| MP 4.01.18 | Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome | |
| Medical Policy | ||
| Section OB/Gyn/Reproduction |
Original Policy Date 4/16/04 |
Last Review Status/Date Reviewed with literature search/5:2009 |
| Issue 5:2009 |
Return to Medical Policy Index |
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Description
Pelvic congestion syndrome is a condition of chronic pelvic pain of variable location and intensity, which is associated with dyspareunia and postcoital pain and aggravated by standing. The syndrome occurs during the reproductive years, but unlike endometriosis is not related to parity. The underlying etiology is thought to be related to varices of the ovarian veins, leading to pelvic congestion. As there are many etiologies of chronic pelvic pain, the pelvic congestion syndrome is often a diagnosis of exclusion, with the identification of varices using a variety of imaging methods, such as magnetic resonance imaging (MRI), computed tomography (CT) scanning, or contrast venography. For those who fail medical therapy with analgesics, surgical ligation of the ovarian vein has been considered. More recently, embolization therapy of the ovarian and internal iliac veins has been proposed.
Policy
Embolization of the ovarian vein and internal iliac veins is considered investigational as a treatment of pelvic congestion syndrome.
Policy Guidelines
Embolization of the ovarian vein may require an overnight hospital stay. Embolization of the internal iliac veins has been performed on an outpatient basis.
There are no specific CPT codes for this procedure. The following nonspecific CPT codes may be used:
36012: Selective catheter placement, venous system: second order or more selective, branch
37204: Transcatheter occlusion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck
Benefit Application
BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices, drugs, biologics and imaging may not be considered investigational and thus may be only assessed on their basis of their medical necessity.
Rationale
At the time this policy was created, the published data regarding embolization therapy for pelvic congestion syndrome were considered inadequate to permit scientific conclusions, due to the lack of standardized diagnostic criteria for pelvic congestion and the lack of controlled trials of embolization therapy. Published studies of embolization stated that all patients had ovarian varices, however, the diagnostic criteria were not provided. For example, Stones stated that pelvic congestion can be identified when dilated uterine and ovarian veins are present with reduced venous clearance of contrast medium. However, the degree of dilation defining a varix and the definition of reduced venous clearance were not provided. (1) In other case series the authors did not detail their diagnostic criteria.
A case series of 56 patients reported that varices were identified using a variety of imaging methods including ultrasound, CT, or MRI. (2) In this study, bilateral ovarian vein embolization therapy was performed using gel foam and coils as an inpatient procedure (for postoperative pain control), followed 3 to 10 weeks later by embolization of the internal iliac arteries, performed as an outpatient procedure. The second procedure was performed to reduce the risk of recurrence based on the observation that there was free communication between the ovarian venous plexus and the internal iliac vein tributaries. The study endpoints included technical success and pre- and postoperative pain assessment using a visual analogue scale. The procedures were considered a technical success in all patients, although in 2 patients the coils inadvertently embolized to the pulmonary circulation where they were retrieved without incident. Recurrences of varices were noted in 3 patients; 2 underwent repeat internal iliac vein embolization, while the third refused further treatment. In terms of pain control, the mean VAS score fell from 7.8 to 2.7 over a 12-month period. The time to pain improvement was very variable among the women. Based on a questionnaire completed by 24 of the 56 patients, the menstrual cycle was unchanged. In a separate review article, Venbrux comments on the challenges of imaging ovarian varices; for example, patients are typically imaged in the supine position when the varices may collapse and thus may not be detected. (3) Venbrux recommends that patients with a strong clinical history suggestive of pelvic congestion and initially negative imaging studies should undergo selective ovarian and internal iliac venography, with the option of proceeding to embolization if the varices are demonstrated at venography. Maleux and colleagues reported on the results of ovarian vein embolization in 41 patients. (4) Unlike the Venbrux study, in which the patients underwent bilateral ovarian and internal iliac vein embolization, in this study 32 patients underwent unilateral embolization of the left ovarian vein based on the findings at venography, while the remaining 9 patients underwent bilateral embolization therapy. No patient underwent embolization of the internal iliac vein. The authors reported a technical success rate of 98%. Pain relief was assessed via a questionnaire filled out at variable times after the procedure. The questionnaire asked the patient to rate their pain as very painful, painful, bearable, or no pain. There was no formal