Références bibliographiques

Embolization of symptomatic pelvic vein in women - Editors revised version

Phlebol Digest 2008;21:27-9
CRETON D, HENNEQUIN L, KOHLER F, et al.

Introduction

In women, clinical symptoms of pelvic vein incompetence (PVI) have been recognised for years. Modern radiological investigation of pelvic veins has made it possible better to understand, pelvic vein anatomy [1]. The aim of this series was to use evaluation of symptoms in women of reproductive age to select those where pelvic venous embolisation was indicated amongst those presenting with non-saphenous varices and to evaluate the outcome at three years.

Materials and Methods

Patients

Between 2000 and 2002 amongst 895 female patients assessed in a phlebological practice, 24 non-menopausal women were selected who presented with non-saphenous varices of pelvic origin and clinical symptoms of PVI. The first criteria for selection was the presence of non-saphenous varices of pelvic origin. The second selection criteria depended on the extent of symptoms of PVI. Only 3 particularly clear symptoms were chosen to be evaluated. These were selected based on the findings of a previous study [2], in which a significant correlation between radiological PVI and these three symptoms was demonstrated. Symptoms were assessed by 3 visual analogue scales (VAS) graduated from 0 to 10 completed by the patient during consultations: VAS for pelvic menstrual pain occurring specifically before or during menstruation, VAS for pain on the varicose vein tracks occurring specifically before or during menstruation, VAS for dyspareunia occurring specifically during or after intercourse. The scores obtained were added to produce a global symptom score ranging from 0 to 30. Non-menopausal women with a score above 6 were chosen for inclusion.

Angiography and embolisation

Angiography was carried out via a femoral vein under local anaesthesia.

Venous opacification was first carried out at rest and then under pressure (Valsalva). Each ovarian or internal iliac vein with reflux was embolised at the same time as the selective catheterisation. Embolisation was carried out with metallic coils (Cook, Bloomington, USA) with a 0.038’’ calibre. No glue, foam, or sclerosing product was used.

Surgery

After pre-operative ultrasound marking of varices, phlebectomies were carried out under femoral bloc. Post operative compression was achieved by two superimposed class II French stockings for two days and then by one stocking for 2 weeks.

Clinical outcome

Outcome was assessed on clinical freedom varices and symptoms of pelvic pain. Assessment was performed by the same investigator, after one month to evaluate symptoms during the following menstrual periods. At one, two and three years, the same assessment was repeated. The same 3 VAS was completed and the global symptom score was calculated.

The clinical assessment of varices was divided into 4 categories :

  • Type 1 : Absence of varicose veins (equivalent to class C0, C1)
  • Type 2 : Presence of only very few new varices
  • Type 3 : Presence of new varices, but fewer than previously
  • Type 4 : Presence of the same amount of varicose veins as before treatment

Statistics

The comparison of clinical results with the type of recurrences was performed by one factor analysis of variance. Statistical significance was accepted for a P value of less than 0.05.

Results

The mean age of patients was 41.5 years. The mean number of pregnancies was 2.5 per patient. There was no incompetent sapheno femoral junction.

Results of embolisation

All patients selected for inclusion in this series were found to have radiologically demonstrated PVI. The distribution of the embolized pelvic veins is reported in the Table I. All these incompetent veins were successfully embolized. On average, the number of used coils was 7.3 per ovarian vein and 5.6 per internal iliac vein. The only immediate complication was the migration of a 3 mm coil, just after deployment in a branch of the left internal iliac vein; it migrated into the lower lobar branch of the left pulmonary artery with no clinical consequences.

Symptoms

All patients were re-evaluated at 45-days, 1, 2 and 3 years, except for 2 patients who were lost from the 3-year follow-up. At 45-days, pain assessed by VAS showed a significant amelioration in symptoms. The difference was statistically significant between each preoperative and postoperative sign (P <.001) (Figure 1). After-45 days, the clinical score had decreased from 15.3 to 3.1, with maintenance of the improvement at the 3 years follow-up. Improvement of the global symptom score was respectively 77%, 80% and 76% at one, 2- and 3-year follow-up. Evolution of clinical scores for each patient prior to embolisation and up to 3-years follow-up is reported in the Figure 2.

Varicose veins

Among the 22 patients re-evaluated 3-years following treatment, 10 presented with a type 1, 7 presented with a type 2, 3 a type 3, and 2 a type 4 recurrence. Two patients presented with other varices in another part of the limb. Due to the small number of patients in the 4 types of results no significant difference can be demonstrated concerning the final clinical score. After gathering these 4 groups into only 2 groups: good results (type 1 + 2) bad results (type 3 + 4) a significant association was demonstrated between the patients with a poor symptom score and varicose vein recurrence (bad results) (P <.001)

Discussion

The outcome in our series of patients shows that embolisation as treatment for PVI gives satisfactory clinical results at 3-years follow-up. Our results compare with those of other series. There are very few published studies with results at three years follow-up [3-6]. In pre-menopausal women, non-saphenous varicose veins of the upper thigh associated with symptoms of PVI suggest that the pelvic veins should be investigated as a possible source of symptoms. The results concerning varicose vein recurrences are difficult to evaluate. Even if there appears to be a correlation between symptom recurrence and varicose vein recurrence it is difficult to claim that embolisation can prevent varicose vein recurrence. No studies have been able to clarify this. This may in part explain why indications for embolisation are more questionable in post-menopausal women, who usually have few symptoms which could be improved by treatment.

REFERENCES

  1. Castro Castro J, Zubicoa Ezpeleta S, Cadena Corrales J, Carrion Otero EO, Leal Monedero J. Anatomia del sistema venoso de los miembros inferiors y de la pelvis. In Leal Monedero J, (ed) Insuficiencia venosa cronica de la pelvis y de los miembros inferiores. Madrid, Mosby, 1997 :1-11
  2. Creton D, Hennequin L. Insuffisance veineuse pelvienne chez la femme présentant des varices périnéales. corrélation anatomo-clinique, traitement par embolisation et résultats (31 cas). Phlébologie 2003 ;56 :257-64
  3. Maleux G, Stockx L, Wilms G, Marchal G. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J Vasc Interv Radiol 2000 ;11:859-64
  4. Garrett JP, Wetton N, Tyrrel MR. Ovarian vein embolisation as an adjunct in the treatment of vulval and atypical leg varicosities. Phlebology 2002;17:3-9
  5. Venbrux AC, Chang AH, Kim HS, Montague BJ, Hebert JB, Arepally A, et al. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol 2002 ;13:171-8
  6. Pieri S, Agresti P, Morucci M, De' Medici L. Percutaneous treatment of pelvic congestion syndrome. Radiol Med 2003;105:76-82
Table 1: Number of embolisations of corresponding incompetent pelvic veins
Type of incompetent pelvic veinNumber of cases
Left ovarian vein 11
Left ovarian vein + left internal iliac vein 5
Left ovarian vein + right internal iliac vein 2
Right internal iliac vein 3
Left internal iliac vein 2
Left and right internal iliac vein 1
Figure 1

Evolution of pelvic pain, venous pain and dyspareunia as assessed by VAS. The bar graph shows the mean scores for each symptom at the five observation points. The possible range of scores was 0 (no pain) – 10 (most severe pain).

Figure 2

Evolution of clinical scores for each patient prior to embolisation and up to 3-years follow-up. The vertical axis shows the global symptom score, obtained by summing each of the three symptoms scores at each time point. A maximum value of 30 is possible.

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