Nonvascular Interventions
Gynecological interventions can be done via transabdominal, transvaginal, or transrectal
route under ultrasound (US) guidance and via transabdominal or transgluteal route
under computed tomography (CT) guidance. Local anesthesia is sufficient for most cases,
using 2% lignocaine injection (or 2% lignocaine gel in case of transvaginal/transrectal
route).
In deep-seated lesions where a safe window between bowel loops might be difficult
to obtain on transabdominal US, transvaginal/transrectal approach or CT guidance is
required.
Biopsies
Image-guided biopsies in gynecology are primarily used in evaluating complex adnexal
masses with documented spread such as malignant ascites, peritoneal deposits, or distant
metastases ([Fig. 1]). This is due to the dreaded possibility of causing dissemination in an otherwise
localized malignant tumor, especially in cystic neoplasms. Though this is supported
only by anecdotal evidence in literature with more recent studies deeming the risk
to be theoretical,[1]
[2] it is advisable to avoid performing such procedures unless left with no feasible
alternative. Ovarian tumors without peritoneal spread can be biopsied if local invasiveness
precludes surgery and tissue diagnosis is required to initiate chemotherapy. Image-guided
biopsies are also very useful in the evaluation of omental and peritoneal deposits
to confirm metastatic disease.
Fig. 1 (A) Axial section of contrast-enhanced CT showing a large, complex abdominopelvic mass.
(B) Transabdominal US-guided biopsy done from the solid portion of the complex mass
seen in (A). (C) Axial T2-weighted MRI showing a left adnexal mass. (D) Transvaginal US-guided biopsy done from the mass lesion seen in (C) with the arrow pointing to the biopsy needle. CT, computed tomography; MRI, magnetic
resonance imaging; US, ultrasound.
Biopsies can be performed using semiautomatic or automatic devices ([Fig. 2]). We prefer semiautomatic biopsy guns (18/20G × 16 cm) for transabdominal/transgluteal
biopsies and automatic devices (18/20G × 25 cm) for transvaginal/transrectal biopsies.
Longer needles are required for endoluminal procedures (along with a needle guide)
to match the length of the endoluminal probe.
Fig. 2 (A) Semiautomatic biopsy gun kit (20G × 16 cm) and (B) automatic biopsy gun (18G × 25 cm) with an endoluminal ultrasound probe, needle
guide, and probe cover.
Percutaneous biopsies can be done in the in-plane or out-of-plane technique ([Fig. 3]), though the former is preferred wherever possible as the entire length of the needle
can be visualized in a single frame.
Fig. 3 Graphic representation of (A) in-plane technique and (B) out-of-plane technique with the positioning of the needle relative to the ultrasound
probe shown above and the corresponding appearance on the ultrasound image shown below.
Aspiration
Radiological imaging plays a major role in the evaluation and monitoring of ovarian
cystic lesions, with guidelines in place providing a detailed roadmap.[3] Beyond diagnosis, the management of these lesions has also come under the purview
of radiology. Image-guided ovarian cyst aspiration is an established treatment of
choice in pre- and perimenopausal women with persistent, symptomatic cysts that have
no US features of malignancy. In postmenopausal women, however, cyst aspiration is
not recommended, with the disease best treated surgically, where possible, irrespective
of US appearance.[4] Benign features on US include simple cysts, cysts with few thin (<3 mm) smooth septations,
diffuse low-level internal echoes, and absent internal vascularity.[3] Aspiration should be avoided in complex/multilocular cysts and cysts with typical
features of mature cystic teratoma. Endometriotic cyst aspiration is controversial
and percutaneous puncture should be avoided in the initial stages due to the risk
of pelvic adhesions. It can be attempted, preferably via transvaginal approach, in
patients with chronic pain who wish to retain their reproductive potential.
Technique is the same as in biopsies, with the choice of approach determined by the
route, which gives the best visibility of the cyst. We prefer the use of a spinal
needle (18/20G, 9 cm) for transabdominal approach and Chiba needle (18/20G, 20 cm)
for transvaginal/transrectal aspirations ([Figs. 4] and [5]).
