pelvic congestion syndrome presentation [read-only]
TRANSCRIPT
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PELVIC CONGESTION SYNDROME
What Is It?
� “Chronic Pelvic Pain arising from
dilated and refluxing incompetent
pelvic veins. This is often described as
a constant dull ache, often aggravated
by standing.
� There are no uniform, generally
accepted clinical criteria for the
diagnosis of PCS.
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Who Gets It?
Multiparous women of reproductive age, suggesting both mechanical and hormonal mechanisms.
Etiology?
Largely unclear.
May or may not be related to venous dysfunction elsewhere.
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Anatomy
Anatomy
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How Is The
Diagnosis Made?
MR
Abdominal US
TransVaginal US
CT
Catheter Venogram
MRI
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MRI
Abdominal US
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TransVaginal US
CT
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Therapy
Hormonal HysterectomyPelvic vein
ligation/transpositionPelvic vein
embolization
Interventional Therapy
� Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC
� Embolotherapy for Pelvic Congestion Syndrome
� J Vasc Interv Radiol. 2006; 17:289-297.
� Average follow up of 48 months
� 83% of patients with resolution of substantial improvement in symptoms
� KEY: Address all refluxing components at the time of venography
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Pelvic
Vein
Embolization
� In 2017, open surgery for PCS is a thing of the
past
� Morbidity, expense, blood loss and recovery are
much reduced by endovascular techniques
� Embolization can take several forms….
Embolotherapy
TechniquesCoils
11
Glue
22
Foam
33
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Deployment
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Venous Coils
Embolization
Case
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Male PCS?
Nutcracker
Syndrome
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Presentation
� Compression of L RV, leading to GV hypertension
and large varices
� Left flank pain, hematuria
� NO medical therapy
� Intervention is the preferred method of
management
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Diagnosis
� CT Venogram
� Abdominal CT
� MRI/A
Nutcracker Endovascular Therapy
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Issues
� Conceptually simple (very good)
� Quick, outpatient therapy (good)
� Unknown long term outcomes (maybe
bad)
� Known consequences of stent
compression (possibly bad)
� Potential for stent embolization to
heart (that’s really bad)
An Alternative?
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� Journal of Vascular Surgery: Venous and Lymphatic Disorders
� Volume 4, Issue 1, January 2016, Pages 114–118
� Venous and Endovenous Techniques
� Left ovarian to left external iliac vein transposition for the treatment of
nutcracker syndrome
• John V. White, MDa Connie Ryjewski, APN, CNS
• Richard N. Messersmith, MD Lewis B. Schwartz, MD
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An Alternative?
Iliac Vein Transposition
� Long term results are not yet know, but similar operations performed
elsewhere have excellent long term outcomes….
� …and no intravascular metal…
� …being compressed extrinsically
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Vamos a Ver
(We’ll See)
InternalIliac Vein
Incompetence?
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Bibliography
� Daniels JP, Champaneria R, Shah L, et al. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol 2016: 1478-1486
� White JV, Ryjewski C, Messersmith RN, Sbrana f, Schwartz Lewis. Left ovarian to left external iliac vein transposition for the treatment of nutcracker syndrome. J Vasc Surg: Venous and Lym Dis 2016; 4: 114-8
� The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technology Assessment, National Institute for Health Research (UK): Vol 20, Issue 5, Jan 2016