A Keep-It-Simple embolisation approach to treat Pelvic Congestion Syndrome without compromising clinical effectiveness.

doi:10.21203/rs.3.rs-4190572/v1

Background:

There are two approaches to treat Pelvic Congestion Syndrome (PCS): 1. the Keep-It-Simple (KIS) approach, embolising only the refluxing vein(s), typically only the left ovarian vein (LOV), unless right ovarian vein (ROV), left or right internal iliac vein (IIV) tributaries were also refluxing; and 2. the extensive (EXT) approach, embolising empirically almost all of the LOV, ROV, left and right IIV tributaries.

The aim of the study is to show if the KIS approach is sufficient to effectively treat PCS, minimising the number of veins treated and number of coils used, and without injecting sclerosing agents into the pelvic veins or the use of occlusion balloons.

Materials and Methods:

This is a single institution retrospective cohort study. Our records identified 154 women who had undergone venogram for possible PCS, with a view to proceed with embolisation. Refluxing veins were treated with the KIS approach, using minimal number of coils “sandwiching” sclerosing foam. Short term follow up was conducted at 6 weeks; long term follow-ups (between 12-60 months) were conducted by an electronic survey consists of 19 questions, assessing pelvic pain/ pressure, leg and back pain, fatique, bladder and menstrual symptoms.

Results:

Most women (73.4%) required unilateral OV embolisation only; just 14.4% required bilateral OV embolisation; and only 12.2% required pelvic vein embolisation. Most cases required only 4 pushable coils. Clinical success was 89.1% at 6 weeks and 83.7% at 1-5 years. VAS drop of 5.2 (7.8 to 2.7) was achieved. There was no coil dislodgement or other complications.

Conclusion:

The KIS approach embolising only the refluxing veins can achieve similar effective clinical outcome for PCS as the EXT approach. This carries implications for potential savings in procedure time, cost, and radiation does. The EXT approach of empirically embolising all 4 sets of veins may not be necessary to achieve an effective outcome.

Surgical Obstetrics & Gynecology

Pelvic congestion syndrome

ovarian vein embolisation

pelvic venous embolisation

Chronic pelvic pain in women caused by pelvic venous congestion (PCS) is treatable by venous embolisation [1]. There are two divergent philosophical approaches to conduct the procedure: the Keep-It-Simple (KIS) approach-embolising only the refluxing vein(s), typically only the left ovarian vein (LOV), unless right ovarian vein (ROV), left or right internal iliac vein (IIV) tributaries were also refluxing [2, 3]; and the Extensive (EXT) approach-embolising empirically almost all of the LOV, ROV, left and right IIV tributaries [4, 5].

Previous EXT cohort studies and KIS cohort studies have reported similar clinical outcomes (1). The KIS approach would be associated with lower procedure time, less radiation exposure, smaller number of coils and theoretically a lower risk of coil migration. There is potential for reducing healthcare cost by using the KIS approach, considering PCS prevalence. However, a recent systemic review on clinical outcome studies seems to be dominated by the EXT approach, with large number of ROVs and IIVs embolised to treat PCS [6]. The aim of the current study is to show if the KIS approach is sufficient to effectively treat PCS, minimising the number of veins treated and number of coils used, and without injecting sclerosing agents into the pelvic veins or the use of occlusion balloons.

Patient recruitment and treatment

This is a single institution retrospective non-randomised cohort study. Local ethics approval was obtained in 2022. Review of electronic records of a women’s health interventional radiology clinic, for a 5-year period between 2018 and 2022, identified 154 women who had undergone diagnostic venogram for possible PCS, with a view to proceed with embolisation in the same setting, if refluxing veins were found.

Only women with convincing symptoms of PCS were recommended for the venogram (dull aching pelvic pain or discomfort towards the end of the day or after physical activities, leg pain, pain during and after sexual intercourse). If clinical history suggests other potential pathologies, they were investigated and excluded.

All women treated required imaging features of PCS, such as pelvic varicosity, dilated adnexal veins of more than 5mm, increased flow during Valsalva, or refluxing ovarian vein, on either TVUS, contrast enhanced CT or magnetic resonance imaging with venogram (MRI/MRV).

