Diagnostic and Interventional Imaging (2017) 98, 843—848

ORIGINAL ARTICLE /Interventional imaging

Embolization of ovarian vein for pelvic

congestion syndrome with ethylene vinyl
®
alcohol copolymer (Onyx )
C. Marcelin ∗, J. Izaaryene , M. Castelli , P.A. Barral ,
A. Jacquier , V. Vidal , J.M. Bartoli

Department of Medical Imaging, hôpital de la Timone, 264, rue Saint-Pierre, 13005 Marseille,
France

KEYWORDS Abstract
Chronic pelvic Purpose: To evaluate the safety and efficacy of pelvic embolization using ethylene vinyl alcohol
®
syndrome; copolymer (Onyx ) for pelvic congestion syndrome.
Pelvic congestion Material and methods: Between March 2012 to September 2016, 17 women (mean age,
syndrome; 44.7 ± 12.2 (SD) years; range: 34—71 years) presenting with pelvic congestion syndrome were
®
Safety; evaluated for transvenous embolization with Onyx . Pelvic congestion syndrome was initially
Embolization; diagnosed by clinical examination and the results of transvaginal Doppler ultrasound and further
®
Onyx confirmed by pelvic venography. Primary and secondary clinical efficacy was defined respec-
tively by the resolution of the symptoms after embolization and at the end of the follow-up,
irrespective to the number of embolization procedures.
Results: Technical efficacy of embolization was 100% with no significant complications during
and after embolization. After a mean follow-up time of 24.2 months (range: 6—69 months)
a primary and secondary clinical efficacy of 76.4% (13/17 women) and 94.1% (16/17 women)
respectively were observed. Four women (23.5%) underwent a second embolization procedure
with one woman requiring a third embolization procedure. These additional embolization pro-
cedures were associated with direct puncture of vulvar varices for sclerotherapy in two women.
Five women (29%) had recurrent symptoms 21 months post-treatment (7—42 months).
®
Conclusion: Pelvic embolization using ethylene vinyl alcohol copolymer (Onyx ) has a favorable
clinical success for pelvic congestion syndrome.
© 2017 Published by Elsevier Masson SAS on behalf of Editions françaises de radiologie.

∗ Corresponding author.
E-mail address: clement.marcelin@gmail.com (C. Marcelin).

