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Table31.1 THE VENOUS CLINICAL SEVERITYSCORE
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CHARACTERISTIC ABSENT=0 MILD=1 MODERATE=2 SEVERE=3
Pain None Occasional/nonanalgesia
Varicose Veins > 4mm None Few Multiple GSV Extensive GSV and SSV
Venous Edema None Evening/Ankle A ernoon/Above knee Morning/requiring elevation
Skin Pigmentation None Limited/Brown Di use lower 1/3/purple Wide/purple
In ammation None Mild cellulitis in
Induration None Focal <5cm Medial or lateral less
Number of active ulcers None 1 2 3
Active ulcer duration <3months >3months <12months > 12months
Active ulcer diameter None <2cm 2–6cm >6cm
Compression None or
noncompliant
restricting
marginal area
Intermittent use Compression stockings
With moderate activity/
analgesia use
Moderate involving
most ofgaiter area
than lower 1/3
worn most days
Daily pain, limitations
to activities or regular
analgesia
Severe cellulitis or signi cant
eczema
1/3 of leg or more
Compression stockings
worndaily
Reliability is the degree to which measurements on
the same individual are similar under di erent conditions.
Test-retest comparisons are the most appropriate method
for assessing reliability if the instrument is intended as an
evaluative tool. Reliability can also be assessed using internal consistency; this checks the extent to which similar
questions give consistent replies.
Responsiveness considers whether the tool is sensitive
to assess measurable change. If meaningful comparisons are
to be made then a standardized measure of responsiveness
is required. e standardized response mean represents the
mean change in score over two points in time divided by the
standard deviation of the score di erences and allows such a
14
comparison.
SYSTEMSPECIFICTOOLS
CLINICAL SCORING SYSTEMS
Consistent and accurate diagnosis and classi cation of clinical signs and symptoms are required before posttreatment
responses can be analyzed. e CEAP (for clinical, etiological, anatomical, pathophysiological) classi cation, originally
developed in 1994, was included in the international recommendations for the reporting standards in venous disease
15
published in 1995.
It was further modi ed in 2004 16 and
is available in several major languages and has now been
adopted worldwide by the vascular community. e CEAP
classi cation is purely descriptive and is not a quanti able
scoring system, nor is it sensitive to changes following intervention, and for this reason the Venous Clinical Severity
Score (VCSS), Venous Segmental Disease Score (VSDS),
and Venous Disability Score (VDS) were designed, based
17
on the CEAP classi cation.
e VCSS is a simple clinical
scoring system is based around ten clinical domains with a
potential maximum score of 30 (see Table31.1). It has been
used in the assessment of treatment outcomes and in clinical
18,19
trials.
It is currently under revision, in order to modify
the language with the aim of further evaluating the criteria
in certain categories to make it more easily applicable to
patients without a ecting the sensitivity, and therefore making it an easier tool for clinicians to use as part of their routine
20
practice as well as in clinical reserach.
e VSDS assesses
the anatomical and pathophysiological components of the
CEAP. e scores are allocated based on re ux or obstruction observed in eleven venous segments on venous imaging—usually color duplex. e VDS is a score ranging from
0 to 3 based on the degree of impairment to daily activities
and reliance on compression. At present the VSDS and VDS
are infrequently used in clinical practice and clinical trials.
In order to fully evaluate and compare di erent treatments or results from di erent publications, there is the
need for standardization of the severity of venous disease,
both from a clinical and function perspective.
Currently there are several system- or disease-speci c
instruments for measuring health-related quality of life in
patients with varicose veins or chronic venous disease of the
lowerlimb.
SYSTEMSPECIFIC
QUESTIONNAIRES
A B E R D E E N V A R I C O S E V E I N
QUESTIONNAIREAVVQ
e Aberdeen Varicose Vein uestionnaire was originally
21
designed by Garratt etal. as a postal questionnaire.