Diagnostic and therapeutic venogram protocol

Catheter venography was performed to interrogate the bilateral renal, ovarian, and internal iliac veins; external compression of the left renal vein and left common iliac vein were checked and excluded. With our “Keep-It-Simple” (KIS) protocol, only refluxing ovarian and /or internal iliac vein tributaries that were connected to the pelvic varicosity were embolised. Valsalva was used to demonstrate reflux, unless evident on quiet respiration.

A “Sandwich” technique was typically used to embolise the ovarian vein, deploying a nest of 1–2 pushable coils distally at the pelvic brim level to slow down the flow to near stasis, then followed with 1-2mL of sclerosing foam injected proximal to the coil nest. The catheter was then positioned further proximally, to about 5cm from its junction with renal vein on the left, or IVC on the right, and a second nest of 1–2 coils were deployed, followed with 1 ml of sclerosing foam, injected slowly and proximal to the coils nest. Any significant ovarian vein branches were either individually embolised, or their junctions covered by coils and sclerosing foam. Any refluxing internal iliac vein anterior division tributaries feeding the pelvic varicosity were also embolised, typically using only one nest of coils, and optional sclerosing foam just proximal to the coil nest, if deemed safe to do so(Fig. 1).

Pushable coils used were fibred platinum, 14cm long (Nester Coils, COOK Australia), sized at 20% larger than the measured diameter of the target vein. Retractable coils were rarely used, only when the operator felt unsafe to use pushable coils due to the unfavourable anatomy of the target vein. The sclerosing foam was prepared with Tusarri method mixing 4mL air with 2mL 3% sodium tetradecyl sulfate (Fibro-Vein, Australasian Medical and Scientific Limited) or 3% polidocanol (Aethoxysklerol, Getz Healthcare Pty Ltd, Australia).

All procedures were performed under local anaesthetic with conscious sedation (intravenous midazolam and fentanyl), using right internal jugular vein approach under ultrasound guidance, via 5Fr sheath and 5Fr diagnostic catheters, such as MP A1 (Cordis Australia). Glyceryl trinitrate 50mg topical patch was applied 30 minutes prior to procedure to prevent venous spasm.

Short and long term follow up

Short term clinical follow up was conducted at 6 weeks. Short term success was achieved if the women reported “Complete or Significant improvement of symptoms”, and “Happy or Very happy” with the outcome.

Long term follow-ups (between 12–60 months) were conducted by using an electronic survey consist of 19 questions (Appendix 1). Pelvic pain using visual analogue scale (VAS) at baseline and follow up on the scale of were recorded, and reduction in VAS was calculated. Overall long-term clinical success was achieved if the women answered “Very Happy/Very Satisfied” or “Happy / Satisfied”. Success was not achieved if women answered “Not sure”, “Unhappy/Unsatisfied”, or “Very Unhappy/Very Unsatisfied”.

Changes of other ancillary symptoms, such as pelvic pressure, back pain, leg pain/heaviness, bladder symptoms, pain during sex, pain after sex, heavy menstrual bleeding, period pain, premenstrual pain or bloating, fatigue, and requirement for pain medications, were surveyed and recorded as “All gone”, “Significant improvement”, “Some improvement,” “No change”, or “Worsen”.

Women, who were subsequently found to have an alternative diagnosis of pelvic pain, or who had complex/ multiple causes of pelvic pain, were excluded from the long-term results analysis. A substantial percentage of women in our cohort also had co-existing adenomyosis undergoing concurrent management and were not excluded from result analysis. Women who required repeat venogram and embolisation of additional veins were identified and their outcome reported.

Study objectives and statistical analysis

The primary outcome was to confirm the effectiveness of KIS approach to conduct venous embolisation for PCS. Secondary outcomes included whether demographics (e.g. age, parity), symptomatic length, type of symptom (e.g. back pain, leg pain, bladder symptoms) or other factor was significant for clinical success.

The data collected were analysed with SPSS version 24 (Armonk, NY: IBM Corp.). Patients’ characteristics were reported using frequency and descriptive analyses. Follow-up was calculated from the date of the embolisation to the date of last follow-up. A p-value of 0.05 or less was considered significant. Binary logistic regression analysis was performed for factors influencing treatment success or symptomatic return.

During the 5-year study period, 154 women underwent diagnostic venogram and 139 women had refluxing veins identified and embolised (Table 1), with 102 (73.4%) proceeded with unilateral ovarian vein embolisation only (70.5% LOV only; 2.9% ROV only), 20 (14.4%) required bilateral ovarian vein embolisation; and 17 (12.2%) required pelvic vein embolisation (Table 2). The average number of coils used per case was six, and most women required only four coils.

