Paradigm shift and long-term results in the diagnosis and treatment of pelvic venous disorder.

Conception and design: FR, AK Analysis and interpretation: FR, AK Data collection: FR, AK Writing the article: FR Critical revision of the article: FR, AK Final approval of the article: FR, AK Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: FR

Funded by Dante Pazzanese Institute . Corporation Dante Pazzanese Institute was not involved in the study design or collection, analysis, and interpretation of data. Corporation Dante Pazzanese was not involved in the decision to submit the manuscript for publication.

Data were derived from a single-center retrospective cohort analysis using prospective data from a prior randomized controlled trial 1 on iliac vein stenting, supplemented by consecutively enrolled PeVD 2 patients treated per protocol. Institutional Ethics Committee approval was obtained (protocols: 4965/CAAE: 16219.1.0000.5462; NCT02149212 ), with adherence to the Declaration of Helsinki. Inclusion criteria included patients aged 18 to 80 years with CPP and pelvic varicose veins ≥6 mm on transvaginal ultrasound examination, symptomatic varicocele (chronic scrotal pain or abnormal semen analysis), renal vein obstruction (flank/lumbar pain, hematuria, or proteinuria with left renal vein [LRV] diameter ratio of >4.9), or symptomatic iliac vein obstruction, regardless of the limb involved (Clinical, Etiological, Anatomical, Pathophysiological [CEAP] classification C3-C6 with >50% stenosis). 1 The indication for angioplasty with stent placement considered the laterality of symptoms and the presence and characteristics of iliac vein obstruction. The details of the diagnostic and therapeutic criteria used were described in a previous publication. 1 All participants had a preoperative visual analog scale score of >5 and ≥24 months of postoperative follow-up. Exclusion criteria comprised peripheral arterial disease, active malignancy (pelvic/extra pelvic), congestive heart failure, iodine contrast allergy, renal failure, body mass index of >40 kg/m 2 (which limits the feasibility of duplex ultrasound examination), and noncompliance with postoperative follow-up. Patients completed structured questionnaires, including the visual analogue scale for pain and Short Form-36, at baseline and during postoperative follow-up at 30 days, 3 months, 6 months, and annually. All participants underwent preoperative Doppler ultrasound examination 3 , 4 in the reverse Trendelenburg position, and computed tomography (CT) venography. 5 , 6 Venous obstruction and reflux patterns were assessed and compared with intraoperative venography and intravascular ultrasound (IVUS) findings. Incompetence and reflux in the gonadal and internal iliac veins were classified according to Szary et al. 7 Treatment strategies were based on clinical symptoms and preoperative examination findings ( Figs 1 and 2 ). Patients were discharged on the same day as their outpatient procedures. Fig 1 Preoperative and intraoperative diagnostic protocol. Patients with complaints of chronic pelvic pain (CPP) (VASP > 5) and documented pelvic varicose veins on transvaginal ultrasound examination, and those with Nutcracker and/or May-Thurner-Cockett syndromes symptoms associated with CPP (VASP > 5) were submitted to preoperative Doppler ultrasound examination 3 , 4 and computed tomography (CT) angiography 5 , 6 , 7 that were compared with intraoperative venography and IVUS. 8 CEAP , Clinical, Etiological, Anatomical, Pathophysiological; CVD , chronic venous disease; IVUS , intravascular ultrasound; VASP , visual analogue scale for pain. Fig 2 Preoperative DSUV 3 , 4 and computed tomography (CT) angiography 5 , 6 , 7 evaluation of the presence of abdominopelvic venous obstruction and reflux patterns. (A) Aortomesenteric angle. (B) Beak angle. (C) Renal vein diameter ratio. (D) Iliac vein and gonadal vein minimum diameters. (E) Varicose vein maximum diameter. (F) Varicose vein quadrants. (G) Iliac vein maximum and minimum diameters. (H) Left iliac and IVC angle. (G) Lumbosacral angle. Gonadal, IIV and pelvic venous reflux gradings 7 : Grade I: Left ovarian vein (LOV) reflux (Ø 5.5-6.0 mm). Dilation of left parauterine venous plexuses (PUVP) (Ø up to 5.0-5.5 mm). No overload of the LIIVs). Grade I/II: LOV reflux (Ø 6.0-6.5 mm). PUVP reflux on the left side (≤5.5 mm). Mild volumetric left IIV dilation (Ø up to 5-6 mm). Grade II: Dilated LOV trunk (≤7 mm). Distension of the left PUVP (6.0-6.5 mm) and bilateral IIV reflux (≤6 mm). ROV and right IIV, gradually widen (≤5.5 mm). Grade II/III: LOV reflux (Ø 7.5-8.0 mm). Branches of left IIV becomes wider (6.5-7.0 mm). Overload of the lower ROV and right PUVP (Ø up to 6.0-6.5 mm). Grade III: Expansion of the LOV trunk (Ø > 8 mm) left PUVP (7-8 mm), bilateral IIV (≤7.5 mm), ROV lower two-thirds diameter of 6.5 to 7.5 mm with narrow upper segment, right PUVP up to 6.5 to 7.0 