Introduction



[Date][Carrier Medical Director][Carrier Name][Coverage Reconsideration Department][Carrier Address]Sub:[Patient Name][Patient Id][Group No.][Claim No.:]Request for coverage for Ovarian and Internal Illiac Vein Embolization for Pelvic Venous Disease (Pelvic Congestion Syndrome) [Carrier Medical Director]:On [insert date of request denial], an insurance coverage denial notice was received from your company that [Insert Treatment: ovarian embolization or internal illiac vein embolization] of pelvic venous disease is considered experimental and medically unnecessary, hence not covered by insurance. This is a formal request to extend coverage for [Insert Treatment: ovarian embolization or internal illiac vein embolization] for[Patient Name], who has been diagnosed with pelvic venous disease.[Patient Name] has been seen and evaluated by a [Insert Referring Physician Type: ] who [is/are] in agreement that [Insert Treatment: ovarian embolization or internal illiac vein embolization] is the best treatment option for management of this pelvic venous disease.This letter is an appeal for approval of [Insert Treatment: ovarian embolization or internal illiac vein embolization] for treatment of pelvic venous disease to be rendered at [center]. The use of [Insert Treatment: ovarian embolization or internal illiac vein embolization] techniques for treatment of pelvic venous disease has already been established. Once a candidate is deemed eligible for embolization, the choice of embolization modality should lie on the performing physician to be able to use the modality to best serve the patient with comparable efficacy and equal safety.[Patient Signature][Patient Name]IntroductionThe Society of Interventional Radiology (SIR) is a professional medical association that represents approximately 8,000 members, including most US physicians who are practicing in the specialty of vascular and interventional radiology. The society is dedicated to improving public health through pioneering advances in minimally invasive, image-guided therapies. The society appreciates the opportunity to comment on ovarian and internal iliac vein embolization (OVE) as a treatment of pelvic venous disease (PeVD).MethodologyThe SIR carrier advocacy group is determined to ensure insurance coverage recommendations across the country are up to date with current literature. Policies are periodically reviewed by the committee and evaluated by experts in the field. If a determination is made that the policy is inappropriately denying coverage, we initiate an extensive literature review gathering all of the current evidence. Based on this evidence, SIR provides recommendations for changes to this policy that address our primary concerns. Background informationSIR recently became aware of your denial to provide coverage for services treating PeVD with OVE. PeVD is caused by hypertension and varicose veins in the peri-uterine venous plexus and is the female analog of a painful scrotal varicocele in men. Women with PeVD often have severe lifestyle-limiting chronic pelvic pain (CPP). PeVD is more common in women who have prior several pregnancies, is often not considered as a cause of the pain resulting in long-standing suffering. As with other sources of poorly treated chronic pain, PeVD is known to contribute to an overlapping pain syndrome, with the development of central sensitization, catastrophizing, and very frequently depression from ineffective treatments. Patients can have significant pain following coitus, and even simple acts of standing or sitting can be debilitating. PeVD can present not only as chronic pelvic pain but also as lower-extremity and vulvar varicosities, lower extremity swelling and pain, and left-flank pain and hematuria. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Em4HB2vz","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":267,"uris":[""],"uri":[""],"itemData":{"id":267,"type":"article-journal","abstract":"Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2018.10.008","ISSN":"1535-7732","issue":"6","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 30857986","page":"781-789","source":"PubMed","title":"Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel","title-short":"Research Priorities in Pelvic Venous Disorders in Women","volume":"30","author":[{"family":"Khilnani","given":"Neil M."},{"family":"Meissner","given":"Mark H."},{"family":"Learman","given":"Lee A."},{"family":"Gibson","given":"Kathleen D."},{"family":"Daniels","given":"Jane P."},{"family":"Winokur","given":"Ronald S."},{"family":"Marvel","given":"Richard P."},{"family":"Machan","given":"Lindsay"},{"family":"Venbrux","given":"Anthony C."},{"family":"Tu","given":"Frank F."},{"family":"Pabon-Ramos","given":"Waly M."},{"family":"Nedza","given":"Susan M."},{"family":"White","given":"Sarah B."},{"family":"Rosenblatt","given":"Mel"}],"issued":{"date-parts":[["2019",6]]}}}],"schema":""} 1 To deny effective treatment to these patients with encumbering symptoms and to label this treatment as "not medically necessary" as described by the medical policy from Anthem BlueCross is to sentence them to a lifetime of suffering. There is a long list of causes for CPP in women including endometriosis, adenomyosis, pelvic inflammatory disease, interstitial cystitis, migraines, irritable bowel syndrome, fibromyalgia, chronic pelvic pain, pelvic floor tension myalgia, nerve entrapments, gastrointestinal disease, adhesions, chronic fatigue syndrome, postural hypotension syndrome, vulvodynia, and PeVD. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FfgYQFcv","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":267,"uris":[""],"uri":[""],"itemData":{"id":267,"type":"article-journal","abstract":"Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2018.10.008","ISSN":"1535-7732","issue":"6","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 30857986","page":"781-789","source":"PubMed","title":"Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel","title-short":"Research Priorities in Pelvic Venous Disorders in Women","volume":"30","author":[{"family":"Khilnani","given":"Neil M."},{"family":"Meissner","given":"Mark H."},{"family":"Learman","given":"Lee A."},{"family":"Gibson","given":"Kathleen D."},{"family":"Daniels","given":"Jane P."},{"family":"Winokur","given":"Ronald S."},{"family":"Marvel","given":"Richard P."},{"family":"Machan","given":"Lindsay"},{"family":"Venbrux","given":"Anthony C."},{"family":"Tu","given":"Frank F."},{"family":"Pabon-Ramos","given":"Waly M."},{"family":"Nedza","given":"Susan M."},{"family":"White","given":"Sarah B."},{"family":"Rosenblatt","given":"Mel"}],"issued":{"date-parts":[["2019",6]]}}}],"schema":""} 1 With such a large differential of diagnoses, securing a diagnosis of PeVD can be frustrating for patients who often undergo invasive procedures like laparoscopy for evaluation and treatment without success. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nqKZMqll","properties":{"formattedCitation":"\\super 1,2\\nosupersub{}","plainCitation":"1,2","noteIndex":0},"citationItems":[{"id":267,"uris":[""],"uri":[""],"itemData":{"id":267,"type":"article-journal","abstract":"Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2018.10.008","ISSN":"1535-7732","issue":"6","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 30857986","page":"781-789","source":"PubMed","title":"Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel","title-short":"Research Priorities in Pelvic Venous Disorders in Women","volume":"30","author":[{"family":"Khilnani","given":"Neil M."},{"family":"Meissner","given":"Mark H."},{"family":"Learman","given":"Lee A."},{"family":"Gibson","given":"Kathleen D."},{"family":"Daniels","given":"Jane P."},{"family":"Winokur","given":"Ronald S."},{"family":"Marvel","given":"Richard P."},{"family":"Machan","given":"Lindsay"},{"family":"Venbrux","given":"Anthony C."},{"family":"Tu","given":"Frank F."},{"family":"Pabon-Ramos","given":"Waly M."},{"family":"Nedza","given":"Susan M."},{"family":"White","given":"Sarah B."},{"family":"Rosenblatt","given":"Mel"}],"issued":{"date-parts":[["2019",6]]}}},{"id":269,"uris":[""],"uri":[""],"itemData":{"id":269,"type":"webpage","title":"Evaluation of chronic pelvic pain in females - UpToDate","URL":"","accessed":{"date-parts":[["2020",6,25]]}}}],"schema":""} 1,2 Up to 35% of women with CPP do not have a diagnosis made, and a significant majority of these women have PeVD. OVE is a safe and effective treatment for PeVD that yields pain relief with few complications. Large case series demonstrate substantial clinical relief in CPP in women treated with OVE as an outpatient minimally invasive procedure, with few complications and good durability. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"h6nw0mIs","properties":{"formattedCitation":"\\super 3,4\\nosupersub{}","plainCitation":"3,4","noteIndex":0},"citationItems":[{"id":341,"uris":[""],"uri":[""],"itemData":{"id":341,"type":"article-journal","abstract":"Objectives Pelvic vein embolisation is increasing in venous practice for the treatment of conditions associated with pelvic venous reflux. In July 2014, we introduced a local anaesthetic \"walk-in walk-out\" pelvic vein embolisation service situated in a vein clinic, remote from a hospital. Methods Prospective audit of all patients undergoing pelvic vein embolisation for pelvic venous reflux. All patients had serum urea and electrolytes tested before procedure. Embolisation coils used were interlock embolisation coils (Boston Scientific, USA) as they can be repositioned after deployment and before release. We noted (1) complications during or post-procedure (2) successful abolition of pelvic venous reflux on transvaginal duplex scanning (3) number of veins (territories) treated and number of coils used. Results In 24 months, 121 patients underwent pelvic vein embolisation. Three males were excluded as transvaginal duplex scanning was impossible and six females excluded due to lack of complete data. None of these nine had any complications. Of 112 females analysed, mean age 45 years (24-71), 104 were for leg varices, 48 vulval varices and 20 for pelvic congestion syndrome (some had more than one indication). There were no deaths or serious complications to 30 days. Two procedures were abandoned, one completed subsequently and one was technically successful on review. One more had transient bradycardia and one had a coil removed by snare during the procedure. The mean number of venous territories treated was 2.9 and a mean of 3.3 coils was used per territory. Conclusion Pelvic vein embolisation under local anaesthetic is safe and technically effective in a remote out-patient facility outside of a hospital.","container-title":"Phlebology","DOI":"10.1177/0268355517734952","ISSN":"1758-1125","issue":"8","journalAbbreviation":"Phlebology","language":"eng","note":"PMID: 28992753","page":"575-579","source":"PubMed","title":"Pelvic vein embolisation of gonadal and internal iliac veins can be performed safely and with good technical results in an ambulatory vein clinic, under local anaesthetic alone - Results from two years' experience","volume":"33","author":[{"family":"Whiteley","given":"Mark S."},{"family":"Lewis-Shiell","given":"Chiyinde"},{"family":"Bishop","given":"Sophia I."},{"family":"Davis","given":"Eluned L."},{"family":"Fernandez-Hart","given":"Tim J."},{"family":"Diwakar","given":"Previn"},{"family":"Beckett","given":"David"}],"issued":{"date-parts":[["2018",9]]}}},{"id":249,"uris":[""],"uri":[""],"itemData":{"id":249,"type":"article-journal","abstract":"PURPOSE: Ovarian vein embolization has been used recently to treat pelvic congestion syndrome. The purpose of this study is to evaluate the clinical efficacy and safety of ovarian vein embolization in the treatment of symptomatic pelvic varices.\nMATERIALS AND METHODS: We performed ovarian vein embolization in 41 patients (mean age, 37.8 years; range, 30-58 years): 32 patients underwent unilateral embolization and nine patients underwent bilateral embolization. All had lower abdominal pain and pelvic varicosities were found on retrograde ovarian vein venography. Embolization was performed with a mixture of enbucrilate and lipiodized oil in all but one patient, in whom enbucrilate and minicoils were used. Initial technical success rate and clinical follow-up (1-61 months; mean, 19.9 months), conducted with use of mailed questionnaires, are reported.\nRESULTS: Initial technical success rate was 98%. Immediate complications were noted in two patients (4%) in the form of migration of some fragments of glue (used as embolic agent), which was treated conservatively. Clinical follow-up reveals variable symptomatic relief in 9.7% of cases and a total relief of symptoms in 58.5% of cases. Results in patients who had insufficient ovarian veins bilaterally were no better than those in patients for whom only the left ovarian vein was found insufficient.\nCONCLUSIONS: Transcatheter embolization of the ovarian veins is a safe and feasible technique leading to complete relief of symptoms in more than half of cases. No statistically significant difference in clinical outcome could be noted between patients presenting with bilateral insufficient ovarian veins, who underwent bilateral embolization, and patients presenting with an insufficient left ovarian vein, who underwent left unilateral embolization.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/s1051-0443(07)61801-6","ISSN":"1051-0443","issue":"7","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 10928522","page":"859-864","source":"PubMed","title":"Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results","title-short":"Ovarian vein embolization for the treatment of pelvic congestion syndrome","volume":"11","author":[{"family":"Maleux","given":"G."},{"family":"Stockx","given":"L."},{"family":"Wilms","given":"G."},{"family":"Marchal","given":"G."}],"issued":{"date-parts":[["2000",8]]}}}],"schema":""} 3,4The safety and efficacy of embolization for both gonadal vein embolization in men and OVE in women are well supported by several systematic reviews and other strong literature. These two syndromes are comparable with a common etiology. Given that male varicocele treatment is routinely covered by insurance, it is unfair to deny women coverage for the same condition. Khilnani & Rosenblatt (2015) postulated that the discrepancy between varicocele therapy and PeVD arose from an inaccurate description of the entity now known to be PeVD in 1949 when psychological stress was hypothesized to be responsible for the symptoms. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"XPjdhALV","properties":{"formattedCitation":"\\super 5\\nosupersub{}","plainCitation":"5","noteIndex":0},"citationItems":[{"id":286,"uris":[""],"uri":[""],"itemData":{"id":286,"type":"webpage","title":"The Biggest Challenge to Pelvic Congestion Embolization: Reimbursement - Endovascular Today","URL":"","accessed":{"date-parts":[["2020",6,26]]}}}],"schema":""} 5 They further attribute the incongruity as arising from a more challenging and expensive workup for PeVD with its varicose veins deep in the pelvis as compared to varicoceles, which can be more easily visualized or palpated. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"vLZ60teT","properties":{"formattedCitation":"\\super 5\\nosupersub{}","plainCitation":"5","noteIndex":0},"citationItems":[{"id":286,"uris":[""],"uri":[""],"itemData":{"id":286,"type":"webpage","title":"The Biggest Challenge to Pelvic Congestion Embolization: Reimbursement - Endovascular Today","URL":"","accessed":{"date-parts":[["2020",6,26]]}}}],"schema":""} 5 Regardless of the origin of this double standard, the medical community will no longer tolerate any gender bias against women with analogous disease processes as men. As such, we respectfully request that you reconsider OVE as a medically necessary designation for the treatment of PeVD.Services interventions: Diagnostic and therapeuticDiagnosis of PeVD depends on vigilant evaluation of symptoms and careful attention to imaging results. A multidisciplinary consensus panel published in our society's leading scientific journal, the Journal of Vascular and Interventional Radiology (JVIR), highlights four potential clinical presentations of PeVD: 1) CPP including sexual, genitourinary, pelvic floor or anorectal symptoms; 2) pelvic-origin lower extremity and vulvar varicosities with or without symptoms; 3) lower extremity edema or exercise-induced limb pain, and 4) renal symptoms of hematuria or flank pain. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"uWJo82PZ","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":267,"uris":[""],"uri":[""],"itemData":{"id":267,"type":"article-journal","abstract":"Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2018.10.008","ISSN":"1535-7732","issue":"6","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 30857986","page":"781-789","source":"PubMed","title":"Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel","title-short":"Research Priorities in Pelvic Venous Disorders in Women","volume":"30","author":[{"family":"Khilnani","given":"Neil M."},{"family":"Meissner","given":"Mark H."},{"family":"Learman","given":"Lee A."},{"family":"Gibson","given":"Kathleen D."},{"family":"Daniels","given":"Jane P."},{"family":"Winokur","given":"Ronald S."},{"family":"Marvel","given":"Richard P."},{"family":"Machan","given":"Lindsay"},{"family":"Venbrux","given":"Anthony C."},{"family":"Tu","given":"Frank F."},{"family":"Pabon-Ramos","given":"Waly M."},{"family":"Nedza","given":"Susan M."},{"family":"White","given":"Sarah B."},{"family":"Rosenblatt","given":"Mel"}],"issued":{"date-parts":[["2019",6]]}}}],"schema":""} 1 Given the variable presentation, there is no single survey instrument that can diagnose PeVD. However, scales such as the 10-point visual analogue scales (VAS) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wuNfn3cB","properties":{"formattedCitation":"\\super 6\\uc0\\u8211{}11\\nosupersub{}","plainCitation":"6–11","noteIndex":0},"citationItems":[{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"To evaluate the efficacy of various treatments for pelvic congestion syndrome in patients with different stress levels, we analyzed one hundred six patients with pelvic congestion syndrome, confirmed with laparoscopy and venography, who did not respond to medication after 4-6 months medication. They were divided into three groups: (embolotherapy; hysterectomy with bilateral oophorectomy and hormone replacement therapy; and hysterectomy with unilateral oophorectomy). The visual analog scale was used to measure degree of pain; stress level data were scored with the revised social readjustment rating scale. Embolotherapy was significantly more effective at reducing pelvic pain, compared to the other methods (p < 0.05). The mean percentage decrease in pain was significantly greater in the patients with lower stress scores (p < 0.05). Ovarian and/or internal iliac vein embolization appears to be a safe, well-tolerated, effective treatment for pelvic congestion syndrome that has not responded to medication.","container-title":"The Tohoku Journal of Experimental Medicine","DOI":"10.1620/tjem.201.131","ISSN":"0040-8727","issue":"3","journalAbbreviation":"Tohoku J. Exp. Med.","language":"eng","note":"PMID: 14649734","page":"131-138","source":"PubMed","title":"Comparison of treatments for pelvic congestion syndrome","volume":"201","author":[{"family":"Chung","given":"Min-Hyung"},{"family":"Huh","given":"Chu-Yeop"}],"issued":{"date-parts":[["2003",11]]}}},{"id":238,"uris":[""],"uri":[""],"itemData":{"id":238,"type":"article-journal","abstract":"PURPOSE: To evaluate the long-term clinical outcome of transcatheter embolotherapy in women with chronic pelvic pain caused by ovarian and pelvic varices.\nMATERIALS AND METHODS: The study population included consecutive patients referred to a tertiary-care interventional radiology service from 1998 to 2003 because of a high degree of clinical suspicion of pelvic and ovarian varices. Visual analog scales and questionnaires during clinic visits were used to measure pain perception levels. Basal female hormonal levels were obtained and compared.\nRESULTS: Of 131 patients referred (mean age, 34.0 years+/-12.5), percutaneous transfemoral venography confirmed the presence of ovarian varices in 127 (97.0%), all of whom were treated with embolotherapy. Internal iliac embolotherapy was performed in 108 of 127 patients (85.0%). Ninety-seven patients completed long-term clinical follow-up (mean 45 months+/-18). The mean pelvic pain level had improved significantly from 7.6+/-1.8 before embolotherapy to 2.9+/-2.8 after embolotherapy (P<.0001). Significant improvement in each category of specific symptoms was also noted (P<.0001). Overall, 83% of the patients exhibited clinical improvement at long-term follow-up, 13% had no significant change, and 4% exhibited worsened condition. No significant change was noted in hormone levels after embolotherapy. Two successful pregnancies were noted after ovarian and pelvic vein embolotherapy.\nCONCLUSION: Direct venographic evaluation with embolotherapy can achieve significant improvement in pain perception levels in patients with chronic pelvic pain caused by pelvic venous congestion.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1097/01.RVI.0000194870.11980.F8","ISSN":"1051-0443","issue":"2 Pt 1","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 16517774","page":"289-297","source":"PubMed","title":"Embolotherapy for pelvic congestion syndrome: long-term results","title-short":"Embolotherapy for pelvic congestion syndrome","volume":"17","author":[{"family":"Kim","given":"Hyun S."},{"family":"Malhotra","given":"Amit D."},{"family":"Rowe","given":"Peter C."},{"family":"Lee","given":"Judy M."},{"family":"Venbrux","given":"Anthony C."}],"issued":{"date-parts":[["2006",2]]}}},{"id":245,"uris":[""],"uri":[""],"itemData":{"id":245,"type":"article-journal","abstract":"PURPOSE: This study was designed to evaluate the clinical outcome and patients' satisfaction after a 5 year follow-up period for pelvic congestion syndrome (PCS) coil embolization in patients who suffered from chronic pelvic pain that initially consulted for lower limb venous insufficiency.\nMETHODS: A total of 202 patients suffering from chronic pelvic pain were recruited prospectively in a single center (mean age 43.5 years; range 27-57) where they were being treated for lower limb varices. Inclusion criteria were: lower limb varices and chronic pelvic pain (>6 months), >6 mm pelvic venous caliber in ultrasonography, and venous reflux or presence of communicating veins. Both ovarian and hypogastric veins were targeted for embolization. Pain level was assessed before and after embolotherapy and during follow-up using a visual analog scale (VAS). Technical and clinical success and recurrence of leg varices were studied. Patients completed a quality questionnaire. Clinical follow-up was performed at 1, 3, and 6 months and every year for 5 years.