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Monday, December 7, 2020

Embolization for Pelvic Venous Disorders in Women

Pelvic Venous Disorders in Women due to Pelvic Varices: Treatment by Embolization: Experience in 520 Patients


Clinical question
Is pelvic vein embolization with metallic devices a safe and effective treatment for pelvic venous disorders in women with chronic pelvic pain?

Take away point
Over 5 years of follow up, pelvic vein embolization with metallic devices significantly decreased symptomatology with a 5% recurrence rate and 2.1% major complication rate.

Reference
De Gregorio MA, Guirola JA, Alvarez-Arranz E, Sánchez-Ballestin M, Urbano J, Sierre S. Pelvic Venous Disorders in Women due to Pelvic Varices: Treatment by Embolization: Experience in 520 Patients. J Vasc Interv Radiol. 2020;31(10):1560-1569. doi:10.1016/j.jvir.2020.06.017

Click here for abstract

Study design
Single-institution cohort study of 520 women undergoing pelvic vein embolization with either metallic coils or vascular plugs for symptomatic pelvic venous disorders.

Funding source
No reported funding.

Setting
Academic hospital, University of Zaragoza, Spain.




Figure
The evolution of pelvic pain by visual analog scale in women with pelvic venous disorder treated by an embolization procedure using metallic devices (coils or plugs). FPC = fibered platinum coil; VP = vascular plug.

Summary


Embolization of the pelvic veins is the treatment of choice for pelvic venous disorders (PeVDs); however, evidence regarding safety and efficacy of this treatment is limited. The authors performed an observational study of 520 cases of PeVD treated with metallic device embolization with interval follow up over a 5-year period.

Women presenting with clinical symptoms of PeVD for more than 6 months without evidence of other causative pathology, with a transvaginal ultrasound diagnosis of pelvic varicosities, and with venography showing grade II or III reflux as defined by the Hiromura classification, retention of contrast in the pelvic venous plexus, and/or filling of the vulvovaginal or lower extremity varicose veins were included in the study. Patients with malignancy or vascular compression syndromes were excluded as were patients who received other embolic devices or agents.

Embolization was achieved with either fibered platinum coils or vascular plugs with the primary procedural endpoint being occlusion of the four main pelvic veins (MPVs): the left and right ovarian veins and the left and right internal iliac veins. All devices were oversized by approximately 20-35% in ovarian veins and 15-20% in internal iliac veins.

Follow up exams were conducted at 1, 3, 6, and 12 months and then annually up to 5 years at which times clinical symptoms were evaluated using a 0-10 point visual analog scale (VAS) and transvaginal ultrasound. Recurrence and complication data were also tracked over the follow up period.

A total of 520 women met criteria with 261 undergoing embolization with coils and 259 with vascular plugs. Technical endpoint success was 84.8% with 100% success of embolization of at least one MPV. There was a 5% recurrence rate with 65.3% of those cases undergoing reintervention. There were 57 minor complications (10.9%) including access site hematoma, ovarian vein extravasation, and low back pain. There were 11 major complications, all of which were device migration (2.1%). Ten of the major complications were seen in patients receiving coil embolization and one in a patient who received plug embolization. No patient deaths were reported.

Average length of follow up was 58.7 ± 5.7 months with significant decrease in reported pain level of 7.63 ± 0.9 pretreatment to 0.91 ± 1.5 at 5 years posttreatment. Time to clinical improvement was 14.2 ± 0.9 months for patients with severe pain (VAS score of 8-10) and 8.6 ± 1.3 months in patients with moderate pain (VAS score of 5-7). There were no statistically significant differences between groups treated with coils or plugs.

Commentary


The authors investigate the safety and efficacy of metallic device embolization of the pelvic veins in a relatively large cohort of women with symptomatic PeVD. Although the authors designate their study as retrospective, the nature of their data collection is prospective (patients were consented for study participation prior to intervention and symptomatology metrics were assessed at baseline and future follow up). While this prospective nature adds to the reliability of the results, if the study had been run as a randomized controlled trial (RCT) between coils and plugs, it would have offered an even more robust comparison, particularly since previously published RCTs comparing coils and plugs have not had as large a sample size nor as long term a follow up. Furthermore, although major complication rate between groups was not statistically significant, there was arguably clinical significance in device migration rate with 10/11 instances of device migration occurring in cases of coil embolization. Comparison via RCT would offer further insight into these results. Overall, the strength of this study lies in its large sample size and long term follow up data. The significant and persistent decrease in symptomatology with low complication rates adds to existing data supporting pelvic vein embolization as treatment for symptomatic PeVD. The authors discuss that additional studies comparing specific agents and devices is needed to fully understand treatment options for PeVD.

Post Author
Catherine (Rin) Panick, MD
Resident Physician, Integrated Interventional Radiology
Dotter Interventional Institute
Oregon Health & Science University

@MdPanick

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