Fig. 4 (A) Chiba needle of 20/18 gauge and length 20 cm used for transvaginal/transrectal aspiration
and (B) 18G spinal needle used for transabdominal aspiration.
Fig. 5 Transvaginal US images (A) and (B) showing needle aspiration of an adnexal cyst with complete collapse of the cyst
in (C). US, ultrasound.
Drainage Procedures
Complex pelvic collections such as abscesses with dense internal echoes/debris have
a high chance of recurrence/incomplete drainage after simple needle aspiration. Image-guided
placement of drainage catheters is preferable in such collections[5] ([Fig. 6]). Prior to catheter placement, needle aspiration can be done to confirm the presence
of pus or to obtain samples for diagnostic tests.
Fig. 6 Axial (A) and sagittal (B) sections of contrast-enhanced CT delayed phase showing a pelvic collection with
an air fluid level in the rectouterine space with the bladder (white arrow) compressed
anteriorly. A narrow window is seen between the bladder and adjacent bowel loops through
which a pigtail catheter (C) was inserted under CT guidance. CT, computed tomography.
Pigtail catheters are widely used for drainage procedures. They are available in two
kits, one with a guidewire and serial dilator set and another with a metal trocar
([Fig. 7]). The former is introduced using the Seldinger technique, whereas the latter is
inserted via direct puncture.
Fig. 7 Pigtail drainage catheters (A) with guidewire and serial dilator set and (B) with trocar.
Sclerotherapy
Sclerotherapy has emerged over the years as a promising alternative to laparoscopic
cystectomy for the management of ovarian endometriomas due to concern over the risk
of reduction in ovarian reserve associated with surgery.[6] It can also be used to treat recurrent pelvic collections such as lymphoceles/seromas.
Needle aspiration of endometriomas has a high recurrence rate, and repeated aspirations
increase the risk of the development of pelvic adhesions.
Catheter-directed sclerotherapy is preferred over direct needle injection due to the
risk of needle displacement and peritoneal spillage of the sclerosant. Similar to
drainage catheter placement, an 8Fr pigtail catheter is inserted into the endometrioma
either via Seldinger technique (using Chiba needle, guidewire, and serial dilator)
or direct puncture (using trocar). The cyst contents are aspirated, and a cystogram
(by injecting radiopaque contrast material) is performed to confirm the absence of
peritoneal leak. Ninety-five percent ethanol is then infused into the cyst at a volume
of 25% of the aspirate (maximum dose of 100 mL).[7] The patient is then made to change positions intermittently, ensuring a 360-degree
rotation, thereby allowing the sclerosant to mix well with any residual contents and
coat the cyst wall epithelium entirely. After 20 minutes, the injected ethanol is
completely reaspirated, and the catheter is removed.
Radiofrequency Ablation
RFA is a minimally invasive, uterus-preserving procedure for the treatment of symptomatic
uterine leiomyomas.[8]
[9]
[10] It involves the placement of a specialized electrode under US or CT guidance into
the lesion, through which high-frequency alternating current is passed, that causes
agitation of surrounding molecules ([Fig. 8]). This results in the production of heat, which at temperatures above 60°C causes
coagulative necrosis. A grounding pad is required for the completion of the circuit.
The volume of ablated tissue is dependent on the electrode design, the amount of power
supplied, and its duration. The uniformity of ablation can be limited by charring
of tissue and proximity to vessels, the so-called heat-sink effect. RFA may be preferred
over uterine fibroid embolization (UFE) in cases where the fibroids are smaller and
limited in number, and when preservation of fertility is of paramount importance,
as evidenced by multiple documented healthy pregnancies in post-RFA patients.[8] The requirement of an expensive cath-lab setup also limits the availability of UFE
as a treatment option. RFA has also been found to be of use in the local control of
hepatic metastasis in ovarian malignancies.[11]
Fig. 8 (A) Multipronged RFA electrode, (B) microwave antenna with port for cold saline infusion (black arrow), transabdominal
US images (C) and (D) showing RFA electrode tip within a fibroid (C) pre- and (D) postablation. Multiple hyperchoic foci with postacoustic dirty shadowing (white
arrow) noted within the fibroid in image (D), suggestive of gas bubbles formed during the ablation process. RFA, radiofrequency
ablation; US, ultrasound.
