Laparoscopic excision of a coil‐loaded ovarian vein for refractory pelvic pain after embolization: A case report

Pelvic congestion syndrome (PCS) is a recognized cause of chronic pelvic pain driven by reflux in dilated ovarian and internal iliac veins. Ovarian vein embolization (OVE) achieves high technical success and symptom improvement for most patients,1, 2 yet a minority report persistent or worsened pain. Proposed mechanisms of pain include perivenous inflammation, coil protrusion beyond the vein wall, or residual reflux.3, 4 Comparative data indicate that both surgery and embolization can reduce pain, with outcomes depending on patient selection.5 When conservative measures fail and the clinical picture points to coil-related pain, surgery might be appropriate. This report details laparoscopic excision of coil-loaded ovarian veins in a patient who had bilateral coil placement. A 32-year-old multiparous woman presented with constant left-sided non-cyclical pelvic pain that intensified 3 months after OVE for PCS performed elsewhere. The index OVE included coil placement in both ovarian veins per procedural records. Pain worsened with standing and improved on recumbency. Non-steroidal anti-inflammatory drugs, a short opioid course, and progestins were ineffective. On examination, there was left pelvic sidewall tenderness without peritoneal signs. Transvaginal ultrasound, magnetic resonance imaging, and contrast-enhanced computed tomograpy showed post-embolization changes without alternative gynecologic pathology. Other causes of chronic pelvic pain were considered and excluded with no urologic or gastrointestinal pathology identified. Review of the fluoroscopic record confirmed bilateral coil packs, more substantial on the left (Figure 1a). Multidisciplinary discussion favored left-sided coil-related pain. The patient consented to laparoscopy primarily focused on the symptomatic side, with the understanding that bilateral excision could be performed if intraoperative findings justified it, and expressed a preoperative preference for removal on both sides. Under general anesthesia in dorsal lithotomy position, a 10-mm umbilical camera port and two working ports (5 mm and 10 mm) were placed. Retroperitoneal entry was obtained lateral to the infundibulopelvic ligament. The left ureter was identified and kept in view. Dense fibrosis tracked along the left gonadal vein, with coil loops visible through the venous wall (Figure 1b). Proximal and distal control of the coil-loaded segment was achieved with bipolar coagulation, followed by segmental excision. The coil stack was retrieved through the 10-mm port using a specimen bag for protected en bloc and piecemeal extraction (Figure 1c). The right retroperitoneum was then opened lateral to the right infundibulopelvic ligament. The right ureter was identified and protected. Similar fibrotic changes were present along the right gonadal vein, which also contained coils. Proximal and distal control was secured with bipolar coagulation. The coil-loaded right ovarian vein segment was likewise excised, and the coils were removed through the 10-mm port in the same protected fashion. Hemostasis was meticulous on both sides. Operative time was 65 min; estimated blood loss was 50 mL. No intraoperative complications occurred. Macroscopic examination confirmed coil-filled venous segments with marked fibrosis (Figure 1d). Pain improved within 24 h. The patient was discharged on postoperative day 1. On a visual analog scale (VAS), preoperative pain was 5–7/10 and decreased to 1–2/10 1 week after surgery. At 6 and 12 months, she reported complete absence of pelvic pain and full return to activities without further interventions. Ovarian vein embolization is an established therapy for PCS with high rates of clinical improvement,1, 2 but coil-related complications can produce persistent pelvic pain in a small subset of patients.3, 4 Mechanisms include pericoil fibrosis, protrusion beyond the venous wall, focal neural irritation, and thrombophlebitis of the treated segment.3, 4 Our case is notable for bilateral coil placement with unilateral symptoms, highlighting that laterality of pain and imaging correlation should guide surgical targeting. Comparative data suggest that both surgical ligation/excision and endovascular approaches can reduce pain, with patient selection driving outcomes.5 Rare but serious late events such as coil migration, including pulmonary complications, are reported and should remain on the clinician's radar during follow-up.6 Technical points that supported a safe outcome included a strictly retroperitoneal approach, early ureter identification, obtaining proximal and distal venous control prior to venotomy, and protected coil retrieval within a bag to prevent fragment loss. Durable symptom resolution in this patient supports laparoscopic excision as a definitive option when conservative therapy fails. In women with refractory pelvic pain after OVE, laparoscopic segmental excision of the coil-loaded symptomatic ovarian vein can achieve rapid and durable pain relief after multidisciplinary evaluation. Previous reports on surgical coil removal describe symptom relief in selected patients but emphasize potential risks, including dense retroperitoneal fibrosis, ureteral injury, bleeding, and technical difficulty of complete coil retrieval. These limitations underscore the need for careful patient selection, meticulous retroperitoneal dissection, and protected extraction techniques.3-6 This report is limited by its single-case design, which precludes generalization of outcomes. Causal inference is limited, and the effectiveness and safety of laparoscopic coil excision cannot be extrapolated beyond carefully selected patients; larger series and comparative studies are required. MM: conceptualization, surgery, data curation, writing—original draft, supervision. DS: surgical assistance, data acquisition, patient follow-up, writing—review & editing. DP: literature review, preparation of figures, data interpretation, writing—review & editing. NM: data analysis, preparation of timeline, writing—review & editing. PP: literature search, reference formatting, writing—review & editing. AT: critical revision, methodological support, international expertise, writing—review & editing. All authors read and approved the final manuscript. No external funding. The authors declare no competing interests. According to institutional policy, single-patient image reports did not require IRB review. The case was managed in accordance with the Declaration of Helsinki. Written informed consent was obtained for publication of clinical details, intraoperative images, macroscopic specimen, and, if provided, a short surgical video. Data sharing is not applicable to this article as no new data were created or analyzed in this study.