\nRESULTS: Technical success was 100%. Clinical success was achieved in 168 patients (93.85%), with complete disappearance of symptoms in 60 patients (33.52%). Pain score (VAS) was 7.34 ± 0.7 preprocedural versus 0.78 ± 1.2 at the end of follow-up (P < 0.0001). Complications were: groin hematoma (n = 6), coil migration (n = 4), and reaction to contrast media (n = 1). Twenty-three cases presented abdominal pain after procedure. In 24 patients (12.5%), there was recurrence of their leg varices within the follow-up. The mean degree of patients' satisfaction was 7.4/9.\nCONCLUSIONS: Coil embolization of PCS is an effective and safe procedure, with high clinical success rate and degree of satisfaction.","container-title":"Cardiovascular and Interventional Radiology","DOI":"10.1007/s00270-013-0586-2","ISSN":"1432-086X","issue":"4","journalAbbreviation":"Cardiovasc Intervent Radiol","language":"eng","note":"PMID: 23456353","page":"1006-1014","source":"PubMed","title":"Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients","title-short":"Endovascular treatment of pelvic congestion syndrome","volume":"36","author":[{"family":"Laborda","given":"Alicia"},{"family":"Medrano","given":"Joaquin"},{"family":"Blas","given":"Ignacio","non-dropping-particle":"de"},{"family":"Urtiaga","given":"Ignacio"},{"family":"Carnevale","given":"Francisco Cesar"},{"family":"Gregorio","given":"Miguel A.","non-dropping-particle":"de"}],"issued":{"date-parts":[["2013",8]]}}},{"id":294,"uris":[""],"uri":[""],"itemData":{"id":294,"type":"article-journal","abstract":"Ovarian and pelvic (internal iliac) varices have long been recognized as a source of chronic pelvic pain in women. The technique of transcatheter embolotherapy for ovarian and pelvic varices requires selective catheterization of the ovarian and internal iliac veins, followed by contrast venography and embolization. The long-term effects of treatment are the subject of ongoing investigation. This article provides a concise background on ovarian and pelvic varices and reviews the recently published literature on their embolization for the treatment of pelvic venous incompetence (also known as pelvic congestion syndrome).","container-title":"Current Opinion in Obstetrics & Gynecology","DOI":"10.1097/00001703-199908000-00006","ISSN":"1040-872X","issue":"4","journalAbbreviation":"Curr. Opin. Obstet. Gynecol.","language":"eng","note":"PMID: 10498026","page":"395-399","source":"PubMed","title":"Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome)","volume":"11","author":[{"family":"Venbrux","given":"A. C."},{"family":"Lambert","given":"D. L."}],"issued":{"date-parts":[["1999",8]]}}},{"id":251,"uris":[""],"uri":[""],"itemData":{"id":251,"type":"article-journal","abstract":"OBJECTIVE: To evaluate the safety and effectiveness of transcatheter embolization using coils for treatment of pelvic congestion syndrome (PCS) and to elucidate prognostic factors for clinical success.\nMETHODS: Data were retrospectively analyzed from 113 women with PCS who underwent endovascular embolization of ovarian and pelvic varicose veins at Hospital Clínico Universitario, Zaragoza, Spain between January 2001 and January 2011. Pain score was evaluated before and after the procedure via a visual analog scale (VAS). Associated symptoms (dysmenorrhea, dyspareunia, urinary urgency, and lower limb symptoms) were also evaluated. Patients were followed up for 12 months.\nRESULTS: The technical and clinical success was 100%. At 12 months, 53% of patients had no pelvic pain and 47% reported a reduction in pelvic pain. The average VAS was 7.34 before the procedure and 0.47 at 12 months. Complete relief of pain and associated symptoms was achieved for 37% of patients. Urinary urgency, lower limb symptoms, and vulvar and lower limbs varicosities were prognostic factors related to incomplete treatment success. The global complication rate was low (5/113, 4.4%).\nCONCLUSION: Transcatheter embolization was a safe and effective treatment for PCS. Lower limb symptoms, urinary urgency, and varicosities were associated with incomplete clinical success.","container-title":"International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics","DOI":"10.1016/j.ijgo.2013.10.008","ISSN":"1879-3479","issue":"1","journalAbbreviation":"Int J Gynaecol Obstet","language":"eng","note":"PMID: 24486124","page":"65-68","source":"PubMed","title":"Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome","volume":"125","author":[{"family":"Nasser","given":"Felipe"},{"family":"Cavalcante","given":"Rafael N."},{"family":"Affonso","given":"Breno B."},{"family":"Messina","given":"Marcos L."},{"family":"Carnevale","given":"Francisco C."},{"family":"Gregorio","given":"Miguel A.","non-dropping-particle":"de"}],"issued":{"date-parts":[["2014",4]]}}},{"id":298,"uris":[""],"uri":[""],"itemData":{"id":298,"type":"article-journal","abstract":"AIM: To assess the efficacy of venous embolization treatment for the pelvic congestion syndrome (PCS).\nPATIENTS AND METHODS: Retrospective study of 33 female patients undergoing pelvic venous embolization between January 2008 and May 2012 in Bordeaux. The inclusion criteria were clinical symptoms of PCS documented by transabdominal Doppler ultrasound and/or pelvic magnetic resonance imaging. Patients with pelvic varicose veins feeding saphenous varicose veins were excluded. The efficacy of treatment was assessed on a Visual Analog Scale (VAS).\nRESULTS: Thirty-three patients were included and the mean follow up period was 26months (3-59months). The VAS was 7.37 (standard deviation: 0.99) before embolization and 1.36 (standard deviation: 1.73) after embolization (P<0.0001). Twenty patients reported that their symptoms had completely disappeared, 11 had partially disappeared and two had gained no improvement. A significant fall was found in the number of patients with dyspareunia (P<0.0001). A single technical embolization failure was reported.\nCONCLUSION: Our series demonstrates the efficacy of embolization treatment with a significant fall in the VAS in patients with PCS.","container-title":"Diagnostic and Interventional Imaging","DOI":"10.1016/j.diii.2013.09.011","ISSN":"2211-5684","issue":"3","journalAbbreviation":"Diagn Interv Imaging","language":"eng","note":"PMID: 24183954","page":"301-306","source":"PubMed","title":"Evaluation of the efficacy of endovascular treatment of pelvic congestion syndrome","volume":"95","author":[{"family":"Hocquelet","given":"A."},{"family":"Le Bras","given":"Y."},{"family":"Balian","given":"E."},{"family":"Bouzgarrou","given":"M."},{"family":"Meyer","given":"M."},{"family":"Rigou","given":"G."},{"family":"Grenier","given":"N."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 6–11 have been used to evaluate symptom severity and treatment response. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"zUfdUMTJ","properties":{"formattedCitation":"\\super 12\\nosupersub{}","plainCitation":"12","noteIndex":0},"citationItems":[{"id":275,"uris":[""],"uri":[""],"itemData":{"id":275,"type":"article-journal","abstract":"Objective\nTo determine the change in health-related quality of life associated with uterine fibroid embolization (UFE).\nMaterials and Methods\nA health-related quality-of-life questionnaire was administered before and after therapy. The questionnaire contained validated scales from the Medical Outcomes Study, with additional domains and symptom items specific to fibroids. Patients treated with UFE for symptomatic uterine leiomyomata completed a health-related quality of life questionnaire before therapy. A follow-up quality of life questionnaire and an additional brief questionnaire to assess symptom improvement were completed 3 and 6 months postprocedure. Confirmatory reliability and validity testing was also conducted. Mean scores for each scale on the quality of life questionnaire were calculated and change scores were computed.\nResults\nFifty women were enrolled in the study and completed the baseline assessment. Health-related quality of life scores improved in all instances at follow-up. Mean change scores were statistically significant for all domains between baseline and month 3 (P < .01) and between baseline and month 6 (P < .05) except backache (P = .12).\nConclusion\nPatients undergoing UFE report significant improvements in health-related quality of life and fibroid-specific symptoms. These findings suggest that the measurement of health-related quality of life may be an effective means of comparing the outcome of UFE with other fibroid therapies.","container-title":"Journal of Vascular and Interventional Radiology","DOI":"10.1016/S1051-0443(99)70235-6","ISSN":"1051-0443","issue":"10","journalAbbreviation":"Journal of Vascular and Interventional Radiology","language":"en","page":"1293-1303","source":"ScienceDirect","title":"Uterine Fibroid Embolization: Measurement of Health-Related Quality of Life before and after Therapy","title-short":"Uterine Fibroid Embolization","volume":"10","author":[{"family":"Spies","given":"James B."},{"family":"Warren","given":"Elisabeth H."},{"family":"Mathias","given":"Susan D."},{"family":"Walsh","given":"Sheila M."},{"family":"Roth","given":"Antoinette R."},{"family":"Pentecost","given":"Michael J."}],"issued":{"date-parts":[["1999",11,1]]}}}],"schema":""} 12 Improvement in quality of life and a reduction rather than elimination of pain is a primary measure of success. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"u9vIyR5M","properties":{"formattedCitation":"\\super 13\\nosupersub{}","plainCitation":"13","noteIndex":0},"citationItems":[{"id":273,"uris":[""],"uri":[""],"itemData":{"id":273,"type":"article-journal","abstract":"BACKGROUND: Chronic pelvic pain is a common and debilitating condition; its aetiology is multifactorial, involving social, psychological and biological factors. The management of chronic pelvic pain is challenging, as despite interventions involving surgery, many women remain in pain without a firm gynaecological diagnosis.\nOBJECTIVES: To assess the effectiveness and safety of non-surgical interventions for women with chronic pelvic pain.\nSEARCH METHODS: We searched the Menstrual Disorders and Subfertility Group Specialised Register. We also searched (from inception to 5 February 2014) AMED, CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS. We handsearched sources such as citation lists, trial registers and conference proceedings.\nSELECTION CRITERIA: Randomised controlled trials (RCTs) on non-surgical management of chronic pelvic pain were eligible for inclusion. We included studies of women with a diagnosis of pelvic congestion syndrome or adhesions but excluded those with pain known to be caused by endometriosis, primary dysmenorrhoea (period pain), active chronic pelvic inflammatory disease or irritable bowel syndrome. We considered studies of any non-surgical intervention, including lifestyle, physical, medical and psychological treatments.\nDATA COLLECTION AND ANALYSIS: Study selection, quality assessment and data extraction were performed independently by two review authors. Meta-analysis was performed using the Peto odds ratio (Peto OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). The primary outcome measure was pain relief, and secondary outcome measures were psychological outcomes, quality of life, requirement for analgesia and adverse effects. The quality of the evidence was assessed by using GRADE methods.\nMAIN RESULTS: Twenty-one RCTs were identified that involved non-surgical management of chronic pelvic pain: 13 trials were included in the review, and eight were excluded. The studies included a total of 750 women-406 women in the intervention groups and 344 in the control groups. Included studies had high attrition rates, and investigators often did not blind adequately or did not clearly describe randomisation procedures. Medical treatment versus placebo Progestogen (medroxyprogesterone acetate (MPA)) was more effective than placebo at the end of treatment in terms of the number of women achieving a greater than 50% reduction in visual analogue scale (VAS) pain score immediately after treatment (Peto OR 3.00, 95% CI 1.70 to 5.31, two studies, n = 204, I(2) = 22%, moderate-quality evidence). Evidence of benefit was maintained up to nine months after treatment (Peto OR 2.09, 95% CI 1.18 to 3.71, two studies, n = 204, I(2) = 0%, moderate-quality evidence). Women treated with progestogen reported more adverse effects (e.g. weight gain, bloatedness) than those given placebo (high-quality evidence). The estimated effect of lofexidine on pain outcomes when compared with placebo was compatible with benefit and harm (Peto OR 0.42, 95% CI 0.11 to 1.61, one study, 39 women, low-quality evidence). Women in the lofexidine group reported more adverse effects (including drowsiness and dry mouth) than women given placebo (moderate-quality evidence). Head-to-head comparisons of medical treatments Head-to-head comparisons showed that women taking goserelin had greater improvement in pelvic pain score (MD 3, 95% CI 2.08 to 3.92, one study, n = 47, moderate-quality evidence) at one year than those taking progestogen. Women taking gabapentin had a lower VAS pain score than those taking amytriptyline (MD -1.50, 95% CI -2.06 to -0.94, n = 40, low-quality evidence). Study authors reported that no statistically significant difference was observed in the rate of adverse effects among women taking gabapentin compared with women given amytriptyline. The study comparing goserelin versus progestogen did not report on adverse effects. Psychological treatment Women who underwent reassurance ultrasound scans and received counselling were more likely to report improved pain than those treated with a standard 'wait and see' policy (Peto OR 6.77, 95% CI 2.83 to 16.19, n = 90, low-quality evidence). Significantly more women who had writing therapy as a disclosure reported improvement in pain than those in the non-disclosure group (Peto OR 4.47, 95% CI 1.41 to 14.13, n = 48, very low-quality evidence). No difference between groups in pain outcomes was noted when other psychological therapies were compared with standard care or placebo (quality of evidence ranged from very low to low). Studies did not report on adverse effects. Complementary therapy Distension of painful pelvic structures was more effective for pain when compared with counselling (MD 35.8, 95% CI 23.08 to 48.52 on a zero to 100 scale, one study, n = 48, moderate-quality evidence). No difference in pain levels was observed when magnetic therapy was compared with use of a control magnet (very low-quality evidence). Studies did not report on adverse effects.The results of studies examining psychological and complementary therapies could not be combined to yield meaningful results.\nAUTHORS' CONCLUSIONS: Evidence of moderate quality supports progestogen as an option for chronic pelvic pain, with efficacy reported during treatment. In practice, this option may be most acceptable among women unconcerned about progestogenic adverse effects (e.g. weight gain, bloatedness-the most common adverse effects). Although some evidence suggests possible benefit of goserelin when compared with progestogen, gabapentin as compared with amytriptyline, ultrasound versus 'wait and see' and writing therapy versus non-disclosure, the quality of evidence is generally low, and evidence is drawn from single studies.Given the prevalence and healthcare costs associated with chronic pelvic pain in women, RCTs of other medical, lifestyle and psychological interventions are urgently required.","container-title":"The Cochrane Database of Systematic Reviews","DOI":"10.1002/14651858.CD008797.pub2","ISSN":"1469-493X","issue":"3","journalAbbreviation":"Cochrane Database Syst Rev","language":"eng","note":"PMID: 24595586","page":"CD008797","source":"PubMed","title":"Non-surgical interventions for the management of chronic pelvic pain","author":[{"family":"Cheong","given":"Ying C."},{"family":"Smotra","given":"Grisham"},{"family":"Williams","given":"Amanda C. de C."}],"issued":{"date-parts":[["2014",3,5]]}}}],"schema":""} 13 Transcatheter venography is the gold standard for the diagnosis of PeVDs as it can be used to evaluate for ovarian, internal iliac, or renal pathology. Intravascular, transabdominal, and transvaginal ultrasound are also tools used to supplement diagnostic workup. Cross-sectional imaging such as computerized tomography (CT) and magnetic resonance imaging (MRI) are also useful in the diagnosis of PeVD. Once a patient has been diagnosed with PeVD, it is important to direct treatment towards eliminating retrograde flow in the abnormal ovarian vein(s). Doing so reduces pressure in the pelvic veins, which in turn alleviates or improves symptoms. OVE is a percutaneous, catheter-based procedure that results in occlusion of the abnormal ovarian vein(s) and effectively eliminates the retrograde flow that creates the pelvic varicose veins. It is performed on an outpatient basis. The OVE procedure begins with a renal vein and ovarian venogram to confirm that retrograde flow is present. If reflux and retrograde flow are identified within the left and/or right ovarian vein, the retrogradely flowing veins are occluded to eliminate this reflux and reduce the pressure within pelvic varicosities. Surgical ligation of abnormal ovarian veins and hysterectomy with bilateral salpingo-oophorectomy are other approaches to treatment but are more invasive, less effective, and are associated with more morbidity. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"iz4GXM80","properties":{"formattedCitation":"\\super 14\\nosupersub{}","plainCitation":"14","noteIndex":0},"citationItems":[{"id":277,"uris":[""],"uri":[""],"itemData":{"id":277,"type":"article-journal","abstract":"Chronic pelvic pain in women is a common and disabling illness caused by numerous organic pathologies usually accompanied by varying psychological dysfunctions. Many patients may receive misdiagnosis, misdirected therapies, or do not seek help at all. Pelvic congestion may be responsible for pain in patients without more common diseases, such as endometriosis and pelvic adhesions, among others. Our view of this condition is evolving. In the United States, this medical condition remains controversial. More recent research from the United Kingdom has caused a fresh look at the diagnosis and treatment of chronic pelvic pain produced by pelvic congestion. Potentially, many patients may benefit from a reconsideration of this approach.","container-title":"JSLS : Journal of the Society of Laparoendoscopic Surgeons","ISSN":"1086-8089","issue":"2","journalAbbreviation":"JSLS","note":"PMID: 11394421\nPMCID: PMC3015423","page":"105-110","source":"PubMed Central","title":"Current Concepts of Pelvic Congestion and Chronic Pelvic Pain","volume":"5","author":[{"family":"Perry","given":"C. Paul"}],"issued":{"date-parts":[["2001"]]}}}],"schema":""} 14 Mandatory requirements for a trial of pharmacotherapy prior to OVE as required by Aetna are unnecessarily prolonging patients' suffering. Unlike other causes of CPP such as endometriosis, PeVD cannot be treated medically, and policies supporting early and effective treatment of the underlying cause of PeVD with OVE are needed.Scope and clinical indicationsBlue Cross Blue Shield Association (BCBSA) Evidence Positioning Systems indicates that the definition of the disease and defining a patient population is unclear. However, multiple studies referenced within the below rationale clearly stipulate that the patient population are premenopausal women usually between the age of 20-45 years old, with CPP with prolonged standing, after coitus with no other demonstrable cause, ovarian or pelvic venous varicosities with reflux found on imaging with or without vulvar and perineal varicose veins. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"l4CGXJwB","properties":{"formattedCitation":"\\super 7,15\\uc0\\u8211{}20\\nosupersub{}","plainCitation":"7,15–20","noteIndex":0},"citationItems":[{"id":238,"uris":[""],"uri":[""],"itemData":{"id":238,"type":"article-journal","abstract":"PURPOSE: To evaluate the long-term clinical outcome of transcatheter embolotherapy in women with chronic pelvic pain caused by ovarian and pelvic varices.\nMATERIALS AND METHODS: The study population included consecutive patients referred to a tertiary-care interventional radiology service from 1998 to 2003 because of a high degree of clinical suspicion of pelvic and ovarian varices. Visual analog scales and questionnaires during clinic visits were used to measure pain perception levels. Basal female hormonal levels were obtained and compared.\nRESULTS: Of 131 patients referred (mean age, 34.0 years+/-12.5), percutaneous transfemoral venography confirmed the presence of ovarian varices in 127 (97.0%), all of whom were treated with embolotherapy. Internal iliac embolotherapy was performed in 108 of 127 patients (85.0%). Ninety-seven patients completed long-term clinical follow-up (mean 45 months+/-18). The mean pelvic pain level had improved significantly from 7.6+/-1.8 before embolotherapy to 2.9+/-2.8 after embolotherapy (P<.0001). Significant improvement in each category of specific symptoms was also noted (P<.0001). Overall, 83% of the patients exhibited clinical improvement at long-term follow-up, 13% had no significant change, and 4% exhibited worsened condition. No significant change was noted in hormone levels after embolotherapy. Two successful pregnancies were noted after ovarian and pelvic vein embolotherapy.\nCONCLUSION: Direct venographic evaluation with embolotherapy can achieve significant improvement in pain perception levels in patients with chronic pelvic pain caused by pelvic venous congestion.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1097/01.RVI.0000194870.11980.F8","ISSN":"1051-0443","issue":"2 Pt 1","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 16517774","page":"289-297","source":"PubMed","title":"Embolotherapy for pelvic congestion syndrome: long-term results","title-short":"Embolotherapy for pelvic congestion syndrome","volume":"17","author":[{"family":"Kim","given":"Hyun S."},{"family":"Malhotra","given":"Amit D."},{"family":"Rowe","given":"Peter C."},{"family":"Lee","given":"Judy M."},{"family":"Venbrux","given":"Anthony C."}],"issued":{"date-parts":[["2006",2]]}}},{"id":301,"uris":[""],"uri":[""],"itemData":{"id":301,"type":"article-journal","abstract":"PURPOSE: Chronic pelvic pain (CPP) in the presence of dilated and refluxing pelvic veins is often described as pelvic congestion syndrome (PCS), although the causal relationship between pelvic vein incompetence and CPP has not been established. Percutaneous embolization is the principal treatment for PCS, with high success rates cited. This study was undertaken to systematically and critically review the effectiveness of embolization of incompetent pelvic veins.