VENOUS INSUFFICIENCY

PELVIC CONGESTION SYNDROME

Introduction

Last updated: apr 5, 2023

Approximately 15% of women aged 20-50 have pelvic vein insufficiency, with 60% of them being symptomatic. This condition typically affects the left side and is effectively treatable.

Venous anatomy
 

Anatomy

Risk factors

  • Pregnancy
  • Previous pelvic surgery
  • Estrogen therapy
  • Obesity, phlebitis
  • Heavy lifting
  • Venous anomalies
  • Endometriosis, fibroids
  • Tumors
  • Genetic predispositions such as FOXC2, TIE2, NOTCH3
  • Thrombomodulin
  • Type 2 transforming growth factor-β receptor.
  • There is an association with polycystic ovaries.
  • During pregnancy, venous capacity increases by 60%, potentially leading to valve incompetence

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SVM
 

Indications

  • Bloating
  • Nausea
  • Vaginal discharge
  • Swelling in the pubic area
  • Lower back pain
  • Pain in the anal region
  • Urge incontinence
  • Hip pain
  • Leg varicose veins
  • Sexual arousal
  • Dyspareunia
  • Possible irritable bowel syndrome (IBS)

 

Pre procedural

  • Transabdominal and transvaginal ultrasound
  • Computed tomography venography (CTV)
  • Magnetic resonance venography

 

Materials

Essentials

  • Ultrasound
  • Sterile drapes
  • 1% lidocaine
  • Chiba needle
  • 5 ml contrast
  • Amplatz wire
  • 8.5F drain
  • Fixation
  • Urine bag connector

Non-Essentials

 

Positioning the patient

  • Prone
  • Head first

 

The procedure in steps

  • Time out
  • Infiltration with Lidocaine
  • Ultrasound-guided venous puncture
  • Placement of a sheath
  • Administration of Heparin (5000 IU)
  • Diagnostic catheterization with a Superglide Cobra catheter
  • Selective catheterization of the left renal vein
  • Possible direct catheterization of the left ovarian vein
  • Deep renal vein series under Valsalva maneuver
  • Identification of the right ovarian vein and contributing iliac branches
  • Embolization options include pushable 0.035" coils and glue
  • Often complemented by additional coil clusters proximally in the veins.
  • Closure by manual compression

 

Complications

  • Access site complications (0.4%), hematoma, pseudoaneurysm, fistula
  • Testicular pain post-procedure, may last up to 10 days
  • Spasm, perforation. In case of perforation, avoid gluing due to the risk of damaging the ureter
  • Coil migration, rare when the correct coil size is used
  • Pelvic vein thrombosis
  • Phlebitis, occurs only with sclerotherapy (typically begins 24-48 hours post-procedure)
  • Post-embolization syndrome
  • Recurrence rate of 2-24% according to the literature

 

Post-op

  • Bed rest for around 4 h
  • Vitals should be recorded every half hourly for first 2 h post procedure.
  • Check urine for blood, when bloody ruin persist > 5 h, consider angiography
  • If sepsis is suspected, a broad spectrum injectable antibiotic is started round the clock.
  • Nephrostomy tube should be checked for its patency periodically and if blocked can be gently washed with diluted 5 ml betadine/antibiotic solution.

 

Follow-up

  • In case of a "permanent" catheter change it every 3 months
  • Prophylaxis with suppressive antibiotics is not recommended

 

Report

Time-out akkoord. Echografisch onderzoek toont matige dilatatie van het verzamelsysteem van de --SIDE-- nier. Onder echogeleide aanprikken van het verzamelsysteem. Installatie van 5 ml contrast. Onder fluoroscopische controle inbrengen van een 8F pigtail. Interne fixatie door middel van "lock" van de pigtail. Externe fixatie met SecurAcath

 

Patient folder

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Literature

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  1. J. Mark Ryan, MD, S. M. Key, Siobhan A. Dumbleton, MD, and Tony P. Smith, MD Nonlocalized Lower Gastrointestinal Bleeding: Provocative Bleeding Studies with Intraarterial tPA, Heparin, and Tolazoline J Vasc Interv Radiol 2001 Nov;12(11):1273-7

  2. Baum ST. Arteriographic diagnosis and treatment of gastrointestinal bleeding. In Baum ST, Pentecost MJ, eds. Abrams' angiography interventional radiology. 2nd ed. Philadelphia, Pa:Lippincott, Williams & Wilkins, 2006:488.

  4. Poultsides GA, Kim CJ, Orlando R 3rd, et al. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg. 2008;143:457-461.

  5. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006;17:959-964.

  6. Dixon S, Chan V, Shrivastava V et al. Is there a role for empiric gastroduodenal artery embolization in the management of patients with active upper GI hemorrhage? Cardiovasc Intervent Radiol. 2013 Aug;36(4):970-7.

  7. Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol 2012;13 Suppl 1:S31-S39.

  9. van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22(2):209-24.

  10. Sildiroglu O, Muasher J, Arslan B, Sabri SS, Saad WE, Angle JF, Matsumoto AH, Turba UC. Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy. J Clin Gastroenterol. 2014;48(8):687-92.

