PeVD) - pelvic congestion syndrome - nutcracker syndrome - may thurner syndrome - endovascular therapy

Publication History

Received: 14 September 2023

Accepted: 23 November 2023

Article published online:
19 February 2024

• References

• 1 Bałabuszek K, Toborek M, Pietura R. Comprehensive overview of the venous disorder known as pelvic congestion syndrome. Annals of Medicine 2022; 54: 22-36
• 2 Jurga-Karwacka A, Karwacki GM, Schoetzau A. et al. A forgotten disease: Pelvic congestion syndrome as a cause of chronic lower abdominal pain. PLoS ONE 2019; 14: e0213834
• 3 Tanaka ME, Keefe N, Caridi T. et al. Interventional Radiology in Obstetrics and Gynecology: Updates in Women’s Health. RadioGraphics 2023; 43: e220039
• 4 O’Brien MT, Gillespie DL. Diagnosis and treatment of the pelvic congestion syndrome. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2015; 3: 96-106
• 5 Asciutto G, Asciutto KC, Mumme A. et al. Pelvic Venous Incompetence: Reflux Patterns and Treatment Results. European Journal of Vascular and Endovascular Surgery 2009; 38: 381-386
• 6 Szary C, Wilczko J, Plucinska D. et al. The Number of Pregnancies and Deliveries and Their Association with Selected Morphological and Hemodynamic Parameters of the Pelvic and Abdominal Venous System. JCM 2021; 10: 736
• 7 Knuttinen M-G, Xie K, Jani A. et al. Pelvic Venous Insufficiency: Imaging Diagnosis, Treatment Approaches, and Therapeutic Issues. American Journal of Roentgenology 2015; 204: 448-458
• 8 Gavrilov SG. Vulvar varicosities: diagnosis, treatment, and prevention. IJWH 2017; 9: 463-475
• 9 Malgor RD, Adrahtas D, Spentzouris G. et al. The role of duplex ultrasound in the workup of pelvic congestion syndrome. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2014; 2: 34-38
• 10 Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ. et al. Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review. Acta Obstet Gynecol Scand 2018; 97: 776-786
• 11 De Maeseneer MG, Kakkos SK, Aherne T. et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. European Journal of Vascular and Endovascular Surgery 2022; 63: 184-267
• 12 Kashef E, Evans E, Patel N. et al. Pelvic venous congestion syndrome: female venous congestive syndromes and endovascular treatment options. CVIR Endovasc 2023; 6: 25
• 13 Park SJ, Lim JW, Ko YT. et al. Diagnosis of Pelvic Congestion Syndrome Using Transabdominal and Transvaginal Sonography. American Journal of Roentgenology 2004; 182: 683-688
• 14 Yang DM, Kim HC, Nam DH. et al. Time-resolved MR angiography for detecting and grading ovarian venous reflux: comparison with conventional venography. BJR 2012; 85: e117-e122
• 15 Meissner MH, Khilnani NM, Labropoulos N. et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. Phlebology 2021; 36: 342-360
• 16 Tiralongo F, Distefano G, Palermo M. et al. Liquid and Solid Embolic Agents in Gonadal Veins. JCM 2021; 10: 1596
• 17 Champaneria R, Shah L, Moss J. et al. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess 2016; 20: 1-108
• 18 Brown CL, Rizer M, Alexander R. et al. Pelvic Congestion Syndrome: Systematic Review of Treatment Success. Semin Intervent Radiol 2018; 35: 35-40
• 19 Meneses L, Fava M, Diaz P. et al. Embolization of Incompetent Pelvic Veins for the Treatment of Recurrent Varicose Veins in Lower Limbs and Pelvic Congestion Syndrome. Cardiovasc Intervent Radiol 2013; 36: 128-132
• 20 de Carvalho SFC, Metzger PB, Fernandez MG. et al. Pelvic venous reflux embolization in the treatment of symptomatic pelvic congestive syndrome: A systematic review with meta-analysis. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2023; 11: 412-421.e6