\nMATERIALS AND METHODS: A comprehensive search strategy encompassing various terms for pelvic congestion, pelvic pain, and embolization was deployed in 17 bibliographic databases, with no restriction on study design. Methodologic quality was assessed. The quality and heterogeneity generally precluded meta-analysis. Results were tabulated and described narratively.\nRESULTS: Twenty-one prospective case series and one poor-quality randomized trial of embolization (involving a total of 1,308 women) were identified. Early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility, but no concerns were noted. Transient pain was common following foam embolization, and there was a < 2% risk of coil migration.\nCONCLUSIONS: Embolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2016.04.016","ISSN":"1535-7732","issue":"10","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 27397619","page":"1478-1486.e8","source":"PubMed","title":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review","title-short":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain","volume":"27","author":[{"family":"Daniels","given":"Jane P."},{"family":"Champaneria","given":"Rita"},{"family":"Shah","given":"Laila"},{"family":"Gupta","given":"Janesh K."},{"family":"Birch","given":"Judy"},{"family":"Moss","given":"Jonathan G."}],"issued":{"date-parts":[["2016",10]]}}},{"id":231,"uris":[""],"uri":[""],"itemData":{"id":231,"type":"article-journal","abstract":"Chronic pelvic pain (CPP) is a common cause of gynecologic referral. Pelvic congestion syndrome, which is said to occurs due to ovarian vein incompetence, is a recognized cause of CPP. The aim of this paper is to briefly describe the clinical manifestations, and to review the role of diagnostic and interventional radiology in the management of this probably under-diagnosed condition.","container-title":"Cardiovascular and Interventional Radiology","DOI":"10.1007/s00270-007-9160-0","ISSN":"0174-1551","issue":"6","journalAbbreviation":"Cardiovasc Intervent Radiol","language":"eng","note":"PMID: 17805925","page":"1105-1111","source":"PubMed","title":"Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology","title-short":"Chronic pelvic pain due to pelvic congestion syndrome","volume":"30","author":[{"family":"Ganeshan","given":"Arul"},{"family":"Upponi","given":"Sara"},{"family":"Hon","given":"Lye-Quen"},{"family":"Uthappa","given":"M. C."},{"family":"Warakaulle","given":"Dinuke R."},{"family":"Uberoi","given":"Raman"}],"issued":{"date-parts":[["2007",12]]}}},{"id":233,"uris":[""],"uri":[""],"itemData":{"id":233,"type":"article-journal","abstract":"PURPOSE: To compare safety and efficacy of vascular plugs (VPs) and fibered platinum coils (FPCs) for embolization in pelvic congestion syndrome (PCS).\nMATERIALS AND METHODS: A randomized, prospective, single-center study enrolled 100 women with PCS from January 2014 to January 2015. Patients were randomly assigned to 2 groups, and embolization was performed with FPCs (n?= 50) or VPs (n?= 50). Mean age of patients was 42.7 years ± 7.60, and mean visual analog scale (VAS) score for pelvic pain before treatment was 7.4 ± 7.60. Primary outcome (clinical success at 1 y using a VAS), number of devices, procedure and fluoroscopy times, radiation doses, costs, and complications were compared, and participants were followed at 1, 3, 6, and 12 months.\nRESULTS: Clinical success and subjective improvement were not significantly different at 1-year follow-up (89.7% for FPCs vs 90.6% for VPs; P?= .760). Mean number of devices per case was 18.2 ± 1.33 for FPCs and 4.1 ± 0.31 for VPs (P < .001). Three FPCs and 1 VP migrated to pulmonary vasculature approximately 3-6 months after the embolization procedure; all were retrieved without complications. The FPC group had a significantly longer fluoroscopy time (33.4 min ± 4.68 vs 19.5 min ± 6.14) and larger radiation dose (air kerma 948.0 mGy ± 248.45 vs 320.7 mGy ± 134.33) (all P < .001).\nCONCLUSIONS: Embolization for PCS resulted in pain relief in 90% of patients; clinical success was not affected by embolic device. VPs were associated with decreased fluoroscopy time and radiation dose.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2017.09.011","ISSN":"1535-7732","issue":"1","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 29174618","page":"45-53","source":"PubMed","title":"A Randomized Trial of Endovascular Embolization Treatment in Pelvic Congestion Syndrome: Fibered Platinum Coils versus Vascular Plugs with 1-Year Clinical Outcomes","title-short":"A Randomized Trial of Endovascular Embolization Treatment in Pelvic Congestion Syndrome","volume":"29","author":[{"family":"Guirola","given":"Jose A."},{"family":"Sánchez-Ballestin","given":"Maria"},{"family":"Sierre","given":"Sergio"},{"family":"Lahuerta","given":"Celia"},{"family":"Mayoral","given":"Victoria"},{"family":"De Gregorio","given":"Miguel A."}],"issued":{"date-parts":[["2018",1]]}}},{"id":243,"uris":[""],"uri":[""],"itemData":{"id":243,"type":"article-journal","abstract":"PURPOSE: To evaluate the therapeutic effectiveness of ovarian vein embolization using coils for pelvic congestion syndrome (PCS), a common cause of chronic pelvic pain in multiparous women.\nMETHODS: Between November 1998 and June 2005, 67 patients were diagnosed with PCS and underwent ovarian vein coil embolization. Through medical records and telephone interviews, the pre-embolization pain level and post-embolization pain control were assessed. In addition, in those cases where pain persisted after embolization or where patients were dissatisfied with the procedure, additional treatments and subsequent changes in pain scores were also analyzed. Evaluation after coil embolization was performed within 3-6 months (n = 3), 6 months to 1 year (n = 7), 1-2 years (n = 13), 2-3 years (n = 7), 3-4 years (n = 7), 4-5 years (n = 13), or 5-6 years (n = 17).\nRESULTS: Among a total of 67 patients, 82% (55/67) experienced pain reduction after coil embolization, were satisfied with the procedure, and did not pursue any further treatment. Twelve patients (18%, 12/67) responded that their pain level had not changed, or had become more severe. Among them, 9 patients were treated surgically and the remaining 3 patients remained under continuous drug therapy.\nCONCLUSION: Ovarian vein embolization using coils is a safe and effective therapeutic method for treatment of PCS. It is thought that surgical treatment should be considered in cases where embolization proves ineffective.","container-title":"Cardiovascular and Interventional Radiology","DOI":"10.1007/s00270-007-9040-7","ISSN":"0174-1551","issue":"4","journalAbbreviation":"Cardiovasc Intervent Radiol","language":"eng","note":"PMID: 17468903","page":"655-661","source":"PubMed","title":"Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome","volume":"30","author":[{"family":"Kwon","given":"Se Hwan"},{"family":"Oh","given":"Joo Hyeong"},{"family":"Ko","given":"Kyung Ran"},{"family":"Park","given":"Ho Chul"},{"family":"Huh","given":"Joo Yup"}],"issued":{"date-parts":[["2007",8]]}}},{"id":247,"uris":[""],"uri":[""],"itemData":{"id":247,"type":"article-journal","abstract":"BACKGROUND: Chronic pelvic pain is not a rare health problem among women. One of the most common causes of chronic pelvic pain is pelvic congestion syndrome (PCS). We have reviewed all medical literature on the endovascular treatment of PCS and hereby provide a brief overview of the anatomy, pathophysiology, and clinical aspects of ovarian and pelvic varices. We describe the technique of transcatheter embolization, the complications thereof and the clinical results of the treatment.\nMETHODS: A literature search was performed using PubMed, Science Direct, Google Scholar, and Scopus to identify case series on the endovascular treatment of PCS up until the end of November?2014.\nRESULTS: Twenty studies with a total of 1081 patients were included in the review. There were no randomized trials, and only one study included a control group. The immediate technical success rate in the occlusion of the affected veins was 99%. Seventeen studies reported the 1- to 3-month clinical success of 641 patients. Of these, 88.1% reported moderate to significant relief in the symptoms and 11.9% reported little or no relief. In 17 studies, long-term results were reported, and the follow-up varied between 7.3?months and 5?years. In late follow-up, 86.6% reported relief of the symptoms and 13.6% experienced little or no relief.\nCONCLUSIONS: The immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5?years after the procedure. However, there are no randomized or high-quality controlled trials, and the level of evidence therefore remains at?C.","container-title":"Journal of Vascular Surgery. Venous and Lymphatic Disorders","DOI":"10.1016/j.jvsv.2016.01.002","ISSN":"2213-3348","issue":"3","journalAbbreviation":"J Vasc Surg Venous Lymphat Disord","language":"eng","note":"PMID: 27318059","page":"355-370","source":"PubMed","title":"Efficacy of endovascular treatment for pelvic congestion syndrome","volume":"4","author":[{"family":"Mahmoud","given":"Osman"},{"family":"Vikatmaa","given":"Pirkka"},{"family":"Aho","given":"Pekka"},{"family":"Halmesm?ki","given":"Karoliina"},{"family":"Alb?ck","given":"Anders"},{"family":"Rahkola-Soisalo","given":"P?ivi"},{"family":"Lappalainen","given":"Kimmo"},{"family":"Venermo","given":"Maarit"}],"issued":{"date-parts":[["2016"]]}}},{"id":253,"uris":[""],"uri":[""],"itemData":{"id":253,"type":"article-journal","abstract":"BACKGROUND: Chronic pelvic pain accounts for up to 30% of outpatient gynecologic visits in the United States, potentially affecting up to 40% of the female population during their lifetime. Pelvic congestion syndrome (PCS) is defined as chronic pelvic pain resulting from reflux or obstruction of the gonadal, gluteal, or periuterine veins, sometimes associated with perineal or vulvar varices. It can also be caused by compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta, also known as the nutcracker syndrome. Whereas PCS accounts for up to 30% of patients presenting with chronic pelvic pain, it is frequently underdiagnosed. We reviewed the literature to investigate the current state of the diagnosis and treatment of this disorder.\nMETHODS: An online database search was performed with MEDLINE. MeSH headings included PCS, chronic pelvic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies.\nRESULTS: Our MEDLINE search revealed more than 3756 references to chronic pelvic pain. Specific references to PCS, pelvic chronic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies, however, included only 260 references. Thirty-seven references were small series including fewer than 50 patients or individual case reports documenting medical, surgical, or endovascular treatment of PCS. The majority of these papers demonstrated successful treatment of symptoms from PCS with embolization of one or both ovarian veins in addition to treatment of refluxing internal iliac vein branches. In addition, open surgery and, more recently, endovascular stenting of LRV obstruction have shown some promise in alleviating symptoms attributed to nutcracker syndrome.\nCONCLUSIONS: Diagnosis of PCS requires a careful history, physical examination, and noninvasive imaging. Several large case series have demonstrated the efficacy of embolotherapy in the reduction of pelvic pain; thus, it is the most favored treatment option for patients with PCS. For patients with outflow obstruction due to nutcracker syndrome, a limited number of studies have demonstrated remission of symptoms with stenting of the LRV as an alternative to open surgery.","container-title":"Journal of Vascular Surgery. Venous and Lymphatic Disorders","DOI":"10.1016/j.jvsv.2014.05.007","ISSN":"2213-3348","issue":"1","journalAbbreviation":"J Vasc Surg Venous Lymphat Disord","language":"eng","note":"PMID: 26993690","page":"96-106","source":"PubMed","title":"Diagnosis and treatment of the pelvic congestion syndrome","volume":"3","author":[{"family":"O'Brien","given":"Marlene T."},{"family":"Gillespie","given":"David L."}],"issued":{"date-parts":[["2015",1]]}}}],"schema":""} 7,15–20 We suggest that policies align to justify treatment with OVE of any patient with evidence of PeVD and CPP without another identifiable cause.RationaleDespite claims from BCBSA, United Healthcare, Aetna, Highmark Commercial, and Anthem Blue Cross that OVE for PeVD is investigational, for the past 15 years, OVE has been associated with good clinical outcomes in most women suffering from the symptoms of PeVD. The procedure is technically successful in almost 100 percent of patients with a high degree of safety. Symptomatic improvement tends to be seen in >80 percent of patients undergoing OVE. In a 2016 literature review, of the embolization procedure for pelvic congestion syndrome, Mahmoud et al. (2016) analyzed 20 studies involving 1,081 total patients and found that 88.1% of patients reported "moderate to significant relief" within the first 90 days and 86.6% reported overall "relief of symptoms" in late follow-up. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"98AfkU4G","properties":{"formattedCitation":"\\super 19\\nosupersub{}","plainCitation":"19","noteIndex":0},"citationItems":[{"id":247,"uris":[""],"uri":[""],"itemData":{"id":247,"type":"article-journal","abstract":"BACKGROUND: Chronic pelvic pain is not a rare health problem among women. One of the most common causes of chronic pelvic pain is pelvic congestion syndrome (PCS). We have reviewed all medical literature on the endovascular treatment of PCS and hereby provide a brief overview of the anatomy, pathophysiology, and clinical aspects of ovarian and pelvic varices. We describe the technique of transcatheter embolization, the complications thereof and the clinical results of the treatment.\nMETHODS: A literature search was performed using PubMed, Science Direct, Google Scholar, and Scopus to identify case series on the endovascular treatment of PCS up until the end of November?2014.\nRESULTS: Twenty studies with a total of 1081 patients were included in the review. There were no randomized trials, and only one study included a control group. The immediate technical success rate in the occlusion of the affected veins was 99%. Seventeen studies reported the 1- to 3-month clinical success of 641 patients. Of these, 88.1% reported moderate to significant relief in the symptoms and 11.9% reported little or no relief. In 17 studies, long-term results were reported, and the follow-up varied between 7.3?months and 5?years. In late follow-up, 86.6% reported relief of the symptoms and 13.6% experienced little or no relief.\nCONCLUSIONS: The immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5?years after the procedure. However, there are no randomized or high-quality controlled trials, and the level of evidence therefore remains at?C.","container-title":"Journal of Vascular Surgery. Venous and Lymphatic Disorders","DOI":"10.1016/j.jvsv.2016.01.002","ISSN":"2213-3348","issue":"3","journalAbbreviation":"J Vasc Surg Venous Lymphat Disord","language":"eng","note":"PMID: 27318059","page":"355-370","source":"PubMed","title":"Efficacy of endovascular treatment for pelvic congestion syndrome","volume":"4","author":[{"family":"Mahmoud","given":"Osman"},{"family":"Vikatmaa","given":"Pirkka"},{"family":"Aho","given":"Pekka"},{"family":"Halmesm?ki","given":"Karoliina"},{"family":"Alb?ck","given":"Anders"},{"family":"Rahkola-Soisalo","given":"P?ivi"},{"family":"Lappalainen","given":"Kimmo"},{"family":"Venermo","given":"Maarit"}],"issued":{"date-parts":[["2016"]]}}}],"schema":""} 19 Another strong literature review conducted within the same year by Daniel et al. (2016) analyzed 20 studies composed of 1,308 women, and the analysis reported that 75% of participants reported "substantial relief" from pain "with low rates of repeated interventions." ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"XEuBwatA","properties":{"formattedCitation":"\\super 15\\nosupersub{}","plainCitation":"15","noteIndex":0},"citationItems":[{"id":301,"uris":[""],"uri":[""],"itemData":{"id":301,"type":"article-journal","abstract":"PURPOSE: Chronic pelvic pain (CPP) in the presence of dilated and refluxing pelvic veins is often described as pelvic congestion syndrome (PCS), although the causal relationship between pelvic vein incompetence and CPP has not been established. Percutaneous embolization is the principal treatment for PCS, with high success rates cited. This study was undertaken to systematically and critically review the effectiveness of embolization of incompetent pelvic veins.\nMATERIALS AND METHODS: A comprehensive search strategy encompassing various terms for pelvic congestion, pelvic pain, and embolization was deployed in 17 bibliographic databases, with no restriction on study design. Methodologic quality was assessed. The quality and heterogeneity generally precluded meta-analysis. Results were tabulated and described narratively.\nRESULTS: Twenty-one prospective case series and one poor-quality randomized trial of embolization (involving a total of 1,308 women) were identified. Early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility, but no concerns were noted. Transient pain was common following foam embolization, and there was a < 2% risk of coil migration.\nCONCLUSIONS: Embolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2016.04.016","ISSN":"1535-7732","issue":"10","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 27397619","page":"1478-1486.e8","source":"PubMed","title":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review","title-short":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain","volume":"27","author":[{"family":"Daniels","given":"Jane P."},{"family":"Champaneria","given":"Rita"},{"family":"Shah","given":"Laila"},{"family":"Gupta","given":"Janesh K."},{"family":"Birch","given":"Judy"},{"family":"Moss","given":"Jonathan G."}],"issued":{"date-parts":[["2016",10]]}}}],"schema":""} 15 In regard to randomized studies, Kim et al. (2006) treated ovarian veins in 127 patients followed by interval internal iliac vein embolization, and 83% of patients showed clinical improvement 45 months after treatment, with no significant long-term complications. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cxetRYJG","properties":{"formattedCitation":"\\super 7\\nosupersub{}","plainCitation":"7","noteIndex":0},"citationItems":[{"id":238,"uris":[""],"uri":[""],"itemData":{"id":238,"type":"article-journal","abstract":"PURPOSE: To evaluate the long-term clinical outcome of transcatheter embolotherapy in women with chronic pelvic pain caused by ovarian and pelvic varices.\nMATERIALS AND METHODS: The study population included consecutive patients referred to a tertiary-care interventional radiology service from 1998 to 2003 because of a high degree of clinical suspicion of pelvic and ovarian varices. Visual analog scales and questionnaires during clinic visits were used to measure pain perception levels. Basal female hormonal levels were obtained and compared.\nRESULTS: Of 131 patients referred (mean age, 34.0 years+/-12.5), percutaneous transfemoral venography confirmed the presence of ovarian varices in 127 (97.0%), all of whom were treated with embolotherapy. Internal iliac embolotherapy was performed in 108 of 127 patients (85.0%). Ninety-seven patients completed long-term clinical follow-up (mean 45 months+/-18). The mean pelvic pain level had improved significantly from 7.6+/-1.8 before embolotherapy to 2.9+/-2.8 after embolotherapy (P<.0001). Significant improvement in each category of specific symptoms was also noted (P<.0001). Overall, 83% of the patients exhibited clinical improvement at long-term follow-up, 13% had no significant change, and 4% exhibited worsened condition. No significant change was noted in hormone levels after embolotherapy. Two successful pregnancies were noted after ovarian and pelvic vein embolotherapy.\nCONCLUSION: Direct venographic evaluation with embolotherapy can achieve significant improvement in pain perception levels in patients with chronic pelvic pain caused by pelvic venous congestion.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1097/01.RVI.0000194870.11980.F8","ISSN":"1051-0443","issue":"2 Pt 1","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 16517774","page":"289-297","source":"PubMed","title":"Embolotherapy for pelvic congestion syndrome: long-term results","title-short":"Embolotherapy for pelvic congestion syndrome","volume":"17","author":[{"family":"Kim","given":"Hyun S."},{"family":"Malhotra","given":"Amit D."},{"family":"Rowe","given":"Peter C."},{"family":"Lee","given":"Judy M."},{"family":"Venbrux","given":"Anthony C."}],"issued":{"date-parts":[["2006",2]]}}}],"schema":""} 7 The most extensive study with the longest follow up was completed in Europe; wherein Laborda et al. (2013) prospectively followed 202 patients over five years and showed an astounding 93.9% clinical success rate and a significant reduction in the Visual Analog Pain Scale from 7.3 (out of 10) to 0.8. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mqGcOACd","properties":{"formattedCitation":"\\super 8\\nosupersub{}","plainCitation":"8","noteIndex":0},"citationItems":[{"id":245,"uris":[""],"uri":[""],"itemData":{"id":245,"type":"article-journal","abstract":"PURPOSE: This study was designed to evaluate the clinical outcome and patients' satisfaction after a 5 year follow-up period for pelvic congestion syndrome (PCS) coil embolization in patients who suffered from chronic pelvic pain that initially consulted for lower limb venous insufficiency.\nMETHODS: A total of 202 patients suffering from chronic pelvic pain were recruited prospectively in a single center (mean age 43.5 years; range 27-57) where they were being treated for lower limb varices. Inclusion criteria were: lower limb varices and chronic pelvic pain (>6 months), >6 mm pelvic venous caliber in ultrasonography, and venous reflux or presence of communicating veins. Both ovarian and hypogastric veins were targeted for embolization. Pain level was assessed before and after embolotherapy and during follow-up using a visual analog scale (VAS). Technical and clinical success and recurrence of leg varices were studied. Patients completed a quality questionnaire. Clinical follow-up was performed at 1, 3, and 6 months and every year for 5 years.