Long-term clinical effectiveness of endovenous interventions for pelvic venous disorders

INTRODUCTION: Endovenous therapies are the current standard of care for the management of pelvic venous disorders (PeVD) secondary to pelvic venous insufficiency. We previously reported superior short-term results after iliac vein stenting (ST) compared to ovarian vein embolization (OVE). The purpose of this investigation is to determine the long-term durability and clinical effectiveness of endovenous therapies for PeVDs and identify the time period where maximal pain reduction is observed. METHODS: A retrospective review of prospectively collected data at the Center for Vascular Medicine from October 2016 to October 2022 was performed. Women with a PeVD secondary to an iliac vein stenosis and/or ovarian vein reflux were included. Assessments and interventions consisted of an evaluation for other causes of PeVD by a Gynecologist, CEAP, pre, 1, 3, 6, 12, 24 and 36 month post-operative visual analog pain scores (VAS), trans-abdominal duplex ultrasound stent surveillance, stent type, diameter and length. Patients were separated into three treatment groups: Pelvic pain alone, leg pain alone or pelvic and leg pain and analyzed according to treatment type. Patients treated with venoplasty or venoplasty and OVE were excluded. Differences between groups were analyzed utilizing analysis of variance. RESULTS: 521 women with a PeVD were evaluated and treated with either OVE alone, OVE and ST or ST alone: Pelvic Pain (n=33), Leg Pain (n=208) and Pelvic + Leg (Mixed) (n=280). The average age of the cohort was 52±13.4. Pelvic and mixed pain patients were younger compared to leg patients (p≤0.001). No racial differences by symptom presentation were observed. Patients with pelvic and leg symptoms had a higher prevalence of endometriosis and ovarian cysts (p≤0.001). The average pre-intervention ST, OVE and OVE+ST VAS scores by presentation were the following: Pelvic (ST+OVE: 3.07±3.71, OVE: 5.27±3.2), Leg (ST: 6.18±3.07), Mixed (ST: 7.47±2.28, OVE+ST: 6.67±2.56). Significant improvements in pain scores were observed in all treatment groups. Regardless of symptom presentation, patients who received OVE+ST demonstrated significant pain reduction at one month with no further decrement in pain that was sustained up to 36 months (p≤0.001). ST and OVE alone patients demonstrated pain reduction up to 3 months with no further pain decrement that was sustained up to 36 months (p≤0.001). CONCLUSIONS: Women with PeVD often present with concomitant pelvic and lower extremity venous symptoms. Regardless of symptomatology or treatment modality, patients report improved and sustained symptom relief up to 36 months. Patients receiving OVE + ST demonstrated maximal pain reduction at one month with sustained relief up to 36 months whereas OVE or ST patients alone required 3 months for maximal and sustained pain reduction. These data suggest that combined therapies provide faster pain relief in patients with ovarian vein reflux and iliac vein stenoses. If a staged approach with OVE followed by stenting is employed, ST should be considered at 3 months as no further improvement at six months was observed.