mm, IIV trunk and branches (≤6.5 mm). Grade IV: Significant distention of the LOV (Ø > 10 mm). ROV contrasts quickly through its dilated ostium (often Ø > 5-6 mm). Bilateral PUVP and IIV plexus dilated (>6.5 mm). IVC , inferior vena cava; LCIV , left common iliac vein; LEIV , left external iliac vein; LIIV , left internal iliac vein; RCIV , right common iliac vein; REIV , right external iliac vein; RIIV , right internal iliac vein. Preoperative and intraoperative diagnostic protocol. Patients with complaints of chronic pelvic pain (CPP) (VASP > 5) and documented pelvic varicose veins on transvaginal ultrasound examination, and those with Nutcracker and/or May-Thurner-Cockett syndromes symptoms associated with CPP (VASP > 5) were submitted to preoperative Doppler ultrasound examination 3 , 4 and computed tomography (CT) angiography 5 , 6 , 7 that were compared with intraoperative venography and IVUS. 8 CEAP , Clinical, Etiological, Anatomical, Pathophysiological; CVD , chronic venous disease; IVUS , intravascular ultrasound; VASP , visual analogue scale for pain. Preoperative DSUV 3 , 4 and computed tomography (CT) angiography 5 , 6 , 7 evaluation of the presence of abdominopelvic venous obstruction and reflux patterns. (A) Aortomesenteric angle. (B) Beak angle. (C) Renal vein diameter ratio. (D) Iliac vein and gonadal vein minimum diameters. (E) Varicose vein maximum diameter. (F) Varicose vein quadrants. (G) Iliac vein maximum and minimum diameters. (H) Left iliac and IVC angle. (G) Lumbosacral angle. Gonadal, IIV and pelvic venous reflux gradings 7 : Grade I: Left ovarian vein (LOV) reflux (Ø 5.5-6.0 mm). Dilation of left parauterine venous plexuses (PUVP) (Ø up to 5.0-5.5 mm). No overload of the LIIVs). Grade I/II: LOV reflux (Ø 6.0-6.5 mm). PUVP reflux on the left side (≤5.5 mm). Mild volumetric left IIV dilation (Ø up to 5-6 mm). Grade II: Dilated LOV trunk (≤7 mm). Distension of the left PUVP (6.0-6.5 mm) and bilateral IIV reflux (≤6 mm). ROV and right IIV, gradually widen (≤5.5 mm). Grade II/III: LOV reflux (Ø 7.5-8.0 mm). Branches of left IIV becomes wider (6.5-7.0 mm). Overload of the lower ROV and right PUVP (Ø up to 6.0-6.5 mm). Grade III: Expansion of the LOV trunk (Ø > 8 mm) left PUVP (7-8 mm), bilateral IIV (≤7.5 mm), ROV lower two-thirds diameter of 6.5 to 7.5 mm with narrow upper segment, right PUVP up to 6.5 to 7.0 mm, IIV trunk and branches (≤6.5 mm). Grade IV: Significant distention of the LOV (Ø > 10 mm). ROV contrasts quickly through its dilated ostium (often Ø > 5-6 mm). Bilateral PUVP and IIV plexus dilated (>6.5 mm). IVC , inferior vena cava; LCIV , left common iliac vein; LEIV , left external iliac vein; LIIV , left internal iliac vein; RCIV , right common iliac vein; REIV , right external iliac vein; RIIV , right internal iliac vein. Patients with imaging-confirmed gonadal vein reflux underwent gonadal vein embolization as the primary modality for treating PeVD in both etiologic settings ( Fig 3 )—primary gonadal vein incompetence and secondary incompetence owing to renal vein obstruction—provided there were no concomitant renal symptoms (flank pain, hematuria, or proteinuria). Treatment involved embolization of the incompetent gonadal vein, venous plexus, and internal iliac vein, based on preoperative findings. 7 , 9 , 10 The procedure was performed under local anesthesia, and patient cooperation for breath-holding and Valsalva maneuvers. Prophylactic antibiotics and intraoperative unfractionated heparin (2500 U) were administered. Most procedures used right femoral vein access with selective catheterization as needed; for right gonadal and internal iliac embolization, jugular or brachial access was used. Unilateral catheterization of the left gonadal vein and pelvic plexus was performed for Szary 7 grades I, II, and III cases, and bilateral gonadal and internal iliac vein embolization was reserved for grade IV cases, with volumes of 3% polidocanol limited to no more than 10 mL. Internal iliac vein occlusion was considered necessary only if there was significant incompetence involving multiple branches of the internal iliac vein. Pelvic ovarian and uterine varicose veins were treated with 3% polidocanol foam, and the gonadal vein was addressed using foam and coils via the Tessari and sandwich technique 10 ( Fig 4 ). The same approach was used for varicocele. For symptomatic vulvar, pubic, or lower limb varicose veins of pelvic origin, microcatheters delivered polidocanol foam via a top-down technique targeting the internal iliac vein, escape pelvic points and tributaries. Fig 3 Endovenous pelvic venous disease (PeVD) treatment strategy protocol. (A) Patients with isolated chronic pelvic pain (CPP) underwent pelvic embolization. The gonadal vein,∗ internal iliac vein,∗ and escape points∗ were treated based on the criteria outlined in the text. (B) Patients with CPP associated with chronic venous disease ( CVD ) classified as