http://dx.doi.org/10.1016/j.diii.2017.05.011
2211-5684/© 2017 Published by Elsevier Masson SAS on behalf of Editions françaises de radiologie.
844
Pelvic congestion syndrome (PCS) presents with anatom-
ical varicosities and incompetent parametrial veins. This
condition is one of the main causes of chronic pelvic pain
along with endometriosis, adenomyosis and uterine fibroma
[1—3]. PCS symptoms include non-cyclic pelvic pain more
than six months, dyspareunia, urinary urgency, painful defe-
cation, pelvic vein varicosities and vulvo-perineal and lower
limb varicosities. Symptoms are usually exacerbated with
menses, prolonged standing and activities that increase
abdominal pressure [1].
Endovascular treatment of PCS is challenging and
requires occlusion of incompetent pelvic veins [4]. The goal
of pelvic embolization is to reduce excessive blood flow
within the pelvis. Most authors have reported the use of
metallic coils and sclerotherapy [5—12] for this procedure,
with a clinical efficacy ranging from 58 to 93% [5—6,8,10,13].
However, sclerotherapy does not allow a monitoring with
fluoroscopy and coils convey a risk of migration or further
recanalization [12].
® Negative laparoscopy for pelvic pain
Ethylene vinyl alcohol copolymer (Onyx , Ev3 Irvine, CA,
®
USA) is a relatively new embolic agent. Onyx is dissolved
in various concentrations of dimethyl sulfoxide (DMSO) and
opacified with micronized tantalum powder for visualization
during angiogram.
The purpose of this study was to evaluate the safety and
®
clinical efficacy of pelvic embolization with Onyx in women
with PCS.
Material and methods
Patients
A search of the interventional radiology database was per-
formed to identify patients with PCS who were treated using
®
pelvic embolization with Onyx between January 2012 and
July 2016. The need for informed consent was waived by
our local ethic committee. Seventeen consecutive women
were retrieved. They had a mean age of 44.7 years ± 12.2
(SD) (range: 34—71 years). They received pelvic emboliza-
®
tion with Onyx because of clinical symptoms including
abdominal pain (17/17; 100%), dyspareunia (10/17; 59%),
dysmenorrhea (6/17; 35%), mictional urgency or painful
defecation (3/17; 18%), vulvar or perilabial varicosities
(3/17; 18%) and lower limb varices (11/17; 65%). Character-
istics of the 17 patients are reported in Table 1. Each woman
underwent physical examination and transvaginal Doppler
ultrasound, followed by magnetic resonace imaging of the
pelvis to exclude any associated disease such as endometrio-
sis or adenomyosis. Confirmation of the diagnosis of PCS
was obtained by venography. Venography was performed
under local anesthesia for each woman before emboliza-
tion to confirm any enlarged ovarian vein and uterine venous
engorgement. Venography was performed with the patient
in supine position on a tilt table with and without valsalva
maneuver. A 5-French sheath was placed in the right femoral
vein and phlebography was performed to study the gonadal
veins and afferent vessels. A 5-Fr catheter was used to
catheterize the right renal vein along with a valsalva maneu-
ver to investigate any ovarian vein varicocele. Incompetent
segments were localized by ovarian and pelvic varicose phle-
bography by an opacification during the valsalva maneuver.
C. Marcelin et al.
Table 1 Characteristics of 17 women who underwent
pelvic embolization for pelvic congestion syndrome.
Mean [range]
Age (year) 44.7 [34—71]
Parity 2.6 [0—7]
Gravidity 2.2 [0—4]
Symptoms
Chronic pelvic pain 17
Dyspareunia 10
Vulvoperineal varicosities 3
Painful defecation, mictional urgency 3
Painful menstruation, dysmenorrhea 6
Lower limb varices 11
Medical history
®
Essure placement for birth control 1
Intern iliac vein thrombosis 1
Laparoscopic surgery for endometriosis 1
1
Procedure
Embolization was proposed as a first-line treatment after
a discussion by a multidisciplinary committee comprised of
gynecologists, vascular surgeons and radiologists.
All embolization were performed under general anes-
thesia using the same angiographic unit (GE Healthcare,
Milwaukee, WI, USA). A 6 F sheath was placed into the right
femoral vein. Then a 6 F renal double curb guiding catheter
was placed on the left renal vein ostium; and a 5 F cobra
catheter was used to select the left renal vein. A 0.035-
In guidewire (Terumo, Tokyo, Japan) was then manipulated
caudally into the left ovarian vein and a microcatheter
® ®
(Direxion , Boston Scientific, or Progreat , Terumo, Tokyo,
Japan) was used to selectively catheterize the ovarian vein
during the valsalva maneuver. Embolization of each pelvic
vein varicosity was performed through the left ovarian
vein.
For the embolization, ethylene vinyl alcohol copolymer
® ® ®
(Onyx 18) and metallic coils (Concerto , Ev3, or IDC ,
Boston Scientific) were used. Coils were employed first when
the pelvic vein varicosities were widely dilated with an
anastomosis of the iliac internal vein to reduce blood flow
velocity and diminish the risk of non-target embolization of
® ®
Onyx . Onyx was slowly injected under fluoroscopic con-
trol on road mapping to assure full control and visualization.
Embolization of the left ovarian vein was performed at the
end of the procedure until inferior sacroiliac articulation
and embolization was continued in case of collateral of left
ovarian vein, to occlude completely all of them.
After embolization, women were admitted to the gyne-
cology department for 24 hours, to monitor pain and femoral
access. Paracetamol and anti-inflammatory medications
were given orally for pain. In case of persistent symptoms, a
second intervention was planned two months later. Barring
complications, patients were discharged with a 3-day oral
anti-inflammatory (Ibuprofen, 3 × 100 mg/day). Prospective
clinical follow-up was performed until September 2016 via
telephone interviews.
Embolization of ovarian vein for pelvic congestion syndrome 845

