Gonadal Vein Embolization for Pelvic Congestion Syndrome

BY DAVID FELDSTEIN, MD

CASE PRESENTATION

A 68-year-old woman presented with persistent pelvic pain and pressure predominantly on the left side that she had experienced for several years. The symptoms were exacerbated upon prolonged standing, and would improve after lying down and in the morning hours. There was no reported postmenopausal bleeding. Her symptoms were consistent with pelvic congestion syndrome. Treatment options included conservative hormonal therapy (eg, medroxyprogesterone), hysterectomy with oophorectomy, and gonadal vein embolization. After discussing the efficacy of the provided treatment options, the patient decided to proceed with gonadal vein embolization.

Figure 1. Initial digital subtraction venography.
Figure 1. Initial digital subtraction venography..
Figure 2. Postembolization venography showed successful occlusion of the left gonadal vein and its tributaries and collateral vessels.
Figure 2. Postembolization venography showed successful occlusion of the left gonadal vein and its tributaries and collateral vessels.

PROCEDURE DESCRIPTION

Embolization was performed via a right transfemoral vein approach. The left renal vein was selected utilizing a 5-F cobra catheter. Digital subtraction venography demonstrated significant reflux throughout a dilated left gonadal vein (Figure 1). Multiple distended collaterals were visualized draining across midline into the right hemipelvis. Delayed imaging also revealed collateral drainage into the left internal iliac vein. A Renegade® STC-18 Microcatheter (Boston Scientific Corporation) with a Fathom™-16 Steerable Guidewire (Boston Scientific Corporation) were advanced through the 5-F base catheter into the distal gonadal vein. Embolization of the left gonadal vein and associated tributaries was then performed using multiple Interlock™-18 Fibered IDC Coils (Boston Scientific Corporation) ranging in diameters of 10 to 12 mm. Coils were placed within 3 to 5 cm of the left gonadal/renal vein confluence. Postembolization venography demonstrated successful occlusion of the left gonadal vein and its tributaries/collaterals (Figure 2).

RESULTS

At 2-week follow-up, the patient demonstrated significant improvement in pelvic pain/pressure. There were no reported access site complications. If symptoms recur, the likelihood of right gonadal vein embolization was discussed. Right gonadal vein embolization was not performed at the time of initial therapeutic intervention, due to predominantly left-sided symptoms.

DISCUSSION

The 0.018-inch coil delivery system is preferred for this procedure, as it allows for preferential selection of the distal gonadal vein branches, as well as the smaller tributaries/collaterals. Literature suggests that lack of embolization of these tributaries/collaterals can lead to clinical failure and/ or recurrence.

David Feldstein, MD
Radiology Affiliates Imaging
Nazareth Hospital
Philadelphia, Pennsylvania
Disclosures: None.

Results from case studies are not necessarily predictive of results in other cases. Results in other cases may vary.

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Renegade STC 18 Microcatheter

CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician. Rx only. Prior to use, please see the complete “Directions for Use” for more information on Indications, Contraindications, Warnings, Precautions, Adverse Events, and Operator’s Instructions.

INTENDED USE/INDICATIONS FOR USE The Renegade STC 18 Microcatheter is intended for peripheral vascular use. The microcatheter can be coaxially tracked over a steerable guidewire in order to access distal, tortuous vasculature. Once the subselective region has been accessed, the microcatheter can be used for the controlled and selective infusion of diagnostic, embolic, or therapeutic materials into vessels. Diagnostic, embolic, therapeutic agents to be used in accordance with specifications outlined by the manufacturer.

CONTRAINDICATIONS None Known.

WARNING The Renegade STC 18 Microcatheter is not intended for use in the coronary vasculature or the neurovasculature.

PRECAUTIONS •This device should be used only by physicians thoroughly trained in percutaneous, intravascular techniques and procedures. •Never advance or withdraw an intravascular device against resistance until the cause of the resistance is determined by fluoroscopy. Movement of the microcatheter or guidewire against resistance may result in separation of the microcatheter or guidewire tip, damage to the microcatheter or guidewire tip, or vessel perforation. •Because the microcatheter may be advanced into narrow subselective vasculature, repeatedly assure that the microcatheter has not been advanced so far as to interfere with its removal.

ADVERSE EVENTS The Adverse Events include, but are not limited to: •Vessel trauma •Embolism •Hemorrhage/Hematoma •Vasospasm •Infection •Air embolism •Allergic reaction

90960758 Rev/Ver. AB

Fathom-16 Steerable Guidewire

CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician. Rx only. Prior to use, please see the complete “Directions for Use” for more information on Indications, Contraindications, Warnings, Precautions, Adverse Events, and Operator’s Instructions. 

INTENDED USE/INDICATIONS FOR USE The FATHOM -16 Steerable Guidewire is intended for general intravascular use in the peripheral vasculature. It can be used to selectively introduce and position catheters and other interventional devices within the peripheral vasculature. This device should be used only by physicians trained in percutaneous, intravascular techniques and procedures.

CONTRAINDICATIONS None known.

WARNINGS The FATHOM Steerable Guidewire is not intended for use in the coronary vasculature or the neuro vasculature.

ADVERSE EVENTS Complications attributed to endovascular procedures are the following: •Vessel trauma •Vessel damage •Embolism (catheter/device, air bubble, plaque, thrombus, air embolism, thromboembolism) •Pseudoaneurysm •Seizure/stroke •Vessel dissection •Hematoma at the puncture site •Nerve injury •Infection •Perforation of the vessel •Vessel spasm •Hemorrhage •Vascular thrombosis •Vessel occlusion •Death •Bleeding •Failed treatment •Inability to position guidewire •Damage to the catheter

92289650 Rev/Ver. 

Interlock Fibered IDC Occlusion System

CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician. Rx only. Prior to use, please see the complete “Directions for Use” for more information on Indications, Contraindications, Warnings, Precautions, Adverse Events, and Operator’s Instructions.

INTENDED USE/INDICATIONS FOR USE The Interlock Fibered IDC Occlusion System is a modified interlocking detachable coil indicated to obstruct or reduce rate of blood flow in the peripheral vasculature. This device is not intended for neurovascular use.

CONTRAINDICATIONS None known.

GENERAL PRECAUTIONS Do not advance the Interlock Fibered IDC Occlusion System if it becomes lodged within the microcatheter. Determine the cause of the resistance and replace the microcatheter and coil if necessary.

ADVERSE EVENTS The complications that may result from a peripheral embolization procedure include, but are not limited to: •Complications related to catheterization (e.g., hematoma at the site of entry, vessel injury, etc.) •Death •Emboli •Foreign body reactions necessitating medical intervention •Hemorrhage •Infection necessitating medical intervention •Ischemia •Pain •Recanalization •Temporary neurological deficit •Tissue necrosis •Undesirable clot formation of the vasculature •Vasospasm

90960711 Rev/Ver. AB

 

 

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