ENDOEVIDENCIA DEBEMOS TRATAR LA INSUFICIENCIA

1 /14
BUENAS TARDES
LUIS FERNANDO GARCIA V
Cirujano Vascular
Hospital Militar-Clínica Colombia-Clinica de Marly
2 /14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
CLINICA
Multiparidad
“Dismenorrea” : Dolor premenstrual pélvico tipo peso y en MMII
“Dispareunia” : Dolor Poscoital
Várices mediales al tendón aductor y cara posterior de muslo
Síntomas urinarios - Rectales
Hemorroides
Dolor pélvico crónico
TRATAMIENTO MEDICO
†Acetato de medroxiprogesterona: suprime la función ovárica. no siempre es efectivo.
†Dihidroergotamina vasoconstrictor solo es efectivo en la fase aguda y solo por pocos
días.
†La eficacia de los aines no ha sido probada.
Abordaje
Extraperitoneal
Manejo Laparoscopico
EMBOLIZACION
CT and MRI of Pelvic Varices in Women
Fergus V. Coakley, .Shaju L. Varghese, and Hedvig Hricak
Abstract: Pelvic varices in women consist of tortuous and dilated parauterine an d
ovarian veins and have a characteristic appearance at CT and MRI. Imaging is critica l
in the evaluation of pelvic varices, both to prevent confusion with other conditions an d
because pelvic varices may be secondary to serious underlying pathology. Additionally,
primary pelvic varices are associated with the pelvic pain syndrome, and patient s
with the pelvic pain syndrome may benefit from therapeutic venous embolization .
Secondary pelvic varices are rarely associated with pelvic pain.
Secondary causes of pelvic varices include inferior
vena caval obstruction, portal hypertension, increase d
pelvic blood flow, and vascular malformations . Occlusion
of the inferior vena cava may be due to chronic
thrombosis, intracaval tumor, extrinsic compression, o r
surgical ligation
In summary, primary pelvic varices and the pelvi c
pain syndrome are associated, although the two can occur
independently . The etiology of both conditions is
unknown. Structural and functional causes have bee n
proposed .
Pelvic varices are common in pregnancy and the
postpartum
period (7), due to the physiological increase i n
blood flow to the gravid uterus
9
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
Prof. Abraham Lechter
10/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
Prof. Abraham Lechter
10/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
Anatomy of the gonadal veins : A reappraisal
A. Lechter, MD, G . Lopez, MD, C . Martinez, MD, and). camacho, MD, Bog„ta . Ulm bin
Variations in anatomy were found quite frequently during bilateral gonadal vein
dissection and resection for pelvic varices in the past 5 years (120 cases) . In about on e
fourth of the cases, routine gonadal phlebography was not technically feasible or did r of
correlate exactly with the operative findings. Some cases of male varicocele showe d
recurrence after surgery . These facts, in addition to the scarce information provided b y
anatomy textbooks, induced us to study thoroughly the gonadal veins . One hundre d
cadaver dissections (200 veins) were done for length, diameter, number, and location of
valves and collaterals, number of trunks in each side, and mode of termination in th e
renal vein and vena cava . Topographic division of the veins by thirds facilitated the
information . Variations from the classic anatomic description were encountere d
frequently. As to the number of trunks, at the middle third, where the vein is usuall y
divided, only 60% have one trunk on the left and only 75% have one on the right side .
The rest are multiple; as many as four and six trunks in the lower third were found.
The knowledge of these anatomic variations, not clearly described before, is of grea t
importance to both surgeons and invasive radiologists and conducive to successfu l
results . (SURGERY 1991 ;109:735-9. )
11/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
12/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
LES VARICES VULVAIRE S
P.A. OUVRY *, P.A.G. OUVRY et A . DAVY
Les varices vulvaires sont plus fréquentes qu'on ne le pensait classiquement,
elle s
peuvent étre génantes . Lemur recherche doit faire partie de l'examen clinique
de tout e
femme enceinte et de toute multipare surtout s'il existe chez elles d'autres
signe s
d'insuffisance j sance veineuse.
Phléhologie, 1991, 44, n°2, 375-380 .
13
14
15
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
We do not recommend the use of coil
occlusio n
alone in this situation since we believe
that due to thei r
relatively inert quality, which causes little
endothelial
damage, they may allow late
recanalization throug h
their metallic architecture .
Ovarian Vein Embolization for th e
Treatment of the Pelvic Congestio n
Syndrome. Part II : Diagnosis,
Treatment ,
and Clinical Impact
Patrizio Capasso
Louisiana State University Medical Center, New Orleans, LA, US A
INTERVENTION Vol 4 No 4 2001
16
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
17
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
INSUFFISANCE VEINEUSE PELVIENNE
chez la FEMME PRÉSENTANT
des VARICES PERINÉALES .
CORRELATION ANATOMO-CLINIQUE ,
TRAITEMENT par EMBOLISATION et RESULTAT S
(31 CAS).
D. CRETON', L HENNEQUIN PHtEBOLOGIE E 2003, 56, N° 3,
Le syndrome de congestion pelvienne ne dépen d
pas seulement de ('insuffisance veineuse ovarienne. II
dépend souvent d'une insuffisance veineuse mixte
ovarienne
et hypogastrique. Dans la série de Maleux [11 ]
il n'y avait pas de corrélation entre I'amélioration clinique
et ('l'aspect uni ou bilatéral de I'embolisatio n
mais, dons cette série, les explorations n'avaien t
concerné que les veines ovariennes.
