Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3687_Библиотеки_им_академика_М_И_Перельмана
.pdf
312 Chapter 34/Use of System-Specifi c Questionnaires and Determination of Quality of Life after Treatment of Varicose Veins
https://t.me/med1917
disorders of the leg (telangiectasia, varicose veins, edema,
skin changes, and leg ulcers), psychological factors, and
items regarding change over time. There were four language
versions and it was assessed initially in 615 patients. The
results confi rmed that the questionnaire was acceptable, reliable, and had good validity and responsiveness in all four
languages in European and North American populations.19
Construct validity also was demonstrated in comparisons
between multiple languages with the SF-36 and with CEAP
classifi cations.
In 2001 a VEINES study of 1313 patients concluded that
fi ndings concerning quality of life in patients with varicose
veins could only be reliably interpreted when concomitant
venous disease was taken into account. In patients with
varicose veins alone the objectives of cosmetic improvement and the improvement in quality of life should be considered separately. VEINES-QoL was more sensitive to the
combination of venous disorders with varicose veins than
those provided by the SF-36.
20
The relationship between CEAP classifi cation and patientperceived quality of life was evaluated in 2005. The VEINES
cohort of patients was used and it was found that CEAP class
was signifi cantly associated with generic and diseasespecifi c quality of life. CEAP class predicted diseasespecifi c but not generic quality of life scores; higher CEAP
class was associated with poorer disease-specifi c quality of
life. This study also provided further evidence of the validity
of the VEINES-QoL and VEINES-SYM and the specifi city
of CEAP in detecting morbidity attributable to chronic
venous diseases.
21
PROBLEMS
There is a dearth of published data on quality of life
assessments in patients with varicose veins despite the large
number of operations performed each year. There are also a
plethora of techniques now available for the treatment of
varicose veins, yet no assessment with either generic or
disease-specifi c tools.
The possible reasons for the paucity of publications may
be that this research modality is time consuming and the
response rate from the subjects is often poor. Pressure from
a patient-centered National Health Service and National
Institute for Clinical Excellence (NICE) will change this. In
two recent large multicenter national trials, the United
Kingdom small aneurysm trial (UKSAT) and endovascular
aneurysm repair trial (EVAR 1) both used quality of life
tools in their assessment along with the more familiar morbidity and mortality data.
In the forum of innovative therapies for varicose veins,
new techniques will have to undergo rigorous testing and
will have to demonstrate that they are of benefi t before
22,23
funding is approved; quality of life tools will be paramount
in this.
CONCLUSION
The AVVS was one of the fi rst tools to evaluate a surgical
intervention for venous insuffi ciency. It is unique in visually
scoring the extent of varicose veins with a pictorial representation of each patient’s varicose veins on a standardized
grid. The AVVS demonstrated that patients with the worst
scores had the most to gain from surgery. It may be that
AVVS could be used as a prescoring technique to quantify
the severity of disease present and thereby be used as a
means of identifying the patients whose treatment could be
deemed to be the most cost effective.
Each disease-specifi c instrument asks about pain, appearance, and immobility. CIVIQ and VEINES are large multinational instruments that have been shown to be useful in
investigating the lower (less severe) CEAP classes.
At present there is no single quality of life tool that can
be used to measure the impact of venous disorders on
patients. The use of psychometric tools is paramount to the
measurement of surgical outcomes and is intertwined with
future funding of new techniques for venous disease. Quality
of life should be a standard measure in future studies in
assessing treatments for venous diseases, preferably with a
combination of generic and disease-specifi c tools. Following the introduction of a new treatment there is a need for
valid and reliable measures of health outcome in order
for limited resources to be best allocated in the most costeffective manner. The disease-specifi c questionnaires
described earlier are validated, reliable tools, and their use
in future trials is mandatory in conjunction with generic
studies in order to evaluate the impact of new therapies on
patients with varicose veins.
References
1. Darke SG. The morphology of recurrent varicose veins, Eur. J. Vasc.
Surg. 1992. 6, 512–517.
2. Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose
veins and chronic venous insuffi ciency in men and women in the
general population: Edinburgh Vein Study, J. Epidemiol. Community
Health. 1999. 53, 149–153.
3. Coon WW, Willis PW III, Keller JB. Venous thromboembolism and
other venous disease in the Tecumseh community health study, Circulation. 1973. 48, 839–846.
4. Laing W. Chronic venous disease of the legs. 1992. London: Offi ce of
Health Economics.
5. Eklof B. Modern treatment of varicose veins. Br. J. Surg. 1988. 75,
297–298.