Microwave Ablation
Similar to RFA, MWA is a minimally invasive technique of thermal ablation. It uses
microwave energy to generate heat that results in a much more rapid and homogeneous
ablative zone ([Fig. 8]). The indications, technique of antenna placement, and safety profile are similar
to RFA.[12]
[13]
[14] However, unlike RFA, the thermal efficiency of MWA is less susceptible to the heat-sink
effect and tissue impedance due to charring. The use of grounding pads is not required,
thereby avoiding the risk of skin burns. MWA has also been found to produce larger
ablation volumes and less periprocedural pain.[14] It is safe to use in patients with metallic devices such as pacemakers and surgical
clips, which are absolute contraindications for RFA.
High-Intensity Focused Ultrasound
HIFU is a completely noninvasive method of thermal ablation where US energy is focused
in short or continuous pulses over a target area, resulting in the production of heat
and coagulative necrosis. It is used to treat symptomatic uterine fibroids as an alternative
to myomectomy or hysterectomy.[15] HIFU systems can be either US-guided (USgFUS) or MRI-guided (MRgFUS). MRgFUS systems
are more expensive but provide higher spatial and tissue contrast resolution for treatment
planning and proton resonance frequency shift thermometry for intraprocedural monitoring
([Fig. 9]). HIFU has been found to result in shorter hospital stays, lower complication rates,
and higher postprocedural pregnancy rates compared with UAE, while producing symptom
reduction comparable to surgery.[16]
Fig. 9 HIFU procedure. (A) Pretreatment sagittal T2-weighted image with arrows pointing to subserosal and submucosal
uterine fibroids. (B) Pretreatment contrast-enhanced T1 fat-saturated image showing homogeneous enhancement
within the submucosal fibroid. (C) Treatment planning (D) postprocedure contrast-enhanced T1 fat-saturated image showing nonenhancement of
the submucosal fibroid. HIFU, high-intensity focused ultrasound.
Cryoablation
CA is another uterine-sparing ablation technique which, contrary to RFA and MWA, utilizes
the effect of rapid cooling (up to −40°C) to destroy tissue. It works on the principle
of the Joule–Thomson effect, which refers to the drop in temperature attained when
pressurized gas is forced through a valve, resulting in rapid expansion. Cryoprobes
typically employ the use of argon and helium gases with a standard procedure requiring
multiple freeze-thaw cycles that can be time consuming. It has been found to be as
safe and effective as microwave and RFA with the added advantage of the ability to
visualize the ablation zone in real time in the form of an ice-ball formation.[17] This is very helpful, both in planning further cycles to overcome underablation
of the lesion and in stopping the procedure if the ablation zone has reached too close
to a vital structure. Like in RFA, proximity to vessels can result in a “cold-sink
effect.”[17] CA has been associated with less intraprocedural pain than MWA.[18] It has been found to be effective in the treatment of subserosal fibroids, which
are resistant to UAE.[19] Similar to RFA and MWA, it can be used to treat limited hepatic metastasis in ovarian
cancers.[20]
Vascular Interventions
Percutaneous vascular embolization is a highly effective therapeutic approach for
treating various gynecological conditions. This minimally invasive technique eliminates
the need for surgery and extended hospital stays, thereby reducing morbidity and overall
cost while preserving the patient's potential for future fertility.
A comprehensive understanding of pelvic vascular anatomy is crucial for optimizing
outcomes in transcatheter embolization procedures, especially in gynecologic interventions.