  11. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  13. van Dam J, Brugge WR. Endoscopy of the upper gastrointestinal tract. N Engl J Med. 1999;341(23):1738-48.

  15. Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am. 2002 Nov;86(6):1357-99.

  16. Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7: 112-22

  18. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  19. Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998 Aug;64(8):723-8.

  20. Cummings CL. Value of early capsular endoscopy for severe gastrointestinal bleeding. J Natl Med Assoc. 2004;96(12):1653-6.

  21. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med. 2001;344(3):232-3.

  24. Lim JK, Ahmed A. Endoscopic approach to the treatment of gastrointestinal bleeding. Tech Vasc Interv Radiol. 2004 Sep;7(3):123-9.

  25. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage. Gut 1998; 43:79–84.

  26. Zuckier LS. Acute gastrointestinal bleeding. Semin Nucl Med. 2003 Oct;33(4):297-311.

  27. Imbembo AL, Diverticular disease of the colon. In: Sabiston D, Editor. Textbook of Surgery (14th edn). Philadelphia, PA:WB Saunders, 1992:910.

  29. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1088-100. doi: 10.1007/s00270-010-9829-7. Epub 2010 Mar 16.

  31. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006 Jun;17(6):959-64.

  32. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007 Oct;62(10):938-49.

  33. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003;13(1):114-7

  34. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  35. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  36. Aina R, Oliva VL, Therasse E, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12:195-200.

  37. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  38. Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M, Hillon P, Rat P, Ricolfi F, Krausé D. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operative-risk patients. J Clin Gastroenterol. 2008 Apr;42(4):361-7.

  39. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  40. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461.

  42. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, Ring EJ, Welton ML. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997;174(1):24-8.

  43. Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001;177:829-836 7.

  44. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001;12:1399-1405.

  45. Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009;104:2042-2046

  46. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg 1989;209:175-180

  47. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology 1982;142:47-51.

  48. Koh DC, Luchtefeld MA, Kim DG, Knox MF, Fedeson BC, Vanerp JS, et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009;11:53-59

  49. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008;51:301-305

  1. Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7: 112-22

  2. Baum ST. Arteriographic diagnosis and treatment of gastrointestinal bleeding. In Baum ST, Pentecost MJ, eds. Abrams' angiography interventional radiology. 2nd ed. Philadelphia, Pa:Lippincott, Williams & Wilkins, 2006:488.

  4. Poultsides GA, Kim CJ, Orlando R 3rd, et al. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg. 2008;143:457-461.

  5. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006;17:959-964.

  6. Dixon S, Chan V, Shrivastava V et al. Is there a role for empiric gastroduodenal artery embolization in the management of patients with active upper GI hemorrhage? Cardiovasc Intervent Radiol. 2013 Aug;36(4):970-7.

  7. Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol 2012;13 Suppl 1:S31-S39.

  9. van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22(2):209-24.

  10. Sildiroglu O, Muasher J, Arslan B, Sabri SS, Saad WE, Angle JF, Matsumoto AH, Turba UC. Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy. J Clin Gastroenterol. 2014;48(8):687-92.

  11. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  13. van Dam J, Brugge WR. Endoscopy of the upper gastrointestinal tract. N Engl J Med. 1999;341(23):1738-48.

  15. Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am. 2002 Nov;86(6):1357-99.

  16. Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7: 112-22

  18. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  19. Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998 Aug;64(8):723-8.

  20. Cummings CL. Value of early capsular endoscopy for severe gastrointestinal bleeding. J Natl Med Assoc. 2004;96(12):1653-6.

  21. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med. 2001;344(3):232-3.

  24. Lim JK, Ahmed A. Endoscopic approach to the treatment of gastrointestinal bleeding. Tech Vasc Interv Radiol. 2004 Sep;7(3):123-9.

  25. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage. Gut 1998; 43:79–84.

  26. Zuckier LS. Acute gastrointestinal bleeding. Semin Nucl Med. 2003 Oct;33(4):297-311.

  27. Imbembo AL, Diverticular disease of the colon. In: Sabiston D, Editor. Textbook of Surgery (14th edn). Philadelphia, PA:WB Saunders, 1992:910.

  29. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1088-100. doi: 10.1007/s00270-010-9829-7. Epub 2010 Mar 16.

  31. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006 Jun;17(6):959-64.

  32. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007 Oct;62(10):938-49.

  33. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003;13(1):114-7

  34. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  35. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  36. Aina R, Oliva VL, Therasse E, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12:195-200.

  37. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  38. Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M, Hillon P, Rat P, Ricolfi F, Krausé D. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operative-risk patients. J Clin Gastroenterol. 2008 Apr;42(4):361-7.

  39. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  40. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461.

  42. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, Ring EJ, Welton ML. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997;174(1):24-8.

  43. Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001;177:829-836 7.

  44. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001;12:1399-1405.

  45. Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009;104:2042-2046

  46. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg 1989;209:175-180

  47. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology 1982;142:47-51.

  48. Koh DC, Luchtefeld MA, Kim DG, Knox MF, Fedeson BC, Vanerp JS, et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009;11:53-59

  49. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008;51:301-305

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