6. Price P. Defi ning and measuring quality of life, J. Wound Care. 1996.
5, 139–140.
7. Beattie DK, Golledge J, Greenhalgh RM, Davies AH. Quality of life
assessment in vascular disease: Towards a consensus, Eur. J. Vasc.
Endovasc. Surg. 1997. 13, 9–13.
References 313
https://t.me/med1917
8. Calman KC. Quality of life in cancer patients-an hypothesis. J. Med.
Ethics. 1984. 10, 124–127.
9. Aaronson NK, Acquadro C, Alonso J, Apolone G, Bucquet D, Bullinger
M et al. International quality of life assessment (IQOLA) project, Qual.
Life Res. 1992. 1, 349–351.
10. Streiner DL, Norman DR. Health Measurement scales: A practical
guide to their development and use. 1990. Oxford: Oxford University
Press.
11. Katz JN, Larson MG, Phillips CB, Fossel AH, Liang MH. Comparative
measurement sensitivity of short and longer health status instruments,
Med. Care. 1992. 30, 917–925.
12. Rutherford RB, Padberg FT Jr, Comerota AJ, Kistner RL,
Meissner MH, Moneta GL. Venous severity scoring: An adjunct
to venous outcome assessment. J. Vasc. Surg. 2000. 31, 1307–
1312.
13. Garratt AM, Macdonald LM, Ruta DA, Russell IT, Buckingham JK,
Krukowski ZH. Towards measurement of outcome for patients with
varicose veins, Qual. Health Care. 1993. 2, 5–10.
14. Launois R, Reboul-Marty J, Henry B. Construction and validation of
a quality of life questionnaire in chronic lower limb venous insuffi ciency (CIVIQ), Qual. Life Res. 1996. 5, 539–554.
15. Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation
of outcomes in chronic venous disorders of the leg: Development of a
scientifi cally rigorous, patient-reported measure of symptoms and
quality of life, J. Vasc. Surg. 2003. 37, 410–419.
16. Smith JJ, Garratt AM, Guest M, Greenhalgh RM, Davies AH. Evaluating and improving health-related quality of life in patients with varicose veins, J. Vasc. Surg. 1999. 30, 710–719.
17. Mackenzie RK, Lee AJ, Paisley A, Burns P, Allan PL, Ruckley CV,
Bradbury AW. Patient, operative, and surgeon factors that infl uence the
effect of superfi cial venous surgery on disease-specifi c quality of life,
J. Vasc. Surg. 2002. 36, 896–902.
18. Mackenzie RK, Paisley A, Allan PL, Lee AJ, Ruckley CV, Bradbury
AW. The effect of long saphenous vein stripping on quality of life. J.
Vasc. Surg. 2002. 35, 1197–1203.
19. Lamping DL, Abenhaim L, Kurz X, Schroter S, Kahn SR, the VEINES
Group. Measuring quality of life and symptoms in chronic venous
disorders of the leg: Development and psychometric evaluation of the
VEINES-QOL/VEINES-SYM questionnaire. Qual. Life Res. 1990. 7,
621–622.
20. Kurz X, Lamping DL, Kahn SR, Baccaglini U, Zuccarelli F, Spreafi co
G, Abenhaim L. Do varicose veins affect quality of life? Results of an
international population-based study, J. Vasc. Surg. 2001. 34, 641–
648.
21. Kahn SR, M’lan CE, Lamping DL, Kurz X, Berard A, Abenhaim LA,
for the VEINES Study Group. Relationship between clinical classifi cation of chronic venous disease and patient-reported quality of life:
Results from an international cohort study, J. Vasc. Surg. 2004. 39,
823–828.
22. The UK Small Aneurysm Trial Participants. Health service costs and
quality of life for early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. UK Small Aneurysm Trial
Participants, Lancet. 1998. 352, 1656–1660.
23. EVAR Trial Participants. Endovascular aneurysm repair versus open
repair in patients with abdominal aortic aneurysm (EVAR trial 1):
Randomised controlled trial, Lancet. 2005. 365, 2179–2186.
This page intentionally left blank
https://t.me/med1917
CHAPTER
https://t.me/med1917
35
Pelvic Congestion Syndrome:
Diagnosis and Treatment
GRAEME RICHARDSON
INTRODUCTION
Pelvic congestion syndrome (PCS) is still treated with
skepticism by the medical community, yet in most instances
it could be called the female varicocele, and is the female
version of male varicocele which is well recognized.