It consists of thirteen questions relating to varicose veins including observable signs, symptoms experienced, the use of
248 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
compression hosiery, the e ect of varicose veins on daily
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activities, and concerns regarding cosmesis, scores range
from 0 (no disease) to 100 (severe disease). e original
paper surveyed 373 patients with varicose veins selected from
a hospital and general practice setting. Acomparison was
made with 900 members of the general population, selected
randomly from the electoral register in Aberdeen, who were
sent a similar questionnaire without the condition-speci c
tool. Ahigh correlation with the SF36 generic health pro le
con rmed the validity of the questionnaire and illustrated
that the perceived health of patients with varicose veins was
21
signi cantly lower than that of the general population.
In
1999 the AVVQ was shown to be responsive to changes following surgery in a cohort of 137 consecutive patients with
22
primary varicose veins.
Based on data collected from the
AVVQ, SF36, and twenty- ve questions that focused on
symptoms and concerns, it was concluded that the AVVQ
was a valid measure of quality of life for patients pre- and
postsurgery. It also con rmed that patients had a signi cant
improvement in quality of life following surgery. Since its
introduction, the AVVQ has become a well-established
and valid tool for measuring quality of life and has been
used in numerous clinical trials and cohort studies to assess
improvements following surgery and endovenous thermal
18,23–26
ablation procedures in patients with varicose veins.
At
present it is validated in Englishonly.
CHRONIC VENOUS INSUFFICIENCY
QUESTIONNAIRE CIVIQ
e original version of the CIVIQ was developed from a
cross-sectional observational study in over 2,000 patients,
of whom over 50% had a diagnosis of venous insu ciency based on clinical signs and reported symptoms. e
CIVIQ2 was devised following a second analysis using a
questionnaire of 20 equally weighted questions on the 1,001
patients with venous disease based on 4 criteria including
physical, psychological, and social concerns as well as pain.
e CIVIQ2 questionnaire has been shown to be appropriate, speci c, and reliable for the assessment of chronic lower
27
limb venous insu ciency.
And since its original publication in 1996 it has been shown to be reliable and responsive
in the assessment of patients with chronic venous insu ciency, following venous out ow stenting in a study to 870
28
patients
and has also been successfully used to evaluate
improvement following endovenous thermal ablation procedures for varicose veins in a number of clinical trials.
29,30
In recent years its use has becoming increasingly popular.
THE CHARING CROSS VENOUS
ULCERATION QUESTIONNAIRE
C X V U Q
e CXVUQ was designed to assess quality of life speci cally in patients with venous leg ulceration. An ulcer-speci c
questionnaire was designed with questions relating to physical discomfort, the e ects on daily activities and social activities, emotional consequences, and perspectives regarding
dressings and mobility. It was validated with the SF36 in a
31
group of ninety-eight patients,
it has found to be reliable
and responsive to treatment in this patient group, however is
not designed for use in patients without venous ulceration.
VENOUS INSUFFICIENCY
EPIDEMIOLOGY AND ECONOMIC
STUDY V EINS
e Veins uestionnaire was developed over 10years from
an international prospective cohort study of 5,688 outpatients with chronic venous disease, that evaluated epidemiological factors and outcomes. e questionnaire consists
of two separate categories: e VEINES quality-of-life
questionnaire (VEINES QoL) consists of twenty- ve
items relating to the impact of chromic venous disease
on quality of life. e VEINES symptom questionnaire
(VEINS-SYM) consists of ten questions evaluating symptoms. Together they form a questionnaire of thirty- ve
di erent items with two summary scores. It was originally
validated in English, French, French Canadian, and Italian
and has been shown to be acceptable, reliable, valid, and
responsive in patients with deep venous thrombosis.
has also been shown to correlate with the SF36 and the
33
CEAP
classi cation as further evidence of its validity, and
in a study of 1,313 patients the VEINES QoL was found to
be more sensitive to quality-of-life changes associated with
varicose veins in combination with venous disorders than
34
the SF36.
It was also suggested that in patients with varicose veins alone, cosmetic concerns and quality of life/relief
of symptoms should be considered separately. In addition
to the assessment of deep venous thrombosis the VEINES
questionnaire has been used to evaluate a wide spectrum
of venous disorders from telangiectasia, to varicose veins,
edema and skin changes, and leg ulceration in patients from
the original VEINES study population and responsiveness
in an additional 1516 patients following treatment, where
treatment outcomes were correlated with quality of life.
