Transcatheter cyanoacrylate embolization vs. pharmacologic therapy for gonadal vein reflux in symptomatic pelvic...

Pelvic venous disorders (PeVDs) with gonadal vein reflux are a frequently overlooked cause of chronic pelvic pain in women. Although embolization is increasingly used in practice, high-quality comparative evidence-particularly for cyanoacrylate glue-remains limited. This randomized controlled trial compares cyanoacrylate embolization with conservative pharmacologic management in women with symptomatic PeVDs.

Forty women with imaging-confirmed gonadal vein reflux were randomized (1:1) to receive either micronized purified flavonoid fraction (Daflon^®, 500 mg twice daily) or transcatheter cyanoacrylate embolization. The primary endpoint was the change in pelvic pain measured by the visual analog scale (VAS). Secondary outcomes included dyspareunia and dysmenorrhea VAS scores, clinical success, symptom recurrence, and adverse events over 12 months.

Embolization yielded earlier and more durable symptom improvement. At 12 months, mean pelvic pain VAS scores were significantly lower in the embolization group (3.20 ± 0.77 vs. 5.10 ± 0.97; P < 0.001). Additionally, dyspareunia improved significantly with embolization (1.75 ± 0.91 vs. 3.95 ± 1.91; P < 0.001), whereas dysmenorrhea outcomes were comparable between groups. Clinical success was achieved in 95% of patients who received embolization, compared with 70% of those who received Daflon^®, although this difference did not reach statistical significance (P = 0.091). Lower recurrence was observed in the embolization arm (10% vs. 45%, P = 0.031). Kaplan-Meier analysis demonstrated superior recurrence-free survival with embolization (log-rank P = 0.013), and Cox regression identified embolization as an independent protective factor against recurrence (hazard ratio: 0.12; 95% confidence interval, 0.02-0.74; P = 0.021). No major complications were reported.

In women with symptomatic gonadal vein reflux, cyanoacrylate embolization, compared with conservative pharmacologic therapy, appears to provide significantly greater and more durable symptom relief, with low recurrence and an excellent safety profile, although the difference in clinical success rates did not reach statistical significance.

In this randomized trial, cyanoacrylate embolization was particularly beneficial for women with documented gonadal vein reflux and symptoms dominated by non-cyclic pelvic pain and dyspareunia. In appropriately selected patients, early intervention may reduce recurrence and avoid prolonged medical therapy with limited durability. Although these preliminary findings support embolization as a potential definitive therapeutic option, larger confirmatory studies are needed before it can be recommended over second-line status.