Study endpoints
The primary endpoint was clinical efficacy. Primary and
secondary clinical efficacy was defined respectively by the
resolution of the symptoms after the embolization and at the
end of the follow-up irrespective of number of embolization.
Clinical failure was defined by the absence of any clinical
modification.
Secondary endpoints were technical efficacy defined as
the achievement of total occlusion of the ovarian and vari-
cose pelvic veins. Safety was defined as the absence of
complications according to the Clavien-Dindo grading system
[14]. The dose area product (DAP) (mG.cm2 ) was obtained
for all interventions. Recurrence was defined by the return
of clinical symptoms of pelvic congestion.
All women were contacted by telephone to record the
recent findings and questioned about any lower abdominal
pain, dyspareunia, dysmenorrhea, lower limb varicosities
and perineal varicosities. In case of recurrent symptoms, a
consultation was proposed for a clinical examination, pelvic
ultrasound and venography.
Statistical analysis
Continuous variables were expressed as mean, standard
deviation (SD) and range. Descriptive statistics, including
proportions and percentages were used to report the results
of pelvic embolization.
Results
On the average, an embolization was performed two months
after the diagnosis of PCS (range: 1—6 months). All women
(17/17; 100%) had an embolization of their left gonadal vein
and 8/17 women (47%) had a left obturator vein emboliza-
tion (Fig. 1). Embolization of pudendal veins were performed
in six women in combination with ischiatic vein embolization
in 3/17 women (18%) (Fig. 2) and sacral vein embolization
in 1/17 women (6%). The technical efficacy was 100%.
Outcomes
Mean follow-up time was 24.2 months (range: 6—69 months).
Primary and secondary clinical efficacy were 76.4% (13/17
women) and 94.1% (16/17 women) respectively. Four women
(24%) had a second embolization of pelvic varicosities one to
three months later. One woman underwent a third emboliza-
tion at four months. Repeat embolization were performed
in association with a direct puncture of vulvar varices for
®
sclerotherapy (Aetoxysclerol 3%, Lauromacrogol, Kreussler,
Wiesbaden) in two women and resulted in a clinical suc-
cess. During the follow-up, 5/17 women (29%) had recurrent
symptoms 21 months after their embolization (range: 7—42
months).
Neither minor nor major complications were noted. The
average DAP was 380 mG.cm2 (range: 90—800 mG.cm2 ).
®
The mean volume of Onyx injected was 5.2 mL ± 2.2 (SD)
(range: 2—9 mL). Coils were used with 8/17 women (47%).
Discussion
Our results indicate that pelvic embolization is a feasible
and safe endovascular procedure for the treatment of PCS.
Embolization for PCS is recommended with a 2B level of evi-
dence, according to the Society for Vascular Surgery and the
American Venous Forum [15].
Pelvic embolization for PCS is challenging because of
communications between ovarian veins and internal iliac

®
Figure 1. Forty-three-year-old woman with pelvic congestion syndrome who underwent pelvic embolization with Onyx . A. Pelvic venog-
raphy shows reflux of contrast material from dilated left ovarian vein (arrowhead) into uterine plexus (star), left obturator vein (black arrow)
and left iliac vein (white arrow). B. Pelvic venography shows complete occlusion of dilated uterine plexus (star), and left obturator vein
®
(black arrow). C. Non-subtracted pelvic venography shows Onyx in dilated left ovarian vein (arrowhead), dilated uterine plexus (star),and
left obturator vein (black arrow). The embolic mixture is visible on this non-subtracted image.
846 C. Marcelin et al.

®
Figure 2. Thirty-six-year-old woman with pelvic congestion syndrome who underwent pelvic embolization with Onyx . A.Venography
shows reflux from right obturator (dashed arrow) and pudendal vein (arrowhead). B. Non-subtracted pelvic venography shows selective
®
microcatheterization of left obturator vein (black arrow). C. Non-subtracted pelvic venography shows Onyx in dilated left obturator vein
(black arrow) and right dilated obturator vein (dashed arrow). The embolic mixture is visible on this non-subtracted image.

