pelvic venous insufficiency - meet...
TRANSCRIPT
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Pelvic venous insufficiencymy best practice, warning and complications prevention
O Hartung
Nice, June 1st 2017
Dpt of Vascular SurgeryCHU Nord, Marseille, FRANCE
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Pelvic venous insufficiency
All manifestations due to pelvic venous
system dysfunction
Mainly pelvic varicose veins
Can cause
Pelvic congestion syndrome
Lower limb varicose veins
Underdiagnosed and undertreated
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3 mechanisms of pelvic VV (Greiner)
Type 1 : reflux secondary to pelvic vein
incompetence
Type 2 : obstructive lesions of venous outflow
Type 3 : secondary to a local extra venous
phenomenon (endometriosis…)
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In which patients?
Mainly premenopausal multiparous women
Chronic pelvic pain without gynecologic cause
Lower limb varicose veins
Recurrence after GSV treatment
Atypical varicose veins
Vulvar and/or inguinal varicose veins
+/- PCS
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Strategy : Diagnosis
Pelvic varicose veins : duplex–scan +++
Presence of multiple dilated tubular structures into
the pelvis with a venous blood Doppler signal and a
diameter > 5 mm
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Strategy : Diagnosis
2 different contexts :
Isolated PCS => other causes?
Gynecologic examination
Pelvic echography, CT, MRI
Lower limb varicose veins due to PVI => TRT
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Strategy : Diagnosis
Identification of pathologic veins
DS, CTV, MRV
Anatomic variations
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Strategy : Diagnosis
Identification of pathologic veins
DS, CTV, MRV
Anatomic variations
Selective phlebography
Brachial or femoral approach
Local anesthesia without urinary drainage
Both OV and both IIV + Iliocavography and LRV
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Strategy : Diagnosis
Exclude obstructive lesions
DS, CTV, MRV, phlebography, IVUS
Iliocaval (MTS +++)=> stenting
Nutcracker syndrome => TRT if very disabled
Contraindication to isolated LOV embolization
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Strategy : Treatment
Embolization
During or secondary to diagnostic phlebography
Methods :
Coils + foam
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Strategy : Treatment
Embolization
During or secondary to diagnostic phlebography
Methods :
Coils + foam
Amplatzer
Glue
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Right ovarian vein
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Right ovarian vein
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Left ovarian vein
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Left ovarian vein
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Left ovarian vein
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Left internal iliac vein
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Left internal iliac vein
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Left internal iliac vein
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Strategy : Treatment
Embolization
Local anesthesia
Poorly invasive
Ambulatory
Do not preclude from future pregnancies
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Strategy : Treatment
Other TRT
Medical TRT : can improve symptoms but none
resolved symptoms and PVI
Surgical TRT:
ovarian or internal iliac vein ligation
ovariectomy
total hysterectomy with bilateral salpingo-ovariectomy
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Results
Leal Monedero : 1186 embolizations
coils + foam 95.6% improvement vs coils 76% at 6M and less coils
Greiner : 24 p, 74 embolized veins with glue and coils
Good clinical results without reflux recurrence on the treated veins
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Series N Veins Technique FU
Results (%)
Improved
Capasso 19 OV Enbucrilate and/or coils 15.4M 74%
Tarazov 6 OV Coils 24M 100%
Machan 23 OV Coils 15M 78%
Cordts 9 OV Coils + gelatin 13.4M 100%
Cotroneo 22 OV Coils 3M 60%
Richardson 28 OV Coils + foam 22.2M SS
Maleux 41 OV Enbucrilate + coils 19.9M 68.2%
Bachar 6 OV Coils 7.7M 83%
Pieri 33 OV 3% STS 9M 61%
Chung 52 OV Coils 26.6M SS
van der Vleuten 21 OV Coils 18M 62%
Kim 127 OV Gelfoam + SM + coils 45M 83%
Tropeano 22 OV Foam 15M 90%
d’Archembeau 48 OV Coils 43M 73%
Gandini 38 OV 3% STS foam 12M 100%
Kwon 67 OV Coils 40M 82%
Scultetus 7 OV Coils 27M 43%
6 IIVT Coils 83%
12 IIVT + OVR Coils + OVR 83.4%
Creton 24 OV +/- IIVT Coils 36M 76%
Laborda 202 OV +/- IIVT Coils 89% 60M 93%
Nasser 113 OV +/- IIVT Coils 12M 100%
Lasry 30 OV +/- IIVT Coils 6M 90%
Hocquelet 33 OV +/- IIVT Coils + foam 23M 93%
Asciutto 35 OV / IIVT Coils 45M Embolisation >>>
Monedero 215 OV / IIVT Coils + foam 6M 90%
Venbrux 56 OV / IIVT Coils and foam 22M SI
Ratnam 218 OV / IIVT Coils 0.9M 95%
Hartung 78 OV / IIVT Coils + foam 4M 91%
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Complications
Rare
Dye extravasation => No foam
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Complications
Rare
Dye extravasation => No foam
Coils or glue embolization
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Coils embolizationLeal Monedero : 1186 embolizations
coils + foam : > results and less coils
Less cephalic
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Coil migration
During the procedure
Recapture or stock
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Coil migration
During the procedure
Recapture or stock
Late embolization
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Complications
Rare
Dye extravasation => no foam
Coils or glue embolization
Foam
Hematoma at access site
DVT/PE : early walking, heparin?
Transient arrhythmia
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Iliocaval obstructive lesions
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Iliocaval obstructive lesions
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Iliocaval obstructive lesions
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Nutcracker syndrome
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Conclusion
Disabling pathology
Endovascular treatment for reflux : poorly invasive,
sure, efficient and well tolerated
Obstruction must be recognized and treated if
indicated
Quality of results relies on experience
Patients selection
Technique