Transcatheter embolization is utilized both for emergent control of pelvic and vaginal
hemorrhages, as well as elective treatment of uterine fibroids and pelvic congestion
syndrome. This technique is effective in managing bleeding complications resulting
from various gynecological conditions, including benign conditions, advanced-stage
cancer, and complications from gynecologic-obstetric surgeries.[21]
Transcatheter embolization is performed in an angiography suite with digital subtraction
angiography capabilities or in an operating room equipped with similar angiographic
technology. To manage pain and reduce anxiety, moderate sedation is administered intravenously
using short-acting narcotics and benzodiazepines. After sterile preparation of the
planned puncture site, the common femoral artery or radial artery is accessed utilizing
a single-wall puncture technique. A 4- or 5-French short sheath is then introduced
to maintain the access ([Fig. 10]).
Fig. 10 Photograph shows standard hardware used for transfemoral uterine artery embolization.
(A) A 5-French femoral access short sheath, (B) 5-French Roberts uterine artery catheter, (C) angled hydrophilic guide wire, and (D) microcatheter.
Transcatheter embolization procedures are either performed via a transarterial route,
such as UFE, or a transvenous route, such as gonadal vein (GV) and pelvic vein embolization
in pelvic venous disorders (PeVDs).[21]
The procedure is usually preceded by cross-sectional imaging, which helps assess the
vascular pathology and anatomy to plan the procedure. Typically, a 4- or 5-French
selective angiographic catheter is used to access the internal iliac arteries, while
a 2- or 3-French microcatheter and microwire may be employed for selective catheterization
of smaller branches ([Fig. 10]). Once extravasation or another pathological condition is identified, the catheter
is optimally positioned for embolization. The choice of embolic material depends on
the indication. Transient but urgent pathologies such as postpartum hemorrhage will
need swift, nonselective embolization using a nonpermanent agent (Gelfoam). At the
same time, elective pathologies such as fibroid or adenomyosis require permanent particulate
embolic agents (polyvinyl alcohol [PVA] or Embospheres). Focal pathologies such as
pseudoaneurysms, require liquid (N-butyl cyanoacrylate) or mechanical agents (coils)
([Fig. 11]). These agents and sclerosants (sodium tetradecyl sulfate) are used during GVE for
pelvic venous disease (PeVD).[21]
[22]
Fig. 11 Embolic agents commonly used in gynecological conditions. (A) Absorbable gelatin sponge packet (Gelfoam). (B) 0.018″ pushable fibered coil. (C) n-Butyl cyanoacrylate glue (1 mL) and lipiodol vial. (D) Polyvinyl alcohol particles (500–710 µm) vial.
Identification of the uterine artery, which is one of the initial branches of the
anterior division of the internal iliac artery, is relatively easy due to its typical
morphology. From lateral to medial, there are three portions: the descending, transverse,
and ascending portions. The ascending segment, which courses along the body of the
uterus, has a typical corkscrew appearance, which, when hypertrophied, becomes quite
evident on the angiograms. The origin is profiled in the ipsilateral oblique projections
([Fig. 12]). Due to the abundant collateral supply of the uterus, uterine necrosis from UAE
is uncommon.[15] Transradial access is gaining traction worldwide as a favored route in view of patient
comfort, early mobilization, reduced complications, and potentially reduced costs.
Fig. 12 Ipsilateral oblique image from selective right internal iliac artery digital subtraction
angiography shows characteristic “U”-shaped course of uterine artery consisting of
descending segment (thin arrow), transverse segment (arrowhead), and distal ascending
segment (thick arrow), which has a typical corkscrew appearance.
Transarterial Procedures
Uterine Fibroid Embolization
Uterine fibroids are the most prevalent benign tumors of the pelvis, affecting approximately
20 to 40% of women of reproductive age.[23] These fibroids can be asymptomatic and may be discovered incidentally during routine
pelvic USs.[23] However, they can also lead to a range of symptoms, with the most common being menorrhagia
or dysmenorrhea. Other possible symptoms include urinary urgency, constipation, infertility,
and pain, all of which necessitate treatment.
UFE is a minimally invasive treatment option, an alternative to surgical options such
as myomectomy and hysterectomy, particularly for patients who prefer to preserve their
uterus.[24] Uterine fibroids are commonly initially detected on transvaginal or transabdominal
pelvic US. Contrast-enhanced magnetic resonance imaging (CE MRI) helps determine the
exact size, location, and number of fibroids and their enhancement patterns ([Fig. 13A–C]). It also rules out other potential causes of a patient's symptoms.