SPECIFIC QUALITY OF LIFE AND
OUTCOME RESPONSEVENOUS
SQORV
e SQOR-V questionnaire was developed by a
French-American collaboration and published in 2007.
e aim was to develop a patient-reported outcome measure that would fully evaluate symptoms, impairment to
activities, cosmetic concerns, and the psychological impact
of the disease including concerns regarding risk to health.
e authors proposed that existing disease-speci c tools
were insu ciently sensitive to fully evaluate venous symptoms experienced by patients with supposedly mild disease
32
It
35
36
USE OF SYSTEMSPECIFIC QUESTIONNAIRES • 249
of clinical CEAP classC0–C3, and designed the question-
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naire in order to evaluate this particular group of patients.
Forty-six questions were carefully composed to evaluate symptoms, with a rating scale of 1 to 5 instead of yes/
no answers in order to improve accuracy and sensitivity.
uestions are divided into 5 domains, each with a possible
total score of 20, giving a possible range of scores from 20
(no disease) to 100 (severe disease). It was originally developed in English and then translated into French, in which
it was initially validated, along with the SF12 and a Center
for Epidemiologic Studies-Depression scale (CES-D) in a
group of 202 patients. It has been shown to have internal
consistency, reducibility, structural validity, convergent
36
validity, and clinical validity
and has now been validated
in several other languages including English and Spanish. To
date there have been few published studies of the SQOR-V,
however early data collected in an English-speaking population suggest that it is responsive to change following endovenous thermal ablation treatments in patients of C2–C4
disease, and correlates with the AVVQ and VCSS scores.
37
Larger studies are awaited to support it’s widespread use and
superior sensitivity in this target patientgroup.
DIFFICULTIES WITH
DISEASESPECIFIC QUALITY
OFLIFE
following their intervention. e data is collected centrally
and will be used in the clinical evaluation and assessment of
the performance of treatment centers and research into the
40
clinical and cost-e ectiveness of treatments.
C O N C L U S I O N
e AVVQ was one of the rst disease-speci c tools
designed for the evaluation of varicose veins and remains the
most popular to date, however, a number of newer questionnaires are gaining in popularity. At present there is no single
tool that can be used in isolation, and consideration should
be given to the population under investigation. With the
introduction of rationing for venous interventions, accurate
and appropriate measurement of outcomes to support the
cost-e ectiveness of treatments are of paramount importance. e cost-e ectiveness of treatments is calculated in
quality-adjusted life years (QALYs), a measure of disease
burden and at present is calculated based on generic quality
of life tools. In the future the assessment of the disease burden attributable to chronic venous disease is likely to become
increasingly important in order to justify the allocation of
resources, and therefore the need arises for the development
of a disease speci c tool in order to assess disease burden.
Because the symptoms of venous insu ciency are notori-
38,39
ously di cult to determine and assess,
nding a single
outcome measure that has su cient scope to encompass the
wide spectrum of symptoms experienced at the extremes of
venous disease while remaining sensitive enough to evaluate
improvements following intervention in those with milder
disease is challenging, and at present no single solution
exists. At present the majority of published clinical studies
rely on a number of di erent disease-speci c, generic, and
clinical-outcome measures, making comparison among different techniques and patient groups di cult. In recent years
there has been a move away from the use of surrogate outcome measures of anatomical and hemodynamic function to
evaluate treatments and toward functional and in particular
disease-speci c, quality-of-life outcomes, which are though
to be more truly representative of the patients’ experience.
e routine use of patient-reported outcome measures has
several drawbacks, including being time-consuming and
open to bias from patients and physicians, however they are
likely to gain increasing popularity in the future. Already in
2009 Patient Reported Outcome Measures (PROMs) for
hip and knee replacements and in hernia and varicose vein
surgery have been introduced in many NHS trusts in the
UK. Patients are requested to complete a preoperative disease speci c and generic quality-of-life questionnaire. For
varicose veins this is based on the EQ-5D and the AVVQ
and they are then sent a postal questionnaire at 3months
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USE OF SYSTEMSPECIFIC QUESTIONNAIRES • 251
32.
