Gray Areas in Vein Disease: In this series of articles, we discuss the uncertain and the unsure. Eight thoughtful, knowledgeable, and confident vein specialists contemplate four venous disease areas: superficial disease; deep disease, reflux; deep disease, post-thrombotic; and acute DVT.
CONTROVERSY OVER the treatment of pelvic venous disorders, formerly known as pelvic congestion syndrome, has been a prominent discussion among vascular interventionalists for many years due to the lack of substantiating randomized, controlled data for ovarian vein embolization (OVE) to allow for acceptance by the Gynecology community or the medical insurance industry. Many cohort studies and systematic reviews have validated measurable, statistically significant improvements in visual analog scale (VAS) pain scores following ovarian vein embolization, but there is a lack of clear diagnostic criteria, disease classification, and disease-specific quality of life tools.1 In addition, recent publications evaluating the use of iliac vein stenting for non-thrombotic iliac vein lesions (NIVL) have demonstrated significant and possibly greater improvements in VAS pain scores than with OVE alone or staged treatment starting with OVE followed by iliac vein stenting.2
The questions that vascular and venous specialists face daily are, “Does this patient have pelvic venous disorders or venous origin chronic pelvic pain (CPP)?” and “How do you treat the patient with renal vein compression, iliac vein compression, and ovarian vein reflux?” The major challenge is that we have more to learn to avoid diagnostic errors before we can answer these questions with a high level of certainty, but the recent addition of the Symptoms-Varices-Pathophysiology (SVP) classification will begin the process.3 Additional efforts to create disease-specific, quality-of-life tools and randomized, controlled trials to demonstrate efficacy of interventions are critically necessary.
The decision of which pathophysiologic etiology to treat when a patient has a solitary process of either primary ovarian vein reflux or NIVL is straightforward, although it still involves adequate patient conversation to create clear patient expectations. In the case of choosing OVE or stenting when both ovarian vein reflux and left NIVL are present, my personal belief is to perform a staged treatment starting with bilateral OVE despite the publication by Santoshi, et al. The predominant reason for this is that a critical component of proper OVE is treatment of the pelvic variceal reservoir, which was not performed in that study. Venous hypertension resulting in mechanical venous stretching is likely responsible for nociceptor activation. Lack of treatment of the pelvic variceal reservoir leads to persistent venous stretch arising from the internal iliac veins and persistent CPP.
Additionally, long-term risk of venous thromboembolic complications with iliac vein stenting in a young, pre-menopausal population is currently unproven.
Although the etiology of venous origin pelvic pain is not clearly from reflux or obstruction pathophysiology, individualized assessment and treatment to decrease venous hypertension and eliminate the pelvic variceal reservoir will likely lead to the best clinical outcomes with primary treatment from the ovarian veins existing as the treatment modality with greatest research support and least long-term risk potential. Future randomized, controlled trials demonstrating efficacy using newly created diagnostic and evaluative tools will more clearly answer these questions.
- Khilnani NM, Meissner MH, Learman LA, Gibson KD, Daniels JP, Winokur RS, Marvel RP, Machan L, Venbrux AC, Tu FF, Pabon-Ramos WM, Nedza SM, White SB, Rosenblatt “Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel.” Journal of Vascular and Interventional Radiology, Volume 30, Issue 6, 2019, Pages 781-789
- Santoshi AKN, Lakhanpal S, Satwah V, Lakhanpal G, Malone M, Pappas PJ. “Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency.” Journal of Vascular Surgery: Venous and Lymphatic Disorders, Volume 6, Issue 2, 2018, Pages 202-211.
- Meissner MH, Khilnani NM, Labropoulos N, Gasparis AP, Gibson K, Greiner M, Learman LA, Atashroo D, Lurie F, Passman MA, Basile A, Lazarshvilli Z, Lohr J, Kim M, Nicolini PH, Pabon-Ramos WM, Rosenblatt M. “The Symptoms-Varices-Pathophysiology (SVP) Classification of Pelvic Venous Disorders: A Report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.” Journal of Vascular Surgery: Venous and Lymphatic Disorders, Published online January 30, 2021.