Importance of iliac vein compression in pelvic pain could be underestimated

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Left to right: Peter Pappas, Sanjiv Lakhapal and Ratnam Santoshi

A presentation at the American Venous Forum (AVF; 14–17 February, New Orleans, USA) has attempted to shed light on what could be an underdiagnosed cause of pelvic pain caused by pelvic venous insufficiency—iliac vein compression.

Ratnam K N Santoshi (Center for Vein Restoration/Center for Vascular Medicine & Lakhanpal Vein Foundation, Greenbelt, USA) shared with AVF delegates that chronic pelvic pain is currently reported in 2–10% of gynaecological consultations and may be responsible for 20% of laparoscopies performed. Up to 40% of this pain is caused by pelvic venous insufficiency. “The current literature indicates that ovarian vein reflux is the primary etiology of pelvic congestion syndrome,” Santoshi said. The best way to treat this problem, Santoshi and co-investigators Sanjiv Lakhapal (Founder and chief executive officer of the Center for Vein Restoration/Center for Vascular Medicine & Lakhanpal Vein Foundation) and Peter Pappas (also of the Center for Vein Restoration/Center for Vascular Medicine & Lakhanpal Vein Foundation) hypothesised, is to employ a staged approach in which the iliac vein obstruction is treated first, followed by embolisation to alleviate the ovarian vein reflux.

Santoshi and colleagues conducted a retrospective chart review of 227 women who underwent interventions at their centre for pelvic congestion syndrome from January 2012 to September 2015. All patients had a complete gynaecological evaluation with preoperative lower extremity and ovarian vein venous duplex prior to the procedure. Pre- and post-procedural visual analogue scale (VAS) pain scores were recorded for all patients. Santoshi reported that the majority of patients with ovarian vein reflux and obstructive lesions were treated with staged procedures (embolisation followed by stenting), with a subset of patients treated with simultaneous embolisation and stenting due to travel restrictions.

Most patients were treated with embolisation and stenting (n=127), 50 were treated with stent only, 39 were treated with embolisation only, eight were treated with embolisation and venoplasty, and three with venoplasty only. The average age of the study population was 46.4±10.15 years and the average number of pregnancies was 3.36±1.99. Preoperatively, 42% of patients had no lower extremity disease, while 56% had lower extremity disease.

For embolisation, most patients underwent chemical rather than coil embolisation, and the majority of interventions took place in the left common iliac veins.

Santoshi reported that the patients who had embolisation with a stent implantation had a higher pain resolution (58% complete and 36% partial resolution) compared with those treated with embolisation alone (35% complete and 54% partial resolution) or stenting alone (50% complete and 20% partial resolution). The visual analogue pain scores showed a reduction in pain from 7.41±1.33 preoperatively to 3.15±3.1 postoperatively for patients who underwent embolisation only (p<0.001), reduction of 8.62±0.96 to 1.63±2.36 for patients who underwent embolisation with stenting (p<0.001), and reduction of 8.78±0.83 to 1.48±2.57 for patients who underwent stenting only (p<0.001).  Only nine of 88 patients reported a decrease in pain with ovarian vein embolisation only prior to stenting, however there was a significant reduction in pain in these patients post-stent implantation.

“Eighty per cent of the investigated patients with pelvic vein reflux had an iliac vein obstructive process, and this observation is probably secondary to the use of intravascular ultrasound,” Santoshi said. “In patients with ovarian vein reflux and an iliac vein stenosis, we recommend addressing the iliac vein stenosis first and staging the ovarian vein embolisation based on post-procedural VAS. We would consider simultaneous treatment in patients with large pelvic reservoirs and uncompensated ovarian vein reflux.”

“In this investigation, we did not routinely visualise the right ovarian vein and we did not utilise balloon occlusion venography,” Santoshi continued. “Therefore, it is possible that residual disease may be the reason some patients experience an incomplete response. Future investigations should stratify patients based on compensated and uncompensated outflow disease.”

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