At 6-week follow up, short-term success was achieved in 114/128 (89.1%) women (with women “Happy or Very Happy “with the overall outcome, reporting “Complete Resolution” or “Significant Improvement” of symptoms) (Fig. 2).

Long-term follow up survey was responded by 101/118 (85.6%) women. The mean follow up period was 34 months (range: 12–60 months). Seven women declined to participate in the survey. Eight women, who were found to have alternative or multiple contributing causes of pelvic pain, were excluded from the results analysis. Eighty-six women’s long-term outcome was available for analysis.

Overall long-term success was achieved in 72/86 (83.7%) women (with women “Very Happy/Very Satisfied” or “Happy / Satisfied” with overall outcome).

Three women required one repeat venogram and additional embolisation; one woman required two repeat venograms and further embolization. These four women were eventually able to achieve long-term success.

For those who reported symptomatic relief, majority reported relief within 1 months (70.9%) (17.4% immediate relief, 23.3% within a week, 30.2% within a month).

Mean pain reduction was 5.2 on VAS (from 7.8 ± 1.7 to 2.7 ± 1.7; p < 0.001) and the modal VAS score was 8 pre-procedure and 0 at long-term follow up. Notably 41.7% no longer required pain medications and 86.1% reported some reduced requirement for pain medications. Post procedure, eight (6.3%) patients experienced mild to moderate pelvic or loin pain, which was attributed to thrombophlebitis. No worsening of pain or pelvic pressure was recorded; only one patient reported worsening of leg pain/ pressure, one patient reported worsening of period pain and one patient reported worsening of heavy menstrual bleeding. There were no cases of infection/haemorrhage, or readmission for unexpected outcomes. There was no coil migration or dislodgement.

When assessing the impact of covariates influencing long term clinical success, patients who had pre-procedure pelvic pressure (90.7 vs 36.3%, p < 0.001), back pain (91.4 vs 74.3%, p = 0.042), leg pain (92.3 vs 70.5%, p = 0.015), bladder symptoms (92.5 vs 76.0%, p = 0.046), fatigue (93.8 vs 71.0%, p = 0.007), period pain (90.0 vs 75.0%, p = 0.063), pre-menstrual bloating (95.9 vs 58.3%, p < 0.001) were associated with treatment success. Upon binary logistic regression analysis, none of the covariates remained significant.

When assessing the impact of covariates influencing long-term symptomatic return, patients who did not have fatigue (34.2 vs 14.5%, p = 0.032) and patients who were aged ≥ 45 (36.5 vs 11.1%, p = 0.005) were more likely to have symptomatic return. Patients with bladder symptoms were more likely to have symptom return was close but did not meet statistical significance (30.4 vs 15.0%, p = 0.091). Upon binary logistic regression analysis, fatigue (p = 0.02) and age ≥ 45 (p = 0.001) remained significant

This study confirmed that the KIS approach was effective in treating PCS, achieving short-term success in 114/128 (89.1%) women and long-term success in 72/86 (83.7%) women.

Our KIS approach results compare favourably with the EXT approach reported by Kim and Venbrux [4] on 127 cases over 5 years (1998 to 2003) with mean clinical follow-up of 45 months, achieving a similar 83% improvement, by trying to embolise all four veins in two separate sessions (84% had bilateral OVE, 85% also had iliac vein embolisation), yet 13% showed no improvement. There was 4% women reported worsening of symptoms, and we propose that this could be due to occlusion of non-refluxing drainage pathways and forced injection of sclerosing agent into pelvic vein causing pelvic thrombophlebitis. Notably there was no worsening of pelvic pain or pressure was recorded in our cohort.

In contrast, with our KIS approach, despite selectively embolising refluxing veins only, only 4.7% women required a repeat session of venogram and further embolisation to address residual or recurrent symptoms. We avoided unnecessary embolisation of antegrade non-refluxing pathways.

