• Image1
  • Image2
  • Image3
  • Image4
  • Image5
  • Image6
     

Ovarian Vein Embolization
Introduction
Ovarian vein incompetence is a common cause of pelvic pain and congestion in women, particularly those who have had children. The incompetence can also cause vulval avarices and contribute to venous problems in the legs, such as recurrent varicose veins and leg pain related to the menstrual cycle. Over the past 5 years Southern Sydney Angiography has successfully performed more than 300 ovarian vein embolisations making us probably the most experienced unit in the country for this procedure. Patient satisfaction with this minimally invasive procedure is extremely high.


Definition

There is one ovarian vein on each side. These are designed to return blood from the pelvis back up to the heart. The flow should be upward and reversed flow is prevented by one valve at the top end of each vein. When the valve is 'incompetent' (leaky) then blood can regurgitate from the kidney regions down into the pelvis. This causes dilatation of pelvic veins and places undue pressure on the veins in the pelvis. This situation is often caused by previous pregnancies when the enlarging foetus compresses the ovarian veins, causes them to enlarge and leads to valve failure.


Cause
The veins in the body are the low pressure component of the cardiovascular system. Because the system is a low pressure one it relies on valves to ensure that blood only flows in the correct direction - back to the heart. The blood from the left ovary drains up to the left kidney vein via the left ovarian vein. The right ovarian vein drains into the inferior vena cava rather than the kidney vein. The conjunction of the left ovarian vein and the left kidney vein can cause problems if the valve in the vein does not work. There is one valve at the junction of the ovarian vein and the left kidney vein. If this valve is absent or does not work then blood from the left kidney will flow back from the kidney and into the pelvis causing a bunch of enlarged pelvic veins. This can cause varicose veins in the vulva and contribute to varicose veins in the leg. It can also cause the pelvic venous congestion syndrome.

The diagnosis of ovarian vein incompetence is made by ultrasound measurement of the ovarian vein. If either vein measures more than 8mm in diameter it can be considered incompetent. The more incompetent the larger the diameter and the more likely it is to cause symptoms. The stretched vein can cause a nagging ache in the pelvis or loin particularly toward the end of the day. It can cause pelvic pain or leg pain related to the menstrual cycle. It can result in a feeling of the need to pass urine frequently (as a bag of enlarged veins sits above the bladder). The incompetence can cause vulval varicose veins and can exacerbate varicose veins in the legs. The enlarged pelvic veins can leak down into the legs causing or worsening varicose veins in the legs.

Because the veins are a low pressure system (unlike arteries which are high pressure) then a leak in the veins from the left kidney down into the pelvis is akin to a water leak in a two-story house. The water leaks into the lower level from above and puddles. The leak from above must be blocked to fix the puddle.


Embolization
A common technique to treat ovarian vein incompetence is ovarian vein embolization. This involves puncturing the skin with a needle and then passing a very thin plastic tube into the body. The entry point is a vein in the neck or the top of the leg. Both are safe and equally comfortable. As no cut is made in the skin, no mark will be left on the skin. The tube then passes inside the body which the patient cannot feel. It is passed into the ovarian vein down into the pelvis. The patient cannot feel any of this as there is no touch sensation in the veins. The vein is then blocked with fine stainless steel filaments called coils. These block the vein and prevent blood from the left kidney from swelling the veins next to the testis. Coils are very safe and have been in use for over thirty years. They can be considered in a similar manner to fillings in teeth. They are designed to occlude veins. In addition, a small amount of liquid sclerosant (called "fibrovein") is injected into the vein which ensures that the vein does not re-open after blockage. Commonly only one vein requires embolization (usually the left). If however both veins require embolization, then this is normally performed at separate sessions. It is normal to have pelvic or back pain for up to one week following the procedure. This is normally quite tolerable when one side is done at a time but is much worse when both are embolized on the same day.


Where does the Blood Go?
When the ovarian vein is blocked the blood will pass back toward the heart by alternative or “collateral” channels. These are small channels and do not allow reversal of flow which was the underlying cause of the venous leak.


How effective is embolization?
The success rate for curing the incompetent vein is above 90% for embolization.


How is the embolisation performed?
It is performed by an interventional radiologist in an angiography suite as an out-patient or day only procedure. A light sedation is given. The skin is numbed by local anaesthesia. Either a vein in the neck or a vein at the top of the leg (depending on patient preference) is used for access. Both are equally safe and comfortable and will not leave any mark or scar, as it is only a puncture not a cut. Using x-ray guidance the tube is directed into the left kidney vein and then down the left ovarian vein until it is just above the left hip. Small amount of contrast (X-ray dye) is injected to confirm position. Stainless steel or platinum coils are used to block the faulty vein. Sometimes sclerosing agent is also used to reduce the chance of recurrence. Only the vein above the hip is treated not the varicocoele directly –the change in pressure dynamics will then lead to the variciocele resolving after about 6 weeks. The procedure itself usually takes about 30 minutes.


What happens after the procedure?
You will be resting in the recovery for 1-2 hours until the sedation wears off. You need to arrange transport as you are not allowed to drive after the sedation. When you get home you should take it easy. Drink plenty of fluid. Normal activity can be resumed the following day except that you should avoid strenuous physical activity for 5 days after-that is no marathons, weightlifting etc. You can experience mild discomfort in the abdomen and flank for up to 7 days – it is not severe. The symptoms should resolve over about 7 days. You should also see your phlebologist or vascular surgeon for further follow-up of varicose veins in the legs. These will still require treatment but hopefully the outcome will be more permanent when the leak from above is fixed.


Are there any complications with embolization?
Minor complications may occur such as neck discomfort at the entry site, mild back ache and nausea. All of these symptoms normally resolve within a week. Migration of coils in the lungs is exceptionally rare and usually has no significant consequence.


Who are interventional radiologists?
They are doctors sub specialized in using catheter based devices to treat disease using imaging guidance such as X-ray, CT and ultrasound. Traditional surgery cuts the skin to see inside. We puncture the skin to perform surgical procedures and use the imaging equipment to see inside the body. Because there is no wound there is very little discomfort or recovery required.


Other Links 
Other useful information ccan be found at the following link:
http://www.sirweb.org/patients/chronic-pelvic-pain
http://www.cirse.org/index.php?pid=105

 

dummy