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Indications & Patient Selection
Indications
- Pelvic Congestion Syndrome (PCS): chronic pelvic pain (≥6 months) caused by pelvic varicosities from ovarian vein and/or internal iliac vein incompetence
- Demographics: multiparous women aged 20–45 years; dilated pelvic veins (ovarian vein >5 mm, pelvic varicosities >4 mm)
- Classic symptoms: dull aching pelvic pain worsened by prolonged standing/sitting, after intercourse (dyspareunia), and premenstrually; characteristically relieved by lying down
- Associated findings: vulvar varicosities, left flank/leg varicosities
- Diagnosis: pelvic US with duplex for reflux; MRI/MRV pelvis; catheter venography (gold standard); Valsalva maneuver uncovers reflux on static imaging
- Workup before referral: gynecology consultation to exclude endometriosis, ovarian cysts, and PID; VAS pelvic pain score; sexual/functional impact assessment
Contraindications
- Absolute: Active pelvic infection · Pregnancy · Severe uncorrectable coagulopathy · IVC thrombosis or atresia precluding venous access
- Relative: Postmenopausal (PCS less likely; pain frequently subsides after menopause) · No hemodynamic reflux demonstrated on venography (do not embolize anatomically dilated veins without confirmed reflux)
- Note: Dilated pelvic veins on imaging are not sufficient for treatment — hemodynamic reflux must be confirmed at catheter venography before embolization
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Pre-Procedure Checklist
Access planning. Right internal jugular (RIJ) approach preferred for left ovarian vein (direct coaxial angle to left renal vein). Right common femoral approach is an acceptable alternative. Plan 6Fr sheath at RIJ or 5Fr sheath at CFA.
Catheter and wire selection. 5Fr Cobra or Berenstein catheter for initial navigation; Reverse-curve catheter (RIM, Simmons) as backup for difficult left ovarian vein takeoff. Microcatheter (2.7Fr Progreat) for distal ovarian vein branch embolization.
Embolic materials. Coils: Nester 0.035” fibered coils or 0.018” microcoils sized to ovarian vein diameter. Sclerosant: 3% sodium tetradecyl sulfate (STS) foam (Tessari technique: mix 1:4 STS:air) or polidocanol foam. Both agents should be available.
Contrast and imaging. Iohexol 300 for venography. Confirm fluoroscopy table and DSA capability (subtraction mask for venograms). Review pre-procedure MRI pelvis for varicosity distribution and identify nutcracker anatomy.
Sedation. IV midazolam + fentanyl (conscious sedation). Patient can be awake and perform Valsalva during venography — this is an advantage. Confirm NPO status and IV access.
Baseline pain score. Document VAS pelvic pain score before the procedure. Confirm gynecology evaluation has excluded other pelvic pathology (endometriosis, ovarian cysts, PID).
Consent points. Discuss: post-embolization syndrome (common, 2–5 days), coil migration risk, non-target embolization, 20–30% partial recurrence at 2 years, possible need for bilateral treatment and internal iliac embolization in same session.
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Relevant Anatomy
Ovarian Vein Drainage
- Left ovarian vein: drains into the left renal vein at a right angle; longer course than the right; higher reflux rate because absence of valves is found in 13–15% of women on the left vs. 6% on the right
- Right ovarian vein: drains directly into the IVC on the right lateral wall at an oblique angle; smaller ostium; less commonly incompetent but significant reflux occurs in ~41% of symptomatic patients
- Valvular incompetence: reflux occurs in 43% of symptomatic patients; 31% left, 41% right (Ahlberg et al.)
