Effects of venoactive drug therapy and ovarian vein interventions on vasoactive neuropeptide and cytokine levels in patients with pelvic venous disorders.

OBJECTIVE: To study and compare the effects of venoactive drug (VAD) therapy and ovarian vein embolization or resection (OVE or OVR, accordingly) on the levels of vasoactive peptides and cytokines in patients with pelvic venous disorders (PeVD). METHODS: The study included 70 consecutive female patients with PeVD symptoms, such as chronic pelvic pain (CPP), dyspareunia, dysuria, and vulvar varicosities. Based on the results of clinical examination and duplex ultrasound (DUS) of the pelvic veins, the patients were allocated to the VAD therapy (n=38) or OVE/OVR (n=32). Additionally, the enzyme-linked immunosorbent assay (ELISA) tests were performed to determine levels of calcitonin gene-related peptide (CGRP), substance P (SP), interleukins 6 and 8 (IL-6, IL-8) and monocyte chemotactic protein-1 (MCP-1) after a 2-month course of VAD therapy and at 3 months after OVE/OVR. RESULTS: The VAD therapy was associated with a significant decrease in CPP in 84% of patients with PeVD and isolated lesions of the parametrial veins (PVs) and uterine veins (UVs). VAD had no significant effect on the pelvic venous reflux. No changes in the CGRP, SP, IL-6, IL-8 and MCP-1 levels were detected after treatment. At 3 months after OVE or OVR, all patients with PeVD and combined lesions of the ovarian veins (OVs), PVs and UVs reported almost complete relief of CPP. Along with elimination of reflux in OVs, the disappearance of reflux in PVs and UVs was noted. A decrease in the CGRP and SP levels was observed (0.7 ± 0.1 ng/mL and 0.12 ± 0.02 ng/mL before treatment; 0.5 ± 0.12 ng/mL and 0.09 ± 0.06 ng/mL after treatment, respectively; all P<0.05). No changes in cytokine levels were revealed. CONCLUSION: Treatment with VAD is associated with the CPP relief, but has no significant effect on the CGRP, SP, IL-6, IL-8, and MCP-1 levels. OVE/OVR results in the CPP relief, elimination of the pelvic venous reflux and a significant decrease in the CGRP and SP levels, but does not change cytokine levels.

[Ultrasonic geometry of synthetic endoprostheses after transabdominal preperitoneal hernioplasty of inguinal hernias]. / Ul'trazvukovaia geometriia sinteticheskikh éndoprotezov posle transabdominal'noi preperitoneal'noi gernioplastiki pakhovoi gryzhi.

OBJECTIVE: To assess position of mesh endoprosthesis in retroperitoneal space after TARR hernioplasty using ultrasound in early and long-term postoperative period. MATERIAL AND METHODS: There were 30 patients with inguinal hernias after TARR procedure. Standard technology of laparoscopic transabdominal preperitoneal hernioplasty was used in all patients. In all cases, a large-pore monofilament polypropylene mesh 10x15 cm was used. Control examination and ultrasound of the mesh implant were performed the next day, in 1, 3, 6, 12 months after surgery. Correct position of the implant was determined by its placement at the level of pubic bone with complete overlap of posterior wall of the inguinal canal and inner ring. RESULTS: US-image of the implant is present in two geometric forms - linear and sinusoid. The shape of prosthesis varies depending on postoperative period and the use of fixing elements. Thus, sinusoidal shape of prosthesis was observed in patients without fixation of prosthesis the next day and in 1 month after TARR. Geometry of the implant acquired the form of a straight line after 3 months and became almost a straight line in 12 months after surgery. Linear shape of prosthesis in early postoperative period was found after intraoperative fixation of endoprosthesis. Sinusoidal shape is noted after 3 months. Ultrasonic pattern of endoprosthesis looked as a thin hyperechoic band with thickness of 1.2-3.9 mm. Mean thickness of prosthesis was 2.2±0.1 mm the next day after surgery, 2.8±0.2 mm after 1 month and 1.6±0.05 mm after 12 months. CONCLUSION: Geometry of synthetic implants after TARR hernioplasty undergoes significant changes and depends on duration of postoperative period and fixation of the prosthesis.