A study by Laborda et al. for ultrasound-proven PCS treated patients with EXT approach embolization had a total of 179 patients (88.6%) completed the 5-year follow-up period achieving VAS drop of 6.6 from 7.34 to 0.78. However, there was a relatively long time 13.5 +/- 1.9 months for patients with severe pain to see clinical improvement [5]. In contrast, with our KIS approach, VAS drop of 5.2 was achieved, and 71.9% reported symptom relief within 1 month. Immediate relief of pelvic congestion symptoms is expected after embolisation of refluxing veins, unless procedural induced pain is masking and delaying the expected improvement. This divergent results between KIS and EXT could be that the latter contributing to extensive pelvic thrombophlebitis and occlusion of antegrade non-refluxing drainage pathways.

Laborda and colleagues also reported four cases of coil migration (1.9%), that were considered as major complications, with two coils to the right external iliac vein and two to the pulmonary arteries [5]. In comparison with our KIS approach, only a small percentage (12.2%) of women required iliac vein coil embolization, which carries a greater risk of coil migration compared to ovarian vein embolization. We hypothesise that embolising fewer iliac veins and having a more targeted approach for refluxing veins minimises the number of coils and risk of complication. When we embolised the tributaries of the anterior division of IIV, coils were placed as distally as possible to avoid coil migration. Furthermore, using the “Sandwich” technique for OV embolization, we did not need to deploy coils within the proximal 5 cm of OV, further reducing the risk of coil mal-deployment. We also used GTN topical patch to prevent venous spasm, which could predispose in proper coil formation in the desired location.

Our study compares similarly to other previous smaller cohort studies utilising the KIS approach to treat PCS. d’Archambeau et al reported a cohort of 66 patients with pain scale drop of VAS 5.74 (from 7.88 to 2.15) by using only an average of 4–5 coils [2]. Kwon et al. reported a cohort of 67 patients achieving pain reduction (Completely gone or Significant reduction) in 82% of cases [3]. Similarly, Kwon also noted the relatively early symptom relief in 2–3 months in most patients. This is in contrast to Laborda’s EXT approach that required 13.5 months to provide appreciable pain relief [5]. Kwon’s observations support, and our results suggest, that pain symptom relief following embolisation should be almost immediate [3], unless complicated by extensive pelvic thrombophlebitis due to indiscriminate embolisation of pelvic vein using EXT approach.

We propose that PCS in females represents a functional analogue to varicocele in males. We belief women’s pelvic varicosity should be treated as men’s pampiniform plexus. The common pathophysiology is the incompetence of the gonadal vein, resulting in increased pressure and reversed flow, congesting the pelvic venous plexus in female and pampiniform plexus in male. When treating male varicocele, one would not contemplate injecting sclerosants into the varicocele itself is necessary, otherwise it will cause painful thrombophlebitis. Similarly, the logical approach to treat PCS is to address the root cause of the congestion (the refluxing gonadal veins). This approach will lead to collapse of the varicosities, which - no longer being subject to the pressure of the refluxing veins – will decompress and will no longer be a cause of symptoms.

Incompetence of iliac vein tributaries can contribute to PCS in female, but published studies utilising KIS technique suggest that this is uncommon [2, 3]

This present study also has some limitations. Firstly our follow-up is relatively short, ranging between 12 and 60 months, but in common with Kwon [3], we have noted that most patient report relief within 1–3 months, and therefore follow up study of treated PCS patients for a minimum of 12 months should be sufficient. Secondly results from this single centre single operator cohort study may not translate to world-wide practice. However, with a consistent technique and strict adherence to protocol, the results can be a useful reference benchmark for future studies. Lastly, our outcome survey questionnaire has not been validated and retrospectively collected data suffers inherent biases. Ideally, to formally validate the KIS approach, a prospective randomised comparison study comparing KIS and EXT approaches would be required.

The KIS approach embolising only the refluxing veins can achieve similar effective clinical outcome for PCS as the EXT approach. This carries implications for potential savings in procedure time, cost, and radiation does. The EXT approach of empirically embolising all 4 sets of veins may not be necessary to achieve an effective outcome.

