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What is Ovarian Vein Embolization?
     

Ovarian vein embolization is a minimally invasive treatment for pelvic congestion syndrome that is used to close off faulty veins so they can no longer enlarge with blood, thus relieving the pain.

Pelvic congestion syndrome, also known as ovarian vein reflux, is a painful condition resulting from the presence of varicose veins in the pelvis. The condition is caused by valves in the veins that help return blood to the heart against gravity becoming weakened and not closing properly, allowing blood to flow backwards and pool in the vein causing pressure and bulging veins. Diagnosis of the condition is done through one of several methods: pelvic venography, magnetic resonance imaging and pelvic and transvaginal ultrasound.

During this procedure, an interventional radiologist inserts a catheter up the femoral vein and into the faulty vein(s). Catheterization requires only a small nick in the skin for insertion and x-ray image guidance of the catheter to its target area. The catheter delivers Dacron filaments-bearing coils that clot the blood and seal the faulty vein. The use of the recently developed Sotradecol foam agent allows the radiologist to block even the smallest veins not previously accessible.

How should I prepare?

You must stop taking aspirin and vitamin E at least five days before the procedure.

Have nothing to eat or drink after midnight prior to the procedure.

In general, you should not eat or drink for eight hours before your procedure. However, you may take your routine medications with sips of water. If you are diabetic and take insulin, you should talk to your doctor as your usual insulin dose may need to be adjusted.

Prior to your procedure, your blood may be tested to determine how well your liver and kidneys are functioning and whether your blood clots normally.

You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials (also known as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or a blood thinner for a specified period of time before your procedure.

Also inform your doctor about recent illnesses or other medical conditions.

Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page (www.RadiologyInfo.org/en/safety/) for more information about pregnancy and x-rays.
You will be admitted to the hospital on the morning of your procedure and be assessed by the interventional radiologist before the procedure begins.

You should wear comfortable, loose-fitting clothing to your exam. You may be given a gown to wear during the procedure.

What does the equipment look like?

In this procedure, x-ray equipment, a catheter and a variety of synthetic materials and medications, called embolic agents, are used.

The equipment typically used for this examination consists of a radiographic table, an x-ray tube and a television-like monitor that is located in the examining room or in a nearby room. When used for viewing images in real time (called fluoroscopy), the image intensifier (which converts x-rays into a video image) is suspended over a table on which the patient lies. When used for taking still pictures, the image is captured either electronically or on film.

A catheter is a long, thin plastic tube, about as thick as a strand of spaghetti.

Your physician will select an embolic agent depending on the size of the blood vessel or malformation and whether the treatment is intended to be permanent or temporary. These include:

  • Gelfoam™, a gelatin sponge material, which is cut into small pieces that are injected into an artery and float downstream until they can go no further. After a period ranging from a few days to two weeks, the material dissolves. Gelfoam is used to control bleeding until the cause can be identified and fixed, or until it has time to heal on its own.
  • particulate agents, including Polyvinyl alcohol (PVA) and gelatin-impregnated acrylic polymer spheres, which are suspended in liquid and injected into the bloodstream to block small vessels. These agents are used to block, or occlude, vessels permanently.
  • various sized metal coils made of stainless steel or platinum are used to block large arteries.
  • liquidsclerosing agents, which are used to destroy blood vessels and vessel malformations. Filling a vessel or a vessel malformation such as a fistula with this liquid agent causes blood clots to form, closing up the abnormal vascular channels.
  • liquid glue, which can be inserted into a fistula or arteriovenous malformation (AVM) where it hardens, filling in this unnecessary passageway between artery and vein.

Other equipment that may be used during the procedure includes an intravenous line (IV) and equipment that monitors your heart beat and blood pressure.

How does the procedure work?

Using x-ray imaging and a contrast material to visualize the blood vessel, the interventional radiologist inserts a catheter through the skin into a blood vessel and advances it to the treatment site. A synthetic material or medication called an embolic agent is then inserted through the catheter and positioned within the blood vessel or malformation where it will remain either permanently or temporarily.

Temporary embolic agents block blood vessels long enough to allow the body to heal on its own. Permanent embolic agents physically plug-up blood vessels and cause scar tissue to form in the vessel. This is important in treating conditions such as arteriovenous malformations and tumors, which would recur if the embolic agent dissolved.

How is the procedure performed?

Image-guided, minimally invasive procedures such as embolization for pelvic congestion syndrome should be performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room.

Prior to your procedure, ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) may be performed.

You will be positioned on the examining table.

You will be connected to monitors that track your heart rate, blood pressure and pulse during the procedure.

A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. You may also receive general anesthesia.

The area of your body where the catheter is to be inserted will be shaved, sterilized and covered with a surgical drape.

A very small nick is made in the skin at the site.