[Neurobiological aspects of venous pelvic pain]. / Neirobiologicheskie aspekty venoznoi tazovoi boli.

Mechanisms of the development of pain in chronic venous diseases (CVD), including pelvic congestion syndrome (PCS), are understudied. The existing hypotheses of the occurrence of venous pelvic pain (VVP) do not allow to answer the question why some patients have no pain syndrome while others have very pronounced pain despite the same morphofunctional changes in the pelvic veins. This review presents current hypotheses of the VPP development, data on some vasoactive neuropeptides (endothelin, calcitonin gene-related peptide, and substance P), their role in the modulation of vascular tone and sensation of pain, possible association between neurogenic inflammation and VPP and provides a rationale for studying the activity of these neurotransmitters in the treatment of PCS and pelvic pain.

Does pelvic congestion syndrome influence symptoms of chronic venous disease of the lower extremities?

OBJECTIVE: The study was aimed at assessing the influence of pelvic congestion syndrome (PCS) on the clinical manifestations of chronic venous disease (CVD) of the lower extremities in patients with concomitant varicose veins of the pelvis and lower extremities. STUDY DESIGN: We examined clinically and with duplex ultrasound 30 women with varicose veins of the lower extremity only (VVLE) and another 45 women with VVLE and concomitant varicose veins of the pelvis (VVP) causing symptoms of the pelvic congestion syndrome (PCS). All patients had chronic venous disease (CVD) of class C2 (n = 47) or C3 (n = 28) according to the CEAP classification. All patients underwent duplex ultrasound (DUS) of the lower extremities and pelvis. Based on the clinical examination and DUS findings, the patients were allocated into two groups: group 1 (n = 30 patients with isolated VVLE without the signs of PCS and pelvic veins lesions) and group 2 (n = 45 patients with concomitant PCS, VVP and VVLE). The rates and severity of varicose, pain, and edema syndromes, and leg heaviness were assessed. RESULTS: The patients of the group 2 had significantly more severe clinical manifestations of CVD, 4 times higher risk of leg pain (odds ratio [OR] 4.23; 95% CI 1.57-11.39), 7 times higher risk of leg edema (OR 7.42; 95% CI 2.23-24.78), 5 times higher risk of leg heaviness (OR 5.3; 95% CI 1.85-15.07), and in general 2 times more severe varicose veins, compared with the group 1. CONCLUSION: The PCS is associated with an increase in the incidence and severity of the CVD symptoms.

Surgical aspects of venous pelvic pain treatment.

This review presents modern information on the anatomy of pelvic veins, mechanisms of development of pelvic congestion syndrome (PCS) and venous pelvic pain (VPP), methods for verifying the venous nature of pelvic pain, as well as opportunities of various surgical interventions on the gonadal veins in treatment of PCS and relief of its most severe symptom, VPP. A comparative analysis of resection and embolization treatment methods and their effects on VPP, as well as rates of postprocedural complications, was carried out. The issues of elimination of specific compression syndromes causing occurrence of VPP, by using open, endoscopic and endovascular techniques are addressed.

Calcitonin Gene-Related Peptide and Substance P As Predictors of Venous Pelvic Pain.

The purpose of this work was to study the contents of calcitonin gene-related peptide (CGRP) and substance P (SP) in the blood plasma of patients with pelvic varicose veins. Thirty women with pelvic varicosities and a reflux blood flow were investigated using duplex ultrasonography. Group 1 included 18 patients with clinical signs of the pelvic congestion syndrome (PCS), including venous pelvic pain (VPP). Group 2 consisted of 12 patients with pelvic varicosities with no clinical signs of PCS. Group 1. The score of VPP intensity ranged from 4 to 8; the mean score being 4.84 ± 0.43. The CGRP level in the studied group ranged from 0.39 to 1.01 ng/mL; the SP level ranged from 0.005 to 1.33 ng/mL. Group 2. The CGRP values were 0.15-0.32 ng/mL, and the SP range was 0.003-0.3 ng/mL. In this group, the levels of the studied peptides were 3-5 times lower than those for the patients with VPP. Group 3. The mean CGRP values were 0.06 ± 0.003 ng/mL, and the mean SP values were 0.03 ± 0.001 ng/mL. These values were considered as the reference parameters; a statistical analysis was performed for them. The correlation analysis revealed a strong relationship between the CGRP and VPP levels (r = 0.82) and a medium correlation between the SP level and pelvic pain in Group 1. The CGRP and SP levels in blood plasma highly correlate with the presence of pelvic venous pain.