- Pregnancy effect: hormonal changes cause massive dilation up to 60x normal diameter; significant distention may persist 6 months postpartum and worsen with subsequent gestations
Pelvic Varicosity Distribution
- Reflux pathway: ovarian vein reflux → broad ligament veins → parametrial, uterine, and vaginal varicosities; cross-filling to contralateral pelvis is common
- Internal iliac tributaries: uterine and vaginal branches of bilateral internal iliac veins are a second independent source of reflux; must be assessed and treated if contributing
- Vulvar and leg varicosities: pelvic varicosities may extend to vulva and upper thigh; these typically regress after ovarian vein embolization within 2–3 months
- Venographic diagnosis criteria: tortuous pelvic vein >4 mm diameter, poor flow (<3 cm/s), distended communicating veins, retrograde filling on Valsalva
Nutcracker Syndrome (Secondary PCS)
- Mechanism: compression of the left renal vein between the superior mesenteric artery (SMA) and aorta → left renal venous hypertension → retrograde flow into left ovarian vein → secondary valvular incompetence
- Recognition: LRV diameter <6 mm at the aorto-mesenteric segment; pressure gradient >3 mmHg across compression; contrast reflux into left ovarian vein seen spontaneously without Valsalva
- Treatment implication: if LRV compression is severe, stenting the left renal vein may be the definitive treatment rather than ovarian vein embolization alone; ovarian vein embolization alone may not control reflux if the underlying venous hypertension persists
- Anatomy diagram concept: Left ovarian vein takeoff from LRV → descends in retroperitoneum → enters pelvic basin → broad ligament varicosity plexus → cross-fills contralateral parametrial and uterine veins
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Technique
Default RadCall approach · share your own below
Supplies
6Fr RIJ sheath (or 5Fr CFA sheath)
5Fr Cobra catheter
5Fr Berenstein catheter
RIM / Simmons reverse-curve catheter
2.7Fr Progreat microcatheter
0.035” Nester fibered coils (8–20 mm)
0.018” microcoils (if using microcatheter)
3% STS foam (Tessari technique, 1:4 STS:air)
Iohexol 300 contrast
IV midazolam + fentanyl
5 mL + 10 mL syringes
3-way stopcock (for foam preparation)
ChloraPrep / sterile drape
Standard Technique — Ovarian Vein Embolization
Steps
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Vascular access
Place 6Fr sheath at right internal jugular vein (preferred) or 5Fr sheath at right common femoral vein. Advance wire and catheter to IVC under fluoroscopy. RIJ approach provides the most direct coaxial angle to the left renal vein and left ovarian vein takeoff.
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Left renal vein catheterization and nutcracker assessment
Advance Cobra catheter to the left renal vein. Perform DSA venogram. Assess for nutcracker anatomy: left renal vein compression at the aorto-mesenteric segment. If contrast spontaneously refluxes into the left ovarian vein during LRV injection, nutcracker is present. Measure LRV diameter and pressure gradient if clinically suspected.
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Left ovarian vein cannulation and diagnostic venogram
Cannulate the left ovarian vein from the left renal vein using the Cobra catheter (gooseneck angulation at the LRV-LOV junction). Advance catheter to the pelvic basin. Perform diagnostic venogram: record ovarian vein diameter, degree of reflux into pelvic varicosities, and whether cross-filling to the contralateral pelvis is present. Have patient perform Valsalva to maximize reflux demonstration.
▶ Left ovarian vein diagnostic venogram
Left ovarian vein venogram: dilated vein (>5 mm) with retrograde reflux into pelvic varicosities — identifies the dominant drainage pathway for embolization.
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Microcatheter placement to distal varicosity plexus
Advance 2.7Fr microcatheter through the Cobra to the most distal extent of the ovarian vein within the pelvic basin, into the varicosity plexus. Position should be within the broad ligament varicosities, distal to the main ovarian vein trunk.
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Sclerosant foam embolization of varicosity plexus
Prepare 3% STS foam using Tessari technique (1:4 STS:air, mixed vigorously through 3-way stopcock until uniform consistency). Inject 2–4 mL aliquots under live fluoroscopy, waiting for slow flow confirmation before each injection. Confirm contrast stagnation indicating foam is filling the plexus. Stop if foam is seen tracking centrally toward the IVC.