Clinical, Etiological, Anatomical, Pathophysiological (CEAP) class C3 to C6 underwent iliac vein stenting. (C) Patients with CPP linked to persistent lumbar or flank pain, as well as hematuria and proteinuria, were treated with renal vein stenting. Fig 4 Gonadal vein and incompetent pelvic venous plexus embolization technique. Venography demonstrating selective catheterization of an incompetent pelvic venous plexus, and contrast migration to the contralateral iliac vein during the Valsalva maneuver (A) . Selective injection of 3% polidocanol foam (B) . Vasospasm and immediate occlusion of the treated pelvic venous plexus (C) . Embolization of the gonadal vein with coil and foam injection—“sandwich” technique (D - F) . Postoperative venography with digital subtraction demonstrating total occlusion of the entire treated territory (G) . Endovenous pelvic venous disease (PeVD) treatment strategy protocol. (A) Patients with isolated chronic pelvic pain (CPP) underwent pelvic embolization. The gonadal vein,∗ internal iliac vein,∗ and escape points∗ were treated based on the criteria outlined in the text. (B) Patients with CPP associated with chronic venous disease ( CVD ) classified as Clinical, Etiological, Anatomical, Pathophysiological (CEAP) class C3 to C6 underwent iliac vein stenting. (C) Patients with CPP linked to persistent lumbar or flank pain, as well as hematuria and proteinuria, were treated with renal vein stenting. Gonadal vein and incompetent pelvic venous plexus embolization technique. Venography demonstrating selective catheterization of an incompetent pelvic venous plexus, and contrast migration to the contralateral iliac vein during the Valsalva maneuver (A) . Selective injection of 3% polidocanol foam (B) . Vasospasm and immediate occlusion of the treated pelvic venous plexus (C) . Embolization of the gonadal vein with coil and foam injection—“sandwich” technique (D - F) . Postoperative venography with digital subtraction demonstrating total occlusion of the entire treated territory (G) . When there was an association among severe symptoms of CVD CEAP C3 through C6 ( Fig 3 ), iliac vein severe obstruction, CPP symptoms, and gonadal and pelvic varicose vein incompetence, the procedure initially performed was iliac vein stenting. The intraoperative treatment technique and postoperative antithrombotic protocol details were described in detail in previous publications 1 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ( Figs 5 and 6 ). Fig 5 Intraoperative venography confirming the data obtained on preoperative Angio CT, obstruction in the left common iliac vein (A) , obstruction in the left renal vein (B) and reflux in the left ovarian vein, and pelvic venous plexus (C to G) , and IVUS confirming obstruction > 80% in the left common iliac vein (H) . Fig 6 Angioplasty and stent placement in the left common iliac vein. (A and B) Preballooning with an 18 × 40 mm XXL (Boston Scientific). (C) A Wallstent × 90-mm placement, post ballooning with the same balloon catheter (D) . (E) Final venography and (F) intravascular ultrasound (IVUS) examination demonstrating complete recovery of the left common iliac vein lumen at the point of greatest obstruction on IVUS control. Intraoperative venography confirming the data obtained on preoperative Angio CT, obstruction in the left common iliac vein (A) , obstruction in the left renal vein (B) and reflux in the left ovarian vein, and pelvic venous plexus (C to G) , and IVUS confirming obstruction > 80% in the left common iliac vein (H) . Angioplasty and stent placement in the left common iliac vein. (A and B) Preballooning with an 18 × 40 mm XXL (Boston Scientific). (C) A Wallstent × 90-mm placement, post ballooning with the same balloon catheter (D) . (E) Final venography and (F) intravascular ultrasound (IVUS) examination demonstrating complete recovery of the left common iliac vein lumen at the point of greatest obstruction on IVUS control. In this situation, our initial approach consisted of LRV stenting without embolization of the left gonadal vein ( Fig 3 ). Procedures were performed under local anesthesia with light sedation. Right femoral vein access was obtained retrograde using a 5F Cobra/Simmons catheter and 0.035″ hydrophilic guidewire. Hemodynamically significant obstruction was defined as a renocaval gradient of >3 mm Hg. 6 The LRV was cannulated with a 6.5F Cobra catheter, and pullback pressure measurements were recorded to calculate the mean gradient. Obstruction sites were confirmed by preprocedural CT venography, IVUS examination, and partial balloon inflation (2 atm). Balloon angioplasty (14-16 mm × 20 mm) used conventional (5-8 atm) or high-pressure balloons (Atlas Gold, ≤18 atm) as needed. After predilation, a stent delivery catheter was advanced over an Amplatz wire into the caudal gonadal vein. The guidewire was redirected toward the renal hilum, and stents (Elgiloy Wallstent, Venovo or Abre