Bilateral ovarian vein embolization for pelvic congestion

A woman in her 30s presented with symptoms of lower abdominal pain and pain during intercourse that had continued for years. The long duration of the symptoms was affecting her daily life and quality of life.

The aim of the assessment was to determine whether the pelvic varices seen on imaging were consistent with the patient's symptoms and whether treatable venous reflux was present.

Widespread pelvic varices around the uterus were seen on pre-procedure imaging. When these findings were assessed together with the symptoms of lower abdominal pain and pain during intercourse lasting for years, they were consistent with pelvic congestion.

Selective venographies performed during the procedure showed reflux into the pelvic variceal bed through both the left and right ovarian veins. Thus, the reflux pathways on both sides were mapped separately during the same session.

The presence of pelvic varices on imaging alone was not considered sufficient to make a treatment decision. The decision to perform embolization was made after considering together the compatibility of the patient's prolonged lower abdominal pain and pain during intercourse with pelvic congestion, and the confirmation of bilateral reflux on venography.

The plan was to reach both ovarian veins through a single venous access, demonstrate the main and collateral pathways carrying the reflux, and treat both sides during the same session.

The procedure was started through a single access in the jugular vein. The catheter was used to reach first one and then the other ovarian venous system. Selective venographies showed contrast refluxing downwards and filling the pelvic varices around the uterus.

The leaking ovarian veins were embolized using a combination of coils and polidocanol (Aethoxysklerol) as a sclerosing agent. A collateral branch contributing to the reflux on the right was also closed during the same session. After embolization of each side, a control venography was obtained to assess whether any continuing reflux into the pelvic variceal bed remained.

At the one-month follow-up, the patient's symptoms of lower abdominal pain and pain during intercourse had markedly improved.

At the one-year follow-up, no recurrence of symptoms was seen. Thus, the early clinical improvement was seen to have been maintained over one year of follow-up.

In the assessment of pelvic congestion, imaging findings and the patient's symptoms are interpreted together. The presence of widespread pelvic varices, the compatibility of the symptoms with a venous-origin condition, and the demonstration of reflux on venography formed the basis of the treatment plan.

In this case, a single jugular venous access provided access to both ovarian venous systems. However, the decision that treatment was complete was based not on the number of accesses or the appearance of the coils, but on demonstrating on the final venographies of both sides that reflux into the pelvic variceal bed had been interrupted.

Lower abdominal pain lasting for a long time or pain during intercourse alone does not establish a diagnosis of pelvic congestion. Similar symptoms may have different causes; the decision is made by considering the clinical assessment and appropriate imaging findings together.

In this patient, the symptoms markedly improved after bilateral venous reflux was treated during the same session, and no recurrence was seen at the one-year follow-up. This result relates to one patient and does not constitute a guarantee of outcomes for other patients.

Possible risks

Pelvic aching may increase temporarily. Bleeding or infection can occur; rarely, embolic material may move to the lungs. Pain may persist or return, especially if another cause of pelvic pain is present.

Other options

Assessment for other causes of pelvic pain, symptom management and gynaecological treatment where appropriate. Embolization is considered only after the venous diagnosis is supported.

Clinical source: CIRSE