PCS is a distinct clinical entity in relatively young multiparous women characterized by chronic pelvic pain in the
setting of pelvic venous varicosities. The syndrome, fi rst
described as a vascular condition by Taylor in 1949,1 was
more recently shown by Hobbs2 to be the result of venous
engorgement of the pelvis due to gross dilatation and incompetence of one or both of the ovarian veins. In a series of
50 symptomatic patients with either pelvic or vulval varicose veins assessed by our ultrasound techniques in Wagga
Wagga, the cause was found to be ovarian vein refl ux in
71% of cases, more often the left than the right (24 : 9).
These cases could well be described as the female varicocele. Saphenofemoral tributaries were the only cause of
vulval varicose veins in approximately 10% of cases, and
the remainder were assumed to be caused by internal iliac
refl ux alone. The latter probably accounts for at least 10%
of the cases of pelvic congestion syndrome. In addition, it
seems likely that segmental pelvic vein refl ux accounts for
a further 10% of cases. Many patients with recurrent leg
varicose veins are found to have a signifi cant component of
their problem from the pelvis. Seeking symptoms of PCS, a
history of vulval varicose veins of pregnancy, and looking
for a contribution from the pelvis in all patients presenting
with leg varicosities will result in a greater awareness of a
common yet poorly understood clinical problem.
ETIOLOGY
Although rarely seen in nulliparous teenagers and young
women, when one may assume the cause is identical to male
varicocele, this condition largely follows pregnancy. Vulval
varicose veins are said to occur in 2 to 7% of pregnancies.
These become larger in subsequent pregnancies, although
they often disappear in the postpartum period. Usually after
three pregnancies some varicose veins remain in the vulva,
upper medial thigh, perianal, or gluteal regions. Probably the
majority of cases are related to massive enlargement of the
ovarian veins draining the pregnant uterus, perhaps associated with internal iliac vein compression. Perhaps after pregnancy some ovarian veins do not return to normal size, and
the limited one or two valves at the upper end of the ovarian
veins may become incompetent. Maybe segmental refl ux
occurs in tributaries of the internal iliac veins such as the
uterine veins, and the round ligament veins, and can be
responsible for persisting pelvic varicosities, even though
we are unable to demonstrate ovarian vein or main trunk
internal iliac vein refl ux. We have often demonstrated this
segmental refl ux in our pelvic ultrasound assessment.
Compression syndromes are a further cause of left ovarian
vein refl ux, particularly superior mesenteric artery compression of the left renal vein and retroaortic left renal vein with
compression. Compression of the left common iliac vein by
the right common iliac artery can produce internal iliac
refl ux.
Although hormonal and psychiatric factors have at times
been implicated in the symptomatology, exacerbation of
symptoms with menstruation, sexual activity, and ovulation
3,4
The Vein Book
315
All rights of reproduction in any form reserved.
Copyright © 2006, Elsevier Inc.
316 Chapter 35/Pelvic Congestion Syndrome: Diagnosis and Treatment
https://t.me/med1917
A
FIGURE 35.1 A. Residual vulval varices. B. Vulval to posterior thigh to lateral calf varices.
suggests increased arterial fl ow to the pelvis at these times
results in pooling of venous blood in the pelvic varicosities.
This results in pressure in the pelvis alone, or if there are
pelvic escape veins some or all of the pressure is transmitted
to the vulva, buttock, or leg varicosities.
If large pelvic veins persist in the broad ligament, typical
pelvic symptoms occur. Associated with these varicosities
there may be pelvic escape through either the internal iliac
tributaries, namely obturator or internal pudendal, or the
round ligament into the vulva and upper medial thigh, or
posteriorly into the buttock and posterior thigh (see Figure
35.1A), sometimes including varices of the vein of the sciatic
nerve producing sciatica. These veins usually feed into either
the long or short saphenous system, and if these are not treated
at the time of treatment of long or short saphenous varicose
veins, then they cause recurrent varicose veins. A typical
pattern is posterior vulval veins coursing posteriorly into the
short saphenous via the Giacomini vein (see Figure 35.1B).
DIAGNOSIS
Clinical suspicion of PCS relies on typical symptoms,
namely pelvic heaviness or deep pelvic pain, which is
present before the menstrual period and on day 1 and sometimes day 2 of menstruation, mid-cycle, and post-coital. The
latter is particularly noticeable on standing up immediately
after having had morning intercourse. This aching may
persist for several hours through the day. The pelvic heavi-
B
ness is particularly severe after long periods of standing.
Many patients complain of dyspareunia and many are aware
of vulval and leg varicosities, which are worse at the time
of their pelvic symptoms. Commonly there are bladder
symptoms related to perivesical varicosities causing frequency or a diffi culty in starting the fl ow of urine. Many
patients have symptoms of irritable bowel syndrome.