\nRESULTS: Technical success was 100%. Clinical success was achieved in 168 patients (93.85%), with complete disappearance of symptoms in 60 patients (33.52%). Pain score (VAS) was 7.34 ± 0.7 preprocedural versus 0.78 ± 1.2 at the end of follow-up (P < 0.0001). Complications were: groin hematoma (n = 6), coil migration (n = 4), and reaction to contrast media (n = 1). Twenty-three cases presented abdominal pain after procedure. In 24 patients (12.5%), there was recurrence of their leg varices within the follow-up. The mean degree of patients' satisfaction was 7.4/9.\nCONCLUSIONS: Coil embolization of PCS is an effective and safe procedure, with high clinical success rate and degree of satisfaction.","container-title":"Cardiovascular and Interventional Radiology","DOI":"10.1007/s00270-013-0586-2","ISSN":"1432-086X","issue":"4","journalAbbreviation":"Cardiovasc Intervent Radiol","language":"eng","note":"PMID: 23456353","page":"1006-1014","source":"PubMed","title":"Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients","title-short":"Endovascular treatment of pelvic congestion syndrome","volume":"36","author":[{"family":"Laborda","given":"Alicia"},{"family":"Medrano","given":"Joaquin"},{"family":"Blas","given":"Ignacio","non-dropping-particle":"de"},{"family":"Urtiaga","given":"Ignacio"},{"family":"Carnevale","given":"Francisco Cesar"},{"family":"Gregorio","given":"Miguel A.","non-dropping-particle":"de"}],"issued":{"date-parts":[["2013",8]]}}}],"schema":""} 8 Furthermore, Gandini et al. (2008) performed a retrospective study which demonstrated statistically significant improvement in pelvic pain, dyspareunia, urinary urgency and menstrual pain in 38 women treated with OVE. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ftWP5I78","properties":{"formattedCitation":"\\super 21\\nosupersub{}","plainCitation":"21","noteIndex":0},"citationItems":[{"id":304,"uris":[""],"uri":[""],"itemData":{"id":304,"type":"article-journal","abstract":"To evaluate the efficacy of transcatheter foam sclerotherapy (TCFS) in pelvic varicocele using sodium-tetradecyl-sulfate foam (STSF), we conducted a retrospective study in 38 patients (mean age, 36.9 years; range, 22-44 years) with pelvic congestion syndrome (PCS) treated between January 2000 and June 2005 by TCFS. Pelvic pain was associated with dyspareunia in 23 (60.5%) patients, urinary urgency in 9 (23.7%) patients, and worsening of pain during menstruation and at the end of a day of work in 7 (18.4%) and 38 (100%) patients, respectively. Diagnosis was made by pelvic and transvaginal color Doppler ultrasound examination, demonstrating ovarian or pelvic varices with a diameter >5 mm presenting venous reflux. TCFS was performed in all patients, using 3% STSF. Follow-up was performed by physical examination, pelvic and transvaginal Doppler ultrasound examination and by a questionnaire-based assessment of pain at 1, 3, 6, and 12 months after the procedure. Technical success was achieved in all patients (100%). In three patients a pelvic colic-like pain occurred immediately after sclerotic agent injection, disappearing spontaneously after a few minutes. No recurrent varicoceles were observed during a 12-month follow-up. A statistically significant improvement in each category of specific symptoms was observed at 1, 3, 6, and 12 months after the procedure. We conclude that TCFS of female varicocele using a 3% STSF is safe and effective for the treatment of PCS. It is associated with a significant reduction of symptoms and can be regarded as a valid alternative to other endovascular and surgical techniques.","container-title":"Cardiovascular and Interventional Radiology","DOI":"10.1007/s00270-007-9264-6","ISSN":"1432-086X","issue":"4","journalAbbreviation":"Cardiovasc Intervent Radiol","language":"eng","note":"PMID: 18172712","page":"778-784","source":"PubMed","title":"Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam","volume":"31","author":[{"family":"Gandini","given":"Roberto"},{"family":"Chiocchi","given":"Marcello"},{"family":"Konda","given":"Daniel"},{"family":"Pampana","given":"Enrico"},{"family":"Fabiano","given":"Sebastiano"},{"family":"Simonetti","given":"Giovanni"}],"issued":{"date-parts":[["2008",8]]}}}],"schema":""} 21 Kwon et al. (2007) reported symptomatic improvement in 82% of 67 patients treated with OVE. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"gWBPmPuY","properties":{"formattedCitation":"\\super 18\\nosupersub{}","plainCitation":"18","noteIndex":0},"citationItems":[{"id":243,"uris":[""],"uri":[""],"itemData":{"id":243,"type":"article-journal","abstract":"PURPOSE: To evaluate the therapeutic effectiveness of ovarian vein embolization using coils for pelvic congestion syndrome (PCS), a common cause of chronic pelvic pain in multiparous women.\nMETHODS: Between November 1998 and June 2005, 67 patients were diagnosed with PCS and underwent ovarian vein coil embolization. Through medical records and telephone interviews, the pre-embolization pain level and post-embolization pain control were assessed. In addition, in those cases where pain persisted after embolization or where patients were dissatisfied with the procedure, additional treatments and subsequent changes in pain scores were also analyzed. Evaluation after coil embolization was performed within 3-6 months (n = 3), 6 months to 1 year (n = 7), 1-2 years (n = 13), 2-3 years (n = 7), 3-4 years (n = 7), 4-5 years (n = 13), or 5-6 years (n = 17).\nRESULTS: Among a total of 67 patients, 82% (55/67) experienced pain reduction after coil embolization, were satisfied with the procedure, and did not pursue any further treatment. Twelve patients (18%, 12/67) responded that their pain level had not changed, or had become more severe. Among them, 9 patients were treated surgically and the remaining 3 patients remained under continuous drug therapy.\nCONCLUSION: Ovarian vein embolization using coils is a safe and effective therapeutic method for treatment of PCS. It is thought that surgical treatment should be considered in cases where embolization proves ineffective.","container-title":"Cardiovascular and Interventional Radiology","DOI":"10.1007/s00270-007-9040-7","ISSN":"0174-1551","issue":"4","journalAbbreviation":"Cardiovasc Intervent Radiol","language":"eng","note":"PMID: 17468903","page":"655-661","source":"PubMed","title":"Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome","volume":"30","author":[{"family":"Kwon","given":"Se Hwan"},{"family":"Oh","given":"Joo Hyeong"},{"family":"Ko","given":"Kyung Ran"},{"family":"Park","given":"Ho Chul"},{"family":"Huh","given":"Joo Yup"}],"issued":{"date-parts":[["2007",8]]}}}],"schema":""} 18 Venbrux et al. (2002) reported symptomatic improvement in 96% of the 56 patients 12 months after being treated with OVE. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"AqKtWUIk","properties":{"formattedCitation":"\\super 22\\nosupersub{}","plainCitation":"22","noteIndex":0},"citationItems":[{"id":263,"uris":[""],"uri":[""],"itemData":{"id":263,"type":"article-journal","abstract":"PURPOSE: The purpose of this study was to analyze the impact of transcatheter embolotherapy on pain perception and menstrual cycle in women with chronic pelvic pain caused by the presence of ovarian and pelvic varices (ie, women with pelvic congestion syndrome or pelvic venous incompetence).\nMATERIALS AND METHODS: From July 1998 to August 2000, 56 patients (mean age, 32.3 y) were treated for chronic pelvic pain. Diagnostic venography of the ovarian veins was followed by transcatheter embolotherapy with a sclerosing agent and coils. A second session was completed to embolize the internal iliac veins in 43 of 56 patients. Visual analog scales (VAS) used to measure pain were administered before embolization and at 3-, 6-, and 12-month follow-up. Questionnaires regarding menstrual history were used as part of the postprocedural analysis.\nRESULTS: Percutaneous transcatheter embolotherapy of ovarian and pelvic varices was technically successful in 56 of 56 patients (100%); three patients developed recurrent varices, two of whom were treated with repeat transcatheter embolotherapy. Two patients, early in the experience, had complications in which coils placed in the internal iliac veins embolized to the pulmonary circulation; the coils were snared without clinical sequelae. On the VAS, the mean baseline pain level was 7.8 (range, 3.2-9.8; n = 56); at 3-month follow-up, it was 4.2 (range, 0.0-7.2; n = 56); at 6 months, 3.8 (range, 0.0-6.7; n = 41); and at 12 months, 2.7 (range, 0.0-6.9; n = 32). Differences were significant (P <.001) between baseline pain levels and those at all follow-up intervals (ie, 3, 6, and 12 months). The mean decrease in VAS was 5.1 (65% decrease). The clinical follow-up in this series ranged between 6 and 38 months; the mean was 22.1 months. Regarding the impact of embolization on menstruation, all 24 patients responding to questionnaires indicated no change in menstrual cycle.\nCONCLUSION: For patients with ovarian/internal iliac varices, transcatheter embolotherapy provides a nonsurgical treatment option. There is a significant decrease in pain based on VAS without any notable impact on menstrual cycle.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/s1051-0443(07)61935-6","ISSN":"1051-0443","issue":"2 Pt 1","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 11830623","page":"171-178","source":"PubMed","title":"Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain","title-short":"Pelvic congestion syndrome (pelvic venous incompetence)","volume":"13","author":[{"family":"Venbrux","given":"Anthony C."},{"family":"Chang","given":"Andrew H."},{"family":"Kim","given":"Hyun S."},{"family":"Montague","given":"Brian J."},{"family":"Hebert","given":"Jillyn B."},{"family":"Arepally","given":"Aravind"},{"family":"Rowe","given":"Peter C."},{"family":"Barron","given":"Diana F."},{"family":"Lambert","given":"Drew"},{"family":"Robinson","given":"J. Courtland"}],"issued":{"date-parts":[["2002",2]]}}}],"schema":""} 22 Other reports by Capasso et al., Sichlau et al. (1994), Tarazov et al. (1997), Maleux et al. (2000), and Cordts et al. (1998), Yasser et al. (2018), and Bachar et al. (2003), Pyra et al. (2015) have all reported similar data to the studies outlined above and support OVE as an effective treatment for PeVD. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rWeTWKHP","properties":{"formattedCitation":"\\super 4,23\\uc0\\u8211{}29\\nosupersub{}","plainCitation":"4,23–29","noteIndex":0},"citationItems":[{"id":249,"uris":[""],"uri":[""],"itemData":{"id":249,"type":"article-journal","abstract":"PURPOSE: Ovarian vein embolization has been used recently to treat pelvic congestion syndrome. The purpose of this study is to evaluate the clinical efficacy and safety of ovarian vein embolization in the treatment of symptomatic pelvic varices.\nMATERIALS AND METHODS: We performed ovarian vein embolization in 41 patients (mean age, 37.8 years; range, 30-58 years): 32 patients underwent unilateral embolization and nine patients underwent bilateral embolization. All had lower abdominal pain and pelvic varicosities were found on retrograde ovarian vein venography. Embolization was performed with a mixture of enbucrilate and lipiodized oil in all but one patient, in whom enbucrilate and minicoils were used. Initial technical success rate and clinical follow-up (1-61 months; mean, 19.9 months), conducted with use of mailed questionnaires, are reported.\nRESULTS: Initial technical success rate was 98%. Immediate complications were noted in two patients (4%) in the form of migration of some fragments of glue (used as embolic agent), which was treated conservatively. Clinical follow-up reveals variable symptomatic relief in 9.7% of cases and a total relief of symptoms in 58.5% of cases. Results in patients who had insufficient ovarian veins bilaterally were no better than those in patients for whom only the left ovarian vein was found insufficient.\nCONCLUSIONS: Transcatheter embolization of the ovarian veins is a safe and feasible technique leading to complete relief of symptoms in more than half of cases. No statistically significant difference in clinical outcome could be noted between patients presenting with bilateral insufficient ovarian veins, who underwent bilateral embolization, and patients presenting with an insufficient left ovarian vein, who underwent left unilateral embolization.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/s1051-0443(07)61801-6","ISSN":"1051-0443","issue":"7","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 10928522","page":"859-864","source":"PubMed","title":"Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results","title-short":"Ovarian vein embolization for the treatment of pelvic congestion syndrome","volume":"11","author":[{"family":"Maleux","given":"G."},{"family":"Stockx","given":"L."},{"family":"Wilms","given":"G."},{"family":"Marchal","given":"G."}],"issued":{"date-parts":[["2000",8]]}}},{"id":308,"uris":[""],"uri":[""],"itemData":{"id":308,"type":"article-journal","abstract":"Pelvic varices of the gonadal veins affect both males and females presenting as varicoceles in the former and utero-ovarian varices in the latter. These varices are frequently encountered in the general population and can be directly associated with a significant morbidity. The affected venous axes can be easily catheterized in a selective, retrograde manner and can then be occluded through this minimally invasive route, thus avoiding the major surgical complications while giving results comparable or superior to those of the various surgical techniques. These pathologic processes and their endovascular treatment will be discussed.","container-title":"Journal De Radiologie","ISSN":"0221-0363","issue":"9 Suppl","journalAbbreviation":"J Radiol","language":"fre","note":"PMID: 10995500","page":"1115-1124","source":"PubMed","title":"[Endovascular treatment of varicoceles and utero-ovarian varices]","volume":"81","author":[{"family":"Capasso","given":"P."}],"issued":{"date-parts":[["2000",9]]}}},{"id":318,"uris":[""],"uri":[""],"itemData":{"id":318,"type":"article-journal","container-title":"Obstetrics and gynecology","issue":"5 Pt 2","note":"ISBN: 0029-7844","page":"892-896","title":"Transcatheter embolotherapy for the treatment of pelvic congestion syndrome.","volume":"83","author":[{"family":"Sichlau","given":"Michael J."},{"family":"Yao","given":"J. S."},{"family":"Vogelzang","given":"Robert L."}],"issued":{"date-parts":[["1994"]]}}},{"id":312,"uris":[""],"uri":[""],"itemData":{"id":312,"type":"article-journal","abstract":"PURPOSE: The aim of this study was to evaluate the clinical effect of therapeutic embolization in the pelvic congestion syndrome caused by ovarian varices.\nMATERIAL AND METHODS: Six women, aged 25-40 years, with pelvic pain syndrome and marked left (n = 5) or bilateral (n = 1) ovarian varicocele were treated by transcatheter retrograde venous embolization.\nRESULTS: The pelvic pain syndrome disappeared in all patients within 4 weeks, and there was regression of the periodic pain in 2 women with dysmenorrhoea. The patients were free of symptoms during the 1-4-year follow-up.\nCONCLUSION: Marked ovarian varices may cause a pelvic pain syndrome. Percutaneous embolization improves both the chronic pain and the dysmenorrhea in these patients. Transcatheter treatment could be considered as an alternative to surgical or laparoscopic ligation in ovarian varicocele.","container-title":"Acta Radiologica (Stockholm, Sweden: 1987)","DOI":"10.1080/02841859709172123","ISSN":"0284-1851","issue":"6","journalAbbreviation":"Acta Radiol","language":"eng","note":"PMID: 9394662","page":"1023-1025","source":"PubMed","title":"Pelvic pain syndrome caused by ovarian varices. Treatment by transcatheter embolization","volume":"38","author":[{"family":"Tarazov","given":"P. G."},{"family":"Prozorovskij","given":"K. V."},{"family":"Ryzhkov","given":"V. K."}],"issued":{"date-parts":[["1997",11]]}}},{"id":319,"uris":[""],"uri":[""],"itemData":{"id":319,"type":"article-journal","abstract":"PURPOSE: This case series describes the early radiographic and clinical results of attempted transcatheter ovarian vein (OV) embolization in 11 women with symptoms that were suggestive of the pelvic congestion syndrome (PCS).\nMETHODS: Eleven women (mean age, 33.1 years) who were multiparous were referred for lower extremity or vulvar varicosities (n = 8) or for tubo-ovarian varicosities (n = 3). After a clinical diagnosis of PCS was established, the women underwent ovarian (n = 5) or ovarian and iliac vein (n = 6) venography. Enlarged or incompetent OVs were embolized with 0.035-inch stainless steel coils or with 0.018-inch platinum microcoils and absorbable gelatin sponge. Incompetent tributaries to hypogastric veins were embolized as well (n = 1). Symptoms before embolization and after embolization were recorded with a standard questionnaire, and the post-embolization symptoms were expressed as individual and overall percent relief.\nRESULTS: Nine of the 11 women underwent embolization. Embolization of both OVs (n = 4), of the left OV alone (n = 4), or of a left obturator vein that communicated with vulvar varices (n = 1) was performed. Eight of the 9 women (88.9%) had more than 80% immediate relief. Overall and individual symptom relief varied from 40% to 100% at the mean 13.4-month follow-up. One woman with variant anatomy and one woman with evidence of prior left OV thrombosis were not treated. There were no major complications. Two women had a mild to moderate return of the symptoms at 6 and 22 months.\nCONCLUSIONS: Transcatheter embolization provides excellent initial and variable midterm relief in women with typical PCS symptoms and with OV or OV and internal iliac (hypogastric) tributary vein incompetence. This interventional technique may replace or complement the traditional surgical approaches to this rarely recognized and poorly understood disease.","container-title":"Journal of Vascular Surgery","DOI":"10.1016/s0741-5214(98)70062-x","ISSN":"0741-5214","issue":"5","journalAbbreviation":"J. Vasc. Surg.","language":"eng","note":"PMID: 9808854","page":"862-868","source":"PubMed","title":"Pelvic congestion syndrome: early clinical results after transcatheter ovarian vein embolization","title-short":"Pelvic congestion syndrome","volume":"28","author":[{"family":"Cordts","given":"P. R."},{"family":"Eclavea","given":"A."},{"family":"Buckley","given":"P. J."},{"family":"DeMaioribus","given":"C. A."},{"family":"Cockerill","given":"M. L."},{"family":"Yeager","given":"T. D."}],"issued":{"date-parts":[["1998",11]]}}},{"id":345,"uris":[""],"uri":[""],"itemData":{"id":345,"type":"article-journal","abstract":"Objectives\nTo assess the technical success and short term clinical efficacy of trans-catheter ovarian vein coiling in the treatment of symptomatic pelvic congestion syndrome in women.\nMethods\nThis study included 10 female patients having pelvic venous congestion treated by coiling and were followed up for 3?months between February 2016 and April 2017 at Ain Shams University hospital, Cairo, Egypt. Symptomatology of pelvic congestion syndrome that was documented either by transvaginal Doppler and/or by MRI with no response to conservative treatment.\nResults\nSymptoms successfully disappeared in 8 patients out of 10. Partial relief of symptoms in one patient that was then disappeared after another session. Only one patient showed no improvement.\nConclusion\nOur study demonstrates high efficacy of ovarian vein coiling as a new technique in the treatment of symptomatic female patients with pelvic congestion syndrome.","container-title":"The Egyptian Journal of Radiology and Nuclear Medicine","DOI":"10.1016/j.ejrnm.2018.03.010","ISSN":"0378-603X","issue":"3","journalAbbreviation":"The Egyptian Journal of Radiology and Nuclear Medicine","language":"en","page":"815-818","source":"ScienceDirect","title":"Trans-catheter ovarian vein coiling in management of symptomatic females having chronic pelvic congestion","volume":"49","author":[{"family":"Abd Elkhalek","given":"Yasser I."},{"family":"Bassiouny","given":"Ahmed Mohamed Mohamed Fahmy"}],"issued":{"date-parts":[["2018",9,1]]}}},{"id":"8DScb2JG/9iuNZIFA","uris":[" users/6078785/items/UBLTC3B7"],"uri":[" users/6078785/items/UBLTC3B7"],"itemData":{"id":339,"type":"article-journal","abstract":"BACKGROUND: Ovarian vein embolization was recently suggested as the preferred treatment for chronic pelvic pain syndrome.\nOBJECTIVE: To evaluate the technical feasibility, complications and early clinical and radiographic results of ovarian vein embolization in women with pelvic pain syndrome.\nMETHODS: Percutaneous transcatheter ovarian vein embolization with coils was performed in six patients aged 27-53 years who presented with pelvic pain syndrome. All had lower abdominal pain, and pelvic varicosities were found on Doppler ultrasound and retrograde ovarian vein venography. Embolization was done unilaterally in three patients (on the left side) and bilaterally in three. Mean follow-up by telephone questionnaire was 7.3 months.\nRESULTS: The procedure was technically successful in all patients. Two patients reported partial relief of symptoms (33.3%) and three had complete relief (50%), for a total of 5 patients (83.3%) with some measure of improvement. There were no complications following the procedure.\nCONCLUSIONS: Percutaneous transcatheter ovarian vein embolization seems to be safe and feasible for the treatment of pelvic pain syndrome. The procedure is performed on an outpatient basis and is well tolerated by patients.","container-title":"The Israel Medical Association journal: IMAJ","ISSN":"1565-1088","issue":"12","journalAbbreviation":"Isr. Med. Assoc. J.","language":"eng","note":"PMID: 14689749","page":"843-846","source":"PubMed","title":"Initial experience with ovarian vein embolization for the treatment of chronic pelvic pain syndrome","volume":"5","author":[{"family":"Bachar","given":"Gil Nissim"},{"family":"Belenky","given":"Alexander"},{"family":"Greif","given":"Franklin"},{"family":"Atar","given":"Eli"},{"family":"Gat","given":"Yigal"},{"family":"Itkin","given":"Maxim"},{"family":"Verstanding","given":"Anthony"}],"issued":{"date-parts":[["2003",12]]}}},{"id":352,"uris":[""],"uri":[""],"itemData":{"id":352,"type":"article-journal","abstract":"OBJECTIVES: The Aim: The aim of the study was to evaluate the effectiveness, safety and clinical outcomes of endovascular embolisation of pelvic congestion syndrome (PCS).\nMATERIAL AND METHODS: This prospective, observational study carried out between January and May of 2014 encompassed 24 female patients aged 22-44 years (average - 31 years) diagnosed with PCS. Diagnosis of PCS was established by medical history physical examination, transvaginal Doppler ultrasound examination and confirmed by MRI. The patients were qualified for phlebography and ovarian vein embolization with 0.035\" detachable coils and/or microcoils. Pelvic pain scores were assessed before and 3 months after the procedure with the visual analog scale (VAS; 0 - no pain, 10 - unbearable pain).