[State of the venous outflow from the small pelvis after surgical correction of pelvioperineal reflux]. / Sostoianie venoznogo ottoka iz malogo taza posle khirurgicheskoi korrektsii pel'vio-perineal'nogo refliuksa.

OBJECTIVE: The study was aimed at assessing the venous outflow from the small pelvis after surgical correction of pelvioperineal reflux with the use of reference methods of examination. PATIENTS AND METHODS: We examines a total of 43 female patients (aged 41.5±5.2 years) presenting with pelvic varicose veins and subjected to phlebectomy on the external genitalia, perineum and lower limbs. All women had no evidence of pelvic venous plethora. All women underwent the following examinations: ultrasonographic angioscanning of pelvic and lower-limb veins, emission computed tomography of pelvic veins prior to operation, as well as 1, 6 and 12 months after surgical interventions. We evaluated efficacy of phlebectomy in elimination of pelvioperineal reflux and varicose syndrome, the frequency of detecting valvular insufficiency of pelvic and lower-limb veins, dynamics of the coefficient of pelvic congestion syndrome in the immediate and remote postoperative periods. RESULTS AND DISCUSSION: No cases of relapses of valvular, perineal varicosity, repeat appearance of varicose veins on the lower extremities, occurrence of signs of pelvic venous congestion were revealed. The frequency of detecting valvular insufficiency of the parametrial, uterine, gonadal and iliac veins remained unchanged. The coefficient of pelvic congestion syndrome did not alter either (Cpcs=0.8±0.11 at baseline versus Cpcs=0.78±0.1 after 12 months). CONCLUSION: The obtained results are indicative of a steady state of the venous outflow from the small pelvis in women with pelvic varicose veins and pelvioperineal reflux after surgical removal of vulvar, perineal and superficial femoral veins.

[Possibilities of local phlebectomy in correction of pelvioperineal venous reflux]. / Vozmozhnosti lokal'noi flebéktomii v korrektsii pel'vio-perineal'nogo venoznogo refliuksa.

The work was based on the results of examination and treatment of 43 female patients presenting with varicose transformation of pelvic, perineal, and lower-limb veins. The inclusion criteria were as follows: the presence of visually determined varicose transformation of the veins of the external genital organs, perineum, posterior surface of the thighs, as well as valvular insufficiency of the mentioned veins by the findings of ultrasonographic angioscanning (USAS). The following exclusion criteria were applied: the presence of pregnancy, symptoms of pelvic venous plethora (PVP), and varicothrombophlebitis. In 33 women correction of the pelvioperineal reflux (PPR) was performed with the help of local phlebectomy on the large pudendal lips and perineum, with the maximally possible mobilization of the vessel within the limits of the operative wound. Miniphlebectomy with the use of Varady phleboextractors was performed in 10 women presenting with isolated varicose transformation of the subcutaneous veins of the posterior femoral surface. The duration of follow up of patients amounted to 3 years. The criteria for efficiency of the carried out treatment were as follows: freedom from varicose syndrome both in the perineum and on the lower extremities, as well as no PVP symptoms during the whole term of follow up. Varicose syndrome of the external genital organs, perineum and posterior surface of the femurs was successfully eliminated in 100% of patients. Meticulous mobilization and removal of the veins of the labia majora, perineum and subcutaneous femoral veins is a reliable method of removing pathological reflux of blood from the intrapelvic to superficial veins of the perineum and lower limbs. 100% of our patients were found to be free from relapses of either vulvar or perineal varicosity, with no evidence of lower limb varicose veins. Local phlebectomy is an efficient method of elimination of varicose syndrome induced by PVP in patients with dilatation of intrapelvic, vulvar and perineal veins.