The diagnosis of PCS is often delayed until investigations
looking for endometriosis, infl ammatory bowel disease,
urinary tract disease, or pelvic infl ammatory disease have
proved negative. It is common for patients to have suffered
marital stress and dissatisfaction with their treating doctor’s
lack of interest in their condition.
INVESTIGATIONS
All patients with symptoms consistent with PCS are examined carefully to exclude other causes of pelvic pathology,
and then undergo standard pelvic ultrasound and duplex
ultrasound assessment of the pelvic, ovarian, and when appropriate, groin and lower limb veins. Earlier reports have advocated venography to demonstrate pelvic varices, either by use
of vulval varicography,5 transuterine,
raphy, or selective ovarian venography.
are invasive and may, in some cases, invalidate assessment
for refl ux. For example, if a catheter is placed selectively
adjacent to or inside the orifi ce of the right or left ovarian vein,
it may pass the only valve present, and injection will then
6,7
per-osseous8 venog-
9,10
These techniques
Investigations 317
https://t.me/med1917
is tilted head up by 60˚ on a motorized ultrasound examination table. Our ultrasound assessment begins with the patient
presenting after six hours of fasting, with a full bladder.
Fasting reduces gut motility, and the full bladder enables
standard gynecological pelvic ultrasound. A full bladder,
however, compresses pelvic varicosities, which may be
visible by transabdominal ultrasound after voiding. Transvaginal ultrasound then follows, and having confi rmed PCS,
we examine the ovarian veins and the internal iliac veins,
including anterior and posterior divisions. The round ligament veins and saphenofemoral tributaries also are assessed.
In Wagga Wagga, windows were developed to assess
ovarian vein incompetence using transabdominal duplex
ultrasound and color fl ow Doppler (3.5 or 5 MHz trans-
12
ducer).
A
and assess refl ux in 93% of cases,13 which compares well
We demonstrated the ability to locate ovarian veins
with the 92% visualization shown by Lechter using venography. The left ovarian vein is found by fi rst locating the left
renal vein as it passes under the superior mesenteric artery.
The ultrasound window is through the left lobe of the liver
and the pancreas. The ovarian vein is located by following
the left renal vein laterally and rotating the transducer through
90 degrees (see Figure 35.2A). A retroaortic left renal vein,
duplicated renal vein, or large ureteric veins are noted if
present. It is important to not confuse accessory renal veins
or the inferior mesenteric vein for the ovarian vein. The right
ovarian vein is found using a window through the liver or
gallbladder, by following the inferior vena cava upward to
where the right ovarian vein enters it anterolaterally at a very
acute angle. Sampling by color and waveform is taken about
2 cm below the termination of the ovarian veins (see Figure
35.2B). The criterion for incompetence in the ovarian vein is
B
FIGURE 35.2 A. Ultrasound left ovarian vein (red) and left renal vein
(blue). B. U/S left ovarian vein/LRV with waveform showing refl ux.
reversed fl ow when lying, sitting, or standing without augmentation. Treatment either by surgery, or more recently
endovascular methods, is based on the ultrasound fi ndings.
demonstrate apparent refl ux. Varicography can demonstrate
the anatomy of vulval and buttock varices and the relevant
pelvic escape veins, but not the physiology, for example,
refl ux (see Figure 35.3). More recently, MRI and multislice
CT have been used to detect pelvic varices11 in the assessment
of chronic pelvic pain. Dynamic MRI techniques currently
are being developed in Madrid (personal communication)
that can show ovarian vein refl ux, but will need to be compared with ultrasound techniques for cost and reliability.
PCS is confi rmed on transvaginal ultrasound by fi nding
excessive pelvic varicose veins in the broad ligament, which
we would grade as mild (<5 mm), moderate (5–7 mm), or
marked (8–10 mm), depending on the diameter, and whether
these pelvic varicosities are found to distend when the patient
Laparoscopy
Laparoscopy sometimes is required to exclude other possible causes for pelvic pain, such as endometriosis or pelvic
infl ammatory disease in patients who have pelvic varices on
ultrasound assessment. We do this with the patient’s gynecologist. Laparoscopy involves using an extra left iliac fossa
port to retract the sigmoid colon. The patient, who initially
is head down for gynecological laparoscopy, is then tilted
head up and the ovarian and broad ligament veins are seen
to distend rapidly if refl ux is present.