Fig. 13 UFE performed using a transfemoral approach in a 43-year-old woman with menorrhagia
due to a uterine fibroid. (A–C) Pelvic contrast-enhanced MRI showing enhancing intramural posterolateral wall uterine
fibroid (thin arrows). Selective DSA of left (D) and right (F) uterine arteries performed using 5-French RUC showing hypertrophied tortuous uterine
arteries (arrow heads). Bilateral uterine fibroid embolization was performed using
500 to 700 µm PVA particles, and (E, G) post-UFE angiogram images show stasis in uterine arteries (thick arrows). DSA, digital
subtraction angiography; MRI, magnetic resonance imaging; RUC, uterine artery catheter;
PVA, polyvinyl alcohol; UFE, uterine fibroid embolization.
A higher T2 signal intensity and greater postcontrast enhancement correlate with improved
success rates following UFE.[25] Additionally, the type of fibroid can significantly impact clinical outcomes. For
example, pedunculated and subserosal fibroids are linked to higher rates of complications
such as expulsion of submucosal fibroids and necrosis or detachment of pedunculated
subserosal fibroids. Understanding these factors is vital for optimizing patient care
and improving treatment outcomes.[15]
Contraindications to UFE include viable pregnancy, active pelvic infections, gynecologic
malignancy, severe renal dysfunction, and uncorrectable coagulopathy. Additionally,
submucosal and pedunculated subserosal fibroids are considered relative contraindications.
UFE is typically performed via the common femoral artery utilizing a 5-French short
sheath ([Fig. 10A]). Selective cannulation of the common iliac and internal iliac arteries is achieved
using a dedicated Roberts uterine artery catheter. After successfully cannulating
the uterine artery, a microcatheter may be advanced past the cervicovaginal branch
of the uterine artery, and UFE is performed using PVA particles (500–700 µm) until
stasis, indicated by stasis in 5 to 10 cardiac cycles. The ipsilateral iliac arteries
are accessed by creating a Waltman's loop, and embolization is performed similarly
to the contralateral side[25] ([Fig. 13]).
Postprocedure management after UFE is an important part of patient care; it focuses
on controlling symptoms related to acute ischemia of the uterus and fibroids and addressing
postembolization syndrome. Patients may experience abdominal cramps, nausea, and pain,
which can start immediately after the procedure and persist during recovery. A multimodal
regimen of acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids is utilized
for effective pain management following the procedure. Additionally, adjuvant techniques
such as hypogastric nerve blocks and intra-arterial lidocaine administered during
embolization may enhance pain control. Antiemetics are also used to address nausea
and vomiting as part of postembolization syndrome management.[25]
[26]
UAE has shown promising results for women with uterine fibroids. Patients experience
a significant reduction in fibroid size, typically between 50 to 60%. Additionally,
around 88 to 92% of women report relief from bulk symptoms, and more than 90% eliminate
uterine bleeding. Overall, about 75% of patients see an improvement in their symptoms.[27]
Complications associated include prolonged vaginal discharge (2–17%), fibroid expulsion
(3–15%), or, in rare cases, septicemia (1–3%). In patients desiring preservation of
fertility, myomectomy is preferred over UFE due to a perceived fear of infertility
after the latter procedure, although no robust data are available.[28]
[29]
Recent studies and trials have provided insights into the efficacy and safety of UAE
compared with other treatments such as myomectomy. The FEMME study, a randomized trial,
compared UAE and myomectomy, finding that both treatments resulted in similar quality
of life improvements. However, myomectomy had a slight edge in fibroid-related quality
of life at 2-year follow-up, whereas UAE was associated with fewer complications,
shorter hospital stays, and quicker return to work. There was no significant difference
in the pregnancy rates or outcomes between UAE and myomectomy.[30]
The EMMY trial, with a 10-year follow-up, showed that UAE and hysterectomy had similar
health-related quality of life outcomes. However, 35% of UAE patients eventually required
a hysterectomy due to persistent symptoms.[31]
UAE is also effective for treating pedunculated fibroids despite initial concerns
about complications such as fibroid torsion. Studies have shown that UAE can safely
treat these fibroids, with a high symptom resolution rate and low complication rates.[21]
Overall, the UAE is a valuable option for women seeking uterine preservation, offering
a minimally invasive alternative with comparable outcomes to surgical options.