• 21 de Macedo GL, Dos Santos MA, Sarris AB. et al. Diagnosis and treatment of the Nutcracker syndrome: a review of the last 10 years. J Vasc Bras 2018; 17: 220-228
• 22 Wang X, Zhang Y, Li C. et al. Results of endovascular treatment for patients with nutcracker syndrome. Journal of Vascular Surgery 2012; 56: 142-148
• 23 Kurklinsky AK, Rooke TW. Nutcracker Phenomenon and Nutcracker Syndrome. Mayo Clinic Proceedings 2010; 85: 552-559
• 24 Daily R, Matteo J, Loper T. et al. Nutcracker syndrome: symptoms of syncope and hypotension improved following endovascular stenting. Vascular 2012; 20: 337-341
• 25 Avgerinos ED, McEnaney R, Chaer RA. Surgical and endovascular interventions for nutcracker syndrome. Seminars in Vascular Surgery 2013; 26: 170-177
• 26 Korkes F. Nutcracker syndrome: how are we cracking the nuts and whose nuts are we cracking?. Int braz j urol 2017; 43: 788-790
• 27 O’Sullivan G, Smith S. Deep venous stenting in females. CVIR Endovascular 2023; 6: 14
• 28 Gagne PJ, Gasparis A, Black S. et al. Analysis of threshold stenosis by multiplanar venogram and intravascular ultrasound examination for predicting clinical improvement after iliofemoral vein stenting in the VIDIO trial. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2018; 6: 48-56.e1
• 29 O’Sullivan GJ, Lohan DA, Cronin CG. et al. Stent implantation across the ostia of the renal veins does not necessarily cause renal impairment when treating inferior vena cava occlusion. J Vasc Interv Radiol 2007; 18: 905-908
• 30 Bajwa R, Bergin D, O’Sullivan GJ. Aiming for the Bottom Corner: How to Score a Field Goal When Landing Venous Stents in May–Thurner Syndrome. Journal of Vascular and Interventional Radiology 2019; 30: 1555-1561
• 31 Milinis K, Thapar A, Shalhoub J. et al. Antithrombotic Therapy Following Venous Stenting: International Delphi Consensus. European Journal of Vascular and Endovascular Surgery 2018; 55: 537-544
• 32 Padrnos JL, Garcia D. May‐Thurner syndrome and thrombosis: A systematic review of antithrombotic use after endovascular stent placement. Research and Practice in Thrombosis and Haemostasis 2019; 3: 70-78
• 33 De Gregorio MA, Guirola JA, Alvarez-Arranz E. et al. Pelvic Venous Disorders in Women due to Pelvic Varices: Treatment by Embolization: Experience in 520 Patients. Journal of Vascular and Interventional Radiology 2020; 31: 1560-1569
• 34 Lakhanpal G, Kennedy R, Lakhanpal S. et al. Pelvic venous insufficiency secondary to iliac vein stenosis and ovarian vein reflux treated with iliac vein stenting alone. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2021; 9: 1193-1198
• 35 Harris LM. Obstruction or reflux as the primary problem in pelvic congestion syndrome. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2021; 9: 1199
• 36 Santoshi RKN, Lakhanpal S, Satwah V. et al. Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2018; 6: 202-211
• 37 Liu J, Han L, Han X. The Effect of a Subsequent Pregnancy After Ovarian Vein Embolization in Patients with Infertility Caused by Pelvic Congestion Syndrome. Acad Radiol 2019; 26: 1373-1377
• 38 Dos Santos SJ, Holdstock JM, Harrison CC. et al. The effect of a subsequent pregnancy after transjugular coil embolisation for pelvic vein reflux. Phlebology 2017; 32: 27-33
• 39 Snow C, Pappas S, Sulakvelidze L. et al. Nitinol stents placed in iliac veins are not associated with prolonged back pain. Phlebology 2023; 38: 44-50