Compression treatment of pelvic congestion syndrome.

Aim To study the influence of compression treatment on clinical manifestations and venous hemodynamics of the pelvis in patients with pelvic congestion syndrome. Materials and methods A prospective study of the various options and modes of compression treatment was carried out and included 74 patients with pelvic congestion syndrome in 2008-2015. The patients were divided into three groups. The first group consisted of 48 patients with symptoms of pelvic congestion syndrome and chronic pelvic pain. They used Class II compression shorts. In the second group, there were 14 patients with pelvic congestion syndrome, vulvar varicosities without pelvic pain. They used Class II compression shorts and stockings. In the third group, 12 women with pelvic congestion syndrome and chronic pelvic pain used only the Class II compression stockings. The treatment continued for 14 days. A clinical criterion was the change of severity of chronic pelvic pain. The evaluation of the treatments has been performed using radionuclide venography and emission computed tomography with labeled in vivo red blood cells. Results Group 1: The compression shorts had a positive effect on the disease in 81.3% of patients. Chronic pelvic pain decreased from 6.4 ± 1.6 to 1.2 ± 0.7 points. The coefficient of pelvic congestion syndrome (Cpcs) decreased from 1.73 ± 0.32 to 1.12 ± 0.27 (p < 0.05). In 18.8% of patients, no positive effect was observed. Group 2: The results of radionuclide venographyshowed accelerating outflow of blood from the lower limbs and reduction of insufficiency of perforating veins. Mean radionuclide transit time decreased in all patients in the tendon, muscle pump parts, popliteal vein and was respectively: 23.6 ± 2.2 s, 29.6 ± 3.4 s, 32.3 ± 4.2 s and after treatment 16.4 ± 3.1 s, 22.1 ± 2.5 s, 25.7 ± 1.9 s (p < 0.05). Group 3: The use of compression stockings class II on the clinical manifestations of pelvic congestion syndrome in the patients. Cpcs also remained unchanged. Conclusion Research has shown the efficiency of class II compression shorts in the treatment of patients with isolated extension of intrapelvic venous plexuses. Class II compression stockings do not have any impact on the clinical manifestations of pelvic congestion syndrome.

[Varicose veins of small pelvis as a cause of vulvar varicosity and varicose veins of lower extremities]. / Varikoznye veny malogo taza kak prichina vul'varnogo varikoza i varikoznoi bolezni nizhnikh konechnostei.

The article is a literature review presenting modern data on applied anatomy of the pelvic veins, diagnosis and treatment of pelvic varicose veins, pelviperineal reflux and vulvar varicosity, lower limb varicose veins, which were caused by pathological reflux from varicose pelvic veins. Presented is the information on tactical approaches in treatment of combined varicose veins of the pelvis and lower limbs, surgical decision-making for correction of pelviperineal reflux, methods of operative and phlebosclerosing interventions on pelvic and superficial veins of the perineum and lower limbs.

[Von Korff questionnaire in assessment of social disadaptation and therapeutic results in women with pelvic varicose veins]. / Anketa Van Korffa v otsenke sotsial'noi dezadaptatsii i rezul'tatov lecheniia patsientok s varikoznoi bolezn'iu taza.