\nRESULTS: Embolisation procedures were performed in 23 out of 24 patients. Nineteen patients underwent unilateral and 4 patients bilateral embolisation of the ovarian vein. In one case, safe and selective vessel catheterization was not possible due to the anatomical variant of venous flow. Nineteen patients underwent unilateral embolisation of the left ovarian vein. Four patients had the left and right ovarian veins embolized; in one of them, the internal iliac vein was additionally closed (the two-stage procedure). The technical success rate was 96%. Procedures lasted 23-78 minutes (32 minutes on average). An average of 40 ml of contrast was administered during the procedures. The total mean radiation dose at the reference point was 389 mGy (from 127 mGy to 1112 mGy). A decrease in pelvic pain intensity according to VAS was considered a clinical success. The median VAS pelvic pain score before the procedure was 8. Three months after the procedure median pelvic pain score decreased to 1 (p < 0.001). In two cases, the ovarian vein was injured and the contrast medium extravasated, which was clinically insignificant. In one case, a small injection site haematoma developed.\nCONCLUSION: Embolisation is a minimally invasive, effective and safe method of treatment for PCS. The cooperation between gynaecologists and interventional radiologists is essential for successful outcomes.","container-title":"Ginekologia Polska","DOI":"10.17772/gp/2420","ISSN":"0017-0011","issue":"5","journalAbbreviation":"Ginekol. Pol.","language":"eng","note":"PMID: 26117971","page":"346-351","source":"PubMed","title":"Evaluation of effectiveness of endovascular embolisation for the treatment of pelvic congestion syndrome--preliminary study","volume":"86","author":[{"family":"Pyra","given":"Krzysztof"},{"family":"Wo?niak","given":"S?awomir"},{"family":"Roman","given":"Tomasz"},{"family":"Czuczwar","given":"Piotr"},{"family":"Trojanowska","given":"Agnieszka"},{"family":"Jargie??o","given":"Tomasz"},{"family":"Paszkowski","given":"Tomasz"}],"issued":{"date-parts":[["2015",5]]}}}],"schema":""} 4,23–29 The reviews provided by BSBSA, Aetna, United Healthcare, and Anthem Blue Cross in support of their rationale for denial of services ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Q28POMOi","properties":{"formattedCitation":"\\super 30\\uc0\\u8211{}35\\nosupersub{}","plainCitation":"30–35","noteIndex":0},"citationItems":[{"id":261,"uris":[""],"uri":[""],"itemData":{"id":261,"type":"article-journal","container-title":"Clinical Obstetrics and Gynecology","DOI":"10.1097/00003081-200312000-00013","ISSN":"0009-9201","issue":"4","journalAbbreviation":"Clin Obstet Gynecol","language":"eng","note":"PMID: 14595225","page":"831-836","source":"PubMed","title":"Pelvic vascular congestion-half a century later","volume":"46","author":[{"family":"Stones","given":"R. William"}],"issued":{"date-parts":[["2003",12]]}}},{"id":327,"uris":[""],"uri":[""],"itemData":{"id":327,"type":"article-journal","container-title":"Cochrane Database of Systematic Reviews","DOI":"10.1002/14651858.CD000387","ISSN":"1465-1858","issue":"2","language":"en","note":"publisher: John Wiley & Sons, Ltd","source":"","title":"Interventions for treating chronic pelvic pain in women","URL":"","author":[{"family":"Stones","given":"Will"},{"family":"Cheong","given":"Ying C."},{"family":"Howard","given":"Fred M."},{"family":"Singh","given":"Shipra"}],"accessed":{"date-parts":[["2020",6,26]]},"issued":{"date-parts":[["2005"]]}}},{"id":329,"uris":[""],"uri":[""],"itemData":{"id":329,"type":"article-journal","container-title":"Phlebology","issue":"1_suppl","note":"ISBN: 0268-3555\npublisher: SAGE Publications Sage UK: London, England","page":"74-77","title":"The outcome of treatment for pelvic congestion syndrome","volume":"27","author":[{"family":"Smith","given":"P. Coleridge"}],"issued":{"date-parts":[["2012"]]}}},{"id":325,"uris":[""],"uri":[""],"itemData":{"id":325,"type":"article-journal","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2010.02.017","ISSN":"1535-7732","issue":"6","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 20494288","page":"796-803","source":"PubMed","title":"Research reporting standards for endovascular treatment of pelvic venous insufficiency","volume":"21","author":[{"family":"Black","given":"Carl M."},{"family":"Thorpe","given":"Kelly"},{"family":"Venrbux","given":"Anthony"},{"family":"Kim","given":"Hyun S."},{"family":"Millward","given":"Steven F."},{"family":"Clark","given":"Timothy W. I."},{"family":"Kundu","given":"Sanjoy"},{"family":"Martin","given":"Louis G."},{"family":"Sacks","given":"David"},{"family":"York","given":"John"},{"family":"Cardella","given":"John F."}],"issued":{"date-parts":[["2010",6]]}}},{"id":348,"uris":[""],"uri":[""],"itemData":{"id":348,"type":"article-journal","abstract":"Chronic pelvic pain (CPP) is a common and costly health problem in gynecology. Operative pathological findings are often absent. In some women with CPP, pelvic venous congestion has been reported; however, this observation has also been made in asymptomatic women. Thus, it is not clear whether pelvic venous congestion causes CPP and, if it does, whether it is a direct or indirect cause. Venography and non-invasive imaging methods are used for the diagnosis, but scoring systems have not been validated. The current mainstay of treatment is venography-controlled embolization, which is less invasive than surgical interventions. However, the only evidence on effectiveness comes from uncontrolled case series. A systematic review of causation evidence is needed to prove whether pelvic venous congestion causes CPP and whether embolization treatment is effective. In addition, if causation is established, good-quality primary randomized controlled trials on embolization may be required.","container-title":"Acta Obstetricia Et Gynecologica Scandinavica","DOI":"10.1111/j.1600-0412.2012.01368.x","ISSN":"1600-0412","issue":"5","journalAbbreviation":"Acta Obstet Gynecol Scand","language":"eng","note":"PMID: 22268663","page":"525-528","source":"PubMed","title":"Does pelvic venous congestion syndrome exist and can it be treated?","volume":"91","author":[{"family":"Ball","given":"Elizabeth"},{"family":"Khan","given":"Khalid S."},{"family":"Meads","given":"Catherine"}],"issued":{"date-parts":[["2012",5]]}}},{"id":350,"uris":[""],"uri":[""],"itemData":{"id":350,"type":"article-journal","abstract":"Chronic pelvic pain (CPP) affects 24% of women worldwide; the cause cannot be identified in 40% despite invasive investigations. Dilated, refluxing pelvic veins may be a cause of CPP and treatment by trans-venous occlusion is increasingly performed when gynecological causes are excluded, but is it effective? A systematic review of the literature published between 1966 and July 2014 was conducted. Two authors independently reviewed potential studies according to a set of eligibility criteria, with a third assessor available as an arbiter. Thirteen studies including 866 women undergoing trans-venous occlusion of pelvic veins for CPP were identified (Level of evidence: one study grade 2b, 12 studies grade four). Statistical significant improvements in pelvic pain were reported in nine of the 13 studies. Technical success was reported in 865 of 866 (99.8%) with low complication rates: coil migration in 14 women (1.6%), abdominal pain in ten women (1.2%) and vein perforation in five (0.6%). In a study on varicose veins of the legs, recurrence was seen in 13% of 179 women 5-years following coil embolization. Subjective improvements in pain were seen in all 13 studies after treatment by trans-venous occlusion. All 13 studies were of poor methodological quality. Complication rates were low and no fatalities occurred. Well-designed studies are essential to determine whether pelvic vein incompetence (PVI) is associated with CPP, and to explore whether trans-venous occlusion of PVI improves quality of life for these women.","container-title":"European Journal of Obstetrics, Gynecology, and Reproductive Biology","DOI":"10.1016/j.ejogrb.2014.12.011","ISSN":"1872-7654","journalAbbreviation":"Eur. J. Obstet. Gynecol. Reprod. Biol.","language":"eng","note":"PMID: 25590499","page":"156-163","source":"PubMed","title":"Trans-venous occlusion of incompetent pelvic veins for chronic pelvic pain in women: a systematic review","title-short":"Trans-venous occlusion of incompetent pelvic veins for chronic pelvic pain in women","volume":"185","author":[{"family":"Hansrani","given":"Vivak"},{"family":"Abbas","given":"Abeera"},{"family":"Bhandari","given":"Sahil"},{"family":"Caress","given":"Ann-Louise"},{"family":"Seif","given":"Mourad"},{"family":"McCollum","given":"Charles N."}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} 30–35, are all outdated in comparison to the systematic reviews conducted by Daniels et al. (2016), Mahmoud et al. (2016), and Brown et al. (2018). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rJQg2uMP","properties":{"formattedCitation":"\\super 15,19,36\\nosupersub{}","plainCitation":"15,19,36","noteIndex":0},"citationItems":[{"id":301,"uris":[""],"uri":[""],"itemData":{"id":301,"type":"article-journal","abstract":"PURPOSE: Chronic pelvic pain (CPP) in the presence of dilated and refluxing pelvic veins is often described as pelvic congestion syndrome (PCS), although the causal relationship between pelvic vein incompetence and CPP has not been established. Percutaneous embolization is the principal treatment for PCS, with high success rates cited. This study was undertaken to systematically and critically review the effectiveness of embolization of incompetent pelvic veins.\nMATERIALS AND METHODS: A comprehensive search strategy encompassing various terms for pelvic congestion, pelvic pain, and embolization was deployed in 17 bibliographic databases, with no restriction on study design. Methodologic quality was assessed. The quality and heterogeneity generally precluded meta-analysis. Results were tabulated and described narratively.\nRESULTS: Twenty-one prospective case series and one poor-quality randomized trial of embolization (involving a total of 1,308 women) were identified. Early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility, but no concerns were noted. Transient pain was common following foam embolization, and there was a < 2% risk of coil migration.\nCONCLUSIONS: Embolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2016.04.016","ISSN":"1535-7732","issue":"10","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 27397619","page":"1478-1486.e8","source":"PubMed","title":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review","title-short":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain","volume":"27","author":[{"family":"Daniels","given":"Jane P."},{"family":"Champaneria","given":"Rita"},{"family":"Shah","given":"Laila"},{"family":"Gupta","given":"Janesh K."},{"family":"Birch","given":"Judy"},{"family":"Moss","given":"Jonathan G."}],"issued":{"date-parts":[["2016",10]]}}},{"id":247,"uris":[""],"uri":[""],"itemData":{"id":247,"type":"article-journal","abstract":"BACKGROUND: Chronic pelvic pain is not a rare health problem among women. One of the most common causes of chronic pelvic pain is pelvic congestion syndrome (PCS). We have reviewed all medical literature on the endovascular treatment of PCS and hereby provide a brief overview of the anatomy, pathophysiology, and clinical aspects of ovarian and pelvic varices. We describe the technique of transcatheter embolization, the complications thereof and the clinical results of the treatment.\nMETHODS: A literature search was performed using PubMed, Science Direct, Google Scholar, and Scopus to identify case series on the endovascular treatment of PCS up until the end of November?2014.\nRESULTS: Twenty studies with a total of 1081 patients were included in the review. There were no randomized trials, and only one study included a control group. The immediate technical success rate in the occlusion of the affected veins was 99%. Seventeen studies reported the 1- to 3-month clinical success of 641 patients. Of these, 88.1% reported moderate to significant relief in the symptoms and 11.9% reported little or no relief. In 17 studies, long-term results were reported, and the follow-up varied between 7.3?months and 5?years. In late follow-up, 86.6% reported relief of the symptoms and 13.6% experienced little or no relief.\nCONCLUSIONS: The immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5?years after the procedure. However, there are no randomized or high-quality controlled trials, and the level of evidence therefore remains at?C.","container-title":"Journal of Vascular Surgery. Venous and Lymphatic Disorders","DOI":"10.1016/j.jvsv.2016.01.002","ISSN":"2213-3348","issue":"3","journalAbbreviation":"J Vasc Surg Venous Lymphat Disord","language":"eng","note":"PMID: 27318059","page":"355-370","source":"PubMed","title":"Efficacy of endovascular treatment for pelvic congestion syndrome","volume":"4","author":[{"family":"Mahmoud","given":"Osman"},{"family":"Vikatmaa","given":"Pirkka"},{"family":"Aho","given":"Pekka"},{"family":"Halmesm?ki","given":"Karoliina"},{"family":"Alb?ck","given":"Anders"},{"family":"Rahkola-Soisalo","given":"P?ivi"},{"family":"Lappalainen","given":"Kimmo"},{"family":"Venermo","given":"Maarit"}],"issued":{"date-parts":[["2016"]]}}},{"id":336,"uris":[""],"uri":[""],"itemData":{"id":336,"type":"article-journal","abstract":"Pelvic venous insufficiency is now a well-characterized etiology of pelvic congestion syndrome (PCS). The prevalence of CPP is 15% in females aged 18 to 50 years in the United States and up to 43.4% worldwide. In addition to individual physical, emotional, and quality-of-life implications of CPP, there are profound healthcare and socioeconomic expenses with estimated annual direct and indirect costs in the United States in excess of 39 billion dollars. PCS consists of clinical symptoms with concomitant anatomic and physiologic abnormalities originating in venous insufficiency. The etiology of PCS is diverse involving both mechanical and hormonal factors contributing to venous dilatation (>5 mm) and insufficiency. Factors affecting the diagnosis of PCS include variance of causes and clinical presentations of pelvic pain and relatively low sensitivity of noninvasive diagnostic imaging and laparoscopy to identify insufficiency compared with catheter venogram. A systematic review of the literature evaluating patient outcomes following percutaneous treatment of PCS is presented.","container-title":"Seminars in Interventional Radiology","DOI":"10.1055/s-0038-1636519","ISSN":"0739-9529","issue":"1","journalAbbreviation":"Semin Intervent Radiol","note":"PMID: 29628614\nPMCID: PMC5886772","page":"35-40","source":"PubMed Central","title":"Pelvic Congestion Syndrome: Systematic Review of Treatment Success","title-short":"Pelvic Congestion Syndrome","volume":"35","author":[{"family":"Brown","given":"Candace L."},{"family":"Rizer","given":"Magda"},{"family":"Alexander","given":"Ryan"},{"family":"Sharpe","given":"Emerson E."},{"family":"Rochon","given":"Paul J."}],"issued":{"date-parts":[["2018",3]]}}}],"schema":""} 15,19,36 In addition, the reviews cited by BCBSA focused on studies with very low sample populations, whereas the 2016 and 2018 reviews had a sample size of up to 1000 patients. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VorrYg0o","properties":{"formattedCitation":"\\super 15,19,36\\nosupersub{}","plainCitation":"15,19,36","noteIndex":0},"citationItems":[{"id":301,"uris":[""],"uri":[""],"itemData":{"id":301,"type":"article-journal","abstract":"PURPOSE: Chronic pelvic pain (CPP) in the presence of dilated and refluxing pelvic veins is often described as pelvic congestion syndrome (PCS), although the causal relationship between pelvic vein incompetence and CPP has not been established. Percutaneous embolization is the principal treatment for PCS, with high success rates cited. This study was undertaken to systematically and critically review the effectiveness of embolization of incompetent pelvic veins.\nMATERIALS AND METHODS: A comprehensive search strategy encompassing various terms for pelvic congestion, pelvic pain, and embolization was deployed in 17 bibliographic databases, with no restriction on study design. Methodologic quality was assessed. The quality and heterogeneity generally precluded meta-analysis. Results were tabulated and described narratively.\nRESULTS: Twenty-one prospective case series and one poor-quality randomized trial of embolization (involving a total of 1,308 women) were identified. Early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility, but no concerns were noted. Transient pain was common following foam embolization, and there was a < 2% risk of coil migration.\nCONCLUSIONS: Embolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2016.04.016","ISSN":"1535-7732","issue":"10","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 27397619","page":"1478-1486.e8","source":"PubMed","title":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review","title-short":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain","volume":"27","author":[{"family":"Daniels","given":"Jane P."},{"family":"Champaneria","given":"Rita"},{"family":"Shah","given":"Laila"},{"family":"Gupta","given":"Janesh K."},{"family":"Birch","given":"Judy"},{"family":"Moss","given":"Jonathan G."}],"issued":{"date-parts":[["2016",10]]}}},{"id":247,"uris":[""],"uri":[""],"itemData":{"id":247,"type":"article-journal","abstract":"BACKGROUND: Chronic pelvic pain is not a rare health problem among women. One of the most common causes of chronic pelvic pain is pelvic congestion syndrome (PCS). We have reviewed all medical literature on the endovascular treatment of PCS and hereby provide a brief overview of the anatomy, pathophysiology, and clinical aspects of ovarian and pelvic varices. We describe the technique of transcatheter embolization, the complications thereof and the clinical results of the treatment.\nMETHODS: A literature search was performed using PubMed, Science Direct, Google Scholar, and Scopus to identify case series on the endovascular treatment of PCS up until the end of November?2014.\nRESULTS: Twenty studies with a total of 1081 patients were included in the review. There were no randomized trials, and only one study included a control group. The immediate technical success rate in the occlusion of the affected veins was 99%. Seventeen studies reported the 1- to 3-month clinical success of 641 patients. Of these, 88.1% reported moderate to significant relief in the symptoms and 11.9% reported little or no relief. In 17 studies, long-term results were reported, and the follow-up varied between 7.3?months and 5?years. In late follow-up, 86.6% reported relief of the symptoms and 13.6% experienced little or no relief.\nCONCLUSIONS: The immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5?years after the procedure. However, there are no randomized or high-quality controlled trials, and the level of evidence therefore remains at?C.","container-title":"Journal of Vascular Surgery. Venous and Lymphatic Disorders","DOI":"10.1016/j.jvsv.2016.01.002","ISSN":"2213-3348","issue":"3","journalAbbreviation":"J Vasc Surg Venous Lymphat Disord","language":"eng","note":"PMID: 27318059","page":"355-370","source":"PubMed","title":"Efficacy of endovascular treatment for pelvic congestion syndrome","volume":"4","author":[{"family":"Mahmoud","given":"Osman"},{"family":"Vikatmaa","given":"Pirkka"},{"family":"Aho","given":"Pekka"},{"family":"Halmesm?ki","given":"Karoliina"},{"family":"Alb?ck","given":"Anders"},{"family":"Rahkola-Soisalo","given":"P?ivi"},{"family":"Lappalainen","given":"Kimmo"},{"family":"Venermo","given":"Maarit"}],"issued":{"date-parts":[["2016"]]}}},{"id":336,"uris":[""],"uri":[""],"itemData":{"id":336,"type":"article-journal","abstract":"Pelvic venous insufficiency is now a well-characterized etiology of pelvic congestion syndrome (PCS). The prevalence of CPP is 15% in females aged 18 to 50 years in the United States and up to 43.4% worldwide. In addition to individual physical, emotional, and quality-of-life implications of CPP, there are profound healthcare and socioeconomic expenses with estimated annual direct and indirect costs in the United States in excess of 39 billion dollars. PCS consists of clinical symptoms with concomitant anatomic and physiologic abnormalities originating in venous insufficiency. The etiology of PCS is diverse involving both mechanical and hormonal factors contributing to venous dilatation (>5 mm) and insufficiency. Factors affecting the diagnosis of PCS include variance of causes and clinical presentations of pelvic pain and relatively low sensitivity of noninvasive diagnostic imaging and laparoscopy to identify insufficiency compared with catheter venogram. A systematic review of the literature evaluating patient outcomes following percutaneous treatment of PCS is presented.","container-title":"Seminars in Interventional Radiology","DOI":"10.1055/s-0038-1636519","ISSN":"0739-9529","issue":"1","journalAbbreviation":"Semin Intervent Radiol","note":"PMID: 29628614\nPMCID: PMC5886772","page":"35-40","source":"PubMed Central","title":"Pelvic Congestion Syndrome: Systematic Review of Treatment Success","title-short":"Pelvic Congestion Syndrome","volume":"35","author":[{"family":"Brown","given":"Candace L."},{"family":"Rizer","given":"Magda"},{"family":"Alexander","given":"Ryan"},{"family":"Sharpe","given":"Emerson E."},{"family":"Rochon","given":"Paul J."}],"issued":{"date-parts":[["2018",3]]}}}],"schema":""} 15,19,36 Moreover, when comparing the complications associated with open pelvic surgical interventions to endovascular interventions, embolotherapy patients had far less significant negative outcomes compared to their counterparts. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"4rrOAbAl","properties":{"formattedCitation":"\\super 4,8,37\\nosupersub{}","plainCitation":"4,8,37","noteIndex":0},"citationItems":[{"id":245,"uris":[""],"uri":[""],"itemData":{"id":245,"type":"article-journal","abstract":"PURPOSE: This study was designed to evaluate the clinical outcome and patients' satisfaction after a 5 year follow-up period for pelvic congestion syndrome (PCS) coil embolization in patients who suffered from chronic pelvic pain that initially consulted for lower limb venous insufficiency.