Mahmoud O, Vikatmaa P, Aho P, Halmesmäki K, Albäck A, Rahkola-Soisalo P et al (2016) Efficacy of endovascular treatment for pelvic congestion syndrome. J Vascular Surgery: Venous Lymphatic Disorders 4(3):355–370
d Archambeau O, Maes M, De Schepper A (2004) The pelvic congestion syndrome: role of the nutcracker phenomenon and results of endovascular treatment. JBR BTR 87(1):1–8
Kwon SH, Oh JH, Ko KR, Park HC, Huh JY (2007) Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Interv Radiol 30:655–661
Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC (2006) Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol 17(2):289–297
Laborda A, Medrano J, de Blas I, Urtiaga I, Carnevale FC, de Gregorio MA (2013) Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Interv Radiol 36:1006–1014
Hanna J, Bruinsma J, Temperley HC, Fernando D, O’Sullivan N, Hanna M, Brennan I, Ponosh S (1971) Efficacy of embolotherapy for the treatment of pelvic congestion syndrome: A systematic review. Ir J Med Sci. 10.1007/s11845-024-03608-6

Table 1: Patient demographics

	Mean	Median	Range
Age	47	45	20-85
Parity	2.5	2	0-7
Pain at baseline (VAS)	7.8	8	0-10

LOV diameter	9 mm
ROV diameter	7 mm

Other pathologies (Data obtained from pre-procedure consultant and survey)
Adenomyosis		30/139 (21.6%)
Lower limb varicose vein		20/139(14.4%)
Endometriosis		3/139(2.2%)
Fibroids		1/139 (0.7%)
PCOS		1/139 (0.7%)

Symptoms duration before diagnosis (Data obtained from survey)
< 5 months		5/86 (5.8%)
6-12 months		18/86 (20.9%)
1-2 years		21/86 (24.4%)
2-5 years		19/86 (22.1%)
More than 5 years		23/86 (26.7%)

Table 2: Procedure details

	Mean	Median	Mode	Range
No of Coils used per case	6	5	4	3 to 16

Veins Embolised	n/139 (%)
LOV only	98/139 (70.5%)
ROV only	4/139 (2.9%)
Bilateral OV	20/139 (14.4%)
LOV+LIIV	4/139 (2.8%)
LOV+RIIV	1/139 (0.75)
RIIV only	3/139 (2.1%)
LIIV only	1/139 (0.72%)
LOV+ROV+LIIV	6/139 (4.3%)
LOV+ROV+RIIV	1/139 (0.72%)
LOV+LIIV+RIIV	1/139 (0.72%)

LOV: Left Ovarian Vein; ROV: Right Ovarian Vein; LIIV: Left Internal Iliac Vein; RIIV: Right Internal Iliac Vein.

Note: only anterior division tributaries of iliac veins were embolised

Table 3: Clinical outcomes in respect of ancillary symptoms.

	No of women with symptoms at baseline n/86 (%)	"All Symptoms Gone" x/n(%)	"Significant Improvement" y/n(%)	"At least some improvement"* z/n (%)
Pelvic Pressure	81/86 (94.2%)	34/81 (41.9%)	32/81 (39.5%)	74/81 (91.4%)
Back Pain	52/86 (60.5%)	8/52 (15.4%)	26/52 (50.0%)	46/52 (88.5%)
Leg pain/heaviness	58/96 (67.4%)	15/58 (25.9%)	30/58 (51.7%)	52/58 (89.7%)
Bladder symptoms	54/86 (62.8%)	8/54 (14.8%)	23/54 (42.6%)	40/54 (74.1%)
Pain during sex	52/86 (60.5%)	12/52 (23.1%)	13/52 (25.0%)	41/52 (78.8%)
Pain after sex	53/86 (61.6%)	14/53 (26.4%)	11/53 (20.8%)	41/53 (77.4%)
Heavy Menstrual bleeding	49/86 (57%)	11/49 (22.4%)	14/49 (28.6%)	37/49 (75.5%)
Period pain	62/86(72.1%)	11/62 (17.7%)	21/62 (33.9%)	49/62 (79.0%)
Premenstural Pain or bloating	67/86 (77.9%)	10/67 (14.9%)	21/67 (31.3%)	49/67 (73.1%)
Fatique	66/86 (76.7%)	11/66 (16.7%)	22/66 (33.3%)	48/66 (72.7%)
Requirement for pain medications	72/86 (83.7%)	30/86 (41.7%)	20/86 (27.8%)	62/86 (86.1%)
* At least some improvement includes patients with symptoms " All gone"; "Significant improvement" and "Some Improvement"

Table 4A: Assessment of covariates affecting long term treatment success.