Ultrasound Assessment
Venography
Many centers rely on clinical fi ndings, then proceed to
selective venography for confi rmation, and then to endovascular treatment. Ultrasound confi rmation of excessive pelvic
varicose veins by transvaginal ultrasound, even if ultrasound
318 Chapter 35/Pelvic Congestion Syndrome: Diagnosis and Treatment
https://t.me/med1917
FIGURE 35.4 Left renal venogram with refl ux into large LOV. Note the
narrow upper end, which helps prevent embolization of coils.
FIGURE 35.3 Varicogram vulval varices with round ligament and obtu-
rator pelvic escape veins.
assessment for ovarian vein refl ux is not possible, should
prevent unnecessary invasive venography, and assist in provision of informed consent, should a patient be referred to
an interventional radiologist for venography with a view to
coils +/– sclerotherapy. Left renal venography is followed
by selective ovarian venography (see Figures 35.4 and 35.5).
If indicated by ultrasound fi ndings, we may do selective iliac
venograms.
TREATMENT
Various methods have been used to treat the symptoms
of pelvic congestion, including psychotherapy, ovarian
suppression,14 intravenous dihydroergotamine,15 and bilateral oophorectomy with hysterectomy.16 Ovarian vein ligation has been performed to eliminate refl ux since 1985, as
either a bilateral procedure,17 or unilateral based on ultrasound assessment (Richardson 1989). The long-term results
of such treatment have been poorly investigated. It is important that any assessment of treatment of venous conditions
needs to have at least fi ve-year follow-up. Of recent years,
however, endovascular ablative techniques have been popularized, and again need to be adequately assessed.
As many of these patients have associated leg varicosities, a treatment plan is required. The pelvic veins are treated
only if there are pelvic symptoms, or if they signifi cantly
contribute to the leg varicosities. In these cases the pelvic
veins are treated initially, and the response of symptoms is
determined over a period of two to three months before
treating the vulval or leg varicosities. In a few instances, the
veins can reduce in size such that sclerotherapy of the residual vulval or leg veins might be appropriate, rather than
surgical treatment.
Ovarian Vein Incompetence
As most cases involve treatment of the left ovarian vein,
the choice of treatment is between operation and endovascular ablation techniques. Laparoscopic treatment has been
investigated, and although it is possible to clip the upper end
of the ovarian veins, it is currently not possible to remove
a segment, nor would it be easy to deal with nearby
tributaries.
Operation
Ovarian vein ligation has been performed on 120 patients
since 1989 by the author. It involves a sympathectomy incision with a muscle splitting extraperitoneal approach to the
ureter and the adjacent ovarian vein, which is ligated carefully using nonabsorbable material at the level of the pelvic
brim. The ligature is then used for traction to enable further
multiple ligations upward to fi nish at approximately 2 cm
from the left renal vein. A narrow Dever retractor is useful
Treatment 319
https://t.me/med1917
FIGURE 35.5 Selective left ovarian venogram fi lling large left broad
ligament varices with crossover to the right broad ligament and drainage
via the ROV and both iliac veins, also showing presacral veins.
quantitative response of symptoms to surgical treatment
20
using visual analogue scales.
Sixty-seven of the 72 patients
responded with a mean follow-up of 33 months (range 4 to
71) with a mean age of 35 years and mean pregnancies of
3.1. Pelvic heaviness was found to improve signifi cantly
(>50%) in 70% of patients, and in 56% of patients, this was
almost complete. Thirteen percent reported little or no
improvement, and when these were subsequently investigated, including further ultrasound and venography, no
ovarian refl ux could be found, and in all cases alternative
diagnoses such as irritable bowel syndrome were present.
Dyspareunia was present preoperatively in 82% of cases,
and 84% of these improved, 50% of these patients reported
complete recovery.
Post-intercourse pelvic aching was present in 75% of
patients, and improved in 70% of cases with 64% having
complete recovery. Bladder symptoms of frequency and
obstruction improved in 45% of patients, and some of the
20% of patients who preoperatively were aware of bowel
spasm improved. Two patients had normal pregnancies
subsequent to ovarian vein ligation with no development
of vulval veins in the pregnancy and no recurrence of
symptoms.
to expose this uppermost portion. There is signifi cant risk of
major hemorrhage if the ovarian vein is not handled gently.
Operation requires approximately two days hospitalization
and two weeks discomfort, which for a mother of young
children is a considerable inconvenience compared with
outpatient endovascular treatment. When choosing the most
appropriate method of ovarian vein ablation, we accept that
surgical ligation is complete, and provided all tributaries
have been ligated, should produce long-term ablation of the
ovarian vein. It can be performed by any general surgeon
and requires no special equipment. It does produce a scar,
however, and discomfort. I should reiterate that I would
ligate only an ovarian vein that was shown to refl ux on
ultrasound assessment. Other surgeons have routinely ligated
2,17
both ovarian veins.