\nMETHODS: A total of 202 patients suffering from chronic pelvic pain were recruited prospectively in a single center (mean age 43.5 years; range 27-57) where they were being treated for lower limb varices. Inclusion criteria were: lower limb varices and chronic pelvic pain (>6 months), >6 mm pelvic venous caliber in ultrasonography, and venous reflux or presence of communicating veins. Both ovarian and hypogastric veins were targeted for embolization. Pain level was assessed before and after embolotherapy and during follow-up using a visual analog scale (VAS). Technical and clinical success and recurrence of leg varices were studied. Patients completed a quality questionnaire. Clinical follow-up was performed at 1, 3, and 6 months and every year for 5 years.\nRESULTS: Technical success was 100%. Clinical success was achieved in 168 patients (93.85%), with complete disappearance of symptoms in 60 patients (33.52%). Pain score (VAS) was 7.34 ± 0.7 preprocedural versus 0.78 ± 1.2 at the end of follow-up (P < 0.0001). Complications were: groin hematoma (n = 6), coil migration (n = 4), and reaction to contrast media (n = 1). Twenty-three cases presented abdominal pain after procedure. In 24 patients (12.5%), there was recurrence of their leg varices within the follow-up. The mean degree of patients' satisfaction was 7.4/9.\nCONCLUSIONS: Coil embolization of PCS is an effective and safe procedure, with high clinical success rate and degree of satisfaction.","container-title":"Cardiovascular and Interventional Radiology","DOI":"10.1007/s00270-013-0586-2","ISSN":"1432-086X","issue":"4","journalAbbreviation":"Cardiovasc Intervent Radiol","language":"eng","note":"PMID: 23456353","page":"1006-1014","source":"PubMed","title":"Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients","title-short":"Endovascular treatment of pelvic congestion syndrome","volume":"36","author":[{"family":"Laborda","given":"Alicia"},{"family":"Medrano","given":"Joaquin"},{"family":"Blas","given":"Ignacio","non-dropping-particle":"de"},{"family":"Urtiaga","given":"Ignacio"},{"family":"Carnevale","given":"Francisco Cesar"},{"family":"Gregorio","given":"Miguel A.","non-dropping-particle":"de"}],"issued":{"date-parts":[["2013",8]]}}},{"id":249,"uris":[""],"uri":[""],"itemData":{"id":249,"type":"article-journal","abstract":"PURPOSE: Ovarian vein embolization has been used recently to treat pelvic congestion syndrome. The purpose of this study is to evaluate the clinical efficacy and safety of ovarian vein embolization in the treatment of symptomatic pelvic varices.\nMATERIALS AND METHODS: We performed ovarian vein embolization in 41 patients (mean age, 37.8 years; range, 30-58 years): 32 patients underwent unilateral embolization and nine patients underwent bilateral embolization. All had lower abdominal pain and pelvic varicosities were found on retrograde ovarian vein venography. Embolization was performed with a mixture of enbucrilate and lipiodized oil in all but one patient, in whom enbucrilate and minicoils were used. Initial technical success rate and clinical follow-up (1-61 months; mean, 19.9 months), conducted with use of mailed questionnaires, are reported.\nRESULTS: Initial technical success rate was 98%. Immediate complications were noted in two patients (4%) in the form of migration of some fragments of glue (used as embolic agent), which was treated conservatively. Clinical follow-up reveals variable symptomatic relief in 9.7% of cases and a total relief of symptoms in 58.5% of cases. Results in patients who had insufficient ovarian veins bilaterally were no better than those in patients for whom only the left ovarian vein was found insufficient.\nCONCLUSIONS: Transcatheter embolization of the ovarian veins is a safe and feasible technique leading to complete relief of symptoms in more than half of cases. No statistically significant difference in clinical outcome could be noted between patients presenting with bilateral insufficient ovarian veins, who underwent bilateral embolization, and patients presenting with an insufficient left ovarian vein, who underwent left unilateral embolization.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/s1051-0443(07)61801-6","ISSN":"1051-0443","issue":"7","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 10928522","page":"859-864","source":"PubMed","title":"Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results","title-short":"Ovarian vein embolization for the treatment of pelvic congestion syndrome","volume":"11","author":[{"family":"Maleux","given":"G."},{"family":"Stockx","given":"L."},{"family":"Wilms","given":"G."},{"family":"Marchal","given":"G."}],"issued":{"date-parts":[["2000",8]]}}},{"id":240,"uris":[""],"uri":[""],"itemData":{"id":240,"type":"article-journal","abstract":"OBJECTIVE. The purposes of this article are to review the causes of pelvic congestion syndrome and the imaging used to make the diagnosis and to summarize the treatment options. CONCLUSION. Pelvic congestion syndrome is one of many causes of chronic pelvic pain. It is thought to arise from ovarian and pelvic venous incompetence. Findings from various noninvasive imaging studies, such as Doppler ultrasound and MRI, in association with the clinical symptoms are critical in establishing the diagnosis.","container-title":"AJR. American journal of roentgenology","DOI":"10.2214/AJR.14.12709","ISSN":"1546-3141","issue":"2","journalAbbreviation":"AJR Am J Roentgenol","language":"eng","note":"PMID: 25615769","page":"448-458","source":"PubMed","title":"Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues","title-short":"Pelvic venous insufficiency","volume":"204","author":[{"family":"Knuttinen","given":"M.-Gracia"},{"family":"Xie","given":"Karen"},{"family":"Jani","given":"Aarti"},{"family":"Palumbo","given":"Alison"},{"family":"Carrillo","given":"Tami"},{"family":"Mar","given":"Winnie"}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} 4,8,37BCBSA has also indicated that there is no clear evidence that the reporting of "relief of pain" is due to a placebo effect and that there is a lack of comparative data to discern its true effect. United Healthcare, Anthem Blue Cross, and Aetna call for randomized control trials to dictate their reimbursement practice, but based on the pain associated with the condition; it would be unethical to risk putting a patient into a randomized controlled placebo group. However, there are recent and updated randomized trials like Guirola et al., 2018, that have proven the efficacy of endovascular embolization with a large sample size. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6nafnJ45","properties":{"formattedCitation":"\\super 17\\nosupersub{}","plainCitation":"17","noteIndex":0},"citationItems":[{"id":233,"uris":[""],"uri":[""],"itemData":{"id":233,"type":"article-journal","abstract":"PURPOSE: To compare safety and efficacy of vascular plugs (VPs) and fibered platinum coils (FPCs) for embolization in pelvic congestion syndrome (PCS).\nMATERIALS AND METHODS: A randomized, prospective, single-center study enrolled 100 women with PCS from January 2014 to January 2015. Patients were randomly assigned to 2 groups, and embolization was performed with FPCs (n?= 50) or VPs (n?= 50). Mean age of patients was 42.7 years ± 7.60, and mean visual analog scale (VAS) score for pelvic pain before treatment was 7.4 ± 7.60. Primary outcome (clinical success at 1 y using a VAS), number of devices, procedure and fluoroscopy times, radiation doses, costs, and complications were compared, and participants were followed at 1, 3, 6, and 12 months.\nRESULTS: Clinical success and subjective improvement were not significantly different at 1-year follow-up (89.7% for FPCs vs 90.6% for VPs; P?= .760). Mean number of devices per case was 18.2 ± 1.33 for FPCs and 4.1 ± 0.31 for VPs (P < .001). Three FPCs and 1 VP migrated to pulmonary vasculature approximately 3-6 months after the embolization procedure; all were retrieved without complications. The FPC group had a significantly longer fluoroscopy time (33.4 min ± 4.68 vs 19.5 min ± 6.14) and larger radiation dose (air kerma 948.0 mGy ± 248.45 vs 320.7 mGy ± 134.33) (all P < .001).\nCONCLUSIONS: Embolization for PCS resulted in pain relief in 90% of patients; clinical success was not affected by embolic device. VPs were associated with decreased fluoroscopy time and radiation dose.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2017.09.011","ISSN":"1535-7732","issue":"1","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 29174618","page":"45-53","source":"PubMed","title":"A Randomized Trial of Endovascular Embolization Treatment in Pelvic Congestion Syndrome: Fibered Platinum Coils versus Vascular Plugs with 1-Year Clinical Outcomes","title-short":"A Randomized Trial of Endovascular Embolization Treatment in Pelvic Congestion Syndrome","volume":"29","author":[{"family":"Guirola","given":"Jose A."},{"family":"Sánchez-Ballestin","given":"Maria"},{"family":"Sierre","given":"Sergio"},{"family":"Lahuerta","given":"Celia"},{"family":"Mayoral","given":"Victoria"},{"family":"De Gregorio","given":"Miguel A."}],"issued":{"date-parts":[["2018",1]]}}}],"schema":""} 17SIR coverage recommendations for change in policy's current methodologyIn summary, patients that present with clinical signs and symptoms, as well as imaging findings consistent with PeVD, are ideal candidates for OVE. In comparison to other treatment alternatives, endovascular embolization has proven to have better clinical outcomes, faster recovery time, and lower rates of repeated interventions required. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Wjs1HIU0","properties":{"formattedCitation":"\\super 4,8,15,37\\nosupersub{}","plainCitation":"4,8,15,37","noteIndex":0},"citationItems":[{"id":245,"uris":[""],"uri":[""],"itemData":{"id":245,"type":"article-journal","abstract":"PURPOSE: This study was designed to evaluate the clinical outcome and patients' satisfaction after a 5 year follow-up period for pelvic congestion syndrome (PCS) coil embolization in patients who suffered from chronic pelvic pain that initially consulted for lower limb venous insufficiency.\nMETHODS: A total of 202 patients suffering from chronic pelvic pain were recruited prospectively in a single center (mean age 43.5 years; range 27-57) where they were being treated for lower limb varices. Inclusion criteria were: lower limb varices and chronic pelvic pain (>6 months), >6 mm pelvic venous caliber in ultrasonography, and venous reflux or presence of communicating veins. Both ovarian and hypogastric veins were targeted for embolization. Pain level was assessed before and after embolotherapy and during follow-up using a visual analog scale (VAS). Technical and clinical success and recurrence of leg varices were studied. Patients completed a quality questionnaire. Clinical follow-up was performed at 1, 3, and 6 months and every year for 5 years.\nRESULTS: Technical success was 100%. Clinical success was achieved in 168 patients (93.85%), with complete disappearance of symptoms in 60 patients (33.52%). Pain score (VAS) was 7.34 ± 0.7 preprocedural versus 0.78 ± 1.2 at the end of follow-up (P < 0.0001). Complications were: groin hematoma (n = 6), coil migration (n = 4), and reaction to contrast media (n = 1). Twenty-three cases presented abdominal pain after procedure. In 24 patients (12.5%), there was recurrence of their leg varices within the follow-up. The mean degree of patients' satisfaction was 7.4/9.\nCONCLUSIONS: Coil embolization of PCS is an effective and safe procedure, with high clinical success rate and degree of satisfaction.","container-title":"Cardiovascular and Interventional Radiology","DOI":"10.1007/s00270-013-0586-2","ISSN":"1432-086X","issue":"4","journalAbbreviation":"Cardiovasc Intervent Radiol","language":"eng","note":"PMID: 23456353","page":"1006-1014","source":"PubMed","title":"Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients","title-short":"Endovascular treatment of pelvic congestion syndrome","volume":"36","author":[{"family":"Laborda","given":"Alicia"},{"family":"Medrano","given":"Joaquin"},{"family":"Blas","given":"Ignacio","non-dropping-particle":"de"},{"family":"Urtiaga","given":"Ignacio"},{"family":"Carnevale","given":"Francisco Cesar"},{"family":"Gregorio","given":"Miguel A.","non-dropping-particle":"de"}],"issued":{"date-parts":[["2013",8]]}}},{"id":301,"uris":[""],"uri":[""],"itemData":{"id":301,"type":"article-journal","abstract":"PURPOSE: Chronic pelvic pain (CPP) in the presence of dilated and refluxing pelvic veins is often described as pelvic congestion syndrome (PCS), although the causal relationship between pelvic vein incompetence and CPP has not been established. Percutaneous embolization is the principal treatment for PCS, with high success rates cited. This study was undertaken to systematically and critically review the effectiveness of embolization of incompetent pelvic veins.\nMATERIALS AND METHODS: A comprehensive search strategy encompassing various terms for pelvic congestion, pelvic pain, and embolization was deployed in 17 bibliographic databases, with no restriction on study design. Methodologic quality was assessed. The quality and heterogeneity generally precluded meta-analysis. Results were tabulated and described narratively.\nRESULTS: Twenty-one prospective case series and one poor-quality randomized trial of embolization (involving a total of 1,308 women) were identified. Early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility, but no concerns were noted. Transient pain was common following foam embolization, and there was a < 2% risk of coil migration.\nCONCLUSIONS: Embolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/j.jvir.2016.04.016","ISSN":"1535-7732","issue":"10","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 27397619","page":"1478-1486.e8","source":"PubMed","title":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review","title-short":"Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain","volume":"27","author":[{"family":"Daniels","given":"Jane P."},{"family":"Champaneria","given":"Rita"},{"family":"Shah","given":"Laila"},{"family":"Gupta","given":"Janesh K."},{"family":"Birch","given":"Judy"},{"family":"Moss","given":"Jonathan G."}],"issued":{"date-parts":[["2016",10]]}}},{"id":240,"uris":[""],"uri":[""],"itemData":{"id":240,"type":"article-journal","abstract":"OBJECTIVE. The purposes of this article are to review the causes of pelvic congestion syndrome and the imaging used to make the diagnosis and to summarize the treatment options. CONCLUSION. Pelvic congestion syndrome is one of many causes of chronic pelvic pain. It is thought to arise from ovarian and pelvic venous incompetence. Findings from various noninvasive imaging studies, such as Doppler ultrasound and MRI, in association with the clinical symptoms are critical in establishing the diagnosis.","container-title":"AJR. American journal of roentgenology","DOI":"10.2214/AJR.14.12709","ISSN":"1546-3141","issue":"2","journalAbbreviation":"AJR Am J Roentgenol","language":"eng","note":"PMID: 25615769","page":"448-458","source":"PubMed","title":"Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues","title-short":"Pelvic venous insufficiency","volume":"204","author":[{"family":"Knuttinen","given":"M.-Gracia"},{"family":"Xie","given":"Karen"},{"family":"Jani","given":"Aarti"},{"family":"Palumbo","given":"Alison"},{"family":"Carrillo","given":"Tami"},{"family":"Mar","given":"Winnie"}],"issued":{"date-parts":[["2015",2]]}}},{"id":249,"uris":[""],"uri":[""],"itemData":{"id":249,"type":"article-journal","abstract":"PURPOSE: Ovarian vein embolization has been used recently to treat pelvic congestion syndrome. The purpose of this study is to evaluate the clinical efficacy and safety of ovarian vein embolization in the treatment of symptomatic pelvic varices.\nMATERIALS AND METHODS: We performed ovarian vein embolization in 41 patients (mean age, 37.8 years; range, 30-58 years): 32 patients underwent unilateral embolization and nine patients underwent bilateral embolization. All had lower abdominal pain and pelvic varicosities were found on retrograde ovarian vein venography. Embolization was performed with a mixture of enbucrilate and lipiodized oil in all but one patient, in whom enbucrilate and minicoils were used. Initial technical success rate and clinical follow-up (1-61 months; mean, 19.9 months), conducted with use of mailed questionnaires, are reported.\nRESULTS: Initial technical success rate was 98%. Immediate complications were noted in two patients (4%) in the form of migration of some fragments of glue (used as embolic agent), which was treated conservatively. Clinical follow-up reveals variable symptomatic relief in 9.7% of cases and a total relief of symptoms in 58.5% of cases. Results in patients who had insufficient ovarian veins bilaterally were no better than those in patients for whom only the left ovarian vein was found insufficient.\nCONCLUSIONS: Transcatheter embolization of the ovarian veins is a safe and feasible technique leading to complete relief of symptoms in more than half of cases. No statistically significant difference in clinical outcome could be noted between patients presenting with bilateral insufficient ovarian veins, who underwent bilateral embolization, and patients presenting with an insufficient left ovarian vein, who underwent left unilateral embolization.","container-title":"Journal of vascular and interventional radiology: JVIR","DOI":"10.1016/s1051-0443(07)61801-6","ISSN":"1051-0443","issue":"7","journalAbbreviation":"J Vasc Interv Radiol","language":"eng","note":"PMID: 10928522","page":"859-864","source":"PubMed","title":"Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results","title-short":"Ovarian vein embolization for the treatment of pelvic congestion syndrome","volume":"11","author":[{"family":"Maleux","given":"G."},{"family":"Stockx","given":"L."},{"family":"Wilms","given":"G."},{"family":"Marchal","given":"G."}],"issued":{"date-parts":[["2000",8]]}}}],"schema":""} 4,8,15,37 PeVD is a high priority for our patients, and current evidence-based research continuously supports OVE as a medically necessary designated treatment. Treatment of scrotal varicoceles, the same pathology in men, with testicular vein embolization is typically covered by most insurance carriers and declining coverage for an analogous disease process in women with a stronger body of evidence to support it would be inequitable and a form of gender bias. We hope that you will utilize the evidence provided in this letter to change your policies surrounding covering for OVE as a treatment of PeVD.Evidence Table: Pelvic Venous DiseaseStudy IDMethodPatient CharacteristicsIntervention(s)Results primary outcomeResults secondary and other outcomesCritical appraisal of review qualityBlack, C. M., Thorpe, K., Venrbux, A., Kim, H. S., Millward, S. F., Clark, T. W. I., Kundu, S., Martin, L. G., Sacks, D., York, J., & Cardella, J. F. (2010). Research Reporting Standards for Endovascular Treatment of Pelvic Venous Insufficiency. Journal of Vascular and Interventional Radiology, 21(6), 796–803. Study Design: Systematic Reviewn = 301, 10 studiesSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aCommon definitions, approaches to diagnosis and treatment, and clinical outcomes assessment in the care of patients with chronic pelvic pain resulting from pelvic venous insufficiency (PVI).Although transcatheter embolization is an established therapy for the treatment of symptomatic PVI, published series are limited by non-standardized reporting, incomplete follow-up, and the use of variable measures of outcome.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: EChung, M.-H., & Huh, C.-Y. (2003). Comparison of Treatments for Pelvic Congestion Syndrome. The Tohoku Journal of Experimental Medicine, 201(3), 131–138.Study Design: RCTn = 106 Group A: embolotherapy group: n=52Group B; hysterectomy + bilateral oophorectomy: n=27Group C: hysterectomy and removal of only the affected ovary: n=27Sources of funding: UndisclosedEligibility Criteria: pelvic congestion syndrome, confirmed with laparoscopy and venography, who did not respond to MPA after 4-6 months medicationPatient Characteristics: 90 left unilateral venous congestion; 8 right unilateral venous congestion; 8 bilateral venous congestion on venography.Group A: Age 40.1 ± 4.9Group B:Age 45.5 ± 3.8Group C: Age 44.1 ± 3.9Venography, Embolization vs. Hysterectomy and oophorectomyPercutaneous transcatheter embolization of ovarian veins and/or the internal iliac vein is a safe and minimally invasive treatment option for the treatment of PCS.Difference in mean pain scores at each follow-up visit, compared with the pretreatment score was significantly decreased in Groups A and B (p < 0.05), but not in Group C.There were no significant differences in stress scores and pain values between the three groups (p >0.05).Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:BCoakley, F. V., Varghese, S. L., & Hricak, H. (1999). CT and MRI of pelvic varices in women. Journal of Computer Assisted Tomography, 23(3), 429–434. Design: Review Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aCT and MRI of Pelvic VaricesPelvic varices in women are relatively common findings at CT or MRI and have a characteristic appearance. Primary pelvic varices are associated with the pelvic pain syndrome, and patients with the pelvic pain syndrome may benefit from therapeutic venous embolization. Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DDaniels, J. P., Champaneria, R., Shah, L., Gupta, J. K., Birch, J., & Moss, J. G. (2016). Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review. Journal of Vascular and Interventional Radiology, 27(10), 1478-1486.e8.Study Design: Review Articlen = 1,308, 22 Studies (1 poor quality RCT; 21 case series)Sources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aEmbolization of incompetent pelvic veinsEmbolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aEarly substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained.Level of Evidence:CEdwards, R. D., Robertson, I. R., MacLean, A. B., & Hemingway, A. P. (1993). Case report: Pelvic pain syndrome-successful treatment of a case by ovarian vein embolization. Clinical Radiology, 47(6), 429–431.Study Design: Review Articlen = 1Sources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: 40-year-old woman with a 2-year history of chronic pelvic pain, dyspareunia, dysmenorrhea. Symptoms were aggravated by prolonged standing and were worse during menstruationBilateral ovarian venous embolizationPatient with the clinical and radiological features of Pelvic pain syndrome, treated by bilateral ovarian venous embolization produced prolonged symptomatic relief.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:D Ganeshan, A., Upponi, S., Hon, L.