AIM: The present study was conducted to examine the possibilities of the Von Korff questionnaire in assessing the impact of pelvic pain on social activity and working ability of women with pelvic varicose veins (PVV) and evaluating the results of treatment of the pathology involved. PATIENTS AND METHODS: The Von Korff questionnaire was administered in a total of 80 women presenting with PVV in order to assess the results of conservative and surgical treatment of PVV. RESULTS: Using the Von Korff questionnaire made it possible to objectively evaluate the psychosocial impact of chronic pelvic pain (CPP). It was determined that in 56 patients the presence of PVV and CPP was accompanied by a low level of social disadaptation and formation of grade I disability. 24 women were found to have moderate and high levels of social disadaptation and grade II-IV disability. Studying the outcomes of conservative and surgical treatment of PPV as assessed by means of the Von Korff questionnaire demonstrated high efficacy of the therapeutic techniques used. In patients subjected to surgical interventions, the CPP degree decreased from 7.6±0.9 to 1.6±0.9 points, the level of social disadaptation fell from 2.8±0.6 to 0.5±0.3 points, and the grade of disability decreased from 2.9±0.4 to 0.8±0.4, which may be regarded as complete restoration of social activity. DISCUSSION: The Von Korff questionnaire used in our study made it possible to objectively evaluate the impact of CPP related to pelvic varicose veins on formation of social disadaptation in women and a decrease in their working ability. In the general structure of the disease, 75% of women appeared to have a low level of social disadaptation and grade I disability, with a third having grade II, III and IV disability and a moderate-to-high level of social disadaptation. In 25% of women, the determined degree of disability averagely amounted to 2.9±0.4, thus suggesting their significant social disadaptation. CONCLUSION: The carried out study showed that the Von Korff questionnaire is an objective and demonstrative tool of clinical determination of the severity of pelvic varicose veins, as well as the effect of CPP on both everyday and social activity of women suffering from the pathology concerned.

Conservative treatment of pelvic congestion syndrome: indications and opportunities.

INTRODUCTION: This brief review describes conservative treatment methods for pelvic venous congestion. Therapy options: The authors present an analysis of the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), ergot alkaloid derivatives, hormonal agents, venoprotective agents, and compression therapy in the treatment of pelvic congestion syndrome (PCS) as well as indications for medical therapy. CONCLUSION: The paucity of studies addressing this topic and the need for large multidisciplinary studies to explore the opportunities for non-surgical treatment of PCS are highlighted.

[Conservative treatment of pelvic varicose veins: indications for and possibilities of therapy]. / Konservativnoe lechenie varikoznoi bolezni taza: pokazaniia i vozmozhnosti terapii.

The article is a literature review containing the data on various conservative methods of treatment for pelvic varicose veins. The authors present herein analysis of efficacy of using non-steroidal anti-inflammatory drugs, derivatives of ergot alkaloids, hormonal drugs, phleboprotectors, compression therapy in treatment of pelvic varicose veins, as well as indications for carrying out pharmacotherapy. Attention is drawn to the critically scarce number of studies dedicated to this issue, underlying the necessity of carrying out large multidisciplinary studies aimed at investigating the possibilities of non-surgical treatment of pelvic varicose veins.

[Micronized purified flavonoid fraction in treatment of pelvic varicose veins].

Presented herein are the results of studying efficacy of micronized purified flavonoid fraction (MPFF) in treatment of pelvic varicose veins (PVV) using reference ray-tracing methods of study. We examined a total of 85 patients with PVV. Of these, 65 subjects were found to have isolated dilatation of pelvic venous plexuses (study group), and 20 were diagnosed as having combined dilation of gonadal veins and venous plexuses of the pelvis (control group). Besides clinical examination, the patients were subjected to ultrasonographic angioscanning (USAS) and emission computed tomography (ECT) of pelvic veins before treatment and 2, 6, 12, 24, 36 and 60 months after the beginning of phlebotrophic therapy. Based on the findings of the clinical and instrumental studies, it was determined that MPFF was most efficient in patients with isolated dilatation of uterine and parametrial veins. In this group of patients, pelvic pain and other symptoms of the disease disappeared completely and the clinical effect persisted for a long time (up to 6-9 months). In the control group, venotonic therapy had a positive effect which was less pronounced as compared to the control group, and pelvic pain reappeared in the nearest time (up to 3 weeks) after withdrawal of MPFF.

[Endovascular embolization of ovarian veins in varicose disease of the small-pelvic veins].