Covariate (listed below)	Rate of group A	Rate of group B	P-value	OR (95%CI)	Selected test
Pelvic pressure Yes (A) vs No (B)	68/75	4/11	<0.001	17.00 (3.97-72.77)	Fisher exact
Back pain Yes (A) vs No (B)	43/47	29/39	0.042*	3.71 (1.06-12.96)	Fisher Exact
Leg pain/Heaviness Yes (A) vs No (B)	48/52	24/34	0.015	5.00 (1.42-17.61)	Fisher Exact
Bladder Symptoms Yes (A) vs No (B)	37/40	35/46	0.046*	3.88 (1.00-16.07)	Fisher Exact
Fatigue Yes (A) vs No (B)	45/48	27/38	0.007**	6.11 (1.56-23.88)	Fisher Exact
Dyspareunia Yes (A) vs No (B)	37/41	35/45	0.15	2.64 (0.76-9.21)	Fisher Exact
Heavy Menstrual Bleeding Yes (A) vs No (B)	33/37	39/49	0.38	2.12 (0.61-7.37)	Fisher Exact
Period Pain Yes (A) vs No (B)	45/50	27/36	0.063	3.00 (0.91-9.89)	Chi-Square
Premenstrual Bloating Yes (A) vs No (B)	47/49	25/37	0.001***	11.28 (2.34-54.42)	Fisher Exact
Medications needed Yes (A) vs No (B)	58/62	14/24	<0.001***	10.36 (2.83-37.93)	Fisher Exact
Agre 45 or more Yes (A) vs No (B)	40/45	32/41	0.17	2.25 (0.69-7.38)	Chi-Square
Parity 3 or more Yes (A) vs No (B)	29/36	43/50	0.50	0.67 (0.21-2.13)	Chi-Square
Ovarian vein diameter ≥10mm Yes (A) vs No (B)	38/43	34/43	0.24	2.01 (061-6.59)	Chi-Square
p≤0.05, p≤0.01, p≤0.001**

Table 4B: Assessment of covariates affecting long-term symptom return.

Covariate (listed below)	Rate of group A	Rate of group B	P value	OR (95%CI)	Selected test
Pelvic pressure Yes (A) vs No (B)	16/75	4/11	0.272	0.48 (0.12-1.82	Fisher exact
Back pain Yes (A) vs No (B)	10/47	10/39	0.798	3.71 (1.06-12.96)	Chi-square
Leg pain/Heaviness Yes (A) vs No (B)	13/52	7/34	0.636	1.286 (0.45-3.64)	Chi-Square
Bladder Symptoms Yes (A) vs No (B)	6/40	14/46	0.091	0.40 (0.14-1.18)	Chi-Square
Fatigue Yes (A) vs No (B)	7/48	13/38	0.032*	0.33 (0.12-0.93)	Chi-Square
Dyspareunia Yes (A) vs No (B)	9/41	11/45	0.785	0.87 (0.32-2.37)	Chi-Square
Pain post Sex Yes (A) vs No (B)	9/41	11/45	0.785	0.87 (0.32-2.37)	Chi-Square
Heavy Menstrual Bleeding Yes (A) vs No (B)	9/37	11/49	0.84	1.11 (0.41-3.04)	Chi-Square
Period Pain Yes (A) vs No (B)	12/50	8/36	0.847	1.11 (0.40-3.06)	Chi-Square
Premenstrual Bloating Yes (A) vs No (B)	9/49	11/37	0.22	0.53 (0.19-1.46)	Chi-Square
Medications needed Yes (A) vs No (B)	14/62	6/24	0.81	0.88 (0.29-2.63)	Chi-Square
Age 45 or more Yes (A) vs No (B)	5/45	15/41	0.005**	0.22 (0.07-0.67)	Chi-Square
Parity 3 or more Yes (A) vs No (B)	9/36	11/50	0.745	0.67 (0.21-2.13)	Chi-Square
Ovarian vein diameter 10mm or more Yes (A) vs No (B)	10/43	10/43	1.00	1.00 (0.37-2.72)	Chi-Square
p≤0.05, p≤0.01, p≤0.001**

The authors declare no competing interests.

Appendix1.docx

A Keep-It-Simple embolisation approach to treat Pelvic Congestion Syndrome without compromising clinical effectiveness.

Status:

Version 1

Abstract

Figures

Introduction

Materials and Methods

Patient recruitment and treatment

Diagnostic and therapeutic venogram protocol

Short and long term follow up

Study objectives and statistical analysis

Results

Discussions

Conclusions

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1