veins. Internal iliac reflux documented before the emboliza-
tion could be resolved after gonadal vein embolization.
For this reason, we first performed ovarian vein emboliza-
tions with pelvic varicosities and then an iliac internal
vein embolization when persistent or recurrent symptoms
appeared.
With a median follow-up period of 22.4 months, which
is similar to those of other studies [6—8,10—12] the clinical
efficacy was 94.1% in our study, again similar to those of
other studies ranging from 58 to 93% [6,8,10,13] (Table 2).
The technical efficacy of pelvic congestion was 100% and was
within the range of those in prior studies that reported 91 to
100% efficacies [3,7,9,10,12]. While the use of glue [13] and
plugs [3] have been reported for pelvic embolization, the
use of coils, with or without sclerotherapy is most frequently
used for pelvic embolization [6—8,10].
®
Onyx has been used to successfully treat arteriovenous
malformations [16—19], type II endoleaks [20—24], tumor
devascularization [25], visceral aneurysm [26] with a limited
number of complications [27]. Embolization is performed
under general anesthesia to prevent painful injection of
®
dimethysulfoxide (DMSO). Onyx , a cohesive liquid agent,
which advances along the varicose veins, is well visualized
during progression as compared to sclerosing agents used for
sclerotherapy. Its malleability allows a complete filling of
®
the varices though the ovarian veins. Onyx helps avoid the
time consuming placement of multiple coils at a similar rate
of recanalization [12] and migration [7]. Compared to glue,
®
Onyx is at low risk for microcatheter entrapment and with
a low migration risk [28]. However, the potential side effects
®
with large amount of Onyx is not known [29]. Compared to
®
sclerotherapy, Onyx does not cause any endothelial surface
®
damage [12]. As a limitation, however, Onyx may be cost
prohibitive.
In the present study, no complications were observed
after pelvic embolization, which is consistent with the lit-
erature data [9,11—13,30]. A major complication of pelvic
embolization is migration of coils or glue fragments [9,13].
This complication was not observed in our study.
Besides pelvic embolization, other options can be used
in women with PCS. A medical treatment option consists
of suppressing ovarian function with medroxyprogesterone

Table 2 Results of studies reporting pelvic embolization for pelvic congestion syndrome.
Study Number of Clinical Technical Follow-up Recurrence rate Complications
Patients success success (month)
rate (%) rate (%)
Maleux et al., 2001 [13] 41 58.5 98 19.9 — 4% glue migration
Venbrux et al., 2002 [32] 56 96 100 22.1 5% 2 coil migrations
Kim et al., 2006 [8] 131 83 100 45 —
Kwon et al., 2007 [7] 67 82 100 3 coil migrations
Gandini et al., 2008 [11] 26 100 100 12 — 7.9% transitory
colic pain
Hocquelet et al., 2014 [6] 33 93 96 26 18%
Nasser et al., 2013 [9] 100 100 12 — 12 coils migration
Laborda et al., 2013 [10] 202 93.85 100 60 12.5% recurrence 4 coils migration
leg varices
Gandini et al., 2014 [11] 38 100 100 12 — —
Pyra et al., 2016 [3] 12 100 91 6 — —
Embolization of ovarian vein for pelvic congestion syndrome
acetate, or GnRH analogue, but symptom relief is often tran-
sitory [31]. A surgical treatment option such as hysterectomy
or ovarian vein ligation carries the risk of residual pain, a
recurrence of symptoms and significant morbidity [31].
In our study, 4/17women (24%) had a second pelvic
embolization because of recurrence of clinical symptoms.
Recurrence of symptoms result of failure of the emboliza-
tion, recanalization or creation of new collateral veins
diverting the flow to the gonadal vein or iliac vein [5].
In the present study, 5/17 women (29%) presented with
recurrent symptoms 7 to 42 months after embolization and
had a new embolization. Recurrences of symptoms reported
in other studies are given in Table 2 [6,10,32].
Our study has several limitations. The limited number of
patients prevents any conclusions in terms of safety, and the
lack of long-term follow-up hinders making any hypothesis
regarding efficacy and reproducibility. We did not compare
®
Onyx to other categories of embolic agents [33]. Since pain
levels are subjective, we did not evaluate the clinical suc-
cess using any visual analog scale (VAS) as did prior studies
[6,8,10]. Because of lack of treatment standards, random-
ized control trials are now mandatory to evaluate different
treatments.
® [15] Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL,
In conclusion, embolization with Onyx is a feasible and
® Gloviczki ML, et al. The care of patients with varicose veins and
safe treatment of pelvic congestion syndrome. Onyx is use-
ful in achieving complete embolization of pelvic varicosities
through an ovarian vein, without the risk of the migration of
embolic material. However, our results need to be confirmed
on a larger population with a longer follow-up period.
Disclosure of interest
The authors declare that they have no competing interest.
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