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Coil embolization — distal to proximal
Withdraw microcatheter. Deploy coils from the distal ovarian vein working proximally to the takeoff from the left renal vein. Coil the entire length of the left ovarian vein. Size coils to 20–30% oversizing relative to vein diameter. Use multiple coils to ensure dense packing. Coils prevent reflux; foam destroys the varicosity walls — the combination is superior to either alone.
▶ Left ovarian vein coil pack
Left ovarian vein coil embolization: deploy from distal varicosity plexus proximally to the ostium — distal-to-proximal technique prevents coil migration.
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Right ovarian vein assessment and embolization
Re-catheterize from IVC to the right ovarian vein (directly from the IVC right lateral wall using Berenstein or C2 catheter; small oblique ostium). Perform diagnostic venogram with Valsalva. If reflux is confirmed, repeat the same distal-to-proximal coil + foam embolization sequence on the right side. Do not skip right-sided assessment even if left-dominant disease was present.
▶ Right ovarian vein coil pack
Right ovarian vein coil embolization — bilateral treatment typically required for durable symptom relief even when symptoms appear unilateral.
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Internal iliac vein assessment
Catheterize bilateral internal iliac veins. Selectively cannulate uterine and vaginal tributaries. Perform venograms. If reflux is present or if pelvic varicosities are not fully accounted for by ovarian vein reflux alone, embolize the contributing tributaries with coils and/or sclerosant foam.
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Final venogram and hemostasis
Perform a completion venogram of the left renal vein region and IVC to confirm: (1) bilateral ovarian vein occlusion; (2) no residual varicosity filling; (3) no coil migration. Remove sheath. Achieve hemostasis at access site. RIJ access: manual pressure 5–10 min. CFA: manual compression or closure device per standard protocol.
Key principle: Treat ALL sources of reflux in the same session. Untreated contralateral ovarian vein reflux or internal iliac tributaries is the #1 cause of treatment failure and recurrence.
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Venographic Landmarks
Left Ovarian Vein
- Takeoff from LRV: gooseneck angulation at the LRV-LOV junction; best approached coaxially from RIJ; catheter should point inferiorly to engage the ostium
- Diameter: 5–8 mm with reflux; normal is <5 mm
- Reflux pattern: contrast flows retrograde into broad ligament and parametrial plexus during Valsalva or spontaneously in severe cases
- Nutcracker sign: spontaneous reflux into left ovarian vein during LRV injection without Valsalva; LRV diameter <6 mm at aorto-mesenteric segment
Right Ovarian Vein and Internal Iliac Tributaries
- Right ovarian vein takeoff: directly from IVC right lateral wall; oblique/caudal orientation; small ostium; Berenstein or C2 catheter usually required from femoral approach; may be absent or atrophic if not a dominant reflux source
- Internal iliac tributaries: catheterize off bilateral internal iliac veins; uterine and vaginal branches are the most common contributing tributaries; assess if pelvic varicosities are not fully explained by ovarian vein reflux
- Cross-filling pattern: contrast refluxing across midline from left to right pelvis on left ovarian venogram indicates bilateral pelvic involvement
- Pressure gradient: nutcracker confirmed if LRV-IVC pressure gradient >3 mmHg
Venographic Criteria for PCS Diagnosis
| Finding | Threshold | Significance |
|---|---|---|
| Ovarian vein diameter | >5 mm | Suggests incompetence; >8 mm highly specific |
| Pelvic varicosity diameter | >4 mm | Venographic diagnostic criterion (Beard et al.) |
| Pelvic venous flow velocity | <3 cm/s | Poor drainage; venographic criterion for PCS |
| Reflux on Valsalva | Any retrograde flow | Confirms valvular incompetence; embolization indicated |
| Nutcracker gradient | >3 mmHg LRV-IVC | Indicates significant LRV compression; consider stenting |
| Distended communicating veins | Present | Confirms pelvic varicosity plexus; third diagnostic criterion |
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Troubleshooting
Problem
Cannot catheterize left ovarian vein from LRV
Likely cause: Acute angulation at LRV-LOV junction; small or atrophic ostium; catheter too straight.
