Pelvic congestion syndrome is a well described, but frequently overlooked cause of chronic pelvic pain often associated with pelvic and/or limb varicosities. The main cause of this condition is female varicocoele. While embolization in the similar condition in males is still debated by interventional radiology literature results versus subinguinal surgery, for women varicocoele embolization represents the most effective and less invasive treatment, writes Antonio Basile, Catania, Italy.
However, this statement is not sustained by widely-related literature if we consider that neither randomised controlled trials nor comparative studies have been published. If we evaluate the results coming from surgical data (laparoscopic ligation) versus that from radiological studies, we may say that surgery is curative in up to 73% of patients while interventional radiology is curative in up to 83% of cases.
Reviewing the radiological literature, however, we note that we are not speaking about one standard technique, but about different embolic techniques. Until about 1997/98, unilateral left ovarian vein (LOV) embolization was the reported embolization technique with pain relief reaching 66%, a disappointing result, even if comparable with surgical outcomes.
After 2000, bilateral ovarian vein embolization was becoming the norm, and in cases in which the right ovarian vein cannot be found or is extremely small, its embolization began not to be considered necessary. Nowadays as assessed by the largest retrospective study on 131 patients published by Kim et al in the Journal of Vascular and Interventional Radiology in 2006, bilateral ovarian vein embolization is considered if the right ovarian vein is refluxing; if the symptoms persist for a period of 3/6 months, it should be followed by the embolization of internal iliac veins which is suggested to be performed without coils but only with sclerosant agents. However, there are still controversies regarding which embolic material is best, up to which part of ovarian vein should be embolized and how to deal with high flow varicocoele through other ipsilateral or controlateral internal iliac veins or ovarian vein.
Reviewing the literature we find good results achieved with sclerosant alone (Gandini R, Cardiovascular and Interventional Radiology 2008), coils alone (Asciutto G, European Journal of Vascular Endovascular Surgery 2009) or with sclerosant plus coils (Kim HS, Journal of Vascular and Interventional Radiology 2006).
The latter technique seems to be more complete and less prone to recurrence because it refers to the sclerosis of distal portion of ovarian vein including periuterine varicosities, with coil embolization of the proximal portion of the left ovarian vein almost up to the left renal vein; the latter step of this technique, releasing coil close to the LRV, could increase the risk of coil migration, for this reason in 2006 we underlined the usefulness of the amplatzer plug at this stage. Not all papers report the embolization of the proximal portion of the left ovarian vein, some authors (Asciutto G, European Journal of Vascular Endovascular Surgery 2009) have achieved good results by only embolizing the distal portion of the left ovarian vein with coils, the same technique used by Gandini only with sclerosant. It can be argued that, compared to what we see in male varicocoele, the ovarian vein has a high flow and only total embolization can obviate collateral development. However, this hypothesis is not always supported.
The last controversy in the literature is focused on the means that can be used to obviate dislocation of embolic material, in particular sclerosants, in cases of high retrograde flow from the left ovarian vein, through the ispilateral internal iliac veins or contralateral ovarian vein or internal iliac veins. Some authors suggest closing the “back doors”— this means that we should use an occlusion balloon with a different venous approach in each involved vessel.
This manoeuvre was suggested by some authors (Gandini R, CIRSE 2011) and used up to three balloon in cases of reflux through ipsilateral and contralateral ovarian vein or internal iliac veins; this sound a little bit complicated and invasive, for this reason I suggest avoiding non-target embolization just by using an occluding balloon in the distal portion of the left ovarian vein, with slow injection of sclerosants.
In conclusion interventional treatment could be considered the gold standard for pelvic congestion syndrome, however the lack of large literature data on this should push the efforts of the interventional radiology community to build a standard, accepted technique and clear scientific evidence by means of randomised trials.
Antonio Basile is with the Department of Diagnostic and Interventional Radiology, Garibaldi Centro Hospital, Catania, Italy.