Presented herein are therapeutic outcomes obtained in treatment of nineteen female patients suffering from varicose disease of the veins of the small pelvis. Based on the findings obtained by ultrasonographic, radionuclide and roentgenocontrast methods of investigation examination they were diagnosed with the syndrome of pelvic venous plethora. The indications for endovasal occlusion of the ovarian veins were the presence of the clinical signs of pelvic venous congestion, dilatation of and blood reflux along the gonadal veins based on the findings of instrumental methods of examination. It was determined that endovascular embolization of the gonadal veins in 84% of cases resulted in permanent relief of chronic pelvic pain.

[Effectiveness of compressive hosiery <> for therapy of chronic venous insufficiency].

Total 40 patients with III grade chronic venous insufficiency underwent conservative treatment with compressive hosiery <>. Patients were divided into 2 groups: the first group used compressive stockings, the second--tights. To objectivize the assessment, all patients underwent volumetry, radionuclide phlebography and regional blood volume measurements. It was shown that in the first group pain syndrome was coped in 73% of patients, edematous--in 60%. According to volumetry data, mean calf volume has reduced by 183+/-41 ml, phlebography has revealed an improvement of muscular-venous pump capacity in 11 patients; in 9 patients it remained unchanged. Blood filling in the affected limb decreased in 16 patients from 10.7% to 8.2% and from 7.5% to 5.3% for thigh and calf, respectively. In the second group an improvement of venous return parameters was more pronounced. Compressive tights relieved pain in lower extremities in 95%, decreased led edema--in 90% of patients. There was significant reduction in calf volume--by 259+/-31 ml to the end of treatment course. Radionuclide phlebography has shown significant improvement of muscular-venous pump evacuatory function and reduction of blood filling in all patients of the second group. In conclusion, results of the study evidenced the effectiveness of compressive hosiery for treatment of chronic venous insufficiency.

Radionuclide assessment of the treatment by compression of patients with chronic venous insufficiency.

A study was made of the efficacy of the compression medical tricot in the treatment of chronic venous insufficiency (CVI). To evaluate the treatment by compression, the authors, in addition to the clinical examination, used radionuclide techniques such as examination of the regional blood volumes and phleboscintigraphy. The results of the given work have shown that the compression products under test are effective agents for the treatment of CVI by compression which improves venous return and the patients' quality of life. The data obtained point out that in addition to the lowering of blood filling, the medical tricot influences the interstitial element of the edematous syndrome, leading to the elimination of the latter one. The use of elastic bandages creates the known difficulties (the necessity of the patient training in bandaging, complexity of creating an adequate bandage, quick depreciation). In view of this fact the use of the compression tricot which possesses the fixed grade of compression for a concrete form and stage of CVI is preferable in the therapy of chronic venous diseases.

Chronic diseases of lower extremity veins in industrial workers of Moscow (results of the epidemiological survey).

This paper describes the results of the study into the prevalence of chronic venous diseases among industrial workers of Moscow. It has been established that chronic venous diseases are fairly prevalent among industrial workers. They affect the people of both sexes (67.5% of women and 50.4% of men), varying age and occupation. With age their incidence rises. The most significant risk factors of the onset of chronic venous diseases include hereditary predisposition, pregnancy and birth, overweight, and intake of hormonal contraceptives. The study has demonstrated that in most cases, such patients are not rendered medical assistance.

The first experience with endovascular stenting of the iliac veins in patients suffering from post-thrombophlebitic disease.

This paper describes the results of the first experience with endovascular stenting of the iliac veins in patients suffering from post-thrombophlebitic disease. During 11 months, the patient with a history of segmental venous thrombosis and involvement of the left iliac veins received conservative treatment which included phlebotropic therapy and elastic compression. Despite these measures the patient demonstrated the symptoms of venous insufficiency such as edema, and pains in the left lower extremity. In addition, control ultrasonography and radionuclide examinations revealed chronic occlusion of the left iliac veins. In view of this circumstance we performed endovascular dilatation and stenting of the iliac veins. The postoperative period was uneventful. After two months the pains in the left lower extremity and its edema were fully removed. Control radionuclide phleboscintigraphy demonstrated complete patency of the left iliac veins. So, endovascular stenting is an effective and safe modality for the treatment of the occlusive forms of post-thrombophlebitic disease.