Next step: The left renal vein is your guide landmark. Switch to a reverse-curve catheter (RIM or Simmons 1) to engage the downward-oriented left ovarian vein ostium. Have the patient perform a Valsalva maneuver to increase venous pressure and open the ostium. If still unsuccessful from RIJ, attempt from femoral approach with a cobra or reversed catheter configuration.
Problem
Right ovarian vein not visualized or not accessible
Likely cause: Right ovarian vein may be very small, atrophic, or not a dominant contributor to pelvic reflux. The IVC ostium can be difficult to engage from femoral approach.
Next step: If no reflux is demonstrated on venography with Valsalva, the right ovarian vein is not a significant contributor — do not embolize. Ensure you have performed an adequate venogram; a Berenstein or C2 catheter from the femoral approach, or a Cobra from the RIJ, improves engagement. If access truly fails but reflux was seen on pre-procedure imaging, note for possible second-session evaluation.
Problem
Sclerosant foam migrates centrally toward IVC
Likely cause: Injection volume too large; flow rate in varicosity plexus is brisk and not stagnant; microcatheter not positioned far enough distally.
Next step: Use smaller aliquots (1–2 mL instead of 3–4 mL). Confirm sluggish or stagnant contrast flow in the varicosity before each foam injection. Re-advance microcatheter more distally. Deploy a coil or two proximal to the injection site to slow antegrade flow before foam injection. Stop foam injection immediately if foam is seen tracking centrally.
Problem
Pelvic pain not improving at follow-up
Likely cause: Missed internal iliac tributaries contributing to varicosity filling; incomplete bilateral ovarian vein embolization; residual cross-filling from contralateral pelvis.
Next step: Obtain follow-up pelvic US or MRV at 3 months to assess for residual varicosities. If residual disease is present, plan a second session to evaluate and embolize bilateral internal iliac uterine/vaginal tributaries. Confirm right ovarian vein was adequately treated at the initial procedure.
Problem
Coil malposition or migration
Likely cause: Coil undersized relative to vein diameter; deployed in a location without adequate landing zone; pushed distally during deployment.
Next step: If coil is in a hemostatic position even if not ideal, assess clinically and consider leaving. If coil has migrated to pulmonary vasculature (check chest radiograph post-procedure), small peripheral coils in distal PA branches may be observed. Large coils or centrally positioned PA coils require snare retrieval in the cardiac catheterization lab. Prevention: size coils 20–30% oversized to vessel diameter.
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Complications
Periprocedural / Early (<1 week)
- Post-embolization syndrome (common): pelvic pain, low-grade fever, nausea/vomiting 2–5 days post-procedure; managed with NSAIDs, anti-emetics, and oral hydration; discharge with pain management plan; warn patients this is expected and does not indicate a complication
- Non-target embolization: sciatic nerve, bladder, or bowel injury from foam sclerosant tracking outside the target veins; avoid foam injection when flow is brisk centrally; use small aliquots and confirm stasis before each injection
- Coil migration to pulmonary vasculature: rare; prevent by sizing coils 20–30% oversized; if small coil migrates to distal PA, may observe; central PA migration requires snare retrieval
- Venous access complications: RIJ hematoma, pneumothorax (RIJ access); CFA hematoma (femoral access); standard post-procedure monitoring and hemostasis protocols apply
Delayed / Long-Term
- Recurrence / treatment failure: 20–30% partial recurrence at 2 years; most commonly due to untreated contralateral ovarian vein or internal iliac tributaries; re-treatment with second-session internal iliac embolization often successful
- Ovarian vein thrombophlebitis: very rare; treated with NSAIDs and anticoagulation if significant
- Ovarian failure: theoretical concern only; ovarian blood supply is entirely arterial (ovarian artery); venous embolization has not been associated with ovarian failure or hormonal disruption in published literature
- Outcomes: 70–80% subjective improvement at 1–2 years (Williams & Murphy; Kim HS et al. JVIR 2006); 85% reduction in dyspareunia; mean success rate ~75% across published series (Daniels et al. JVIR 2016)
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Critical Pearls
✶
Treat ALL sources of reflux in a single session. Embolize bilateral ovarian veins AND internal iliac tributaries (uterine/vaginal branches) at the time of the initial procedure. Failure to treat the contralateral ovarian vein or internal iliac tributaries is the single most common cause of recurrence. Do not stop after treating only the left ovarian vein, even in left-dominant disease.
