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Effective Date: 09/01/2012 Title: Ovarian & Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
Revision Date: Document: BI367:00
CPT Code(s): 37204
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

  1. Pelvic congestion syndrome is a condition of chronic pelvic pain of variable location and intensity, which is associated with dyspareunia and postcoital pain and is aggravated by standing. 
  2. Attempts have been made to treat this syndrome by embolization of the ovarian or internal iliac veins, but lack of scientific evidence prevents assessment of this treatment’s effectiveness. 
  3. This procedure is considered experimental and investigational.

Medical Statement
  1. Embolization of the ovarian vein and internal iliac veins is considered experimental and is not covered.
  2. For other uses of embolization see BI301

 

Codes Used in this BI:

37204

Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck


Background

Pelvic congestion syndrome is a condition of chronic pelvic pain of variable location and intensity, which is associated with dyspareunia and postcoital pain and aggravated by standing. The syndrome occurs during the reproductive years, and pain is often greater before or during meses..  The underlying etiology is thought to be related to varices of the ovarian veins, leading to pelvic congestion. As there are many etiologies of chronic pelvic pain, the pelvic congestion syndrome is often a diagnosis of exclusion, with the identification of varices using a variety of imaging methods, such as MRI, CT scanning or contrast venography. For those who fail medical therapy with analgesics, surgical ligation of the ovarian vein has been considered. More recently, embolization therapy of the ovarian and internal iliac veins has been proposed.

The literature regarding the clinical outcomes of embolization therapy is relatively sparse, consisting entirely of case series, with the largest including 56 patients. In this study Venbrux and colleagues (2002) performed bilateral ovarian vein embolization therapy using gel foam and coils as an inpatient procedure (for postoperative pain control), followed 3 to 10 weeks later by embolization of the internal iliac arteries, performed as an outpatient. The second procedure was performed to reduce the risk of recurrence based on the observation that there was free communication between the ovarian venous plexus and the internal iliac vein tributaries. The study endpoints included technical success and pre and postoperative pain assessment using a visual analog scale. The procedures were considered a technical success in all patients, although in 2 patients the coils inadvertently embolized to the pulmonary circulation where they were retrieved without incident. Recurrences of varices were noted in three patients; two underwent repeat internal iliac vein embolization while the third refused further treatment. In terms of pain control, the mean VAS score fell from 7.8 to 2.7 over a 12 month period. The time to pain improvement was very variable among the women.  Based on a questionnaire completed by 24 of the 56 patients, the menstrual cycle was unchanged. Maleux and colleagues (2000) reported on the results of ovarian vein embolization in 41 patients.  Unlike the Venbrux study above, where the patients underwent bilateral ovarian and internal iliac vein embolization, in this study 32 patients underwent unilateral embolization of the left ovarian vein based on the findings at venography, while the remaining 9 patients underwent bilateral embolization therapy. No patient underwent embolization of the internal iliac vein. The authors reported a technical success rate of 98%. Pain relief was assessed via a questionnaire filled out at variable times after the procedure. The questionnaire asked the patient to rate their pain as very painful, painful, bearable or no pain. There was no formal assessment of pain prior to the procedure. A total of 68.3% of patients reported either partial or complete relief. A variety of other smaller case series report pain relief in from 50-80% of patients (Sichiau,1994; Tarazov,1997; Cordis,1996).

In the largest case series to date, Kim and colleagues (2006) reported results for 127 women treated with bilateral embolotherapy. Ninety-seven patients (76%) completed clinical follow-up (mean duration of 45 months + 18); overall pain scores were reduced from 7.6 to 2.9 (10-point scale).

Kwon and colleagues (2007) reported follow-up by telephone interview of women who had undergone unilateral ovarian vein coil embolization for pelvic congestion syndrome; 55 of 67 patients (82%) reported being satisfied with the procedure; the remainder reported no improvement or a worsening of symptoms.  Of note, 2 recent case series from Italy reported successful treatment of pelvic congestion syndrome with transcatheter foam sclerotherapy without use of coils. (Gandini, 2008; Tropeano, 2008) Although these initial case series suggest that beneficial results may be obtained with a less invasive treatment, controlled studies with longer follow-up are needed. Prospective randomized trials on ovarian and internal iliac vein embolization using a coil are also needed.


Reference

Cordis PR, Eclavea A, et al.(1998) Pelvic congestion syndrome: Early clinical results after transcatheter ovarian vein embolization. J Vasc Surg 1998; 28:862-68.

Gandidn R, Chiocchi M, et al.(2008) Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium tetradecyl-sulfate foam. Cardiovasc Intervent Radiol, 2008; 31(4):778-84.2007

Ganeshan A, Upponi S, et al.(2007) Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology. Cardiovasc Intervent Radiol, 2007; 30:1105-11.

Kim HS, Malhotra AD, et al.(2006) Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol, 2006; 17(2 Pt 1):289-97.

Kwon SH, Oh JH, et al.(2007) Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol, 2007; 30(4):655-61.

Liddle AD, Davies AH.(2007) Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology, 2007; 22(3):100-4.

Maleux G, Stockx L, et al.(2000) Ovarian vein embolization for the treatment of pelvic congestion syndrome: Long term technical and clinical results. J Vasc Interven Radiol 2000; 11:859-64.

Naoum JJ.(2009) Endovascular therapy for pelvic congestion syndrome. Methodist Debakey Cardiovasc J 2009; 5(4):36-8.

Nicholson T, Basile A.(2006) Pelvic congestion syndrome: who should we treate and how? Tech Vasc Interv Radiol, 2006; 9(1):19-23.

Shokeir T, Amr R, Abdelshaheed M.(2009) The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study. Arch Gynecol Obstet, 2009; Feb 4 [Epub ahead of print].
Sichlau MU, Yao JST, et al.(1994) Transcatheter embolotherapy for the tratment of pelvic congestion syndrome. Obstet Gynecol 1994; 83:892-96.

Stones RW.(2003) Pelvic vascular congestion - Half a century later. Clin Obstet Gynecol 2003; 46:831-36.

Tarazov PB, Prozorovakji KV, et al.(1997) Pelvic pain syndrome caused by ovarian varices: treatment of transcatheter embolization. Acta Rad 1997; 98:1023-25.

Tropeano G, Di Stasi C, et al.(2008) Ovarian vein incompetence: a potential cause of chronic pelvic pain in women. Eur J Obstet Gynecol Reprod Biol, 2008; 139(2):215-21.

Venbrux AC, Chang AH, et al.(2002) Pelvic congestion syndrome (pelvic venous incompetence): Impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vas Inter Radilo 2002; 13:171-78.

Venbrux AC, Lambert DL.(1999) Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol 1999; 11:395-99.

 


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