Uterine Artery Embolization in Adenomyosis
Adenomyosis is the abnormal presence of endometrial tissue within the uterine myometrium
with associated hypertrophy and hyperplasia of the stromal myometrium. This condition
predominantly affects women aged 41 to 45 years, with an incidence rate of 1% and
a prevalence of 0.8%. Adenomyosis can present as either focal or diffuse, and it is
typically diagnosed using US and MRI. US findings often include a thickened endometrium,
disruption of the endometrial–myometrial interface, and the presence of cysts within
the myometrium. A thickened junctional zone exceeding 12 mm on MRI is a key diagnostic
criterion for adenomyosis on MRI.
If the patient has menorrhagia or dysmenorrhea, which is medication resistant, invasive
treatment options have to be considered. Hysterectomy remains the primary treatment
option for definitive management, while UAE serves as an alternative strategy for
patients wishing to preserve their uterus. However, UAE for adenomyosis has demonstrated
lower efficacy than UFE. Recent studies indicate that the UAE's success and satisfaction
rates for treating adenomyosis range from 60 to 70% and 72 to 94.3%, respectively.[28]
The technique of UAE is similar to UFE, except that embolization is started with smaller
particles with progressively increased particle size using the 1-2-3 protocol (150–250,
250–355, and 355–500 µm PVA) ([Fig. 14]). This protocol aims to embolize the distal vessels and induce necrosis in the abnormal
endometrial tissue.[32]
Fig. 14 Uterine artery embolization for adenomyosis in a 38-year-old woman with menorrhagia,
dysmenorrhea, and anemia not responding to medical management. (A, B) Pelvic MRI T2 sagittal and axial images show adenomyosis in the posterior uterine
wall (thin arrow). Selective left (C) and right (D) uterine artery DSA images show hypertrophied tortuous uterine arteries. Bilateral
uterine artery embolization was done using 300- to 500-µm PVA particles. A microcatheter
was used on the right side (arrow). The DSA image after embolization shows stasis
in the right uterine artery (E, thick arrow). On 1-year follow-up, the patient had symptomatic improvement with
a reduction in the uterus size on transvaginal sonography (F). DSA, digital subtraction angiography; MRI, magnetic resonance imaging; PVA, polyvinyl
alcohol.
Embolization in Gynecological Malignancies
Embolization may be appropriate in patients with locally advanced uterine malignancies
with intractable bleeding when conservative local treatments are ineffective ([Fig. 15]). Bleeding control within 24 hours occurs in 95% of patients after a pelvic vessel
or UAE.[33]
[34] Permanent embolic agents such as coils and liquid agents are preferred due to their
durable embolic effect and ability to prevent the recurrence of bleeding.
Fig. 15 Embolization of the uterine artery for massive vaginal bleeding in a 54-year-old
woman with advanced-stage inoperable cervical cancer. (A) Aortic bifurcation angiogram shows active contrast extravasation from the right
uterine artery (arrow). (B) Postembolization angiogram shows occlusion of the right uterine artery (arrowhead).
Pelvic Venous Disease
PeVD is a spectrum of symptoms and signs arising from dysfunction in the pelvic veins
and their drainage pathways. PeVD is characterized by noncyclic pelvic pain, dyspareunia,
dysmenorrhea, and extrapelvic symptoms due to venous reflux, varices, or obstruction.[22]
The pelvic venous system includes the uterine, ovarian, and internal iliac veins (IIVs),
which drain blood from the uterus and surrounding structures into the inferior vena
cava (IVC). The left GV drains into the left renal vein, and the right GV drains into
the IVC. Venous incompetence, often due to valve dysfunction or compression, leads
to retrograde flow in the veins, which in turn causes venous hypertension and variceal
formation in venous reservoirs. The PeVD primarily results from three pathophysiological
mechanisms: ovarian vein reflux, compression of the left iliac vein (May–Thurner's
syndrome), and the left renal vein (nutcracker syndrome).[35]
PeVD symptoms include noncyclic chronic pelvic pain, postcoital pain, and vulvar or
lower extremity varices. The symptoms are aggravated by standing and become more severe
by the end of the day. Transvaginal and transabdominal US and time-resolved magnetic
resonance venography are key for diagnosing PeVDs and ruling out other pelvic pathologies.
