The care of patients with varicose veins and associated chronic ...

JOURNAL OF VASCULAR SURGERY
Volume 53, Number 16S Gloviczki et al 39S
Guideline 14. Treatment of pelvic varicose veins
Guideline
No. 14. Treatment of pelvic varicose veins
14.1 We recommend noninvasive imaging with transabdominal and/or transvaginal
ultrasonography, computed tomography or magnetic resonance venography
in selected patients with symptoms of pelvic congestion syndrome or
symptomatic varices in the distribution of the pubis, labia, perineum, or
buttocks.
14.2 We recommend retrograde ovarian and internal iliac venography in patients
with pelvic venous disease, confirmed or suspected by noninvasive imaging
studies, in whom intervention is planned.
14.3 We suggest treatment of pelvic congestion syndrome and pelvic varices with
coil embolization, plugs, or transcatheter sclerotherapy, used alone or
together.
14.4 If less invasive treatment is not available or has failed, we suggest surgical
ligation and excision of ovarian veins to treat reflux.
value for pelvic varices. 373 MR and CT venography criteria
for pelvic venous varices include four or more tortuous
parauterine veins, parauterine veins 4 mm in diameter,
and an ovarian vein diameter 8 mm. 374
Retrograde ovarian and internal iliac venography is the
test of choice for the diagnosis of pelvic venous disorders,
although it is most often reserved for patients in whom
intervention is planned. Venographic criteria for pelvic
congestion syndrome include one or more of the following:
(1) an ovarian vein diameter of 6 mm, (2) contrast
retention for 20 seconds, (3) congestion of the pelvic
venous plexus and/or opacification of the ipsilateral (or
contralateral) internal iliac vein, or (4) filling of vulvovaginal
and thigh varicosities. 375
Treatment. Various nonsurgical and surgical approaches
are available to treat pelvic congestion syndrome.
Pharmacologic agents to suppress ovarian function, such as
medroxyprogesterone or gonadotropin-releasing hormone,
may offer short-term pain relief, but their long-term
effectiveness has not been proven. Surgical approaches,
including hysterectomy with unilateral or bilateral oophorectomy
and ovarian vein ligation and excision, with interruption
of as many collateral veins as possible, have been
suggested for patients unresponsive to medical therapy. 373
Percutaneous transcatheter embolization of refluxing
ovarian and internal iliac vein tributaries with coils, plugs,
or sclerotherapy, usually as combination treatment, has
become the standard approach for management of both
pelvic congestion syndrome and varices arising from a
pelvic source.
Results. Transcatheter therapy has been reported to
improve symptoms in 50% to 80% of patients. Chung and
Huh 374 randomized 106 premenopausal women with
chronic pelvic pain unresponsive to medical treatment to
one of three treatment regimens: (1) ovarian vein embolization,
(2) laparoscopic hysterectomy, bilateral salpingo-
GRADE of
recommendation
Level of
evidence
1. Strong A. High
quality
2. Weak B. Moderate
quality
C. Low or very
low quality
1 C
1 C
2 B
2 B
oophorectomy, and hormone replacement, or (3) laparoscopic
hysterectomy and unilateral oophorectomy. Mean
pain scores as assessed on a 10-point visual analog scale
were significantly improved among those undergoing ovarian
vein embolization or bilateral oophorectomy, but not
among those undergoing unilateral oophorectomy. Pain
reduction at 12 months was greatest in those undergoing
embolotherapy.
CONCLUSIONS
The revolution in endovascular technology has transformed
the evaluation and treatment of venous disease
during the past decade. To keep up with the rapidly changing
technology, in this document the Venous Guideline
Committee of the SVS and the AVF provides evidencebased
guidelines for the management of varicose veins and
associated CVDs in 2011. These guidelines are essential to
the clinical practice using evidence-based medicine and play
a major role—but not the only role—in determining the
best care for patients with varicose veins and more advanced
forms of CVD. The scientific evidence presented in this
document must be combined with the physician’s clinical
experience and the patient’s preference to select the best
diagnostic tests and the best treatment option for each
individual patient.
AUTHOR CONTRIBUTIONS
Conception and design: PG, AC, MD, BE, DG, MG, JL,
RM, MM, HM, FP, PP, MP, JR, MV, TW
Analysis and interpretation: PG, AC, MD, BE, DG, MG,
JL, RM, MM, HM, FP, PP, MP, JR, MV, TW
Data collection: PG, AC, MD, BE, MG, MM, HM, MP,
MV, TW
Writing the article: PG, MD, BE, MG, RM, FP, PP, MP,
JR, MV, TW