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PELVIC CONGESTION SYNDROME
DIAGNOSIS AND TREATMENT
Graeme D. Richardson
INTRODUCTION
Pelvic congestion syndrome (PCS) is still treated with skepticism by the medical community, and in most instances is
called “the female varicocoele.”
PCS is a distinct clinical entity in relatively young
multiparous women characterized by chronic pelvic pain
in the setting of pelvic venous varicosities. e syndrome,
rst described as a vascular condition by Taylor in 1949
was more recently shown by Hobbs
venous engorgement of the pelvis due to gross dilatation
and incompetence of one or both of the ovarian veins. In
a series of y 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
re ux in 71% of cases, more o en the le than the right
(24:9). ese cases could well be described as the female
varicocoele. 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
re ux alone. e latter probably accounts for at least 10% of
the cases of PCS. In addition, it seems likely that segmental
pelvic vein re ux accounts for a further 10% of cases. Many
patients with recurrent leg varicose veins are found to have
a signi 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.
E T I O L O G Y
Although rarely seen in nulliparous teenagers and young
women, when one may assume the cause is identical to male
varicocoele, this condition largely follows pregnancy. Vulval
varicose veins are said to occur in 2 to 7% of pregnancies.
ese become larger in subsequent pregnancies, although
2
to be the result of
1
3,4
they o en disappear in the postpartum period. Usually a er
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
a er 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 re 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 re ux. We have o en demonstrated this
segmental re ux in our pelvic ultrasound assessment.
Compression syndromes are a further cause of le ovarian vein re ux, particularly superior mesenteric artery compression of the le renal vein and retro aortic le renal vein
with compression. Compression of the le common iliac
vein by the right common iliac artery can produce internal
iliac re ux.
While hormonal and psychiatric factors have at times
been implicated in the symptomatology, exacerbation of
symptoms with menstruation, sexual activity, and ovulation
suggests increased arterial ow to the pelvis at these times
results in pooling of venous blood in the pelvic varicosities.
is 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 (Figure32.1A), or posteriorly into the buttock and
posterior thigh, sometimes including varices of the vein of
the sciatic nerve, producing sciatica. ese 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
252
A B
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Figure32.1 ( A) Residual vulval varices. (B)Vulval to posterior thigh to
lateral calf varices.
invalidate assessment for re ux. For example, if a catheter
is selectively placed adjacent to or inside the ori ce of the
right or le ovarian vein, it may pass the only valve present,
and injection will then demonstrate “re ux.” Varicography
can demonstrate the anatomy of vulval and buttock varices
and the relevant pelvic escape veins, but not the physiology
of re ux (Figure32.2). More recently, magnetic resonance
imaging (MRI) and multislice computed tomography (CT)
11
have been used to detect pelvic varices
in the assessment of
chronic pelvic pain. Dynamic MRI techniques are currently
being developed in Madrid (personal communication) that
can show ovarian vein re ux but will need to be compared
with ultrasound techniques for cost and reliability.
short saphenous varicose veins, then they cause recurrent
varicose veins. Atypical pattern is posterior vulval veins
coursing posteriorly into the short saphenous via the vein of
Giacomini (Figure32.1B).
DIAGNOSIS
Clinical suspicion of PCS relies on typical symptoms, namely
pelvic heaviness or deep pelvic pain, which is present before
the period, on Day 1 and sometimes Day 2 of menstruation,
midcycle, and post coitus. e latter is particularly noticeable
on standing up immediately a er having had morning intercourse. is aching may persist for several hours through the
day. e pelvic heaviness is particularly severe a er long periods of standing. Many patients complain of dyspareunia and
many are aware of vulval and leg varicosities that are worse
at the time of their pelvic symptoms. Commonly there are
bladder symptoms related to perivesical varicosities causing
frequency or a di culty in starting the ow of urine. Many
patients have symptoms of irritable bowel syndrome.
e diagnosis of PCS is o en delayed until investigations looking for endometriosis, in ammatory bowel disease, urinary tract disease, or pelvic in ammatory disease
have proved negative. It is common for patients to have
su ered marital stress and dissatisfaction with their treating
doctor’s lack of interest in their condition.