assessment of pain prior to the procedure. A total of 68.3% of patients reported either partial or complete relief. A variety of other smaller case series reported pain relief in 50%–80% of patients. (5-7)2005-2008 Updates Searches of the MEDLINE database for the periods of April 2004 through December 2005 and January 2006 through June 2007 identified only retrospective studies, most from outside of the U.S. A literature search for the period of July 2007 through June 2008 did not identify any publications on treatment of pelvic congestion syndrome using coils. A review article was identified that described radiological criteria for the diagnosis of pelvic congestion syndrome. (8) Transvaginal or transabdominal ultrasound criteria included: 1) tortuous pelvic veins with a diameter of greater than 6 mm; 2) slow blood flow (about 3 cm/sec) or reversed caudal flow; 3) dilated arcuate veins in the myometrium that communicate between bilateral pelvic varicose veins; and 4) sonographic appearances of polycystic changes of the ovaries. In the largest case series to date, Kim and colleagues reported results for 127 women treated with bilateral embolotherapy. (9) Ninety-seven patients (76%) completed clinical follow-up (mean duration of 45 months± 18); overall pain scores were reduced from 7.6 to 2.9 (10-point scale). Kwon and colleagues reported follow-up by telephone interview of women who had undergone unilateral ovarian vein coil embolization for pelvic congestion syndrome; 55 of 67 patients (82%) reported being satisfied with the procedure; the remainder reported no improvement or a worsening of symptoms. (10) Of note, 2 recent case series from Italy reported successful treatment of pelvic congestion syndrome with transcatheter foam sclerotherapy without use of coils. (11, 12) Although these initial case series suggest that beneficial results may be obtained with a less invasive treatment, controlled studies with longer follow-up are needed. Prospective randomized trials on ovarian and internal iliac vein embolization using a coil are also needed. The available scientific evidence does not permit conclusions concerning the effect of this procedure on health outcomes; therefore, the policy statement is unchanged.2009 Update
A search of the MEDLINE database was performed for the period April 2008 through April 2009.
References:
- Stones RW. Pelvic vascular congestion - half a century later. Clin Obstet Gynecol 2003; 46(4):831-6.
- Venbrux AC, Chang AH, Kim HS et al. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol 2002; 13(2 pt 1):171-8.
- Venbrux AC, Lambert DL. Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol 1999; 11(4):395-9.
- Maleux G, Stockx L, Wilms G et al. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J Vasc Interv Radiol 2000; 11(7):859-64.
- Sichlau MJ, Yao JS, Vogelzang RL. Transcatheter embolotherapy for the treatment of pelvic congestion syndrome. Obstet Gynecol 1994; 83(5 pt 2):892-6.
- Tarazov PG, Prozorovskij KV, Ryzhkov VK. Pelvic pain syndrome caused by ovarian varices: treatment by transcatheter embolization. Acta Radiol 1997; 38(6):1023-5.
- Cordts PR, Eclavea A, Buckley PJ et al. Pelvic congestion syndrome: early clinical results after transcatheter ovarian vein embolization. J Vasc Surg 1998; 28(5):862-8.
- Ganeshan A, Upponi S, Hon LQ et al. Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology. Cardiovasc Intervent Radiol 2007; 30(6):1105-11.
- Kim HS, Malhotra AD, Rowe PC et al. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol 2006; 17(2 pt 1):289-97.
- Kwon SH, Oh JH, Ko KR et al. Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol 2007; 30(4):655-61.
- Gandini R, Chiocchi M, Konda D et al. Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol 2008 Jan 3 [Epub ahead of print].
- Tropeano G, Di Stasi C, Amoroso S et al. Ovarian vein incompetence a potential cause of chronic pelvic pain in women. Eur J Obstet Gynecol Reprod Biol 2008 Feb 28 [Epub ahead of print].
- Society of Interventional Radiology (SIR). Pelvic congestion syndrome – chronic pelvic pain in women. Fact sheet. Last updated November 2004. Accessed May 2009. Available at: http://www.sirweb.org/news/newsPDF/facts/Pelvic_Congestion_-_Pelvic_Pain_fact_sheet.pdf.
Codes |
Number |
Description |
CPT |
36012 |
Selective catheter placement, venous system: second order or more selective, branch |
|
37204 |
Transcatheter occlusion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck |
| ICD-9 Procedure | 99.29 | Injection or infusion of other therapeutic or prophylactic substance |
ICD-9 Diagnosis |
625.5 |
Pelvic congestion syndrome |
Index
Embolization Therapy, Ovarian Vein, for Pelvic Congestion Syndrome
Pelvic Congestion Syndrome, Embolization Therapy
Positron Emission Tomography
Policy History
| Date | Action | Reason |
| 04/16/04 | Add policy to OB/Gyn section | New policy |
| 11/9/04 | Replace policy | Coding updated. CPT code 37204 for embolization added |
| 03/7/06 | Replace policy | Policy updated; no additional literature identified; policy statement unchanged |
| 08/14/08 | Replace policy | Policy updated with literature search; rationale edited; references 8, 11 and 12 added; policy statement unchanged. |
| 05/14/09 | Replace policy | Policy reviewed with literature search from April 2008 through April 2009. The policy statement is unchanged; new reference number 13 added. |
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