It would seem unwise to ligate a draining vein that did not refl ux. Some surgeons have advocated
an even more extensive dissection to include the ovarian
pedicle.18 There is no evidence to suggest a more limited
operation such as the Wagga Wagga technique has inferior
results.
Surgical Results
Long-term results in a series of 72 patients treated until
June 1995 in Wagga Wagga certainly encourages one to
treat patients based on the ultrasound fi ndings of ovarian
vein refl ux.19 These patients were sent questionnaires and
were assessed independently by a surgical registrar for their
Ovarian Endovascular Ablation
There have been several reports of single or a few case
reports of successful treatment by ovarian vein emboliza-
21–24
tion.
Thus far, there has been no standardization of the
techniques used by several centers but, in all instances,
coils of various diameters and lengths have been used. In
some centers, sclerotherapy has been used but in the Dutch23
experience, sclerotherapy was contraindicated because of a
perceived risk of entering the portal system. A team in
Vancouver, which has a very large experience of treatment
of male varicocele using similar techniques has utilized a
combination of coils and glue (personal communication).
Since January 1999 we have been using endovascular
techniques. We prefer to use an inguinal approach, and when
cannulation of the ovarian vein is diffi cult, would use a
guiding catheter and still use the groin, rather than a jugular
or brachial approach. Our technique uses stainless steel coils
with attached synthetic fi bers (Cook), choosing a diameter
to oversize by 2 to 3 mm the ovarian vein diameter. In addition, sclerosant has been used with 2 ml of 3% Aethoxysklerol
diluted with about 1 to 2 ml of contrast so that the spread of
sclerosant can be seen clearly on the screen to avoid spillover into the left renal vein. Air is added and the syringe
shaken to produce coarse bubbles. Our hope is that the sclerosant will help obliterate pelvic and broad ligament varices.
By causing spasm we may help prevent migration of the
coils. In no instances have we seen any contrast pass beyond
the ovarian vein or broad ligament veins. Although preparing the sclerosant as a foam would seem desirable, the
320 Chapter 35/Pelvic Congestion Syndrome: Diagnosis and Treatment
https://t.me/med1917
contrast is further diluted and less visible than with coarse
bubbles, and we are less sure of its spread. In an attempt
to reduce the cost to the patient we have tried to use the
minimum number of coils to achieve the following principles. The fi rst coil is deployed at the level of the pelvic brim
just above where it crosses the ureter. Depending on the
anatomy of the ovarian vein, we aim to place a coil across
junctions or selectively coil major tributaries. We try to have
good cross-section coverage of the vein by varying the
deployment, and we aim to have the highest point above all
incompetent tributaries, and within 2 to 3 cm of the left
renal vein. Usually two long (20 cm) coils suffi ce, with occasional shorter coils in tributaries or at the upper end of the
vein. We are aiming for the highest and longest possible
ablation.
Our approach has been via the right femoral vein and
having confi rmed ovarian vein refl ux by a selective left
renal venogram, a guidewire is passed down the ovarian vein
to the pelvis, and a catheter advanced to the level of the
pelvic brim. Approximately one-third of the 2 ml of sclerosant is injected slowly, with the patient holding her breath
with Valsalva as long as possible. In male varicocele
patients, this is combined with compression at the level of
the external ring to avoid the sclerosant passing into the
scrotum.
There are risks to endovascular techniques including
embolization, migration and perforation of coils, irritation
of nerves such as genitofemoral, and the possibility of late
recanalization. There have been reports of recanalization
resulting in recurrent symptoms requiring later surgical
treatment.
Internal Iliac Veins
Where patients are shown to have signifi cant internal
iliac vein refl ux as a cause for the pelvic congestion syndrome, surgical treatment to ligate the main branch or selectively the anterior division has been performed on a few
patients in our series and by others.18 There are risks to the
surrounding structures, such as ureter and iliac vessels.
There are also signifi cant risks to endovascular treatment of
the internal iliac system, being a very large vein at its
junction with the external iliac vein. The shape of the vein
encourages embolization. In one case, we have deployed a
coil into the anterior division together with sclerotherapy.
When the patient has ovarian and internal iliac vein refl ux
on ultrasound assessment, we have treated only the ovarian
vein. Thus far we have not needed to treat the internal iliac
vein because of a disappointing result.