Nitinol; 14-16 mm × 40-60 mm) were deployed with two-thirds placed in the hilar/middle segments and the proximal third covering the obstruction. Cranial stent extension into the inferior vena cava was performed during apnea to minimize displacement. Final stent patency was confirmed by venography and IVUS examination ( Fig 7 ). Fig 7 Intraoperative venography of a patient with low back pain, hematuria and proteinuria refractory to clinical treatment and complaining of CPP. Selective catheterization of the left renal vein (LRV) demonstrating obstruction of the LRV (A) (reno caval pressure gradient of 4.2 mm Hg), gonadal vein and pelvic varicose vein reflux (B and C) , preballooning of the obstruction with XXL 14 × 20 mm (D) , positioning of the Wallstent Stent 14 × 40 in the LRV, note that only the proximal third of the stent is within the inferior vena cava (E) , digital subtraction venography demonstrating the final result (absence of postoperative pressure gradient) (F) . Intraoperative venography of a patient with low back pain, hematuria and proteinuria refractory to clinical treatment and complaining of CPP. Selective catheterization of the left renal vein (LRV) demonstrating obstruction of the LRV (A) (reno caval pressure gradient of 4.2 mm Hg), gonadal vein and pelvic varicose vein reflux (B and C) , preballooning of the obstruction with XXL 14 × 20 mm (D) , positioning of the Wallstent Stent 14 × 40 in the LRV, note that only the proximal third of the stent is within the inferior vena cava (E) , digital subtraction venography demonstrating the final result (absence of postoperative pressure gradient) (F) . Patients underwent scheduled outpatient assessments at 1, 3, 6 months, and annually post intervention. Participants unable to attend in-person visits were contacted by phone for rescheduling or symptom assessment. Evaluations included clinical examination, Doppler ultrasound examination, and abdominal radiographs to assess stent position and integrity. Additional imaging was reserved for patients with recurrent symptoms. Continuous variables were expressed as mean ± standard deviation and compared using the t test. Categorical variables were compared with the χ 2 test. A P value of <.05 was considered statistically significant.

Between January 2012 and May 2022, 175 patients with PeVD underwent intervention. Follow-up data were obtained for 146 patients (83.4%) who adhered to scheduled evaluations over a mean follow-up period of 110 ± 1.6 months; 29 patients (16.6%) were excluded owing to loss to follow-up despite attempts at contact. The initial treatment protocols included ovarian vein embolization (30.8%), spermatic vein embolization (11.7%), iliac vein stenting (53.4%), and renal vein stenting (4.1%). Most patients had PeVD owing to iliac vein compression and reflux in the internal iliac vein, with ovarian vein reflux as the second most common cause. Demographic, clinical characteristics, and initial symptom severity are summarized in Table I . All patients presented with CPP or chronic scrotal pain, and associated symptoms are detailed in Table I . No significant differences were observed between groups for most variables. Hematuria and proteinuria were more prevalent in the renal vein stenting group. Notably, a history of deep vein thrombosis (DVT) was reported in 10 patients (22.7%) undergoing ovarian vein embolization and 27 (34.6%) undergoing iliac vein stenting, whereas none of the patients treated with spermatic or renal vein embolization had a history of DVT ( P = .033). Table I Patients initial characteristics and demographic data (n = 146) Characteristics Ovarian vein embolization Spermatic vein embolization Iliac vein stenting Renal vein stenting P Value Patients 45 (30.8) 17 (11.7) 78 (53.4) 6 (4.1) Age, years 38 ± 8.5 32 ± 11.7 51 ± 8.8 36 ± 4.7 .211 Female sex 45 (100) - 62 (79.5) 6 (100) .237 Gravidity 2.1 ± 2.3 - 2.8 ± 1.8 0.4 ± 1.1 .134 BMI 25.5 ± 4.5 24.8 ± 2.5 23.6 ± 5.6 24.8 ± 3.4 .328 VASP 8.5 ± 1.4 8.3 ± 1.1 8.1 ± 1.8 8.7 ± 0.9 .442  Flank pain 8 (18) 1 (5.8) 12 (15.4) 6 (100) .273  Lumbar pain 7 (15.9) 2 (11.7) 13 (18) 2 (33) .674  Scrotal pain - 17 (100) -  Dyspareunia 43 (97.7) - 54 (69.2) 4 (66) .336  Dysmenorrhea 39 (88.6) - 62 (79.5) 4 (66) .127  Hematuria 3 (6.8) 0 10 (12.8) 100% .002  Proteinuria 0 (0) 0 (0) 2 (2.6) 3 (50) .001 CEAP C3-6S 0 (0) 0 (0) 78 (100) 0 (0) - Vulvar varicose vein 10 (22) - 8 (10.2) 0 (0) .289 Atypical varicose vein 10 (22) 0 13 (18) 0 .104 Varicose vein recidivism 0 0 20 (25.6) 0 .034 DVT history 10 (22.7) 0 (0) 27 (34.6) 0 .033 BMI, Body mass index; CEAP, Clinical, Etiological, Anatomical, Pathophysiological; CPP, chronic pelvic pain; DVT, deep vein thrombosis; VASP, visual analogue scale for pain. Values are number (%) or mean ± standard deviation. Patients initial characteristics and demographic data (n = 146) BMI, Body mass index; CEAP, Clinical, Etiological, Anatomical, Pathophysiological; CPP, chronic