[MIRS-IR Vol II:3; 4/8/98]

Embolization for Chronic Pelvic Congestion Syndrome(Pelvic Varicosities)

Robert Haag, M.D. and Robert A. Wood, M.D.

Introduction
Chronic pelvic pain in women may be a vexing diagnostic problem. Cancer, pelvic inflammatory disease, uterine fibroids, ovarian cysts, lower gastrointestinal tract problems and numerous other medical and psychiatric conditions may produce severe, even debilitating, pelvic pain. An unusual and often difficult to diagnose cause for chronic pelvic pain is chronic venous congestion secondary to ovarian varicosities. This condition is analogues to varicocele in men. In most cases the underlying abnormality is incompetence of gonadal venous valves with dilatation of the gonadal veins. This produces chronic venous hypertension manifested as a palpable varicocele in men and dilatation of the veins of the pelvic floor in women.

The diagnosis of chronic pelvic congestion syndrome may be suggested by the presence of prominent venous structures on pelvic ultrasound, CT or MRI. Unfortunately, these findings are very non-specific and are frequently overlooked while pursuing less obscure causes of chronic pelvic pain. Consequently, many patients are subjected to futile laparotomy or laparoscopy procedures. However, if pelvic congestion syndrome is considered, the diagnosis can be confirmed or ruled out with certainty by gonadal venography. If pelvic congestion is present, transcatheter embolization will provide significant relief in more than 70% of cases.

Case Presentation
A forty-eight year old female presents to the interventional radiology department with an approximately 1½ year history of pelvic floor pain and "pelvic fullness". This pain has dramatically increased over the last week. Patient now has difficulty walking secondary to excruciating pain and complains of dyspareunia. Physical examination demonstrates a well developed, alert and oriented female in moderate distress with severe pelvic pain. Examination of the genitalia revealed a right labial varix. The patient's CBC, electrolytes, and coagulation studies were within normal limits. Informed consent was obtained and angiography performed.

Procedure #1
Pelvic arteriography was performed using a 4 French shepherd's crook catheter. The right internal iliac artery was subselectively catheterized demonstrating normal, but prominent right uterine and right cervical-vaginal branches (not shown). There was no angiographic evidence of an arteriovenous malformation.

The right common femoral vein was entered, and multiple attempts were made, without success, to catheterize the right ovarian vein via both the superior and inferior right renal veins, and the right iliac vein. Therefore, the left ovarian vein was subselected from the left renal vein. Multiple contrast injections were performed to evaluate the the left ovarian vein (figure 1) and the veins of the pelvic viscera and floor (figure 2).

The right internal jugular vein was then entered and a 5 French JB1 catheter was advanced into the right internal iliac vein (figure 3). Transvenous embolization was performed via the right internal iliac vein using 8 ml of Sotradecol . The left ovarian vein catheter was then injected demonstrating markedly decreased opacification of the ovarian and uterine varicosities, and continued patency of left ovarian vein (figure 4). The procedure was then terminated with plans for further embolization to be performed via the left ovarian vein if needed.

Procedure #2
The patient returned approximately two weeks later with continuing complaints of persistent pelvic pain, particularly when upright for long periods of time. The patient stated that the severity of pain had decreased following the first embolization procedure.

Using a right internal jugular vein access, a 5 French JB1 catheter was advanced over a guide wire into the right internal iliac vein and venography was performed (figure 5). The perisacral venous plexus was then catheterized and venography performed (figure 6). The catheter tip was further advanced into a large uterine vein branch and venography performed (figure 7). All of the selective venographic studies revealed engorgement of the pelvic veins. It was therefore decided to proceed with additional embolization. Flow arrest was achieved using a 5.4 French occlusion balloon, and retrograde embolization was performed using Sotradecol. Following injection of Sotradecol, the vein was permanently occluded with stainless steel coils (figure 8).

The left ovarian vein was then selected via the left renal vein and venography performed (figure 9). This again demonstrated a markedly engorged left ovarian vein varix. The diagnostic catheter was exchanged for a 5.4 French occlusion balloon and balloon-occlusion venography was performed. This demonstrated multiple small collateral veins draining superiorly (figure 10). The left ovarian vein and largest draining vein were embolized using the occlusion balloon, Sotradecol, and stainless steel coils. Final venography demonstrated no residual opacification of these ovarian veins or collaterals (figure 11).

Outcome
This case is presented to illustrate marked symptomatic and angiographic improvement of severe pelvic varicosities in a middle-aged female patient. It should be noted that after the first interventional procedure, abdominal sonography was performed but failed to demonstrate any underlying abnormality to account for the patients ovarian varicosities. This appears to be a truly idiopathic case. At 13 months follow-up the patient is generally asymptomatic and describes only a minimal, intermittent sensation of pelvic fullness. There has been complete resolution of right labial varix, and the patient has no further complaints of dyspareunia.

Discussion
Chronic pelvic congestion syndrome is a ill-defined entity that is believed to be caused by ovarian vein reflux. Typical manifestations include pelvic pain, pressure and/or heaviness that worsens throughout the day and is relieved by lying down. Patients commonly suffer dyspareunia and may demonstrate labial or lower extremity varicosities. Many women presenting with this condition undergo laparotomy or laparoscopy which generally yields no useful diagnostic information. In extreme cases, patients have been given erroneous psychiatric diagnoses or considered to be drug seekers.

In a study by Machan, et al, ovarian and pelvic vein embolization was performed in 22 women with chronic pelvic congestion and angiographically demonstrated ovarian varicosities. In 10 cases, embolization produced complete resolution of symptoms, while partial resolution was achieved in another 6 cases. Six patients experienced no improvement. That study demonstrated that, in properly selected and screened patients, embolization is a safe and effective treatment for chronic pelvic congestion syndrome.

Reference
Machan LS, Doyle L, Fry P. Treatment of chronic pelvic congestion syndrome by ovarian vein embolization. Presented at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), Madeira, Portugal, September, 1996.