136 - Heterogeneity in endovascular management of venous origin chronic pelvic pain

Purpose: There is limited evidence substantiating optimal endovascular management to durably eliminate venous origin chronic pelvic pain (VOCPP). We conducted a survey of practicing specialists to determine current embolization practice.

Materials and Methods:

A survey was internationally distributed from June to July 2024 through IR and vascular societal contacts, assessing current practice for managing pelvic venous disorders.

Results:

225 responding physicians treat women with VOCPP. Regardless of pre-procedural imaging findings, both ovarian veins (64%), both internal iliac veins (56%), and one or both common iliac veins (43%) are typically evaluated during the first venogram. 16% would only catheterize a specific vein if they suspected reflux on pre-procedural imaging. 

33% routinely use balloon occlusion venography; 16% perform it in the internal iliac vein, 7% in the ovarian vein, and 10% for all studied veins. If there is concern for iliac vein obstruction (IVO), 70% of respondents would use IVUS.

If both significant IVO and primary pelvic reflux are visualized, 52% would consider a staged treatment, beginning with whichever they deem most significant, then treating the other if symptoms persist. 21% always treat IVO first, 10% always treat reflux first, and 10% treat both IVO and reflux at the same time. 

Venographic/IVUS findings sufficient to place a stent to treat VOCPP included significant appearing IVO alone in 28%, with collateral flow through lumbar veins in 63%, through presacral veins 59%, and with reflux of the left internal iliac vein 54%.

Typical interval after embolization to assess clinical response is < 1 month (15%), 3 months (55%), 6 months (25%), and 12 months (3%). Typically used post-procedural imaging (other than evaluation for procedural complications) was ultrasound 39%, CT 18%, MR 2%, and none 41%.

For patients with ongoing symptoms at 6 months following a technically successful treatment, 41% would evaluate with CT or MR, 31% proceed directly to repeat venogram, 16% wait longer for a response, 5% refer to gynecology, 1% refer to physiotherapy or for surgical ligation, and 7% would perform several of the above depending on the scenario.

Conclusion:

There is significant practice heterogeneity in endovascular management of VOCPP including with venographic technique, criteria for stent placement, management of concurrent primary reflux and IVO, and post-procedure care. This survey demonstrates multiple evidence gaps that require comparative outcomes research to appropriately manage these patients.