Transcript Pelvic Congestion Syndrome. - Center for Vein Restoration

Pelvic Congestion Syndrome
Treatment
S. Lakhanpal MD, FACS
President & CEO
Center for Vein Restoration
Center for Vein Restoration has forty
centers mostly in the Mid-Atlantic and the
NE, providing state of the art vascular care
in a compassionate and cost efficient
manner in the outpatient setting.
Center for Vein Restoration
Maryland/Virginia/DC Offices
FREDRICK
OWINGS MILLS
CATONSVILLE
HERNDON
TYSONS CORNER
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VIENNA
Center for Vein Restoration
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CT
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Michigan Offices
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GRAND RAPIDS
Treatment
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Non Interventional
– Psychotherapy
– Hormonal therapy
• Ovarian suppression
Interventional Pelvic
– TAH-BSO
– Ovarian Vein Ligation
– Percutaneous embolization
– Internal iliac vein varicosity embolization
Interventional (extra-pelvic) Perineal varicosities
– Sclerotherapy
– Phlebectomy
Non Surgical Treatment for PVC
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Primary goal;
– Suppress ovarian function
– Vasoconstriction of dilated veins.
Common treatment drugs;
– Progestins, danazol, Gonadotropin releasing hormone receptor
agonists, phlebotonics, dihydroergotamine, NSAID’s,
phsycotherapy.
Medical therapy is not favored for ‘long term’ therapy because of;
– Side effects
• GnRH agonists (hot flashes, night sweats, vaginal dryness,
mood swings).
• Progestins (bloating, 5lb weight gain).
• Diminishes fertility.
• Adjuvant psychotherapy.
– Medical therapy is not an unreasonable option for short term
therapy to delay any surgical intervention.
Interventional Treatments
• Open Surgery
– For OVR - historical purpose only.
– Phlebectomy
• Catheter based
– Embolizations
– Venoplasty
– Stenting
Surgery open
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First developed by Rundqvist in the
1980s
Technique
– “Sympathectomy” incision
– Muscle-splitting extraperitoneal
approach to the ureter and
adjacent ovarian vein. ligated
– Suture used for traction to
enable multiple ligations that
finish ~ 2cm from left renal vein
– Unilateral vs bilateral, based on
u/s
Results (72 patients -33 month f/u)
– Pelvic heaviness improved in
70% of patients (in 56% almost
complete) 13% little/no
improvement
– Dyspareunia improved in 84%
(50% completed recovery)
– Laparoscopic ligation also
described
Open surgery is now a thing of the past Patients are all treated with endovascular
techniques.
Catheter based: Documentation of Ovarian Vein Reflux
Embolization/ Embolization + Coiling
Schematic Representation of the Embolization
Treatment of Iliac Vein Obstruction
Venoplasty and Venous Stenting
• In a clinically symptomatic patient:
• Once the obstructive lesion has been identified and the
degree of obstruction confirmed by IVUS(see diagnosis of
PCS slides), relief of obstruction is carried out by venoplasty
and venous stenting.
• Currently available stents for such use are the Boston
Scientific ‘wall stents’.
• Multiple studies have shown the effectiveness of venous
stenting in all subsets of patients inclusive of, the elderly,
pre and postmenopausal, obese etc.
• When placed in patients desirous of a future pregnancy,
these venous stents have fared well through a subsequent
pregnancy.
Venous Interventions – Case Presentation
• 71 yr old female
• Presented with 8/10 on the pain scare -chronic painful
left leg
• H/O previous left leg venous ablation with minimal relief
• Duplex showed stenosis of LCIV
Case Study
Case Study
Case Study
Venous Interventio – Case presentation
• 34 yrs old female, severe(7/10) chronic pain in right leg
with swelling ,
• Duplex Compression of LEIV and reflux
Case Study
Case Study
Pregnancy After Ilio-caval Stenting
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J Vasc Surg. 2009 Aug;50(2):355-9. doi: 10.1016/j.jvs.2009.01.034.
Management of pregnancy in women with previous left ilio-caval stenting.
Hartung O1, Barthelemy P, Arnoux D, Boufi M, Alimi YS.
Author information
1Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord, Marseille, France. [email protected]
Abstract
BACKGROUND:
Ilio-caval stenting now represents the first line treatment for disabling obstructive ilio-caval lesions. Most patients are
young women of child-bearing age. We herein report our experience of pregnancy in women who have a history of iliocaval stenting.
MATERIALS AND METHODS:
From November 1995 to April 2008, 119 patients had ilio-caval stenting for obstructive venous disease in our
department. Of these, 62 women were able to become pregnant. When pregnancy occurred, they received preventive
treatment with low molecular weight heparin (LMWH) from the 3rd month of pregnancy to 1 month after delivery and
had to wear elastic stockings. Patients also had to sleep on their right side if possible. They were followed during the
pregnancy by duplex scanning at 3, 6, and 8 months, and then 1 month after delivery.