ULTRASOUND ASSESSMENT
PCS is con rmed on transvaginal ultrasound by nding
excessive pelvic varicose veins in the broad ligament, which
we would grade as mild (<5mm), moderate (5–7mm), or
marked (8–10mm), depending on the diameter, and whether
these pelvic varicosities are found to distend when the patient
is tilted head up by 60 degrees on a motorized ultrasound
examination table. Our ultrasound assessment begins with
the patient presenting a er 6 hours of fasting and with a full
bladder. Fasting reduces gut motility, and the full bladder
enables standard gynecological pelvic ultrasound. Afull bladder however compresses pelvic varicosities, which may be visible by transabdominal ultrasound a er voiding. Transvaginal
ultrasound then follows, and having con rmed PCS, we
examine the ovarian veins and the internal iliac veins, including anterior and posterior divisions. e round ligament veins
and saphenofemoral tributaries are also assessed.
I N V E S T I G A T I O N S
All patients with symptoms consistent with PCS are carefully examined 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,
8
periosseous
venography, or selective ovarian venography.
ese techniques are invasive and may, in some cases,
5
transuterine venography,
PELVIC CONGESTION SYNDROME:DIAGNOSIS AND TREATMENT • 253
9,10
6,7
Figure32.2 Varicogram of vulval varices with round ligament and
obturator pelvic escapeveins.
In Wagga Wagga, windows were developed to assess
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ovarian vein incompetence using transabdominal duplex
ultrasound and color ow Doppler (3.5 or 5 MHz trans-
12
ducer).
veins and assess re ux in 93% of cases,
well with the 92% visualization shown by Lechter
We demonstrated the ability to locate ovarian
13
which compares
14
using
venography. e le ovarian vein is found by rst locating
the le renal vein as it passes under the superior mesenteric
artery. e ultrasound window is through the le lobe of the
liver and the pancreas. e ovarian vein is located by following the le renal vein laterally and rotating the transducer
through 90 degrees (Figure32.3A). Aretroaortic le renal
vein, duplicated renal vein, or large ureteric veins are noted
if present. It is important not to confuse accessory renal
veins or the inferior mesenteric vein for the ovarian vein.
e 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 wave form
is taken about 2cm below the termination of the ovarian
veins (Figure32.3B). e criterion for incompetence in the
ovarian vein is reversed ow when lying down, sitting, or
standing without augmentation. Treatment either by surgery, or more recently endovascular methods, is based on
the ultrasound n d i n g s .
L A P A R O S C O P Y
Laparoscopy is sometimes required to exclude other possible causes for pelvic pain, such as endometriosis or pelvic
in ammatory disease in patients who have pelvic varices on
ultrasound assessment. We do this with the patient’s gynecologist. Laparoscopy involves using an extra le iliac fossa
port to retract the sigmoid colon. e 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 re ux is present.
V E N O G R A P H Y
Many centers rely on clinical ndings, then proceed to selective venography for con rmation, and then to endovascular treatment. Ultrasound con rmation of excessive pelvic
varicose veins by transvaginal ultrasound, even if ultrasound
assessment for ovarian vein re 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 with or without sclerotherapy. Le renal venography
is followed by selective ovarian venography (Figures 32.4
and32.5). If indicated by ultrasound ndings, we may do
selective iliac venograms.
T R E A T M E N T
Various methods have been used to treat the symptoms of
pelvic congestion, including psychotherapy, ovarian sup-
15
pression,
oophorectomy with hysterectomy.
intravenous dihydroergotamine, 16 and bilateral
17
Ovarian vein ligation
has been performed to eliminate re ux since 1985, as either
14
a bilateral procedure (Lechter,
Hobbs 2 ), or unilateral
based on ultrasound assessment (Richardson 1989). e
long-term results of such treatment have been poorly investigated. It is important that any assessment of treatment of
venous conditions have at least a 5-year follow-up. In recent
years, however, endovascular ablative techniques have been
popularized and similarly must be adequately assessed.