Vulval Varicosities
Having treated the ovarian vein, these improve and can
be treated by avulsion techniques by minor surgery, or at the
time of dealing with the long or short saphenous varicosities.
Large round ligament veins can be ligated as they emerge
from the external inguinal ring. Sclerotherapy of residual
minor vulval varicosities is possible, and the author on many
occasions has used 2%Aethoxysklerol. To apply adequate
compression after the sclerotherapy I use cotton balls covered
by tape and the patient wears a fi rm support, such as bicycle
pants, in an attempt to provide as much compression as
practical. Side effects from the sclerotherapy have been surprisingly few.
Ureteric Vein Refl ux
Inevitably unusual cases will appear associated with
venous anomalies. We have treated several cases with large
refl uxing ureteric veins that are tortuous and feed into the
ovarian vein usually in the lower third of the abdomen. They
are often diffi cult to cannulate for coil treatment. Sometimes
the ovarian vein joins a lower renal vein branch, or a large
lumbar vein rather than the renal vein, and sometimes the
ovarian or the renal vein is duplicated. In all cases coming
to endovascular treatment we have to be prepared for such
anomalies and devise the best treatment strategy.
Other Causes of Pelvic Congestion
Some patients present with congestion symptoms or
minor vulval varices, yet we are unable to demonstrate
ovarian or internal iliac incompetence. As with most venous
disease, there is variability related to long periods of standing and the menstrual cycle. Repeat ultrasound studies show
this and we try to perform studies when symptoms are
maximal. There remain patients where there clearly are signifi cant pelvic varices but no source of refl ux. Some of these
are due to venous obstruction associated with collateral
venous pathways. We have observed patients with both fi xed
and intermittent refl ux of internal iliac veins associated with
common iliac vein obstruction. In some cases this is postural, when recumbent there is reversed fl ow, and is associated with 1 to 2 mm AP diameter where the right common
iliac artery crosses the left common iliac vein. Perhaps some
of these patients would benefi t from a venous stent. A retroaortic left renal vein frequently has been associated with
PCS and rarely left renal vein obstruction following surgical
ligation. I avoid ablation of the ovarian vein in these patients
with collateral drainage of the kidney.
Segmental Pelvic Vein Refl ux
There remains a group of patients where we cannot demonstrate a defi nite cause. It appears quite feasible that some
very large pelvic veins in pregnancy don’t shrink and produce
segmental refl ux in uterine and broad ligament veins.
These patients and others whose symptoms fail to resolve
References 321
https://t.me/med1917
after ovarian or iliac vein ablation are best treated by
hysterectomy.
COMPARISON OF RESULTS OF COIL
AND SURGICAL TREATMENT OF
OVARIAN REFLUX
Patients treated by surgery from 1989 until 1998, and
endovascular treatment from 1999 until June 2002 were
studied using a questionnaire with visual analog scales.
Statistical analysis of pelvic heaviness and overall satisfaction showed no difference between endovascular and surgical treatment.25 Both treatments resulted in statistically
signifi cant improvement after treatment. A decision to treat
in both groups was based on clinical fi ndings and ultrasound
assessment, and there was no statistical difference in the
presenting features of patients in either the surgical or the
endovascular series.
Patients undergoing coil treatment were also subjected to
follow-up ultrasound studies at six weeks–six months and
also abdominal radiographs. There was no evidence of coil
migration in 34 patients. Early ultrasounds showed two clots
in broad ligament veins, no signifi cant reduction in diameter
at six to 10 weeks, but some evidence of reduction by six
months.
Long-term results of endovascular treatment have not yet
been reported. Re-canalization remains possible but should
be amenable to further endovascular treatment. Although the
great majority of patients tolerate coil treatment with little
discomfort, anxious patients are more diffi cult to cannulate
the femoral vein, and spasm of the ovarian vein could lead
to perforation. Patients have far less loin discomfort than
after surgery, but it seems excessive exercise should be
restricted. A few patients have severe pain and this could be
due to thrombosis of the ovarian vein or perforation.
Patient satisfaction justifi es ablation of an ovarian vein
shown by ultrasound to refl ux.
Provided endovascular ovarian vein ablation can be
delivered safely and at reasonable cost, then there are defi nite advantages over surgical treatment. Complications can
occur from either method. The incidence of long-term recanalization is unknown.
There is no evidence that endovascular treatment produces better results than surgery. Provided patients are
prepared to accept the scar, pain, hospitalization, and other
potential complications of an operation, at this point one
cannot say surgical treatment has been superseded.
