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Tag: Endovascular treatment

pelvic congestion syndrome
3Jun

What is Pelvic Congestion Syndrome (Pelvic Congestion Syndrome)?

Pelvic congestion syndrome is a vascular disease that presents itself in the form of chronic pelvic pain lasting for more than three to six months. Since Pelvic Congestion Syndrome is essentially a venous syndrome, it must be the incompetency in the interconnected veins around the pelvic region that cause it. To understand the anatomy underlying Pelvic Congestion syndrome, let’s consider the nervous system in the area around the pelvis. Generally, uterine and internal Iliac veins drain the blood from the uterus and vagina. However, sometimes the fundus of the uterus is drained not into the uterine veins but into the ovarian plexus. The ovarian plexus divides into left and right wherein the former drains into the left renal vein and the right ovarian plexus drains right below the right renal vein. Eventually, these vulvoperineal veins drain into the femoral vein. When the veins in this route are damaged, it may result in inefficient drainage, also known as ‘congestion’, hence giving the syndrome its name.

Increased pressure in the pelvic veins is the primary cause of Pelvic Congestion Syndrome. Consequently, the patient will suffer at the hands of ovarian vein reflux or/and varicose veins. While ovarian reflux happens as a result of faulty valves, varicosities are more commonly seen in multiparous women or in simple words, women who have had more than one full-term pregnancy. The dilatation of veins around the pelvis plays a major role in compromising the venous drainage as it allows pooling of the blood, and increases pressure. Research suggests a 60-fold increase in the capacity of pelvic veins during pregnancy/post-pregnancy to sustain the pregnancy, however this often results in chronic pelvic pain pre and post pregnancy. Moreover, while the woman is pregnant, the veins are compressed by the belly, increasing the pressure and eventually leading to venous incompetency. Now that we have touched on the anatomy of Pelvic Congestion Syndrome, let’s delve into its symptoms, diagnosis and treatment.

Symptoms of Pelvic Congestion Syndrome

It is important to understand that Pelvic Congestion Syndrome can be easily misdiagnosed as there are many reasons for pelvic pain. Only a close eye on the pelvic congestion syndrome symptoms can tell apart Pelvic Congestion Syndrome from other causes of pelvic pain. These include but are not limited to pain in the lower back, thigh and pelvic region which also extends to the postcoital region. The painful sensations may worsen on the onset of menstruation and also during strenuous activity, including standing for a long duration. Once these symptoms are ruled out against other pelvic pathologies, a thorough analysis, diagnosis and treatment will be done by an interventional radiologist or a vascular specialist. To recapitulate, consider consulting your doctor to rule out Pelvic Congestion Syndrome if you have identified all or majority of the following symptoms:

  1. A prominent pressure felt in the pelvic region
  2. The pelvic pain has lasted for over 6 months
  3. Pain extending to lower back; dull but discomforting
  4. Irritable bladder leading to urinary/stress incontinence
  5. Anomaly in bowel movements; Alternating between diarrhea and constipation
  6. Dyspareunia: painful sexual intercourse

How to diagnose Pelvic Congestion Syndrome?

The prerequisite of correct diagnosis for Pelvic Congestion Syndrome is having awareness and working knowledge of the syndrome. Since pelvic pain is a symptom that is cross-cutting in the pathophysiology of several diseases, it is important to first rule out other possibilities. The doctor does not only do confirmatory tests to diagnose Pelvic Congestion Syndrome but also tests that help avoids misdiagnosis. Firstly, a manual examination of the pelvic and abdominal area is performed. This may reveal varicosities in the region and tenderness around the ovaries/uterus area, which will need further attention. Secondly, blood and urine tests may be advised to rule out the possibility of an infection or even pregnancy, which are frequent causes of pelvic pain. A transabdominal ultrasound will also be performed. During this, the patient is lying down in the supine position. However, there is a greater possibility of missing Pelvic Congestion Syndrome in the supine position since there is no distension of the veins and hence no pressure. Therefore, a better approach is to consider examinations in both positions. Furthermore, a transvaginal Doppler Ultrasound gives a comprehensive picture of the venous blood flow in the pelvic region and final confirmation can be drawn from an MRI.