As many of these patients have associated leg varicosities, a treatment plan is required. e pelvic veins are only
treated if there are pelvic symptoms, or if they signi 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 2 to 3months before treating
the vulval or leg varicosities. In a few instances, the veins
can reduce in size such that sclerotherapy of the residual
A B
Figure32.3 (A) Ultrasound le ovarian vein (red) and le renal vein (blue). (B)Ultrasound le ovarian vein and le renal vein with waveform
showing re ux.
254 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
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Figure32.4 L e renal venogram with re ux into a large le ovarian vein.
Note the narrow upper end, which helps prevent embolization ofcoils.
vulval or leg veins might be appropriate, rather than surgical
treatment.
Ovarian Vein Incompetence
As most cases involve treatment of the le ovarian vein, the
choice of treatment is between surgery 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.
Surgery
Ovarian vein ligation has been performed on 120 patients
since 1989 by the author. It involves a “sympathectomy”
Figure32.5 Selective le ovarian venogram lling large le broad ligament
varices, with crossover to the right broad ligament, and drainage via the
right ovarian vein and both iliac veins, also showing presacral veins.
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. e ligature is then used for traction to enable
further multiple ligations upward to nish at approximately
2cm from the le renal vein. Anarrow Dever retractor is
useful to expose this uppermost portion. ere is signi cant
risk of major hemorrhage if the ovarian vein is not handled
gently. is surgery requires approximately 2days’ hospitalization and 2 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
however produce a scar and discomfort. Ishould reiterate
that Iwould only ligate an ovarian vein that was shown to
re ux on ultrasound assessment. Other surgeons have rou-
14,2
tinely ligated both ovarian veins.
It would seem unwise
to ligate a draining vein that did not re ux. Some surgeons
have advocated an even more extensive dissection to include
18
the ovarian pedicle.
ere is no evidence to suggest a more
limited operation such as the Wagga Wagga technique has
inferior results.
S U R G I C A L R E S U L T S
Long-term results in a series of seventy-two patients treated
until June 1995 in Wagga Wagga certainly encourage one
to treat patients based on the ultrasound ndings of ovar-
19
ian vein re ux.
ese patients were sent questionnaires
and were assessed independently by a surgical registrar for
their quantitative response of symptoms to surgical treat-
20
ment using visual analogue scales.
Sixty-seven of the
seventy-two patients responded with a mean follow-up of
thirty-three months (range 4 to 71) with a mean age of
thirty- ve years and mean pregnancies of 3.1. Pelvic heaviness was found to improve signi cantly (>50%) in 70% of
patients, and in 56% of patients this was almost complete.
irteen percent reported little or no improvement, and
when these were subsequently investigated, including further ultrasound and venography, no ovarian re 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.
Postintercourse 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
PELVIC CONGESTION SYNDROME:DIAGNOSIS AND TREATMENT • 255
of vulval veins in the pregnancy and no recurrence of
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symptoms.
Ovarian Endovascular Ablation
ere have been several reports of single or a few case
reports of successful treatment by ovarian vein emboliza-
21–24
tion.
us 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
23
Dutch
experience, sclerotherapy was contraindicated
because of a perceived risk of entering the portal system.
Ateam in Vancouver, which has a very large experience
of treatment of male varicocoele 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 di 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 bers (Cook), choosing a diameter to oversize by 2 to 3mm 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 clearly seen on
the screen to avoid spillover into the le 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. While preparing the sclerosant as a foam would seem
desirable, the 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. e 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 3cm of
the le renal vein. Usually two long (20-cm) coils su 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 con rmed ovarian vein re ux by a selective le
renal venogram, a guide wire 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 varicocoele
patients, this is combined with compression at the level of
the external ring to avoid the sclerosant passing into the
scrotum.
ere are risks to endovascular techniques including
embolization, migration and perforation of coils, irritation
of nerves such as the genitofemoral, and the possibility of
later recanalization. ere have been reports of recanalization resulting in recurrent symptoms requiring later surgical
treatment.