-Q., Uthappa, M. C., Warakaulle, D. R., & Uberoi, R. (2007). Chronic Pelvic Pain due to Pelvic Congestion Syndrome: The Role of Diagnostic and Interventional Radiology. CardioVascular and Interventional Radiology, 30(6), 1105–1111.Study Design: Review Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aRole of diagnostic and interventional radiology in the management of chronic pelvic painTranscatheter embolotherapy has been shown to be both a safe and effective alternative which has revolutionized the treatment of PCS.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: DGuirola, J. A., Sánchez-Ballestin, M., Sierre, S., Lahuerta, C., Mayoral, V., & De Gregorio, M. A. (2018). A Randomized Trial of Endovascular Embolization Treatment in Pelvic Congestion Syndrome: Fibered Platinum Coils versus Vascular Plugs with 1-Year Clinical Outcomes. Journal of Vascular and Interventional Radiology, 29(1), 45–53.Study Design: RCTn = 100 (2 groups, 50/50)Sources of funding: UndisclosedEligibility Criteria: Age > 18; Presence of chronic abdominal or pelvic pain for >6 months; >6 mm pelvic venous caliber measured by transvaginal US; Presence of venous reflux or communicating veins by transvaginal Doppler USPatient Characteristics: Mean age of patients was 42.7 years ± 7.60, and mean visual analog scale (VAS) score for pelvic pain before treatment was 7.4 ± 7.60Vascular plugs (VPs) and fibered platinum coils (FPCs) for embolization in pelvic congestion syndrome (PCS)Embolization for PCS resulted in pain relief in 90% of patients; clinical success was not affected by embolic device. VPs were associated with decreased fluoroscopy time and radiation dose.Technical success of procedure: "high success"30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:B Kim, H. S., Malhotra, A. D., Rowe, P. C., Lee, J. M., & Venbrux, A. C. (2006). Embolotherapy for Pelvic Congestion Syndrome: Long-term Results. Journal of Vascular and Interventional Radiology, 17(2), 289–297.Study Design: Prospective Studyn = 131Sources of funding: UndisclosedEligibility Criteria: Patients referred to a tertiary-care IR service 1998-2003 because of a high degree of clinical suspicion of pelvic and ovarian varices.Patient Characteristics: Mean age of patients 34.0 ± 12.5; percutaneous transfemoral venography confirmed the presence of ovarian varices in 127 (97.0%)Transcatheter embolotherapy in women with chronic pelvic pain caused by ovarian and pelvic varices.83% of the patients exhibited clinical improvement at long-term follow-up, 13% had no significant change, and 4% exhibited worsened condition.Technical success of procedure: 100%30-day mortality: n/aProcedure-related morality: n/aNo significant change was noted in hormone levels. 2 successful pregnancies were noted after ovarian and pelvic vein embolotherapy.Level of Evidence:CKnuttinen, M.-G., Xie, K., Jani, A., Palumbo, A., Carrillo, T., & Mar, W. (2015). Pelvic Venous Insufficiency: Imaging Diagnosis, Treatment Approaches, and Therapeutic Issues. American Journal of Roentgenology, 204(2), 448–458.Study Design: Review Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aReview the causes of pelvic congestion syndrome and the imaging used to make the diagnosis and to summarize the treatment options.Pelvic congestion syndrome is one of many causes of chronic pelvic pain. Findings from various noninvasive imaging studies, such as Doppler ultrasound and MRI, in association withthe clinical symptoms are critical in establishing the diagnosis.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:EKwon, S. H., Oh, J. H., Ko, K. R., Park, H. C., & Huh, J. Y. (2007). Transcatheter Ovarian Vein Embolization Using Coils for the Treatment of Pelvic Congestion Syndrome. CardioVascular and Interventional Radiology, 30(4), 655–661.Study Design: Retrospective Studyn = 67Sources of funding: UndisclosedEligibility Criteria: Patients, between Nov 1998 and June 2005, who were diagnosed with PCS and underwent ovarian vein coil embolization.Patient Characteristics: Age: 39.1 ± 9 [25–64]; Symptom duration (months) 32.9 ± 21.6 [6–243]Ovarian vein embolization using for pelvic congestion syndrome (PCS)Ovarian vein embolization using coils is a safe and effective therapeutic method for treatment of PCS.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DLaborda, A., Medrano, J., de Blas, I., Urtiaga, I., Carnevale, F. C., & de Gregorio, M. A. (2013). Endovascular Treatment of Pelvic Congestion Syndrome: Visual Analog Scale (VAS) Long-Term Follow-up Clinical Evaluation in 202 Patients. CardioVascular and Interventional Radiology, 36(4), 1006–1014.Study Design: Prospective Studyn = 202Sources of funding: UndisclosedEligibility Criteria: lower limb varices and chronic pelvic pain (>6 months), >6 mm pelvic venous caliber in ultrasonography, and venous reflux or presence of communicating veins.Patient Characteristics: Age: 43.5 years; range 27–57- where they were being treated for lower limb varicesPelvic congestion syndrome (PCS) coil embolizationCoil embolization of PCS is an effective and safe procedure, with high clinical success rate and degree of satisfaction.Technical success of procedure: 100%30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:CMahmoud, O., Vikatmaa, P., Aho, P., Halmesm?ki, K., Alb?ck, A., Rahkola-Soisalo, P., Lappalainen, K., & Venermo, M. (2016). Efficacy of endovascular treatment for pelvic congestion syndrome. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 4(3), 355–370.Study Design: Prospective Studyn = 1081, 22 studiesSources of funding: “n/a”Eligibility Criteria: A literature search was performed using PubMed, Science Direct, Google Scholar, and Scopus to identify case series on the endovascular treatment of PCS up until the end of November 2014.Patient Characteristics: There were no randomized trials, and only one study included a control group.Medical literature on the endovascular treatment of PCSThe immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5 years after the procedure.Technical success of procedure: Immediate technical success rate in occluding the affected veins was reported to be 100% in 17 studies, and it was 94.7%, 95.8%, and 90.9%, respectively, in three studies.30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:CMaleux, G., Stockx, L., Wilms, G., & Marchal, G. (2000). Ovarian Vein Embolization for the Treatment of Pelvic Congestion Syndrome: Long-Term Technical and Clinical Results. Journal of Vascular and Interventional Radiology, 11(7), 859–864. Study Design: Prospective Studyn = 41Sources of funding: Eligibility Criteria: All had lower abdominal pain. Dyspareunia in 11 & urinary urgency in 6.Patient Characteristics: Age: mean, 37.8; range, 30–58. 32 underwent unilateral embolization and 9 patients underwent bilateral embolization.Ovarian vein embolization in the treatment of symptomatic pelvic varicesTranscatheter embolization of the ovarian veins is a safe and feasible technique leading to complete relief of symptoms in more than half of cases.Technical success of procedure: Initial technical success rate was 98%. 30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: DNasser, F., Cavalcante, R. N., Affonso, B. B., Messina, M. L., Carnevale, F. C., & de Gregorio, M. A. (2014). Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome. International Journal of Gynecology & Obstetrics, 125(1), 65–68.Study Design: Retrospective Studyn = 113Sources of funding: UndisclosedEligibility Criteria: Women with PCS diagnosis treated with endovascular embolization of ovarian & pelvic varicose veins at Hospital Clínico Universitario, Zaragoza, Spain between Jan 1, 2001 - Jan 31, 2011.Patient Characteristics: mean ± SD age of 43.7 ± 4.7 years and had had at least 2 pregnancies.Transcatheter embolization using coils for treatment of pelvic congestion syndrome (PCS)Transcatheter embolization was a safe and effective treatment for PCS. Lower limb symptoms, urinary urgency, and varicosities were associated with incomplete clinical success.Technical success of procedure: 100%30-day mortality: n/aProcedure-related morality: n/aComplication: global complication rate was low (5/113, 4.4%)Level of Evidence:DO'Brien, M. T., & Gillespie, D. L. (2015). Diagnosis and treatment of the pelvic congestion syndrome. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 3(1), 96–106.Study Design: Retrospective StudyPCSn = 959, 21 studiesNutcracker Syndromen = 190, 19 studiesSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: MEDLINE Search revealed 3756+ references to chronic pelvic pain. Only 260 referenced PCS, pelvic chronic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies.Literature in treatment of PCSDiagnosis of PCS requires a careful history, physical examination, and noninvasive imaging. Several large case series have demonstrated the efficacy of embolotherapy in the reduction of pelvic pain; thus, it is the most favored treatment option for patients with PCS.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: CPark, S. J., Lim, J. W., Ko, Y. T., Lee, D. H., Yoon, Y., Oh, J. H., Lee, H. K., & Huh, C. Y. (2004). Diagnosis of Pelvic Congestion Syndrome Using Transabdominal and Transvaginal Sonography. American Journal of Roentgenology, 182(3), 683–688.Study Design: Prospective Studyn = 67 (32pt + 35 control)Sources of funding: UndisclosedEligibility Criteria: Selective ovarian venography showing pelvic varicoceles.Patient Characteristics: Age: range 26–64, mean 39. All had dull pelvic pain of variable intensity that persisted for more than 6 months and increased with prolonged standing and ovarian point tenderness on pelvic examinationEvaluating ovarian veins for diameter and flow direction, presence of pelvic varicocele, diameter of the pelvic veins, change of the duplex waveform during the Valsalva's maneuver, volume of the uterus, and presence of poly- cystic changes in the bined transabdominal and transvaginal sonography are potentially useful as a noninvasive screening tool for determining which patients with chronic pelvic pain may benefit from selective ovarian venography and transcatheter embolization.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:CPhillips, D., Deipolyi, A. R., Hesketh, R. L., Midia, M., & Oklu, R. (2014). Pelvic Congestion Syndrome: Etiology of Pain, Diagnosis, and Clinical Management. Journal of Vascular and Interventional Radiology, 25(5), 725–733.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aIR's involvement with pelvic congestion syndromePCS is a common condition with significant physical and psychosexual consequences. While pathophysiology is multifactorial and is still poorly defined, IR's play a critical role in diagnosing pelvic varicosities and treating PCS-related symptoms with embolization.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: ESmith, P. C. (2012). The Outcome of Treatment for Pelvic Congestion Syndrome. Phlebology: The Journal of Venous Disease, 27(1_suppl), 74–77.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aEmbolization of pelvic and ovarian veins The results of this treatment have been published in a limited number of clinical series, usually with fairly short follow-up periods. Limited clinical evidence supports the use of embolotherapy in the management of pelvic congestion syndrome.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: EStones, R. W. (2003). Pelvic Vascular Congestion—Half a Century Later: Clinical Obstetrics and Gynecology, 46(4), 831–836.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aPelvic congestion: clinical findings and their relationship with appearances using different imaging modalities are considered.The immediate challenge is for gynecologists and radiologists to work together to agree diagnostic criteria and to present care- fully documented studies of the clinical out- comes of radiologic interventions.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: EVenbrux, A. C., Chang, A. H., Kim, H. S., Montague, B. J., Hebert, J. B., Arepally, A., Rowe, P. C., Barron, D. F., Lambert, D., & Robinson, J. C. (2002). Pelvic Congestion Syndrome (Pelvic Venous Incompetence): Impact of Ovarian and Internal Iliac Vein Embolotherapy on Menstrual Cycle and Chronic Pelvic Pain. Journal of Vascular and Interventional Radiology, 13(2), 171–178.Study Design: Prospective Studyn = 56Sources of funding: UndisclosedEligibility Criteria: Patients treated for chronic pelvic pain Jul 1998 to Aug 2000Patient Characteristics: Age: mean 32.3Percutaneous transcatheter embolotherapy of ovarian and pelvic varicesFor patients with ovarian/internal iliac varices, transcatheter embolotherapy provides a nonsurgical treatment option. There is a significant decrease in pain based on VAS without any notable impact on menstrual cycle.Technical success of procedure: 100%30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DReferences from Policy DenialStudy IDMethodPatient CharacteristicsIntervention(s)Results primary outcomeResults secondary and other outcomesCritical appraisal of review qualityAsciutto G, Asciutto KC, Mumme A, Geier B. Pelvic venous incompetence: reflux patterns and treatment results. Eur J Vasc Endovasc Surg. 2009; 38(3):381-386.Study Design:n = 71Sources of funding: NoneEligibility Criteria: varicose reflux towards the ipsi- or contralateral proximal thigh; visualisation of reflux throughout the entire course of the OV; retrograde filling of the main stem of the IIV and at least one side branch (gluteal, ischiadic or obturator veins); and retrograde filling of contrast medium across the midlinePatient Characteristics: Mean age 49 SD 11. Range 27-77 YearsEndovascular obliteration of ovarian veins in patients with symptomatic pelvic venous incompetence (PVI)Combined reflux in more than one pelvic vein is common. In these cases, isolated treatment of ovarian veins or conservative treatment is associated with a poor midterm clinical outcome. A clinical improvement was achieved only in patients with isolated ovarian vein incompetence.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: DBachar GN, Belenky A, Greif F, et al. Initial experience with ovarian vein embolization for the treatment of chronic pelvic pain syndrome. Isr Med Assoc J. 2003; 5(12):843-846.Study Design:n = 6Sources of funding: UndisclosedEligibility Criteria: Lower abdominal pain, and pelvic varicosities were found on Doppler ultrasound and retrograde ovarian vein venography.Patient Characteristics: Age 27-53. Embolization was done unilaterally in 3 patients (on the left side) and bilaterally in 3.Ovarian vein embolization in women with pelvic pain syndromePercutaneous transcatheter ovarian vein embolization seems to be safe and feasible for the treatment of pelvic pain syndrome. The procedure is performed on an outpatient basis and is well tolerated by patients.Technical success of procedure: 100%30-day mortality: 0Procedure-related morality: 02 reported partial relief of symptoms (33.3%) and 3 had complete relief (50%), for a total of 5 patients (83.3%) with some measure of improvement.Level of Evidence: DBall E, Khan KS, Meads C. Does pelvic venous congestion syndrome exist and can it be treated? Acta Obstet Gynecol Scand. 2012; 91(5):525-528.Study Design: Articlen = n/aSources of funding: n/aEligibility Criteria: n/aPatient Characteristics: n/aDoes pelvic venous congestion syndrome exist and can it be treated?A systematic review of causation evidence is needed to prove whether pelvic venous congestion causes CPP and whether embolization treatment is effectiveTechnical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: EBlack CM, Thorpe K, Venrbux A, et al. Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol. 2010; 21(6):796-803.Study Design: Systematic Reviewn = 301, 10 studiesSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aCommon definitions, approaches to diagnosis and treatment, and clinical outcomes assessment in the care of patients with chronic pelvic pain resulting from pelvic venous insufficiency (PVI).Although transcatheter embolization is an established therapy for the treatment of symptomatic PVI, published series are limited by non-standardized reporting, incomplete follow-up, and the use of variable measures of outcome.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: EChung, M.-H., & Huh, C.-Y. (2003). Comparison of Treatments for Pelvic Congestion Syndrome. The Tohoku Journal of Experimental Medicine, 201(3), 131–138.Study Design: RCTn = 106 Group A: embolotherapy group: n=52Group B; hysterectomy + bilateral oophorectomy: n=27Group C: hysterectomy and removal of only the affected ovary: n=27Sources of funding: UndisclosedEligibility Criteria: pelvic congestion syndrome, confirmed with laparoscopy and venography, who did not respond to MPA after 4-6 months medicationPatient Characteristics: 90 left unilateral venous congestion; 8 right unilateral venous congestion; 8 bilateral venous congestion on venography.Group A: Age 40.1 ± 4.9Group B:Age 45.5 ± 3.8Group C: Age 44.1 ± 3.9Venography, Embolization vs. Hysterectomy and oophorectomyPercutaneous transcatheter embolization of ovarian veins and/or the internal iliac vein is a safe and minimally invasive treatment option for the treatment of PCS.Difference in mean pain scores at each follow-up visit, compared with the pretreatment score was significantly decreased in Groups A and B (p < 0.05), but not in Group C.There were no significant differences in stress scores and pain values between the three groups (p >0.05).Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:BCordts PR, Eclavea A, Buckley PJ, et al. Pelvic congestion syndrome: early clinical results after transcatheter ovarian vein embolization. J Vasc Surg. 1998; 28(5):862-868.Study Design: Case Seriesn = 11Sources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: Mean age: 33.1 yearsRadiographic and clinical results of attempted transcatheter ovarian vein (OV) embolization with suspected PCSTranscatheter embolization provides excellent initial and variable midterm relief in women with typical PCS symptoms and with OV or OV and internal iliac (hypogastric) tributary vein incompetence.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aThere were no major complications. Two women had a mild to moderate return of the symptoms at 6 and 22 months.Level of Evidence: DCreton D, Hennequin L, Kohler F, Allaert FA. Embolization of symptomatic pelvic veins in women presenting with non-saphenous varicose veins of pelvic origin - three-year follow-up. Eur J Vasc Endovasc Surg. 2007; 34(1):112-117.Study Design: Case Seriesn = 24Sources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: Mean age: 41.5 years (range 31 - 50).The mean number of pregnancies was 2.5 per patient (range 1 - 4).Clinical results of embolization of symptomatic, incompetent pelvic veins in women presenting withperineal veinsIn women of reproductive age, non-saphenous varicose veins associated with pelvic venous incompetence (PVI) should undergo pelvic vein investigation. Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: DDaniels JP, Champaneria R, Shah L, et al. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol. 2016; 27(10):1478-1486.Study Design: Review Articlen = 1,308, 22 Studies (1 poor quality RCT; 21 case series)Sources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aEmbolization of incompetent pelvic veinsEmbolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aEarly substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained.Level of Evidence:CGandini R, Chiocchi M, Konda D, et al. Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol. 2008; 31(4):778-784.Study Design: Retrospective Reviewn = 38Sources of funding: UndisclosedEligibility Criteria: Diagnosed with PCS and treated between January 2000 and June 2005 by TCFS.Patient Characteristics: Mean age: 36.9; range,22–44. Transcatheter foamsclerotherapy (TCFS) in pelvic varicocele using sodiumtetradecyl-sulfate foam (STSF),We conclude that TCFS of female varicocele using a 3% STSF is safe and effective for the treatment of PCS.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: DGuirola, J. A., Sánchez-Ballestin, M., Sierre, S., Lahuerta, C., Mayoral, V., & De Gregorio, M. A. (2018). A Randomized Trial of Endovascular Embolization Treatment in Pelvic Congestion Syndrome: Fibered Platinum Coils versus Vascular Plugs with 1-Year Clinical Outcomes. Journal of Vascular and Interventional Radiology, 29(1), 45–53.Study Design: RCTn = 100 (2 groups, 50/50)Sources of funding: UndisclosedEligibility Criteria: Age > 18; Presence of chronic abdominal or pelvic pain for >6 months; >6 mm pelvic venous caliber measured by transvaginal US; Presence of venous reflux or communicating veins by transvaginal Doppler USPatient Characteristics: Mean age of patients was 42.7 years ± 7.60, and mean visual analog scale (VAS) score for pelvic pain before treatment was 7.4 ± 7.60Vascular plugs (VPs) and fibered platinum coils (FPCs) for embolization in pelvic congestion syndrome (PCS)Embolization for PCS resulted in pain relief in 90% of patients; clinical success was not affected by embolic device. VPs were associated with decreased fluoroscopy time and radiation dose.Technical success of procedure: "high success"30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:B Hansrani V, Abbas A, Bhandari S, et al. Trans-venous occlusion of incompetent pelvic veins for chronic pelvic pain in women: a systematic review. Eur J Obstet Gyn Reprod Biol. 2015; 185:156-163.Study Design: Systematic Reviewn = 866, 13 StudiesSources of funding: UndisclosedEligibility Criteria: Published between 1966 and July 2014.Patient Characteristics: Included published RCT's RCT, quasi-control trials, cohort studies, and case–control studies with >15 participants.Transvenous occlusion in CCPSubjective improvements in pain were seen in all 13 studies after treatment by trans-venous occlusion. All 13 studies were of poor methodological quality. Complication rates were low and no fatalities occurred.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: noneLevel of Evidence:CHobbs JT. Varicose veins arising from the pelvis due to ovarian vein incompetence. Int J Clin Pract. 2005; 59(10):1195-1203.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aLigation of the ovarian veinsThe pelvic congestion syndrome is due to the incompetence of one or both ovarian veins and can explain some recurrent leg vein problems. Ligation of the ovarian veins is a relatively simple and safe procedure that provides an effective cure for this chronic condition.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:EHocquelet A, Le Bras Y, Balian E, et al. Evaluation of the efficacy of endovascular treatment of pelvic congestion syndrome. Diagn Interv Imaging. 