Pelvic Pain: Pelvic Varicose Vein Embolisation

Pelvic varicosities secondary to Pelvic Venous Insufficiency (PeVI) can cause chronic pelvic pain (CCP) with debilitating symptoms in women. Although various techniques and embolic agents have been reported, embolisation provides about 75% symptom relief, making it a minimally invasive treatment option.

By Gloria Salazar, MD FSIR FCIRSE

Clinical Associate Professor, Vice Chair of Development and Engagement

Ana de Siqueira Bucci, MD

Visiting Scholar
Department of Radiology
University of North Carolina at Chapel Hill

The endovascular approach is the preferred treatment for pelvic varicose veins when venous reflux is documented (Figure 1, to left), involving embolisation of large-vessel territories using various agents (coils/vascular plugs and/or liquid sclerosants).

Ovarian vein embolisation is more commonly performed on the left side. The refluxing ovarian veins are selectively catheterized and distal embolisation of the pelvic reservoir (Figure 2, top right)) is executed with liquid agents under Valsalva maneuver and/or ballon-occlusion. The catheter is then withdrawn, using a “sandwich” technique with light-coil packing and sclerosants. Embolisation is performed up to 2 cm from the confluence of the ovarian veins with the inferior vena cava or left renal vein (Figure 3, bottom right). Vein diameter ranges from 8 to 20 mm, requiring large/long coils or plugs, with 3% sodium tetradecyl sulfate (STS) foam, Gelfoam slurry with sodium morrhurate, or N-butyl cyanoacrylate.

Evaluation of refluxing iliac segments is also required to ensure complete treatment. Internal iliac vein embolisation is executed with sclerosants agents that can be distributed more distally in the tributaries. In the author’s practice, sclerosing agents are used for internal iliac vein varices; however, in selected cases with escape points, a combination of coil/sclerosant can be used.

The main adverse event is coil migration; therefore, a detachable coil is sometimes used at the most proximal aspect of the vein, and/or a ballon-occlusion catheter may be employed.

In conclusion, embolisation effectively treats pelvic varices, providing about 75% symptom relief. While there is no direct comparison of clinical outcomes among embolic agents, procedures are technically successful across various methods.