Key findings on US are dilated GVs (size > 6 mm) with retrograde flow on Valsalva,
pelvic varices, and venous stenosis.[35]
[36]
Catheter-directed venography is a definitive diagnostic tool for PeVDs. Characteristic
findings include an ovarian vein diameter >6 mm, contrast retention >20 seconds, pelvic
venous plexus congestion, opacification of the ipsilateral or contralateral internal
iliac vein, and/or filling of vulvovaginal or thigh varices.[35]
Transcatheter embolization is an effective treatment option for PeVD. Its success
rate is 98 to 100%, and symptom improvement is 80 to 93% in patients at 5 years. The
complication and recurrence rates are low.
-
Gonadal vein embolization (GVE) ([Fig. 16]):
GVE is indicated in patients with gonadal venous reflux and is performed through a
transjugular or transfemoral approach using coils, sclerosants, or both, with technical
success of 96.7 to 100% and clinical success of 90 to 100%.[37]
GVE is a safe procedure. Rare adverse events include pulmonary embolism or coil migration.
Recurrence of symptoms (15%), however, is not uncommon.
-
Pelvic varicosities sclerotherapy ([Fig. 16D]):
GV reflux is associated with pelvic varicosities and is treated with sclerotherapy
using sclerosant foam (3% sodium tetradecyl sulfate). Coils are avoided because of
the risk of coil migration.[37]
-
Venous stenting ([Fig. 17]):
For patients with a suspected primary cause of PeVD due to compression of either the
iliac or renal veins, stenting of the stenosed or compressed vein, preferably by a
dedicated venous stent, is the treatment option with a technical success rate of 94
to 100%. Intravascular US is superior to venography for grading stenosis severity,
determining the exact site of stenosis, and guiding the sizing of the stent. Complications
such as bleeding, stent migration, and thrombosis can occur. Venous stenting is effective
for stenosis-related symptoms; however, the long-term outcome is less studied.[38]
Fig. 16 Left gonadal vein embolization in a 39-year-old multiparous woman with noncyclic
chronic pelvic pain worsening on standing for 1 year. (A) TVS shows dilated parametrial veins with reflux on Valsalva (thin arrow). (B) Venous phase contrast CT pelvis image shows bilateral dilated tortuous parametrial
veins (thin arrows). (C) A transjugular venographic image shows selective catheterization of the left ovarian
vein with reflux in the vein and pelvic varicosities (thick arrows). (D, E) Glue embolization of pelvic varicosities and coil + glue embolization of the left
gonadal vein (arrowhead) were performed. (F) Subtracted venographic image of left ovarian vein following embolization shows complete
occlusion and absence of reflux (thin black arrow).
Fig. 17 Left iliac vein stenting performed in a 25-year-old woman with recurrent pelvic heaviness,
dysmenorrhea, and dyspareunia following left gonadal vein coil embolization (asterisk).
(A) Left iliac venogram image shows extrinsic compression of the left common iliac vein
with reflux into left internal iliac vein, pelvic veins, and into the contralateral
internal iliac vein (thin arrows) and filling of lumbar collaterals. (B) Intravascular ultrasound image demonstrates compression of the left common iliac
vein (thick curved arrow) by the right common iliac artery (thick arrow). Left iliac
vein stenting was performed using a dedicated venous stent. (C) Poststenting venogram showed no reflux into the internal iliac vein and good forward
flow across the stent (arrowhead), coil mass in the left gonadal vein (asterisk).