How to Avoid Pelvic Congestion Syndrome – Risk factors

While Pelvic Congestion syndrome can occur in both men and women, the data is strongly bent in the direction of females. Approximately 3 in every 10 women develop Pelvic Congestion Syndrome. In most cases, multiparous women develop congestion in the pelvic after giving birth. The reason for this has already been discussed above. However, even in a non-pregnant state, the pelvic veins are more vulnerable to dilatation. Even more so, female hormones and congenital venous defects are also counted amongst the causes of Pelvic Congestion Syndrome. Finally, obesity is one of the causes of venous insufficiency and pelvic congestion, too. This is why one of the preventive measures for Pelvic Congestion Syndrome includes maintaining healthy weight gain during pregnancy and otherwise.

Pelvic Congestion Syndrome Treatment: Know Your Options

Medical therapy as a part of conservative management can be employed in patients with non-faulty ovarian veins or isolated dilatation in the venous plexus of the pelvic region. Hormone treatment, non-steroidal anti-inflammatory drugs, psychotropic agents combined with psychotherapy all are approaches taken in medical therapy for PCS. Surgical methods to alleviate PCS include vein ligation, hysterectomy and even uterus repositioning. All of these are highly invasive and data suggests a high recurrence rate, too.

Minimally Invasive Endovascular Treatment

With the advancement in medical science, the treatment options for vascular diseases like pelvic congestion syndrome transitioned from being only a few in number and invasive to becoming minimally invasive and alternative approaches. Pelvic Congestion Syndrome treatment through Endovascular embolization is the safest option and has supplanted other surgical routes.. The treatment aims to remedy the underlying cause of Pelvic Congestion Syndrome, which is the venous reflux. The procedure begins with locating and treating the most severely dilated veins or the ones that are distal. This is done via venography in a semi upright position by inserting guiding catheters into the transfemoral or brachial veins with special dyes. This is performed under anesthesia to reach maximum patient compliance. Once the detailed procedure is performed using valsalva maneuver, the Endovascular surgeon detects the varicose veins and vein reflux. The patient is now ready to go under embolization.

Using microcatheter, the distal/dilated veins are chosen for embolization. A well titrated mixture of Cyanoacrylate mixed with lipoidal or a copolymer dissolved in DMSO serves as the embolizing agent while micronized tantalum powder acts as a contrast agent for easy fluoroscopic guidance and visualization. Through this process, reflux veins are blocked up till the distal ovarian vein to include all possible collateral branch points. The embolization procedure requires no coils. Sometimes, complex venous syndrome calls for multiple embolizations. The success of embolization is assessed on the visual analog scale through the pain scores. The patients undergo a strict follow-up after 1 month and then every six months. Eventually yearly follow up for about five years can be expected.

If you reside in Pakistan and suspect that you might have developed Pelvic Congestion Syndrome then it is time to consult Dr. Imtiaz Ahmad, who is a Consultant Endovascular Surgeon and an Interventional Radiologist. He is the pioneer in bringing and conducting embolization in the country since 2017 in the two cities of Pakistan: Karachi and Lahore. So far, he has treated thousands of patients with varying forms of vascular diseases.

Feel free to WhatsApp all your reports to 03302963300 for free assessment by Dr. Imtiaz Ahmad.

bidding goodbye to fibroids and adenomyosis
15Sep

It is a blessing and a huge honor for Dr Imtiaz Ahmad  and his team to offer a “totally” non surgical definitive treatment for Adenomyosis; offered first time in Pakistan since Nov 2017.

A brief outlook on Fibroids and Adenomyosis

Fibroids and adenomyosis often occur together, but are distinct in their characteristics. The fibroid is a benign tumor that can grow in different layers of the uterus while in Adenomyosis, the uterine inner lining itself grows into the myometrium (The outer layer of the uterus which is muscular). Intersecting symptoms of adenomyosis and fibroids include menorrhagia accompanied by pains and cramps, abdominal and lower back pain and abdominal swelling. However, while uterine fibroids are commonly asymptomatic, adenomyosis comprises excruciating and crippling painful cramps and may also accompany more chronic prolonged symptoms such as heavy bleeding and blood clots especially if fibroids coexist with adenomyosis. It is substantial to ensure that the two are not misdiagnosed, since an inaccurate treatment may prove more detrimental for the patient. Ultrasound imaging is sufficient to diagnose fibroids but to rule out adenomyosis, an MRI is advised. Once the specialist is able to differentiate between fibroids and adenomyosis, he has a clear picture regarding the treatment approach to be taken. At present, the most advanced method available under the non-surgical treatment for fibroids and adenomyosis is the 3-dimensional endovascular treatment. 3-D endovascular treatment for fibroids in Pakistan has been introduced by Dr Imtiaz Ahmad, an endovascular Surgical Specialist, and an Interventional Radiologist, who is well experienced in this field and has bagged thousands of success stories so far.