pelvic pain; DVT, deep vein thrombosis; VASP, visual analogue scale for pain. Values are number (%) or mean ± standard deviation. Many treated patients had additional obstructions or abdominopelvic venous reflux. For example, among those undergoing ovarian vein embolization, 12 patients (26.6%) had iliac vein obstruction (mean severity, 68% ± 26%), and 21 patients (46.6%) had renal vein obstruction (mean severity, 69% ± 21%). Similar patterns were observed in patients receiving other treatments, with detailed frequencies outlined in Table II . Table II Characteristics of anatomical and hemodynamic patterns, along with long-term clinical and technical follow-up results, in patients who underwent pelvic venous disorder (PeVD) endovenous treatment (n = 146) Characteristics Ovarian vein embolization Spermatic vein embolization Iliac vein stenting Renal vein stenting P Value Patients 45 (30.8) 17 (11.7) 78 (53.4) 6 (4.1) Renal vein obstruction >50% 21 (46.6) 8 (47.0) 9 (11.5) 6 (100) Iliac vein obstruction >50% 12 (26.6) 3 (17.6) 78 (100) 1 (16.6) Gonadal vein incompetence 45 (100) 17 (100) 10 (12.8) 6 (100) Bilateral gonadal vein reflux 2 (4.4) 1 (5.8) 4 (5.1) 1 (16.6) .369 Length of hospital stay, hours 8 ± 1.8 7.1 ± 2.1 12.7 ± 2.5 8.4 ± 2.8 .292 Bilateral procedure 4 (8.9) 0 (0) 10 (12.8) None Lost of follow-up 5 (11.1) 3 (17.4) 12 (15.4) 0% .364 Mean follow-up time, months 99 ± 24 96 ± 35 112 ± 16 97 ± 29 .337 Mean preoperative VASP 8.5 ± 1.5 8.3 ± 1.1 8.1 ± 1.8 8.7 ± 0.9 .442 Mean postoperative VASP a 3.1 ± 1.1 3.1 ± 0.4 2.9 ± 1.7 1.88 ± 1.1 .667 P value <.001 <.001 <.001 <0.001 VASP percentage of improvement a 65.3% 62.6% 64,2 % 78.4% .582 Mean preoperative total QOL, SF36 b 36.7 ± 22.6 33.8 ± 33.8 35.8 ± 23.4 38.5 ± 33.8 .0981 Mean postoperative total QOL, SF36 b 74.7 ± 11.8 77.4 ± 13.7 78.4 ± 11.8 79.4 ± 10.9 .5683 P value <.001 <.002 <.001 <.001 QOL SF36 percentage of improvement b 103.7% 128,9% 118,8% 102.1% .552 Complication rate 2 (4.4) 0 (0) 0 (0) 0 (0) .569 Description Two asymptomatic gonadal vein ruptures - - - Reintervention rate 6 (13.3) 0 (0) 8 (10.2) 1 (16.6) .218 Procedure performed Two contralateral gonadal vein embolizations Four gonadal vein embolizations One gonadal and hypogastric vein embolization Four hypogastric vein embolizations Two gonadal + hypogastric veins embolizations Two intrastent angioplasties QOL SF36, SF-36 quality of life questionnaire; VASP, visual analogue scale for pain. Values are number (%) or mean ± standard deviation. a Considering that the best result is a VASP score of 0. b Considering that the best result is a SF36 score of 100. Characteristics of anatomical and hemodynamic patterns, along with long-term clinical and technical follow-up results, in patients who underwent pelvic venous disorder (PeVD) endovenous treatment (n = 146) QOL SF36, SF-36 quality of life questionnaire; VASP, visual analogue scale for pain. Values are number (%) or mean ± standard deviation. Considering that the best result is a VASP score of 0. Considering that the best result is a SF36 score of 100. In the 78 patients undergoing iliac vein stenting, stent length was determined based on CT and IVUS findings, 5 ensuring placement within healthy venous segments. In 36% of cases, stenting extended across the inguinal ligament. The average number of stents per patient was 2.34 ± 0.31. All procedures involved short hospital stays, with follow-up duration consistent across patients ( Table II ). Patients treated according to the protocol demonstrated significant improvements in symptoms and overall quality of life, regardless of the endovenous technique used. In this regard, all patients experienced clinical benefit, and no significant differences were observed among the treatment groups ( Table II ; Fig 8 ). Fig 8 Average visual analogue scale (VAS) scores for pain (0-10) during preoperative and long-term postoperative follow-up for the various endovascular treatment methods performed (n = 146). IVS , iliac vein stenting; OVE , ovarian vein embolization; RVS , renal vein stenting; SVE , spermatic vein embolization. Average visual analogue scale (VAS) scores for pain (0-10) during preoperative and long-term postoperative follow-up for the various endovascular treatment methods performed (n = 146). IVS , iliac vein stenting; OVE , ovarian vein embolization; RVS , renal vein stenting; SVE , spermatic vein embolization. Procedures were performed on an outpatient basis. Throughout the series, only two complications were observed: asymptomatic gonadal vein bleeding, identified intraoperatively as small contrast extravasations during control angiography in patients undergoing ovarian vein embolization (4.4%). These patients were managed conservatively without additional intervention ( Table II ). Reintervention was for recurrent symptoms and rates varied by procedure: iliac vein stenting, 10.2% (including four gonadal vein embolizations, two combined gonadal and hypogastric vein embolizations, and two intrastent angioplasties); ovarian vein embolization, 13.3% (including two contralateral gonadal vein and two combined gonadal and hypogastric vein embolizations); spermatic vein embolization, 0%; and renal vein stenting, 16.6% (including one gonadal and hypogastric vein embolization) (see Table II ). All reinterventions were considered protocol failures and aligned with findings from previous studies, although those reported shorter follow-up durations. 