What are the treatment options for pelvic vascular compression syndrome?

From the Guidelines

Ovarian vein embolization is the most effective treatment for pelvic vascular compression, with approximately 75% of women experiencing substantial pain relief, as evidenced by a meta-analysis of 21 prospective case series 1. When considering treatment for pelvic vascular compression, it is essential to evaluate the severity of symptoms and the underlying anatomical factors.

• The treatment approach typically involves a combination of conservative measures and, in severe cases, endovascular intervention.
• Lifestyle modifications, such as weight loss, regular exercise, and avoiding prolonged sitting or standing, can help manage symptoms.
• Compression stockings (20-30 mmHg gradient) can improve venous return, and pain management may include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen.
• For more severe pain, anticoagulants like low molecular weight heparin may be prescribed to prevent clot formation.
• Ovarian vein embolization has been shown to be effective in providing significant symptomatic improvement, with early substantial pain relief observed in 75% of women undergoing embolization, including combinations of coil, glue, and sclerotherapy 1.
• The procedure has a low complication rate, with transient pain being common following foam embolization, and a <2% risk of coil migration 1.
• Repeat interventions are generally low, and although there are few data on post-treatment impact on menstruation, ovarian reserve, and fertility, no concerns were noted 1.
• It is crucial to exclude other causes, such as nutcracker syndrome, before proceeding with embolization, and to carefully select patients who are likely to benefit from the procedure 1.

From the Research

Treatment Options for Pelvic Vascular Compression

• The treatment for pelvic vascular compression, also known as pelvic congestion syndrome (PCS), typically involves addressing the underlying cause of the compression, such as reflux or obstruction of the gonadal, gluteal, or periuterine veins 2.
• Embolization of one or both ovarian veins, as well as treatment of refluxing internal iliac vein branches, has been shown to be an effective treatment for PCS, with several large case series demonstrating the efficacy of embolotherapy in reducing pelvic pain 2.
• For patients with outflow obstruction due to nutcracker syndrome, stenting of the left renal vein (LRV) has been shown to be a promising treatment option, with some studies demonstrating remission of symptoms 2.
• Antithrombotic therapy, such as aspirin or clopidogrel, may also be recommended for patients with peripheral artery occlusive disease, including those with pelvic vascular compression, to reduce the risk of thromboembolic complications 3, 4.

Management of Pelvic Fractures

• The management of patients with pelvic fractures can be demanding and requires a multidisciplinary approach, including swift and adequate resuscitation, reversal of shock and acidosis, and rapid control of hemorrhage 5.
• Multimodality therapies, including external pelvic stabilization, angioembolization, and preperitoneal pelvic packing, may be useful adjuncts in the management of pelvic fractures, but require appropriately trained and immediately available personnel 5.

Prevention of Thromboembolic Complications

• The use of anticoagulants, such as rivaroxaban, has been shown to be effective in preventing thromboembolic complications in patients with pelvic trauma, with a low incidence of venous thromboembolism (VTE) and no major bleeding events reported in one study 6.
• The use of sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma has been shown to be safe and effective, with a high level of patient compliance and preference for oral prophylaxis 6.