CONCLUSION
La présence de varices non saphéniennes à la racine de la cuisse associée à une symptomatologie d'insuffisance
veineuse pelvienne (score > 8) chez la jeune femme en activité génitale nécessite une exploration veineuse
pelvienne. La symptomatologie, en effet, est un tres bon signe d'insuffisance veineuse pelvienne chez l a
femme jeune en activité génitale. Compte tenu des nombreuses connexions veineuses pelviennes, les
4 axes veineux pelviens devraient étre explorés systématiquement .
Les résultats précoces sont trés satisfaisants sur la symptomatologie mail les résultats sur les récidives ne
sont pas évaluables aujourd'hui . C'est la raison pour laquelle les indications chez la femme ménopausée sont
plus discutables car I'embolisation, dons ce cas, n'aura d'action ni sur la symptomatologie, ni, en ( 'l'absence
d'étude à long terme, sur la prévention de la récidive .
.~~. •
18
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
19
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
20
21
22
Ovarian Vein Embolization for th e
Treatment of Pelvic Congestion
Syndrome: Longi-Term Technical and
Clinical Results
MATERIALS AND METHODS : We performed ovarian vein embolization
in 41 patients (mean age, 37 .8 years; range, 30-58 years) : 32
patients underwent unilateral embolization and nine patients underwent
bilateral embolization. All had lower abdominal pain and
pelvic varicosities were found on retrograde ovarian vein venography.
Embolization was performed with a mixture of enbucrilate
and lipiodized oil in all but one patient, in whom enbucrilate an d
minicoils were used. Initial technical success rate and clinical followup(1-6>i. months; mean, 19.9 months), conducted with use of
mailed questionnaires, are reported .
RESULTS: Initial technical success rate was 98%. Immediate complications
were noted in two patients (4%) in the form of migratio n
of some fragments of glue (used as embolic agent), which was
treated conservatively . Clinical follow-up reveals variable symptomatic
relief in 9 .7% of cases and a total relief of symptoms i n
58.5% of cases . Results in patients who had insufficient ovaria n
veins bilaterally were no better than those in patients for whom
only the left ovarian vein was found insufficient.
CONCLUSIONS: Transcatheter embolization of the ovarian veins is
a safe and feasible technique leading to complete relief of symptoms
in more than half of cases . No statistically significant difference
in clinical outcome could be noted between patients presenting
with bilateral insufficient ovarian veins, who underwent bilateral
embolization, and patients presenting with an insufficient
23
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
24
25
26
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
27/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
28/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
29/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
S 3456 iniciales, 232 estudios relevantes, 13 con criterios
S Todos con mejoría en dolor
S Seguro con buen resultado en 98% pacientes
S Complicaciones
S Migración de coils a pulmón 1.4%
S Perforación de vena blanco 0.6%
S Sin diferencia entre agentes de oclusión
30/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
31/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
32/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
Conclusion
This systematic review reports on 13 studies evaluating trans- venous occlusion of incompetent pelvic veins in women with CPP and pelvic congestion syndrome.
All included studies reported improvements in the frequency and severity of pelvic pain symptoms after treatment. However, all 13 studies were of poor
methodological design with significant bias that limited the value of the evidence to healthcare planning.
Technical success in terms of the initial occlusion of target veins was high (98–100%) with few and minor complications. There were no deaths or serious
morbidity. The impact on quality of life was not assessed in any of the included studies.
Well-designed epidemiological studies are urgently needed to establish the frequency of PVI in women with CPP. RCTs are required to explore the role of transvenous occlusion of incompetent pelvic veins in women with CPP.
33/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
ANTECEDENTES
Profesor Abraham Lechter realiza por primera vez una ligadura
de venas gonadales por Laparotomia en 1985
El Servicio instaura la ligadura extraperitoneal de las venas
gonadales, realizandose el último caso en 2009
2006 se inician primeros casos de Ligadura Laparoscopica
2007 se inicia el estudio y recolección de datos
Se excluye la Cirugía Abierta del estudio y del Servicio
34/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
METODOLOGIA
Ensayo Clínico Controlado Aleatorizado
Se estudiaron 268 pacientes entre 2007 y 2013 (134 cada grupo)
Formulario Recolección de Datos
Inclusión Estudio : Diagnóstico Clínico - Duplex
Flebografía Diagnóstica previa a Intervención
Aleatorización para ser incluido en una rama del estudio
35/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
Resultados
N: 268
36/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
Resultados - Costos
N: 268
37/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
Conclusiones
No diferencias significativas en variables demográficas
Excelente control sintomático del Síndrome de Congestión
Pélvica con las dos técnicas sin diferencia significativa
Baja recidiva en las dos técnicas
No complicaciones mayores en ninguna técnica
Corta incapacidad y bajo uso de analgésicos
Costos similares, ligeramente más elevado en el grupo de
embolización
38/14
DEBEMOS TRATAR LA INSUFICIENCIA
GONADAL?
Conclusiones
No hay estudios que demuestren la indicación o no de
manejo de las varices pélvicas.
Si hay beneficio con el manejo.
Manejo ideal es institucional
39/14
GRACIAS
GRACIAS