References
1. Taylor HC, Wright H. Vascular congestion and hyperaemia, Am J Obst
Gynecol. 1949. 57: 211–230.
2. Hobbs JT. The pelvic congestion syndrome, Br J Hosp Med. March
1990. 43: 200–206.
3. Dodd H, Wright AP. Vulval varicose veins in pregnancy, Br Med J.
1959. 1: 831–832.
4. Dixon JA, Mitchell WA. Venographic and surgical observations in
vulvar varicose veins, J Surg Gynaecol Obstet. 1970. 131: 458–464.
5. Craig O, Hobbs JT. Vulval phlebography in the pelvic congestion syndrome, Clin Radiol. 1974. 24: 517–525.
6. Heiner G, Siegel T. Zur Frage des Iokalen Kontrast Mittel Schadigung
bei der Uterus Phlebography, Z Cl Gynak. 1925. 87: 829.
7. Chidakel N, Ediundh KO. Transuterine phlebography with particular
reference to pelvic varicosities, Acta Radiol. 1968. 7: 1–12.
8. Lea Thomas M, Hobbs JT. Vulval phlebography in the pelvic congestion syndrome, Clin Radiol. 1974. 25: 517.
9. Ahlberg NE, Bartley O, Chidakel N. Retrograde contrast fi lling of the
left gonadal vein, Acta Radiol. 1965. 3: 385.
10. Chidakel N. Female pelvic veins demonstrated by selective renal phlebography with particular reference to pelvic varicosities, Acta Radiol.
1968. 7: 193–209.
11. Gupta A, McCarthy S. Pelvic varices as a cause of pelvic pain: MRI
appearance, Magn Reson Imaging. 1994. 12(4): 679–681.
12. Richardson GD, Beckwith TC, Sheldon M. Ultrasound windows to
abdominal and pelvic veins, Phlebology. 1991. 6: 111–125.
13. Richardson GD, Beckwith TC, Sheldon M. Ultrasound assessment in
the treatment of pelvic varicose veins. Presented to The American
Venous Forum 1991. Fort Lauderdale.
14. Farquhar CM, Rogers V, Franks S, Pearce S, Wadsworth J, Beard RW.
A randomized controlled trail of medroxyprogesterone acetate and
pschycotherapy for the treatment of pelvic congestion, Br J Obstet
Gynaecol. 1989. 96: 1153–1162.
15. Reginald PW, Beard RW, Kooner JS et al. Intravenous dihydroergotamine to relieve pelvic congestion with pain in young women, Lancet.
August 1987: 351–353.
16. Beard RW, Kennedy RG, Gangar KE et al. Bilateral oophorectomy and
hysterectomy in the treatment of intractable pelvic pain associated with
pelvic congestion, Br J Obstet Gynaecol. 1991. 98: 988–992.
17. Lechter A. Pelvic varices: Treatment, J Cardiovasc Surg. 1985. 26:
111.
18. Gomez ER, Villavicencio JL, Conaway CW, Collins PS, Orecclina PM,
Salander JM, Rich NM. The management of pelvic varices by combined retroperitoneal ligation and sclerotherapy (Abstract), European
American Venous Symposium. 1987. Washington DC.
19. Richardson GD, Beckwith TC, Mykytowycz M, Lennox AF. Pelvic
congestion syndrome—Diagnosis and treatment, ANZ J Phlebol. Nov
1999. 3(2): 51–56.
20. Scott J, Huskisson EC. Graphic representation of pain, Pain. 1976. 2:
175–184.
21. Edwards RD, Robertson IR, McLean AB, Hemingway AP. Case report:
Pelvic pain syndrome—Successful treatment of a case by ovarian vein
embolization, Clin Radiol. 1993. 47: 429–431.
22. Sichlau MJ, Yao JST, Vagelzang RL. Transcatheter embolotherapy for
the treatment of pelvic congestion syndrome, Obstet Gynecol. 1994.
83: 892–896.
23. Boomsma J, Potocky V, Kievit C, Vertrulsdonek J, Gooskens V,
Weemhof R. Phlebography and embolization in women with pelvic
vein insuffi ciency, Medica Mundi. 1998. 42(2): 22–29.
24. Cordts P, Eclavea A, Buckley P, DeMaioribus C, Cockerill M, Yeager
T. Pelvic congestion syndrome: Early clinical results after transcatheter
ovarian vein embolisation, Vasc Surg. 1998. 5: 862–868.
25. Richardson GD, Driver B, Ovarian vein ablation: Coils or surgery?
Phlebology. 2006. 21: 16–23.
Соседние файлы в папке Библиотека им академика М.И. Перельмана