14 , 15 , 18 Most reinterventions occurred within 12 to 18 months post procedure, with a mean of 12 ± 5.8 months. Fig 8 illustrates that the iliac vein stenting and ovarian vein embolization groups showed sustained improvement for ≤36 months before plateauing. The spermatic vein embolization group improved until 36 months, then exhibited fluctuations. The renal vein stenting group improved for ≤48 months before outcomes stabilized. Beyond this period, symptoms remained relatively consistent ( Table II , Fig 8 ).

Recognition of PeVD has increased, yet the use of outdated terms—such as nutcracker syndrome and pelvic congestion syndrome—can oversimplify the condition and complicate our understanding and management. PeVD can present with symptoms like left flank pain, hematuria, CPP, and signs of CVD, including lower limb edema, aching, venous claudication, and vulvar or pelvic varicose veins. These symptoms often overlap with conditions such as recurrent varicose veins, 4 hemorrhoids, 19 benign prostatic hyperplasia, 20 bladder and bowel syndromes, 21 endometriosis, 22 and chronic low back pain, 23 potentially leading to underdiagnosis and ineffective treatments. CPP affects approximately 24% of premenopausal women and is a common reason for gynecological consultations. 24 A case-control study found a strong association between CPP and PeVD, with pelvic vein incompetence in 62% of women with CPP vs 19% of controls (odds ratio, 6.79; 95% confidence interval, 4.11-11.47). 25 Another study reported that women with PeVD experienced higher rates of CPP and reduced health status compared to controls. 26 , 27 The prevalence of dilated pelvic veins—a hallmark of PeVD—was 12% among women undergoing imaging, higher in premenopausal (21%) than postmenopausal women (10%), with 18% of those having dilated veins also presenting CPP. 28 In our study, CPP was a key inclusion criterion, with all patients presenting signs or symptoms of CPP or symptomatic varicocele. Notably, 35 women (44.9%) with CVD undergoing iliac vein stenting did not spontaneously report CPP during history taking, despite prior treatments for endometriosis or hysterectomy. Establishing a link between pelvic symptoms and vascular causes remains challenging for both patients and clinicians. The main challenge in managing symptomatic PeVD is selecting the most appropriate treatment. Embolization is frequently indicated for CPP associated with primary or secondary gonadal venous reflux; however, optimal management requires a patient-specific assessment of pelvic venous anatomy and hemodynamics, associated symptom severity and localization, and any coexisting conditions. Primary gonadal venous reflux results from intrinsic valvular incompetence of the gonadal veins themselves, which may be idiopathic or hormonally mediated. Secondary gonadal venous reflux arises from upstream venous outflow obstruction. Both can contribute to CPP associated with PeVD. In this series of 146 patients treated for CPP or scrotal pain, isolated primary gonadal vein reflux was observed in only 18 patients (12.3%), whereas isolated iliac vein obstruction occurred in 54 patients (36.9%). These findings suggest that a substantial proportion of gonadal vein reflux occurs in the setting of proximal venous obstruction. Patients exhibited various combinations of obstruction and reflux patterns ( Table II ). Notably, 53.4% presented with CVD symptoms classified as CEAP class C3 to C6, underscoring the complexity of PeVD. These results highlight the importance of integrating clinical symptomatology with detailed assessments of venous anatomy and physiology to improve disease understanding and guide individualized, patient-centered management. The predominance of CPP in the setting of advanced CVD and the relatively frequent detection of iliac venous obstructive lesions in this study may reflect selection bias and our institution's referral patterns. Limited routine referrals from gynecology for pelvic varicose veins and persistent CPP likely contribute to this. Strengthening multidisciplinary pathways could improve understanding of the importance of PeVD as a differential diagnosis for CPP and enhance referral and assessment processes for these patients. Embolization techniques vary widely, from unilateral left gonadal vein embolization to bilateral procedures involving the ovarian and internal iliac veins, using coils, plugs, and sclerosants. 