✶
Coils + sclerosant foam = superior outcomes. Coils alone prevent antegrade reflux but do not destroy the varicosity wall; foam sclerosant alone may migrate centrally. The combined approach leverages mechanical occlusion (coils) with chemical ablation of the varicosity endothelium (foam), producing durable results superior to either agent alone. Always use both.
✶
Do NOT embolize without confirmed hemodynamic reflux. Dilated pelvic veins on MRI or CT are common and can be incidental. The PCS diagnosis must be confirmed hemodynamically at catheter venography — reflux must be demonstrated during Valsalva or spontaneously. Treating anatomically dilated veins without proven reflux risks complications without benefit and does not treat the patient's pain.
✶
Recognize and address nutcracker anatomy. If the left renal vein is severely compressed (LRV diameter <6 mm at aorto-mesenteric segment, gradient >3 mmHg), the root cause is elevated LRV pressure rather than primary ovarian valve incompetence. In these cases, LRV stenting may be the definitive treatment. Ovarian vein embolization alone may recur because the driving venous hypertension persists.
✶
Outcome counseling: vulvar and leg varicosities regress slowly. Counsel patients that vulvar varicosities and upper leg varicosities from pelvic reflux typically regress over 2–3 months following successful embolization. Do not declare treatment failure based on persistent external varicosities in the immediate post-procedure period. Pelvic pain improvement is the primary endpoint to assess at 1-month follow-up.
✶
Published outcomes: 70–80% improvement at 1–2 years. Kim HS et al. (JVIR 2006) demonstrated 70–80% subjective improvement and 85% reduction in dyspareunia at long-term follow-up with bilateral ovarian vein embolization. Daniels et al. (JVIR 2016) systematic review confirmed mean success rate ~75% across all published embolization series. Set realistic expectations with patients before the procedure.
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References
Citations
- Prologo JD, Ray CE Jr., eds. Advanced Pain Management in Interventional Radiology: A Case-Based Approach. Thieme; 2024. Chapter 43 (Williams R, Murphy T): Pelvic Congestion Syndrome.
- Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006;17(2):289–297.
- Daniels JP, Champaneria R, Shah L, Gupta JK, Birch J, Moss JG. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol. 2016;27(10):1478–1486.
- Tu FF, Hahn D, Steege JF. Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 2010;65(5):332–340.
- Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet. 1984;2(8409):946–949.
- Scultetus AH, Villavicencio JL, Gillespie DL. The nutcracker syndrome: its role in the pelvic venous disorders. J Vasc Surg. 2001;34(5):812–819.
- Edwards RD, Robertson IR, MacLean AB, Hemingway AP. Case report: pelvic pain syndrome — successful treatment of a case by ovarian vein embolization. Clin Radiol. 1993;47(6):429–431. (First reported case of bilateral OVE for PCS.)
- Capasso P, Simons C, Trotteur G, Dondelinger RF, Henroteaux D, Gaspard U. Treatment of symptomatic pelvic varices by ovarian vein embolization. Cardiovasc Intervent Radiol. 1997;20(2):107–111.
- Liddle AD, Davies AH. Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 2007;22(3):100–104.
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- SIR Standards of Practice for Pelvic Vein Embolization
- CIRSE Standards of Practice for PCS Embolization
Primary References
- Kim HS et al. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006;17(2 Pt 1):289-297.
- Prologo JD, Ray CE Jr., eds. Advanced Pain Management in Interventional Radiology. Thieme; 2024. Ch. 43: Pelvic Congestion Syndrome.
- Champaneria R et al. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess. 2016;20(5):1-108.