Symptomatic Pelvic Congestion Syndrome After Stenting for Iliac Vein Chronic Total Occlusion

Purpose: Pelvic congestion syndrome (PCS) is described as chronic pelvic pain arising from dilated and refluxing or insufficient pelvic veins. Reflux in the ovarian veins, with or without an obstructive venous outflow component, is reported to be the primary cause of pelvic venous insufficiency. We present an interesting case of a patient presenting with complete occlusion of the right common femoral and right external iliac vein extending up to the right common iliac vein who subsequently developed PCS requiring embolization.

Materials and Methods: A 60-year-old woman had a history of postthrombotic syndrome secondary to chronic total occlusion of the right common femoral and right external iliac vein extending up to the right common iliac vein on venography. Collateral flow was through the right anterior abdominal wall veins and right internal iliac veins. The occluded vessels were successfully stented. After recanalization and stenting, both collaterals were decompressed; however, the patient developed symptoms of PCS. Imaging before and after stenting showed dilated pelvic plexus and ovarian veins. However, she only became symptomatic after right iliac vein stenting. A diagnosis of PCS was made. Detailed review of literature for similar cases was performed.

Results: Ovarian venogram demonstrated markedly dilated veins on Valsalva maneuver with significant reflux and significant pelvic collaterals. The bilateral ovarian veins were embolized using multiple hydrophilic and CX coils. Posttreatment venogram of the ovarian veins revealed successful coil embolization. No immediate postoperative complications were noted.

Conclusions: Some studies have indicated that the incidence of iliac vein outflow obstruction in PCS is greater than previously reported. Although the data supporting the diagnosis and treatment of PCS are limited, the immediate success rate for the endovascular treatment of patients with PCS is good, and the complication rate is low. Most patients report relief in the symptoms for up to 5 years after intervention.