Using image-guidance, a catheter (a long, thin, hollow plastic tube) is inserted through the skin into a blood vessel and maneuvered to the treatment site.

A contrast material then is injected through your IV and a series of x-rays are taken to locate the exact site of bleeding or abnormality. The medication or embolic agent is then injected through the catheter.

dditional angiograms are taken to ensure the embolic agent is correctly positioned and that any bleeding is controlled.

At the end of the procedure, the catheter will be removed and pressure will be applied to stop any bleeding. The opening in the skin is then covered with a dressing. No sutures are needed.

Your intravenous line will be removed.

You can expect to stay in bed for six to eight hours after your procedure.

The length of the procedure varies from 30 minutes to several hours depending on the complexity of the condition.

What will I experience during and after the procedure?

Devices to monitor your heart rate and blood pressure will be attached to your body.

You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected.

If the case is done with sedation, the intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated.

You may feel slight pressure when the catheter is inserted but no serious discomfort.

As the contrast material passes through your body, you may get a warm feeling.

Most patients experience some side effects after embolization. Pain is the most common and can be controlled by medication given by mouth or through your IV.

Most patients leave the hospital within 24 hours of the procedure, but those who have considerable pain may have to stay longer.

You should be able to resume your normal activities within a week.

Who interprets the results and how do I get them?

The interventional radiologist can advise you as to whether the procedure was a technical success when it is completed.

In cases of bleeding, it may take 24 hours to know whether it has stopped. It may be one to three months after embolization before it is clear whether symptoms have been controlled or eliminated.

What are the benefits vs. risks?

Benefits

  • Embolization is a highly effective way of controlling bleeding, especially in an emergency situation.
  • Worldwide success rates of 85 percent and higher have been reported in women treated with embolization.
  • Embolization is much less invasive than conventional open surgery. As a result, there are fewer complications and the hospital stay is relatively brief—often only the night after the procedure. Blood loss is less than with traditional surgical treatment, and there is no obvious surgical incision.
  • This method can be used to treat tumors and vascular malformations that either cannot be removed surgically or would involve great risk if surgery was attempted.
  • No surgical incision is needed—only a small nick in the skin that does not have to be stitched closed.

Risks

  • There is a very slight risk of an allergic reaction if contrast material is injected.
  • Any procedure that involves placement of a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection.
  • There is always a chance that an embolic agent can lodge in the wrong place and deprive normal tissue of its oxygen supply.
  • There is a risk of infection after embolization, even if an antibiotic has been given.

What are the limitations of Ovarian Vein Embolization?

Successful embolization without injuring normal tissue requires that the catheter be placed in a precise position. This means that the catheter tip is situated so that embolic material can be deposited only in vessels serving the abnormal area. In a small percentage of cases, the procedure is not technically possible because the catheter cannot be positioned appropriately.

Embolisation of Veins of the Pelvis under X-ray control

Embolisation of the Ovarian and Pelvic Veins

Almost all of our patients with Pelvic Vein Reflux which cause the following, will need treatment.

  • Pelvic congestion syndrome
  • Vulval varicose veins
  • Vaginal varicose veins
  • Leg varicose veins arising from the pelvis

The process explained using x-ray images


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1) Using the neck approach as in the previous animation (see treatment page), the catheter can be positioned under X-ray control, into any of the veins that might be a problem.

In this case, the first X-ray (on the right) shows the catheter in the patient's left ovarian vein.
The contrast (a 'dye' the X-ray can see) falls with the blood down the vein and into the Varicose veins of the pelvis - which lie around the ovaries, uterus, bladder and bowel.

These large varicose veins can be clearly seen on the X-ray.

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2) The next picture (on the left) shows that the embolisation coils have been put in the ovarian vein - which is now blocked permanently.

The catheter has now been moved under x-ray guidance and has been positioned into the patient's right sided veins.

This picture actually shows that not only are the ovarian veins a problem in the patient, but the pelvic varicose veins are also coming from another vein - the Internal Iliac Vein on this side.

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3) The final picture (on the right) shows three sets of embolisation coils - all completely and permanently blocking the veins that they are in.

Both ovarian veins are embolised, as is the patient's right internal iliac vein.

By stopping the blood refluxing (falling back down these veins), the pelvic varicose veins should shrink away over a few weeks.

Any vulval varicose veins should also shrink away - and any veins in the legs can now be treated with a reduced chance of them coming back again in the future.

Any symptoms that have been due to the varicose veins in the pelvis (aching, heaviness etc) should slowly improve.

We perform a further trans-vaginal Duplex after 6 - 12 weeks to check whether the veins have been completely treated.

In about 1 in 100 patients, there might still be some reflux in one of the veins that might need one further embolisation attempt. However this is now very rare and most patients have a complete cure after the first embolisation.

 

 
 
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