Interventional radiologists play a critical role in treatment - as well as diagnosis - of venous diseases, with research presented at the SIR annual meeting focusing on classically under-recognised ovarian varicose veins and varicose veins - reflux of non-great saphenous veins.
H S "Kevin" Kim, of the Johns Hopkins Medical University, presented findings of a long-term, large-scale study of 131 women with pelvic congestion syndrome (PCS) - the presence of ovarian and pelvic varicose veins. With 40 patients having undergone laparoscopic procedures and 70 patients MRI studies prior to embolotherapy, Kim argued that PCS is too often under-diagnosed in traditional imaging and laparoscopic studies. He said direct venography performed by IRs should be the "gold standard" test for diagnosing PCS.
Diagnosis of PCS can often be missed because women lie down for a pelvic exam, relieving pressure from the ovarian veins, so that the veins no longer bulge with blood as they do while a woman is standing. PCS is similar to varicose veins in the legs, with the valves in the veins that work against gravity to return blood to the heart becoming weakened and not closing properly. In the pelvis, varicose veins can cause chronic pain and affect the uterus, ovaries and vulva. The pain is usually dull and aching, felt in the lower abdomen and lower back, and often increases following intercourse, during menstrual periods, when tired or standing (worse at end of day) and throughout pregnancy.
While PCS is common in women who have not been pregnant, 37% of the women in Kim's study had previously been pregnant.
Kim's research team performed 262 transfemoral ovarian venographies on the 131 patients with a mean age of 34. The venography confirmed clinical suspicion of pelvic congestion in 97% of patients, who were treated with transcatheter embolotherapy.
Using questionnaires and Visual analog scales (VAS), the researchers recorded a 62% reduction in pain perception levels.
Specific significant improvements included pain on standing, lying, dyspareunia, urinary frequency and menstrual pain. At long term follow up 85% of the women had improved pain levels, 12% had no significant change and only 3% had worsened.
No DVT, PE or organ damage was noted and there was also no significant change in hormonal levels. With two out of four women in the study trying for a baby successfully falling pregnant, Kim told attendants at an SIR press conference that emblotherapy should be performed before hysterectomy on younger women.
Dr Carl M Black of the Intermountain Vein Center, Provo, Utah, also discussed under diagnosis of ovarian varicose veins in his SIR presentation. In his study of 160 female patients evaluated for lower extremity venous reflux (varicose veins), 16% also presented with symptoms and findings of pelvic congestion syndrome. Of these, 92% were found to have venous reflux in the ovarian veins, for which embolisation was performed. Sixty-three per cent reported relief or significant reduction in pain in both the pelvis and the lower extremities following embolisation alone, while 91% of the 22 patients in the PVCS subgroup reported satisfaction following subsequent comprehensive treatment of any remaining sources of lower extremity venous reflux.
Dr Robert J Min, Cornell University, New York, presented research on endovenous laser ablation arguing that the procedure was a safe and highly effective treatment for a common but under-recognised cause of varicose veins - reflux in a variety of veins collectively referred to as non-great saphenous veins. In a media presentation at SIR, Min said the problems caused by a reflux in non-great saphenous were often misdiagnosed and stressed that interventional radiologists must play a role in diagnosis as well as treatment of varicose veins.
Laser treatment is already proven to be a highly effective treatment for reflux in the great saphenous vein, which is the most common underlying cause of varicose veins. However, Min said that in at least 20% of patients varicose veins are caused by non-great saphenous veins or a combination of both types.
In his study, Min adapted the laser procedure, which he first pioneered to treat great saphenous vein reflux, to treat the non-great saphenous veins. Over a 56-month period, the study included 204 limbs in 192 patients with varicose veins not caused by great saphenous vein reflux. Of the 204 limbs treated, 104 were treated for anterior accessory great saphenous vein (AGSV) reflux, 86 for small saphenous vein (SSV) reflux, and 14 for posterior thigh circumflex vein (PTC) reflux.
The subjects were treated with laser energy delivered endovenously via a 600 micron fibre. Min stressed in his presentation that there were no skin burns, paresthesias, DVTs or other heat-related complications.
Successful occlusion of the vein, defined as absence of flow on color Doppler, was achieved in 101 of 104 (97%) AGSVs, 83 of 86 (93%) of SSVs, and 13 of 14 (93%) of PTCs at follow-up after a mean of 24 months (up to as much as 53 months). Min and colleagues noted that of the seven failures, which all occurred early in the study, six occurred before the six month follow-up, indicating that the failure may have been due to inadequate treatment rather than recurrence. All of these cases were successfully retreated.
The study was the first large investigation into treating faulty non-great saphenous veins, and Min said the results were superior to those reported for other treatments of vein reflux in these veins, including surgery, ultrasound-guided sclerotherapy, and radiofrequency ablation.
Laser Treatment is an outpatient procedure performed using duplex ultrasound imaging for guidance.
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