Uterus

Treatment for Fibroids and Adenomyosis

Surgical interventions for the treatment of fibroids and adenomyosis have, time and again, proven to be invasive and are slowly becoming obsolete for that reason. Hysterectomy (removal of the uterus) or myomectomy (removal of fibroids) are the two most common traditional surgical approaches taken towards fibroids and  adenomyomectomy for adenomyosis treatment. Surgical treatments also include endometrial ablation, wherein the inner lining (endometrium) is destroyed using either heat, cold, electricity, or microwaves. Women undergoing surgical procedures to sort their miseries regarding fibroids and adenomyosis must also give up on the idea of conceiving in most cases or be mentally prepared for recurrence. On the contrary, an innovative approach under the umbrella of endovascular procedures has recently gained accolades as being a noninvasive treatment, ensuring that the uterine wall is not damaged, while still being able to get rid of fibroids and adenomyosis completely. More specifically, the best treatment for fibroids and adenomyosis available is known as Uterine Artery embolization, which is a 3-D endovascular treatment that aims at selectively targeting fibroids and adenomyosis.

Fibroids

3-D Precision Guided Endovascular Treatment

Endovascular treatment using 3-dimensional imaging to locate the arteries supplying blood precisely to fibroids or adenomyosis ensures an accurate treatment. The entire procedure does not only comprise the uterine artery embolization but also, a complete set of steps to increase patient compliance and comfort. These include post embolization syndrome management, superior hypogastric nerve plexus block and intra-arterial pain management. Before the endovascular treatment is performed, a complete health analysis is done to assess the medical fitness status of the patient. Once the procedure is finished, you should also expect a thorough follow-up for up to 1 year, depending on the case. In cases where the goal is to achieve pregnancy, fertility status is also kept in check. In short, the treatment in itself is incomplete if the follow-up is not diligently done and as advised.

The 3-D precision-guided endovascular treatment uses live imaging to accurately locate the blood vessels supplying blood to the fibroids or adenomyosis. The imaging also helps assess the number of arteries involved and their sizes. The goal is to block the blood supply to these growths using miniature but programmed and specially engineered permanent devices. To begin, mild conscious sedation is achieved. Following, microcatheters are introduced in the patient’s body through the femoral/radial artery in the leg or wrist. This is achieved without causing any pain as a result of topical cold spray anaesthesia followed by local anaesthesia. Once the blood vessels are located, the FDA approved medical particles are then administered through the catheter. These embolic agents are small micron-sized particles that are engineered /programmed to block the blood supply to only fibroids or adenomyosis while sparing the normal uterine wall. Medical particles/Drugs used in the endovascular treatment are highly specific and are only issued to registered practitioners in America. In this way, embolization is successfully achieved.

The uterine artery embolization constitutes a major portion of the 3-D guided endovascular and may constitute approximately 60-70% of the entire treatment, through this technique management of the  post embolization syndrome is also done. Specific medications are administered at the exact location of the fibroid or adenomyosis, using microcatheters, to avoid post embolization syndrome, which may prolong the recovery time if not addressed at the right moment. Moreover, intra-arterial pain management is also attempted, medications at the specific location are administered so that the extent of pain felt by the patient is reduced by many folds. Finally, to further reduce the pain, the nerves to the pelvis are relaxed using a fluoroscopic guided superior hypo gastric nerve block approach. The analgesic effect is maintained for up to 20 hours.

To conclude, this new treatment for fibroids without surgery, also targeting adenomyosis, has become the talk of the town, and it is with great pride that the best treatment for fibroids and adenomyosis was introduced in Pakistan by Dr Imtiaz Ahmad, which is now helping thousands of patients since November, 2017.