From IVUS to Embolization: Management Tips for Pelvic Congestion Syndrome
As awareness for pelvic congestion syndrome (PCS) increases, the optimal utility of imaging and catheter directed therapies for these conditions remains in question. Vascular experts, Dr. Michael Cumming and Dr. Mark Lessne, discuss the roles of IVUS and CT venography when diagnosing and treating PCS.
The BackTable Brief
Consider using IVUS when looking for nonthrombotic iliac vein compression in the setting of pelvic congestion syndrome.
CT venography with 3D reconstruction can result in detailed anatomical images and venous measurements; Dr. Cumming suggests working closely with a CT technician to optimize a protocol and improve the quality of your scans.
Dr. Cumming has noticed a high correlation between CT venogram and IVUS measurements, which can help triage patients with suspected May-Thurner syndrome and prevent unnecessary catheterization.
In most cases, both Dr. Lessne and Dr. Cumming opt for gonadal vein embolization over stenting in younger patients with PCS.
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Utilizing IVUS for Pelvic Congestion Syndrome
Dr. Lessne utilizes IVUS in suspected cases of nonthrombotic iliac vein compression, as it helps to prognosticate and guide management decisions. Similarly, Dr. Cumming uses IVUS to evaluate the iliac vein in suspected cases of ovarian vein incompetence.
… One last topic I wanted to bring up is whether or not you're using IVUS in pelvic congestion syndrome cases, and if so, how are you using it there?
Yeah. So for me, with pelvic congestion syndrome, the only time I really evaluate using IVUS is if I'm looking for concomitant non thrombotic iliac vein compression. Again, it’s not uncommon in pelvic congestion or chronic pelvic pain or chronic venous insufficiency. Not only that, but keep in mind the left renal vein, the gonadal vein and the iliac vein, they're all a circuit. And so they all interplay with each other. I will tell you that it’s really important for management.
Mark, I agree. And I mean we could spend probably an hour talking about pelvic congestion and it's just remarkable how much we've learned in the last decade. I tend to think of it as primary pelvic congestion, which is ovarian vein incompetence, either related to iliac vein compression or a nutcracker phenomena. I pretty much will IVUS all of these patients, maybe not their renal vein, but certainly their iliac vein.
CT Venography for May-Thurner Syndrome
CT venography with 3D reconstruction is preferred by Dr. Cumming when evaluating for MTS. Performed properly, a CT venogram with 3D reconstruction provides detailed images and venous area measurements. Developing a CT venogram protocol can be difficult, which is why Dr. Cumming suggests working closely with your CT technicians to refine a protocol.
For May-Thurner, how are you stratifying these patients for treatment? I would imagine a lot of this actually comes before you get the patient on the table.
For me, I CT everybody and do a CT venogram. We basically acquire it like a CT angio and build a 3D model with true center line reconstruction through the veins and then check area measurements, which is really time consuming. Historically I've used a third party to do all the 3D work. But if you really take your time and you have a good CT venogram, you can create very detailed anatomical images and area measurements in the vein. You simply can't do it off axial imaging, our brains just can't process that information the way a 3D tool can.
Okay. The CT venogram that you're getting, I don't know if you have any of the information handy, the protocol you use particularly in terms of the re formats. Can you tell us anything about that?
So just using a third party and 3D software, you go down and pick your center line through the IVC and then down both iliac systems. And then from there you can get true perpendicular area measurements of the vein and you come from the common femoral vein back up to the IVC. I've found when you get good at the CT software, the 3D software, you can have really a high degree of correlation between the IVUS and the CT. So this can help us sort of triage patients don't necessarily need to get on the table.
Okay. What type of a delay do you do, like how long before you, you start imaging?
I think our texts actually were triggering off the common femoral vein before ending up. So we do a fixed delay, and we've wrestled with everything from 120 to 180 second delay. I will tell you some of our CT venograms are absolutely beautiful and some of them look like non-contrast studies. And so I think it's a bit of an art, and you just have to be committed to it and sort of have someone who's championing this to make sure it's done correctly and works with the CT techs to make sure that you will find your protocol for your patient population.
Gonadal Vein Embolization in PCS
Both Dr. Lessne and Dr. Cumming prefer gonadal vein embolization over stenting in younger female patients; consider the long term consequences of stent patency versus vein embolization, says Dr. Cumming.
… So for me, embolizing a gonadal vein is almost always going to be my first line therapy before I put a stent in an iliac of a young woman. Renal vein stents I think are really sort of a no go for me, 99.9% of the time. But IVUS is important to exclude the other etiologies and to prognosticate. If I've treated a patient with pelvic congestion and I embolize the gonadal vein, even if I don't stent them that setting, at least we have an explanation.
Some people have shifted their treatment if there is iliac vein compression where they think stenting and relieving the compression should be the primary treatment. However, I have a hard time with that because then you have the long term problems of stent patency. That gives me a lot of concern, particularly in a younger patient. So I would rather go ahead and coil off an ovarian vein, knowing that the long term potential negative consequences of that are really very small.
Dr. Mark Lessne is a practicing interventional radiologist with Charlotte Radiology in North Carolina.
Dr. Michael Cumming is a practicing interventional radiologist in Minneapolis, MN.
Dr. Michael Barraza is a practicing interventional radiologist with Radiology Alliance in Nashville, Tennessee.
Cite this podcast:
BackTable, LLC (Producer). (2019, November 11). Ep 52 – IVUS for Iliac Vein Compression [Audio podcast]. Retrieved from http://www.backtable.com/podcasts
The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
This episode was sponsored by RADPAD radiation protection.