A 49-year-old woman with May-Thurner syndrome and a history of post left common iliac stent placement presented in March 2020 with ongoing pelvic pain. She was diagnosed with pelvic congestion syndrome and gonadal vein insufficiency. She underwent left gonadal vein embolization with Nester coils (Cook Medical, Bloomington, IN) under fluoroscopic guidance (Figure 1). She responded well to embolization with self-reported 70% improvement in overall pelvic pain, resolution of vulvovaginal varicosities, and reduced pain medication needs. However, she continued to have dysmenorrhea, dysuria, rectal pressure, and dyspareunia, which were concerning for deep infiltrating endometriosis (DIE). Diagnostic laparoscopy was decided and complete obliteration of the posterior cul de sac secondary to endometriosis was noted intraoperatively. To treat her likely primary pain generator, DIE was excised from the rectovaginal septum, bilateral uterosacral ligaments, and posterior cul de sac. Coils were visible transperitoneally during the procedure, but left in situ secondary to a significant alternative source of pain being identified (Figure 2). Her recovery was uncomplicated and she reported improvement in symptoms during postoperative follow up.
Gonadal vein embolization was first described in 1978 by Lima et al.  Endovascular treatment is validated by large patient series with long-term follow up using standardized pain surveys. Success rates for coil embolization range from 82.1–100%, while other modalities (such as gels, foams, or beads) yield lower rates, ranging from 68.3–73.7% . Coil placement has been described in ovarian and internal iliac veins endoscopically , but there is little guidance regarding expected intraoperative appearance. Coils can lead to an atretic vein wall by inducing atrophy and mimicking the appearance of protrusion. Coil location, proximity to nerves, and degree of protective retroperitoneal fat in the context of presentation are important to assess intraoperatively. These factors are associated with pathologic coil protrusion/erosion and development of persistent pain . The decision to not remove the coil was made based on the patient’s symptom progression (improvement of symptoms related to the vascular system and ongoing symptoms consistent with DIE) as well as intraoperative findings of cul de sac obliteration. Coil removal should not be performed based on appearance of the coil intraoperatively alone.
Research funding: None reported.
Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Competing interests: None reported.
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© 2022 Lauren Griebel et al., published by De Gruyter, Berlin/Boston
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