29 In our protocol, we adhered to the reflux classification outlined in the literature. 7 Most patients underwent unilateral embolization, as Szary reflux types III and IV were present in only 4% of incompetent gonadal vein cases ( Fig 2 ). Types I, II, and II/III reflux from the left gonadal vein affecting the pelvic reservoir justified unilateral gonadal and pelvic reservoir embolization, which yielded favorable symptom and quality-of-life outcomes ( Table II ). We believe that polidocanol foam injections performed during the Valsalva maneuver mimic the hemodynamic mechanisms—such as reflux and venous hypertension—associated with symptoms. This approach effectively targets the incompetent pelvic reservoir, including much of the contralateral right gonadal vein, while maintaining foam volume within a safe limit of 10 mL per procedure. 10 Our long-term results align with recent meta-analyses, supporting this method's efficacy in targeting the entire incompetent venous plexus and pelvic varicose veins, often obviating the need for bilateral embolization. 29 , 18 Until recently, patients with CPP and pelvic varicose veins were almost exclusively managed with embolization. This trend is evident when comparing the number of published studies that used embolization with those that used iliac or renal stent placement for the treatment of symptomatic pelvic varicose veins. The prevalence of CPP and PeVD in CVD patients is not well-established. However, nonsaphenous pelvic origin varicose veins occur in 22% to 34% of women with pelvic varicose veins. 30 In our practice, 27.6% of patients with CVD (CEAP class C3-C6) and >50% of those with iliac venous obstruction on IVUS exhibited radiological signs of pelvic varicose veins and PeVD symptoms. Among CVD and PeVD patients who underwent iliac vein stenting, 25.6% had a recurrent lower limb varicose veins postprocedure history, highlighting that pelvic venous issues are often unrecognized, especially in recurrent or atypical cases like perineal varicosities. Studies show many patients with PeVD experience symptom relief following iliac vein stenting. Daugherty and Gillespie first reported effective relief of CPP and improved quality of life after stenting nonthrombotic iliac vein lesions. 14 Lakhanpal et al 15 observed complete symptom relief in 76% of 38 patients with iliac vein stenosis and ovarian vein reflux post stenting. Trzesniowski et al 31 reported nearly complete symptom resolution in 83% of patients after iliac vein stenting over approximately 12 months, even with associated internal iliac vein reflux, indicating durable, effective treatment with low complication rates. Villalba et al 32 reported that 98% of patients treated with iliac vein stenting alone experienced symptom improvement, with 73% achieving complete resolution of CPP over a median follow-up of 5 years. Gavrilov et al 33 recommended iliac vein stenting as the first-line therapy, reserving embolization for cases with persistent pelvic symptoms beyond 6 months. Our findings are consistent with these results ( Table II ), demonstrating that most patients maintained significant symptom relief after an even longer average follow-up of 112 ± 16 months (median, 109.5 months), underscoring the long-term durability of the intervention. Recently, Jayaraj 34 emphasized the importance of assessing internal iliac vein reflux in cases of iliac vein obstruction to better understand its role in pelvic venous hypertension and pain—a topic that remains relatively underexplored. The pelvic venous plexus connects the gonadal and iliac internal vein tributaries; in our series, sclerosing agents injected via the gonadal route (during Valsalva maneuver) most often effectively treated the incompetent pelvic varicose vein tributaries, potentially facilitating decompression and symptom relief. However, reintervention was required in 13.3% of cases, including two contralateral gonadal vein embolizations and four hypogastric vein embolizations ( Table II ). Renal vein obstruction is frequently asymptomatic and typically managed conservatively, as intervention is reserved for symptomatic cases. In patients presenting with left flank pain, hematuria, proteinuria, and CPP secondary to gonadal vein reflux and retrograde pelvic flow, current evidence supports addressing the renal vein obstruction as a first-line therapeutic target. By alleviating outflow obstruction, venous hypertension in the renal, gonadal, and pelvic venous plexuses may resolve, potentially reducing symptoms without concurrent embolization of collateral vessels. Berthelot et al 35 reported that left gonadal vein incompetence occurs in approximately 50% of symptomatic LRV obstruction cases and may significantly contribute to PeVD symptoms. Therefore, in patients with CPP associated with persistent renal vein symptoms (eg, left flank pain, hematuria, proteinuria) and gonadal