2014; 95(3):301-306.Study Design: Retrospective Studyn = 33Sources of funding: UndisclosedEligibility Criteria: Female patients undergoing pelvic venous embolization between January 2008 and May 2012 in Bordeaux, FR.Patient Characteristics: 29 of 33 had ovarian and pelvic venousultrasound and abdominopelvic MR. Average age: 41.4 (20-65). Average # of pregnancies 2.15 (0-5)Venous embolization treatment for PCSOur series demonstrates the efficacy of embolization treatment with a significant fall in the VAS in patients with PCS.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DJeanneret C, Beier K, von Weymarn A, Traber J. Pelvic congestion syndrome and left renal compression syndrome - clinical features and therapeutic approaches. Vasa. 2016; 45(4):275-282.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aTreatments for PCSControlled prospective trials are needed to find the best treatment.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:EKies DD, Kim HS. Pelvic congestion syndrome: a review of current diagnostic and minimally invasive treatment modalities. Phlebology. 2012; 27(Suppl 1):52-57.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aTreatments for CPPAlthough medical and open surgical therapies exist, transcatheter percutaneous embolotherapy has been shown to be a safe, effective anddurable therapy for the treatment of PCS. Further prospective randomized studies are needed to refine optimal technique and assess long-term patient outcomes.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:EKim HS, Malhotra AD, Rowe PC, et al. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006; 17(2 Pt 1):289-297.Study Design:n = 131Sources of funding: UndisclosedEligibility Criteria: consecutive patients referred to a tertiary-careinterventional radiology service from 1998 to 2003 because of a high degree of clinical suspicion of pelvic and ovarianvarices.Patient Characteristics: Mean Age, 34.0 ± 12.5Transcatheter embolotherapy in women with chronic pelvicpain caused by ovarian and pelvic varicesSignificant improvement in each category of specific symptoms was also noted (P < .0001). Overall, 83% of the patients exhibited clinical improvement at long-term follow-up, 13% had no significant change, and 4% exhibited worsened conditionTechnical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DKwon SH, Oh JH, Ko KR, et al. Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol. 2007; 30(4):655-661.Study Design: Retrospective Studyn = 67Sources of funding: UndisclosedEligibility Criteria: Patients, between Nov 1998 and June 2005, who were diagnosed with PCS and underwent ovarian vein coil embolization.Patient Characteristics: Age: 39.1 ± 9 [25–64]; Symptom duration (months) 32.9 ± 21.6 [6–243]Ovarian vein embolization using for pelvic congestion syndrome (PCS)Ovarian vein embolization using coils is a safe and effective therapeutic method for treatment of PCS.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DLaborda A, Medrano J, de Blas I, et al. Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Intervent Radiol. 2013; 36(4):1006-1014.Study Design: Prospective Studyn = 202Sources of funding: UndisclosedEligibility Criteria: lower limb varices and chronic pelvic pain (>6 months), >6 mm pelvic venous caliber in ultrasonography, and venous reflux or presence of communicating veins.Patient Characteristics: Age: 43.5 years; range 27–57- where they were being treated for lower limb varicesPelvic congestion syndrome (PCS) coil embolizationCoil embolization of PCS is an effective and safe procedure, with high clinical success rate and degree of satisfaction.Technical success of procedure: 100%30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:CMahmoud O, Vikatmaa P, Aho P, et al. Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord. 2016; 4(3):355-370.Study Design: Prospective Studyn = 1081, 22 studiesSources of funding: “n/a”Eligibility Criteria: A literature search was performed using PubMed, Science Direct, Google Scholar, and Scopus to identify case series on the endovascular treatment of PCS up until the end of November 2014.Patient Characteristics: There were no randomized trials, and only one study included a control group.Medical literature on the endovascular treatment of PCSThe immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5 years after the procedure.Technical success of procedure: Immediate technical success rate in occluding the affected veins was reported to be 100% in 17 studies, and it was 94.7%, 95.8%, and 90.9%, respectively, in three studies.30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:CMaleux G, Stockx L, Wilms G, Marchal G. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long term technical and clinical results. J Vasc Interven Radiol. 2000; 11(7):859-864.Study Design: Prospective Studyn = 41Sources of funding: Eligibility Criteria: All had lower abdominal pain. Dyspareunia in 11 & urinary urgency in 6.Patient Characteristics: Age: mean, 37.8; range, 30–58. 32 underwent unilateral embolization and 9 patients underwent bilateral embolization.Ovarian vein embolization in the treatment of symptomatic pelvic varicesTranscatheter embolization of the ovarian veins is a safe and feasible technique leading to complete relief of symptoms in more than half of cases.Technical success of procedure: Initial technical success rate was 98%. 30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: DMeneses L, Fava M, Diaz P, et al. Embolization of incompetent pelvic veins for the treatment of recurrent varicose veins in lower limbs and pelvic congestion syndrome. Cardiovasc Intervent Radiol. 2013; 36(1):128-132.Study Design: Prospective Studyn = 10Sources of funding: UndisclosedEligibility Criteria: Consulted a vascular surgeon because of recurrent VV in lower limbs after surgery. All of these patients wereincluded in the study because they also had symptoms of PCS, probably due to IPVPatient Characteristics: 100% Women. Fifteen vein segments in 10 women were suitablefor embolization.Embolization of incompetent pelvic veinsEmbolization decreases the risk of VV recurrence after surgery and also improves PCS symptoms in women with VV in lower limbs and IPV.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DNaoum JJ. Endovascular therapy for pelvic congestion syndrome. Methodist Debakey Cardiovasc J. 2009; 5(4):36-38.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aembolize ovarian varicosities and incompetent internal iliac vein branches.This minimally invasive approach has proven safe and efficacious.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:ENasser F, Cavalcante RN, Affonso BB, et al. Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome. Int J Gynaecol Obstet. 2014; 125(1):65-68.Study Design: Retrospective Studyn = 113Sources of funding: UndisclosedEligibility Criteria: Women with PCS diagnosis treated with endovascular embolization of ovarian & pelvic varicose veins at Hospital Clínico Universitario, Zaragoza, Spain between Jan 1, 2001 - Jan 31, 2011.Patient Characteristics: mean ± SD age of 43.7 ± 4.7 years and had had at least 2 pregnancies.Transcatheter embolization using coils for treatment of pelvic congestion syndrome (PCS)Transcatheter embolization was a safe and effective treatment for PCS. Lower limb symptoms, urinary urgency, and varicosities were associated with incomplete clinical success.Technical success of procedure: 100%30-day mortality: n/aProcedure-related morality: n/aComplication: global complication rate was low (5/113, 4.4%)Level of Evidence:DO'Brien MT, Gillespie DL. Diagnosis and treatment of the pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord. 2015; 3(1):96-106.Study Design: Retrospective StudyPCSn = 959, 21 studiesNutcracker Syndromen = 190, 19 studiesSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: MEDLINE Search revealed 3756+ references to chronic pelvic pain. Only 260 referenced PCS, pelvic chronic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies.Literature in treatment of PCSDiagnosis of PCS requires a careful history, physical examination, and noninvasive imaging. Several large case series have demonstrated the efficacy of embolotherapy in the reduction of pelvic pain; thus, it is the most favored treatment option for patients with PCS.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: CPhillips D, Deipolyi AR, Hesketh RL, et al. Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management. J Vasc Interv Radiol. 2014; 25(5):725-733.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aIR's involvement with pelvic congestion syndromePCS is a common condition with significant physical and psychosexual consequences. While pathophysiology is multifactorial and is still poorly defined, IR's play a critical role in diagnosing pelvic varicosities and treating PCS-related symptoms with embolization.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: EPieri S, Agresti P, Morucci M, de' Medici L. Percutaneous treatment of pelvic congestion syndrome. Radiol Med (Torino). 2003; 105(1-2):76-82.Study Design: Retrospective Reviewn = 33Sources of funding: UndisclosedEligibility Criteria: Patient Characteristics: Mean diameter 4.5mm for the right ovarian vein and 6.3mm for the left. 1 pelvic congestion syndrome on the right, 11 on the left and 21 bilaterally. 20 patients had dyspareunia, whereas 8 had urinary urgencyPercutaneous management of pelvic congestion syndrome, using the transbrachial approach and sclerosis alone.Pelvic congestion syndrome and chronic pelvic pain that do not respond to medical therapy can be resolved by percutaneous management.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:Pyra K, Wo?niak S, Roman T, et al. Evaluation of effectiveness of endovascular embolization for the treatment of pelvic congestion syndrome--preliminary study. Ginekol Pol. 2015; 86(5):346-351.Study Design: Prospective Studyn = 24Sources of funding: UndisclosedEligibility Criteria: January and May of 2014. Diagnosed with PCS.Patient Characteristics: 100% Female. 22-44 years (average - 31 years).Endovascular embolization of pelvic congestion syndrome (PCS)Embolization is a minimally invasive, effective and safe method of treatment for PCS.Technical success of procedure: 96%30-day mortality: n/aProcedure-related morality: n/aIn two cases, the ovarian vein was injured and the contrast medium extravasated, which was clinically insignificant. In one case, a small injection site hematoma developed.Level of Evidence:DSichlau MJ, Yao JS, Vogelzang RL. Transcatheter embolotherapy for the treatment of pelvic congestion syndrome. Obstet Gynecol. 1994; 83(5 Pt 2):892-896.Study Design: Case Seriesn = 3Sources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics:100% femaleembolization of pelvic congestion syndromeFindings suggest PVC was the likely etiologic factor in pelvic pain experienced by these women and that transcatheter ovarian vein embolotherapy may be an effective treatment for such a condition.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:ESmith PC. The outcome of treatment for pelvic congestion syndrome. Phlebology. 2012; 27 Suppl 1:74-77.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aEmbolization of pelvic and ovarian veins The results of this treatment have been published in a limited number of clinical series, usually with fairly short follow-up periods. Limited clinical evidence supports the use of embolotherapy in the management of pelvic congestion syndrome.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: EStones RW. Pelvic vascular congestion - half a century later. Clin Obstet Gynecol. 2003; 46(4):831-836.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aPelvic congestion: clinical findings and their relationship with appearances using different imaging modalities are considered.The immediate challenge is for gynecologists and radiologists to work together to agree diagnostic criteria and to present care- fully documented studies of the clinical out- comes of radiologic interventions.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence: ETarazov PG, Prozorovakji KV, Ryzhov VK. Pelvic pain syndrome caused by ovarian varices. Treatment of transcatheter embolization. Acta Radiol. 1997; 38(6):1023-1025.Study Design:n = 6Sources of funding: UndisclosedEligibility Criteria: Patient Characteristics: 100% female, 25-40 years.Therapeutic embolization in the pelvic congestion syndrome caused by ovarian varicesTranscatheter treatment could be considered as an alternative to surgical or laparoscopic ligation in ovarian varicocele.Technical success of procedure: 100%30-day mortality: n/aProcedure-related morality: n/aThe pelvic pain syndrome disappeared in all patients within 4 weeks, and there was regression of the periodic pain in 2 women with dysmenorrhea. The patients were free of symptoms during the 1-4-year follow-up.Level of Evidence:DTu FF, Hahn D, Steege JF. Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 2010; 65(5):332-340.Study Design: Systematic Reviewn = n/aSources of funding: UndisclosedEligibility Criteria: Studiespublished Jan 1966 - May 2009 pertaining to diagnosis and treatment of female PCS-related pelvic pain. Restricted to those containing at least 4 subjects and a specified length of follow-up.Patient Characteristics: n/aDiagnosis and treatment of female pelvic congestion syndromeBoth progestins and gonadotropin -releasing hormone agonists are effective in decreasing pain symptoms. The optimal diagnostic approach for PCS-related pelvic pain remains unclear, and controlled trials comparing medical and interventional treatments are urgently needed for PCS-associated pelvic pain.Technical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DVenbrux AC, Chang AH, Kim HS, et al. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vas Interv Radiol. 2002; 13(2 Pt 1):171-178.Study Design: Prospective Studyn = 56Sources of funding: UndisclosedEligibility Criteria: Patients treated for chronic pelvic pain Jul 1998 to Aug 2000Patient Characteristics: Age: mean 32.3Percutaneous transcatheter embolotherapy of ovarian and pelvic varicesFor patients with ovarian/internal iliac varices, transcatheter embolotherapy provides a nonsurgical treatment option. There is a significant decrease in pain based on VAS without any notable impact on menstrual cycle.Technical success of procedure: 100%30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:DVenbrux AC, Lambert DL. Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol. 1999; 11(4):395-399.Study Design: Articlen = n/aSources of funding: UndisclosedEligibility Criteria: n/aPatient Characteristics: n/aEmbolization for the treatment of pelvic venous incompetenceOverview, no argumentTechnical success of procedure: n/a30-day mortality: n/aProcedure-related morality: n/aLevel of Evidence:EAuthorsSIR's Carrier Advocacy Workgroup (CAW)Chair/Steering: C. Matthew Hawkins, MD, FSIR Workgroup members: Curtis L. Anderson, MD, Ph.D.; Jacob Bundy, MD; Evan W. Harris, MD; Caleb Heiberger; Robert J. Kennedy, MD; Minhaj S. Khaja, MD, MBA, FSIR; Nishita Kothary, MD, FSIR; Gary (Harry) Kramer, Oleksandra Kutsenko, MD; Michelle M. Shnayder, MD, MPH; Dave M. Tabriz, MD Consulting: Meridith J. Englander, MD, FSIR; Raymond W. Liu, MD, FSIR; FSIR Waleska M. Pabon-Ramos, MD, MPH, FSIR; Keith M. Sterling, MD, FSIR; Rajesh Shah, MD, FSIR; Adam D. Talenfeld, MD, FSIR; and the SIR Service Line Advisers Staff support: Miata Koroma, Sandy Dulebohn, Caleb GilbertFinancial statementsThese coverage recommendations were developed in their entirety by the Society of Interventional Radiology (SIR). All participating authors have disclosed potential conflicts of interest consistent with SIR's disclosure policy. Author disclosuresThe authors have no financial mentsComments regarding the coverage recommendations may be submitted to economics@ and will be considered in the development of future revisions of the work.Disclaimer: Disclaimer: This coverage recommendation is proprietary information owned by the Society of Interventional Radiology (SIR). SIR members and other lawful purchasers of this document are authorized to use this recommendation for personal use only. Distribution beyond the member or purchaser's personal use is expressly forbidden, absent written consent from SIR. SIR coverage recommendations should not be construed as including all proper methods of care or excluding other acceptable practices of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. The coverage recommendations do not represent a "standard of care," nor are they intended as a fixed treatment protocol. It is anticipated that there will be patients who will require less or more treatment than the average. It is also acknowledged that in atypical cases, treatment falling outside these criteria will sometimes be necessary. This document should not be seen as prescribing the type, frequency, or duration of intervention. Treatment and accompanying payment should be based on this information in addition to an individual patient's needs as well as the doctor's professional judgment and experience. This document is designed to function as a guide and should not be used as the sole reason for denial of treatment and services. It is not intended to supersede applicable ethical standards or provisions of law. This is not a legal document.References ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY 1.Khilnani, N. M. et al. Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel. J. Vasc. Interv. Radiol. JVIR 30, 781–789 (2019).2.Evaluation of chronic pelvic pain in females - UpToDate. , M. S. et al. Pelvic vein embolisation of gonadal and internal iliac veins can be performed safely and with good technical results in an ambulatory vein clinic, under local anaesthetic alone - Results from two years' experience. Phlebology 33, 575–579 (2018).4.Maleux, G., Stockx, L., Wilms, G. & Marchal, G. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J. Vasc. Interv. Radiol. JVIR 11, 859–864 (2000).5.The Biggest Challenge to Pelvic Congestion Embolization: Reimbursement - Endovascular Today. , M.-H. & Huh, C.-Y. Comparison of treatments for pelvic congestion syndrome. Tohoku J. Exp. Med. 201, 131–138 (2003).7.Kim, H. S., Malhotra, A. D., Rowe, P. C., Lee, J. M. & Venbrux, A. C. Embolotherapy for pelvic congestion syndrome: long-term results. J. Vasc. Interv. Radiol. JVIR 17, 289–297 (2006).8.Laborda, A. et al. Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc. Intervent. Radiol. 36, 1006–1014 (2013).9.Venbrux, A. C. & Lambert, D. L. Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr. Opin. Obstet. Gynecol. 11, 395–399 (1999).10.Nasser, F. et al. Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome. Int. J. Gynaecol. Obstet. Off. Organ Int. Fed. Gynaecol. Obstet. 125, 65–68 (2014).11.Hocquelet, A. et al. Evaluation of the efficacy of endovascular treatment of pelvic congestion syndrome. Diagn. Interv. Imaging 95, 301–306 (2014).12.Spies, J. B. et al. Uterine Fibroid Embolization: Measurement of Health-Related Quality of Life before and after Therapy. J. Vasc. Interv. Radiol. 10, 1293–1303 (1999).13.Cheong, Y. C., Smotra, G. & Williams, A. C. de C. Non-surgical interventions for the management of chronic pelvic pain. Cochrane Database Syst. Rev. CD008797 (2014) doi:10.1002/14651858.CD008797.pub2.14.Perry, C. P. Current Concepts of Pelvic Congestion and Chronic Pelvic Pain. JSLS 5, 105–110 (2001).15.Daniels, J. P. et al. Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review. J. Vasc. Interv. Radiol. JVIR 27, 1478-1486.e8 (2016).16.Ganeshan, A. et al. Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology. Cardiovasc. Intervent. Radiol. 30, 1105–1111 (2007).17.Guirola, J. A. et al. A Randomized Trial of Endovascular Embolization Treatment in Pelvic Congestion Syndrome: Fibered Platinum Coils versus Vascular Plugs with 1-Year Clinical Outcomes. J. Vasc. Interv. Radiol. JVIR 29, 45–53 (2018).18.Kwon, S. H., Oh, J. H., Ko, K. R., Park, H. C. & Huh, J. Y. Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc. Intervent. Radiol. 30, 655–661 (2007).19.Mahmoud, O. et al. Efficacy of endovascular treatment for pelvic congestion syndrome. J. Vasc. Surg. Venous Lymphat. Disord. 4, 355–370 (2016).20.O'Brien, M. T. & Gillespie, D. L. Diagnosis and treatment of the pelvic congestion syndrome. J. Vasc. Surg. Venous Lymphat. Disord. 3, 96–106 (2015).21.Gandini, R. et al. Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc. Intervent. Radiol. 31, 778–784 (2008).22.Venbrux, A. C. et al. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J. Vasc. Interv. Radiol. JVIR 13, 171–178 (2002).23.Capasso, P. [Endovascular treatment of varicoceles and utero-ovarian varices]. J. Radiol. 81, 1115–1124 (2000).24.Sichlau, M. J., Yao, J. S. & Vogelzang, R. L. Transcatheter embolotherapy for the treatment of pelvic congestion syndrome. Obstet. Gynecol. 83, 892–896 (1994).25.Tarazov, P. G., Prozorovskij, K. V. & Ryzhkov, V. K. Pelvic pain syndrome caused by ovarian varices. Treatment by transcatheter embolization. Acta Radiol. Stockh. Swed. 1987 38, 1023–1025 (1997).26.Cordts, P. R. et al. Pelvic congestion syndrome: early clinical results after transcatheter ovarian vein embolization. J. Vasc. Surg. 28, 862–868 (1998).27.Abd Elkhalek, Y. I. & Bassiouny, A. M. M. F. Trans-catheter ovarian vein coiling in management of symptomatic females having chronic pelvic congestion. Egypt. J. Radiol. Nucl. Med. 49, 815–818 (2018).28.Bachar, G. N. et al. Initial experience with ovarian vein embolization for the treatment of chronic pelvic pain syndrome. Isr. Med. Assoc. J. IMAJ 5, 843–846 (2003).29.Pyra, K. et al. Evaluation of effectiveness of endovascular embolisation for the treatment of pelvic congestion syndrome--preliminary study. Ginekol. Pol. 86, 346–351 (2015).30.Stones, R. W. Pelvic vascular congestion-half a century later. Clin. Obstet. Gynecol. 46, 831–836 (2003).31.Stones, W., Cheong, Y. C., Howard, F. M. & Singh, S. Interventions for treating chronic pelvic pain in women. Cochrane Database Syst. Rev. (2005) doi:10.1002/14651858.CD000387.32.Smith, P. C. The outcome of treatment for pelvic congestion syndrome. Phlebology 27, 74–77 (2012).33.Black, C. M. et al. Research reporting standards for endovascular treatment of pelvic venous insufficiency. J. Vasc. Interv. Radiol. JVIR 21, 796–803 (2010).34.Ball, E., Khan, K. S. & Meads, C. Does pelvic venous congestion syndrome exist and can it be treated? Acta Obstet. Gynecol. Scand. 91, 525–528 (2012).35.Hansrani, V. et al. Trans-venous occlusion of incompetent pelvic veins for chronic pelvic pain in women: a systematic review. Eur. J. Obstet. Gynecol. Reprod. Biol. 185, 156–163 (2015).36.Brown, C. L., Rizer, M., Alexander, R., Sharpe, E. E. & Rochon, P. J. Pelvic Congestion Syndrome: Systematic Review of Treatment Success. Semin. Interv. Radiol. 35, 35–40 (2018).37.Knuttinen, M.-G. et al. Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues. AJR Am. J. Roentgenol. 204, 448–458 (2015).INTENTIONALLY LEFT BLANK ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download