Pelvic Congestion Syndrome Presented by Dr. Junish Singh Bagga MS - General Surgery. DNB-SS Peripheral Vascular and EndoVascular Surgery

1. PELVIC
CONGESTION
SYNDROMEDr. Junish Singh Bagga

2. INTRODUCTION
➤ Females of childbearing age.
➤ 1949 - Taylor
➤ 15% pelvic pain - 10% PCS
➤ D/D of PCS
➤ Endometriosis
➤ Uterine fibroma
➤ Pelvic malignancy/SOL
➤ Pudendal nerve compression

3. ANATOMY
➤ Internal iliac vein
parietal branches - superior,
inferior gluteal, sciatic, sacral,
ascending lumbar, obturator
visceral - internal pudendal,
middle hemorrhoidal,
vesicoprostatic/uterine,
gonadal, vesicovaginal
➤ Gonadal veins
utero-ovarian, salpingo-
ovarian (broad ligament)

4. INTERNAL ILIAC -
UTERO-OVARIAN
1. Ovarian vein
2. Internal iliac vein
3. Uterine vein
4. Obturator vein
5. External pudendal vein
6. Great saphenous vein
7. Antero-medial thigh varicosity
8. Postero-lateral thigh varicosity
9. Sciatic vein
10.Vulvar varicosity
11.Internal pudendal vein
12.Cystic, vaginal veins
13.Buttock veins

5. VALVES IN
GONADAL VEINS
Males – upto 40% gonadal veins are devoid of valves
Females – left 13% no valves
right 6%

6. PATHOPHYSIOLOGY
➤ Type 1 -
Vein incompetence.
?hormonal
estradiol - inhibits reflex
vasoconstriction
➤ Type 2 -
Outflow obstruction
MTS, renal vein thrombus,
Budd-chiari
➤ Type 3 -
Local factors
endometriosis, trauma,
tumors, infections

7. CLINICAL FINDINGS
➤ 20-30 year females, multiparous
➤ Disappear after menopause
➤ Rare in men, varicocele, obstructive
pathology
➤ Symptoms
chronic pelvic pain, heaviness, dyspareunia,
dysmenorrhoea, urinary and rectal
symptoms.
relieved on supine position.
➤ Mostly on one side, may be bilateral.
➤ Lower limb symptoms
superficial venous insufficiency, recurrent
varicosity.
atypical varicose veins (buttock, posterior
and lateral aspect of thigh)

8. DUPLEX SCAN
➤ 5 Mhz
➤ Internal iliac + gonadal
veins
➤ Varicosity with venous
doppler signals
➤ > 5mm
➤ Obturator, sciatic, internal
pudendal
➤ Common iliac, IVC, renal
veins
➤ Lower extremity - optional

10. CT VENOGRAPHY
➤ CT Venography - indirect
venography (recirculation)
100-150cc contrast (2ml/kg)
➤ Veins above > 80 HU - diagnostic
➤ Timing is tricky - limiting factor
60 sec - thoracic
70-80 sec - upper extremity
11 sec - pelvis
150-180 sec for lower extremity
➤ Opacification in the arterial phase
➤ Diameter > 7mm

11. MR VENOGRAPHY
➤ T2 weighted, gradient echo MRI
➤ T1 weighted gradient echo with
gadolinium are most effective for
diagnosing pelvic varicosity.
Negatives
Expensive, availability sometimes
limited
Exam may be lengthy
Pt. cooperation
Spatial resolution (vs other
choices)
Limited anatomic coverage

12. CONTRAST PHLEBOGRAPHY
➤ Gold standard
➤ Femoral, brachial approach
➤ Both internal iliac, both gonadal
➤ Ovarian vein valvular
incompetence
➤ >5mm
➤ 20 sec contrast hold
➤ Congestion in pelvic venous
plexus
➤ Opacification of internal iliac
vein
➤ Filling of vulvo-vaginal, thigh
varicosity

13. MEDICAL MANAGEMENT
➤ Medroxyprogesterone
acetate 30mg/day x 6
months
50% improvement in
73% patients
➤ Goserelin acetate
3.6mg/month x 6 months
➤ MPFF 500mg twice daily
for 6 months

14. CONVENTIONAL & LAPAROSCOPIC
SURGERY➤ Hysterectomy + b/l
salpingo-
oophorectomy
➤ Ovarian and/or
internal iliac vein
ligation
➤ Uterine artery and
vein ligation
➤ Oophorectomy

15. ENDOVASCULAR
➤ Basic Principles
➤ Entire internal iliac vein shouldn’t be embolized
➤ Gonadal vein embolisation to be performed proximal to last collateral

16. HARDWARE / INSTRUMENTS
➤ Femoral vein cannulation 5f, 6f
➤ Multi-purpose catheter, Simmon’s catheter(acute angle),
Cobra-2 (60-120)

17. EMBOLIZATION AGENTS
➤ Coils - 0.035 inch
for 4f or 5f cath
0.018 inch -
microcatheters
➤ Vascular plugs -
Amplatzer
➤ Foam sclero can
be added before
coiling or sandwich
➤ Glue -
cyanoacrylate
➤ Internal iliac vein
balloon

18. COMPLICATIONS
➤ Hematoma, access
site complications
➤ Extravasation of
contrast
➤ Coil or glue
embolisation
➤ DVT, PE
➤ Transient cardiac
arrhythmia