Journal of Vascular and Endovascular Therapy

Description

Pelvic congestion syndrome is chronic pelvic pain caused by gonadal vein varicosities, worsened by prolonged standing, sexual intercourse, menstruation, or pregnancy. Multiparous women of reproductive age are at increased risk, and the overall prevalence is about 30% [1]. Venogram is the diagnostic gold standard, and potential treatments include hormone therapy, vasoconstrictive medications, or pelvic coil embolization. It is possible but rare for a pelvic coil to migrate to the pulmonary vasculature, and the few cases reported typically do not describe removal of the coils, as patients were asymptomatic. We present an adult female with pelvic congestion syndrome status-post coil embolization with chest pain and dyspnea, found to have a migrated pelvic coil in her right pulmonary artery.

Surgical Approach

Similarly, the left femoral vein was accessed and upsized to a 9 French sheath, which finally allowed for successful snare removal of the remaining coil. Repeat imaging showed a small residual coil fragment in the right midlung that was deemed not to cause increased injury, thus was left in situ. An intact 16mm Nester coil pack was noted in the left gonadal vein. The patient was observed in the hospital overnight and went home the following day without anticoagulation or other acute complications. The patient followed up with vascular surgery several months later for the remaining gonadal vein coil with no additional interventions.

After much discussion between the patient’s medical providers, they decided that vascular interventional radiology (VIR) would be the least invasive yet still likely successful method for coil retrieval when compared to an open surgical approach. The patient was consented and transported directly to VIR, where the groin was prepped in standard fashion. The right common femoral vein was accessed with a micro puncture kit using ultrasound guidance. A pulmonary angiography catheter was advanced over a guidewire into the right main pulmonary artery via a 7 French sheath. Contrast phase did not show significant clot within the artery. The sheath was exchanged for a long 7 French sheath with the tip in the right pulmonary artery.

Multiple Snares

Multiple snares were passed through the sheath to engage the 20mm Nester coil pack (Cook Medical), however the coil unraveled into small pieces, until eventually a large piece was snared and retracted to the right femoral vein. VIR then performed en bloc removal through the right groin access site given the coil was too large to pass through the sheath; however, a piece of coil remained in the right femoral vein. Multiple attempts to snare the coil via an upsized 11 French sheath were still unsuccessful. None of these cases include removal of neither the coils nor the methods behind the retrieval process. Our patient developed pulmonary infarcts and a pleural effusion, which has not beenpreviously reported, and thus necessitated urgent removal of the migrated coil, as we have described above. Although there were difficulties with VIR removal of the coil, this still prevented the patient from undergoing an open surgical procedure, which could lead to prolonged recovery time, longer hospital stay, and other post-operative complications such as non-healing wounds, infection, hemorrhage, pulmonary embolism, etc. Our patient had complete resolution of her symptoms and no additional complications on follow up. The migration of endovascular coils is a relatively rare complication, with few cases reported in patients with pelvic congestion syndrome. Additionally, the coil retrieval process has not been well described. Careful history should be obtained in patients presenting with chest pain or shortness of breath, including recent procedures. Endovascular retrieval of the migrated coil was a successful and safe intervention in this patient, resulting in symptom resolution without the requirement of long-term anticoagulation or monitoring. Multiple snares were passed through the sheath to engage the 20mm Nester coil pack (Cook Medical), however the coil unraveled into small pieces, until eventually a large piece was snared and retracted to the right femoral vein. VIR then performed en bloc removal through the right groin access site given the coil was too large to pass through the sheath; however, a piece of coil remained in the right femoral vein. Multiple attempts to snare the coil via an upsized 11 French sheath were still unsuccessful. It is possible but rare for a pelvic coil to migrate to the pulmonary vasculature, and the few cases reported typically do not describe removal of the coils, as patients were asymptomatic. We present an adult female with pelvic congestion syndrome status-post coil embolization with chest pain and dyspnea, found to have a migrated pelvic coil in her right pulmonary artery.