Principles of Diagnostics and Treatment of the Pelvic Congestion Syndrome and the Non-saphenous Varicosis of the Lower Limb

Introduction, Objectives, and/or Purpose: Introduction. Reflux in the pelvic veins is the cause of not only the clinical symptoms of the pelvic congestion syndrome (PCS), but also the cause of varicose veins of the lower extremities, in certain cases, the cause of recurrence of the varicose veins of the lower extremities (VVLE) [1]. The source of PCS is varied, but in most cases, it is reflux in the gonadal veins, and only in rare cases it can be caused by the Nutcracker syndrome, May-Turner syndrome, as well as a postthrombotic syndrome and acquired stenosis or compression of the veins by an oncological process. The effectiveness of various methods of treatment, including endovascular ones, in relieving the clinical symptom complex of PCS has been widely studied [2], but data about the efficacy of these methods on the course of VVLE is currently insufficient.
The purpose of this work was to analyze the effectiveness of endovascular scleroembolization of the gonadal veins in the treatment of PCS and non-saphenous VVLE.

Methods: Material and methods. It is a retrospective analysis of the treatment results of 48 women treated in the central hospital of the Ministry of Internal Affairs of the Republic of Uzbekistan with PCS and VVLE. The clinical data of the patients were analyzed retrospectively, and the postoperative result was obtained through a questionnaire using e-mail and a telephone call. Statistical data of patients are given in Table 1. Before the intervention, all patients underwent an ultrasound examination of the veins of the lower extremities and MRI phlebography of the pelvic veins. After confirmation of the reflux in the gonadal vein as the cause of PCS and VVLE, scleroembolization of the gonadal veins was performed as the first step and either thermal obliteration of the veins with mini phlebectomy or sclerotherapy was performed as the second step. In the case of a left-sided lesion of the gonadal vein, femoral access was performed. When both gonadal veins are affected or only the right-sided lesion, the right internal jugular vein access is chosen.
After confirmation of diagnosis, the gonadal vein is catheterized deeper by a 6fr catheter. On the 0.035 guidewire, the catheter is replaced with a balloon catheter with diameters corresponding to the diameter of the vein, and the balloon is inflated and 3% polidocanol foam is injected through the balloon catheter channel in a volume of about 10 ml. The balloon remains inflated for 10 minutes to reduce reflux blood flow and prevent foam washout into the inferior vena cava and pulmonary circulation. Then, on the 0.035 guidewire, the balloon catheter is replaced with a regular 6 fr catheter, and the gonadal vein is embolized using several Gianturco-type coils. After the control phlebography, where occlusion of the gonadal vein or a sharp decrease in blood flow is confirmed, the intervention is completed. After the intervention, the patient is observed in the department for 18 hours for complications, and the next day, if necessary, the second step of the surgical treatment is performed or discharged for outpatient treatment.
Control examination of patients was carried out after 7 days, 30 days, 3, and 6 months.
Complications after surgery are classified as puncture complications, complications associated with contrast agents or drugs used for sclerotherapy, or with coils used for embolization.
The primary endpoint was either complete relief of the clinical symptoms PCS, a decrease in symptoms, or the absence of the effect of the surgery.
The secondary endpoint was the recurrence of VVLE and the recurrence of the symptoms of PCS.

Results: For the period from 2018 to 2022, 48 patients with clinical and anatomical signs of PCS and VVLE were diagnosed and treated, of them, 12 patients were with recurrence of varicose veins. Of these 48 patients, 27 (56.2%) patients underwent scleroembolization of the left gonadal vein, 5 (10.4%) patients underwent scleroembolization of the right gonadal vein, the remaining 16 (33.3%) patients underwent scleroembolization of both gonadal veins. After scleroembolization of the gonadal veins, the severity of VVLE decreased in all patients, and only 31 patients required surgery as a second step. Of these, 14 (29.1%) patients underwent endovenous laser ablation (EVLA) of the GSV with mini phlebectomy, 17 (35.4%) patients underwent isolated mini phlebectomy, and the remaining 21 (43.7%) patients underwent sclerotherapy of VVLE. The mean follow-up period was 36 ± 8.5 months. In the long-term period, we were able to evaluate the results of the operation in 43 patients.
A perioperative complication was noted in 7(15.6%) patients in the form of extravasation of a contrast agent, with pain in the lumbar or hypogastric region. In the early postoperative period, short-term uterine bleeding for 2 days was noted in 3 (6.2%) patients, and in 11(23%) patients, the pain was noted in the area of jugular vein puncture. Major complications in the form of thrombosis of the punctured vein or non-target vein, as well as allergic reactions to the contrast agent or embolic agent, were not noted.
Thus, PCS symptom relief was noted in 27(62.7%) of 43 patients with scleroembolization of the gonadal vein in the follow-up, while in 14(32.5%) patients there was a decrease of the pain symptom, and in 2(4.6%) of patients did not notice the effect of the intervention in relation to the pain symptom. At the same time, recurrence of varicose veins of the perineum and the vulva was noted in 4 (9.3%) patients, and recurrence of varicose veins of the lower extremity was noted in 7 (16.2%) patients, all patients underwent sclerotherapy of newly appeared veins.

Conclusion(s): Conclusions. Scleroembolization of the gonadal veins under balloon protection is an effective method of treating not only the PCS but also non-saphenous VVLE. Surgical treatment as the second step is required only for a few patients.