Internal IliacVeins
Where patients are shown to have signi cant internal iliac
vein re 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
18
in our series and by others.
ere are risks to the surrounding structures, such as ureteric and iliac vessels. ere are also
signi cant risks to endovascular treatment of the internal
iliac system, being a very large vein at its junction with the
external iliac vein. e 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 re ux on ultrasound assessment, we have only treated the ovarian vein. us 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
has on many occasions used 2% aethoxysklerol. To apply
adequate compression a er the sclerotherapy Iuse cotton
balls covered by tape and the patient wears a rm support,
such as bicycle pants, in an attempt to provide as much
compression as practical. Side e ects from the sclerotherapy
have been surprisinglyfew.
Ureteric VeinRe ux
Inevitably unusual cases will appear associated with venous
anomalies. We have treated several cases with large re uxing ureteric veins that are tortuous and feed into the ovarian vein usually in the lower third of the abdomen. ey are
o en di 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.
256 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Other Causes of Pelvic Congestion
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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.
ere remain patients in whom there clearly are signi cant
pelvic varices but no source of re ux. Some of these are due
to venous obstruction associated with collateral venous
pathways. We have observed patients with both xed and
intermittent re ux of internal iliac veins associated with
common iliac vein obstruction. In some cases this is postural, when recumbent there is reversed ow, and is associated with 1- to 2-mm anteroposterior (AP) diameter where
the right common iliac artery crosses the le common iliac
vein. Perhaps some of these patients would bene t from a
venous stent. Aretroaortic le renal vein has frequently been
associated with PCS and rarely le renal vein obstruction
following surgical ligation. Iavoid ablation of the ovarian
vein in these patients with collateral drainage of thekidney.
Segmental Pelvic VeinRe ux
ere remains a group of patients where we cannot demonstrate a de nite cause. It appears quite feasible that some
very large pelvic veins in pregnancy don’t shrink and thus
produce segmental re ux in uterine and broad ligament
veins. ese patients and others whose symptoms fail to
resolve a er ovarian or iliac vein ablation, are best treated
by hysterectomy.
COMPARISON OF
RESULTS OF COIL AND
SURGICAL TREATMENT OF
OVARIANR EFLUX
Patients treated by surgery from 1989 until 1998, and endovascular treatment from 1999 until June 2002 were studied
using a questionnaire with visual analogue scales. Statistical
analysis of pelvic heaviness and overall satisfaction showed
no di erence between endovascular and surgical treat-
25
Both treatments resulted in statistically signi -
ment.
cant improvement a er treatment. Adecision to treat in
both groups was based on clinical ndings and ultrasound
assessment, and there was no statistical di erence 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 6 weeks and 6months
as well as abdominal radiographs. ere was no evidence
of coil migration in thirty-four patients. Early ultrasounds
showed two clots in broad ligament veins, no signi cant
reduction in diameter at 6 to 10 weeks, but some evidence
of reduction by 6months.
Long-term results of endovascular treatment have not
yet been reported. Recanalization remains possible but
should be amenable to further endovascular treatment.
While the great majority of patients tolerate coil treatment
with little discomfort, with anxious patients it is more dif cult to cannulate the femoral vein, and spasm of the ovarian vein could lead to perforation. Patients have far less loin
discomfort than a er surgery, but it seems excessive exercise should be restricted. Afew patients have severe pain,
and this could be due to thrombosis of the ovarian vein or
perforation.
Patient satisfaction justi es ablation of an ovarian vein
shown by ultrasound to re ux.
Provided endovascular ovarian vein ablation can be
delivered safely and at reasonable cost, then there are de nite advantages over surgical treatment. Complications
can occur from either method. e incidence of long-term
recanalization is unknown.
ere 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.
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PELVIC CONGESTION SYNDROME:DIAGNOSIS AND TREATMENT • 257
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