vein incompetence, our primary approach is to treat renal vein obstruction first, with most patients experiencing symptom improvement without additional procedures. Although surgical transposition of the left renal or gonadal vein has been the traditional treatment, endovascular stenting offers a less invasive alternative that avoids abdominal scarring—an important consideration, especially in young patients. In this series, all patients were offered open surgical gonadal vein procedures, but they declined in favor of renal vein stenting. In a Mayo Clinic cohort of 37 patients with LRV obstruction, 36 underwent open surgery (primarily LRV transposition to the inferior vena cava), and one received endovascular intervention. Early outcomes showed no mortality, renal failure, or major complications, with three 30-day reinterventions. All LRVs and gonadal veins were patent at discharge. Over a mean follow-up of 36.8 ± 52.6 months (range, 1-216 months), eight patients required late reinterventions for LRV stenosis (7 [30%]) or occlusion (1), including stent migration retrieval (1) and additional stenting (6). At 24 months, primary, primary-assisted, and secondary patencies were 74%, 97%, and 100%, respectively; freedom from reintervention was 76% at 12 months and 68% at 24 months. Symptoms resolved in 87% of the cases (33/37). 36 Long-term data suggest that open surgical repair, such as LRV transposition, offers superior primary patency, whereas endovascular stenting—although less invasive—requires more frequent reinterventions but yields comparable secondary patency and symptom relief. Notably, many patients initially treated with open surgery later underwent stenting to maintain patency. Recent guidelines recommend LRV transposition as the first-line treatment, given the risk of stent migration with percutaneous approaches. 37 , 38 , 39 In our study, the proposed diagnostic and therapeutic protocol effectively guided treatment selection based on clinical symptoms and preoperative DSUV and CT venography, with minimal influence from intraoperative venography or IVUS findings. Preoperative CT scans 5 also facilitated identification of accessory devices and planning of treatment strategies. Outcomes were favorable in most cases, with low complication and reintervention rates. Compared with previous meta-analyses on gonadal vein embolization, 18 iliac vein stenting, 14 , 15 and renal vein stenting, 37 , 38 , 39 there is potential for further outcome improvements; however, our longer follow-up period, symptom chronicity, and high prevalence of associated obstruction and reflux may have influenced these results. Recently, we have adopted a more aggressive approach by performing concomitant internal iliac vein embolization, which appears to have enhanced clinical outcomes. However, because long-term follow-up data are not yet available, these patients were not included in this review. An important consideration is the study by Gavrilov et al, 40 which reported complications after gonadal vein embolization in 85 patients (56%). The authors classified pelvic vein thrombosis and postembolization syndromes as complications. 40 These phenomena result from local inflammation and the formation of small blood clots in the treated veins. Typically, most symptoms improve within days to weeks. Serious complications such as DVT or pulmonary embolism are rare. Although some patients may experience discomfort or mild symptoms during recovery, these are usually self-limited and resolve without long-term issues. 28 In our view, these effects are expected outcomes related to the use of polidocanol foam and coil injection techniques. This also explains why symptoms of PeVD can persist for several months (≤6 months) before improving ( Fig 8 ). It is important to recognize the limitations of our single-center, retrospective study without a control group, which restricts the ability to draw definitive conclusions. Potential selection bias may also impact the validity and generalizability of our findings. Future research involving larger, more diverse populations and appropriate control groups is essential to validate these results and strengthen the evidence supporting our proposed protocol.

PeVD is a heterogeneous condition that requires comprehensive preoperative assessment of venous obstruction and reflux patterns to ensure effective treatment. Embolization of incompetent gonadal and pelvic varicose veins is generally indicated for patients presenting with pelvic varicose veins and isolated CPP. However, many patients with CPP associated with CVD or renal vein-related symptoms often experience sustained symptom relief following iliac or renal vein stenting alone, without the need for gonadal and pelvic varicose vein embolization. This diagnostic and therapeutic approach demonstrates promising outcomes and merits further investigation through future randomized controlled trials.

None.