RESULTS:
Eight pregnancies occurred in 6 patients (mean age 26.5 years) who had a patent self-expanding stent (1 patient had 3
pregnancies). They had stenting for May-Thurner disease in 3 patients, for post-deep venous thrombosis (DVT) left
common iliac vein occlusion in 1 patient, and during venous thrombectomy in 2 patients. All stents were self-expanding
metallic stents located on the left common iliac vein. One patient had unrelated spontaneous abortion after 2 months of
pregnancy. No DVT or symptomatic pulmonary embolism occurred during pregnancy, delivery, or during the
postpartum period. Four patients needed cesarean delivery and none had hemorrhagic complications. None of the
patients had adverse effects from the treatment. Duplex scan showed compression of the stent(s) at 8 months in 4 patients
with inflow obstruction in 3 patients. Postpartum duplex-scan showed no remaining stenosis in all patients. No stents had
structural damage.
CONCLUSION:
Ilio-caval stent compression can occur during pregnancy but does not lead to structural damage to the self-expanding
stents. Despite this, no cases of DVT occurred with preventive LMWH treatment
Pre Procedural Care
• Timing of the procedure in relation to menstrual or pain
cycle is unimportant.
• The patient should be restricted to clear fluids after midnight
for a morning appointment, and clear fluids after breakfast
for an afternoon appointment.
Post Procedural Care - 1
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Patients are instructed to avoid heavy lifting or exertion more
intense than walking for 3 to 7 days post discharge.
Anti-inflammatory medications are used to control post-procedural
pain; oral narcotics are rarely required.
The first menstrual period after embolization is often unusually
heavy. Patients should be warned and reassured that this is almost
invariably transient.
Patients should be re-evaluated at 3 months for clinical response, at
which time a trans-vaginal ultrasound to assess ovarian vein or
pelvic vein reflux can be performed, providing an objective
treatment assessment.
Ovarian hormone levels following the procedure have been shown
not to be affected.
Physchological counselling must continue
Post Procedural Care -2
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Patients may describe persistent symptoms at 3months. If the
presentation was chronic pelvic pain, careful questioning may reveal
that symptoms have improved but have not completely resolved. It is
important to temper patient expectations as many patients will have
less frequent, less severe pain rather than complete symptom
eradication as their ultimate outcome. Improvement of chronic pelvic
pain may be delayed for more than 6 months post treatment,
particularly when severe at presentation. If the patient has persistent,
unimproved pain at 6 months, repeat venography may be indicated to
evaluate for a recanalized ovarian vein, a missed cause for reflux,
continued filling of pelvic varicosities, or an undiagnosed outflow
obstruction. Consideration should be given to the addition of other
treatments such as physical therapy, neurostimulation, or trigger point
injections.
If the presentation was vulvar or lower extremity varicosities, most
often there will be minimal change at follow-up. The principle role of
ovarian vein embolization is elimination of the highest point of reflux.
Ablation or resection of vulvoperineal or leg varicosities that have not
resolved can be performed with lesser chance of recurrence.
Post Procedural Care - Non Saphenous
Varicosities and PCS
• Regression of lower extremity varicosities does not
necessarily correlate with relief from other symptoms
associated with PCS.
• Disappearance of lower extremity varicosities does correlate
with relief from other symptoms associated with PCS.
Creton D, Hennequin L, Kohler F, Allaert FA. Embolisation of
symptomatic pelvic veins in women presenting with non-saphenous
varicose veins of pelvic origindthree-year follow-up. Eur J Vasc
Endovasc Surg 2007;34:112-7.
Meneses L, Fava M, Diaz P, Andia M, Tejos C, Irarrazabal 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;36:128-32.
AVF Practice Guidelines
1. PCS should NOT be a diagnosis of exclusion, but suspected by
typical symptoms and a past history of vulvar veins in pregnancy
2. Visible perineal varices confirm at least a component of PCS
3. U/S confirms the presence, and in skilled hands can determine the
cause, of pelvic varices.
4. Selective venography confirms the cause and anatomical features,
to then proceed to endovenous ablative treatment by coils with or
without sclerotherapy
5. Both surgical and endovenous ablation of ovarian vein reflux are
equally effective
6. Coil treatment has greater patient acceptance, but long-term results,
particularly possible recanalization, are unknown.
Conclusions
• PCS represents a significant source of chronic pelvic pain
and productivity loss
• A clinical diagnosis - Keep a high index of suspicion
– Chronic pain induces psychological changes. We need
to be sensitive and supportive
– Multidisciplinary approach
• OBGYN
• Interventional team
• Good relief with endovascular techniques
– Patient expectations to be
Conclusions
• Venous outflow obstruction plays an important role in the
clinical expression of chronic venous disease.
• Compression of the left iliac vein at the arterial crossover
point may be present in 1/3rd of the general population
without any venous symptoms.
• The combination of reflux and obstruction gives the highest
levels of venous hypertension and the most severe
symptoms compared with either alone.
• Chronic obstruction of the iliac vein results in severe
symptoms because of poor compensation by collateral
formation.
Conclusions
• Percutaneous endovenous stenting has emerged during the
last decade as the method of choice to treat venous outflow
obstruction due to chronic venous disease.
• Stents have also been placed to relieve obstruction revealed
after removal of acute iliofemoral thrombus.
• Stenting of the venous outflow obstruction of the lower
extremities can be performed with low risk, long-term high
patency rate, and a low rate of in-stent restenosis.
• Intravascular Ultrasound (IVUS) is critical in determining
lesion presence, severity, and balloon/stenting sizing.
Please refer back to the complete presentation on
Pelvic Congestion Syndrome.
Thank You