CASE REPORTS
Hypersensitivity to nickel in a patient treated with
coil embolization for pelvic congestion syndrome
Jennifer Fahrni, MD,a Peter Gloviczki, MD,a Jeremy L. Friese, MD,b and Jamie N. Bakkum-Gamez, MD,c
Rochester, Minn
A 34-year-old woman had persistent symptoms of pelvic
venous congestion syndrome and developed new symptoms of
a systemic allergic reaction after coil embolization of both
ovarian and internal iliac veins. Patch testing revealed
Endovascular devices often contain nickel and other
metals with a high potential for allergic reactions. Even
though nickel allergy, a type IV delayed-reaction hypersen-
sitivity, is widespread in the general population,1 reports of
clinically relevant allergic reactions after device implanta-
tion are rare.
We report a case of allergic reaction to endovascular
coils, inserted for the treatment of ovarian and internal iliac
vein reflux in pelvic congestion syndrome, and review the
literature.
CASE REPORT
A 34-year-old woman with symptoms of severe pelvic pain and
feeling of heaviness and congestion in the pelvis was found to have
pelvic congestion syndrome due to incompetence of both ovarian
and internal iliac veins. Three months after giving birth to her third
child, she underwent percutaneous coil embolization of both
ovarian veins and the internal iliac veins at another institution.
Within days after the intervention, the patient noted progression
of pelvic pain. After a few weeks, she noted new symptoms that
included palpitations, fatigue, night sweats, feeling of heaviness
in both legs, and recurring skin changes described as patchy
dermatitis. These symptoms were so severe that the patient,
formerly an avid runner, was unable to participate in her usual ac-
tivities of daily living and was bed bound at times.
From the Division of Vascular and Endovascular Surgery,a Division of
Vascular and Interventional Radiology,b and Division of Gynecologic
Surgery,c Mayo Clinic.
Author conflict of interest: none.
Reprint requests: Peter Gloviczki, MD, Division of Vascular and Endovas-
cular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905
(e-mail: gloviczki.peter@mayo.edu).
The editors and reviewers of this article have no relevant financial relation-
ships to disclose per the Journal policy that requires reviewers to decline
review of any manuscript for which they may have a conflict of interest.
2213-333X
Copyright Ó 2015 by the Society for Vascular Surgery. Published by
Elsevier Inc.
http://dx.doi.org/10.1016/j.jvsv.2014.04.011
hypersensitivity to nickel and palladium, both components of
the coils used. After surgical removal of the coils and hyster-
ectomy with salpingo-oophorectomy, all her symptoms
resolved. (J Vasc Surg: Venous and Lym Dis 2015;3:319-21.)
On presentation at our clinic, physical examination was unre-
markable with no skin changes, edema, or visible varicosities. Pe-
ripheral vascular examination findings were normal, including
lower extremity plethysmography without signs of venous outflow
obstruction. On duplex ultrasound, deep and superficial veins of
the lower extremities were patent and competent. The extensive
workup also included computed tomography of chest, abdomen,
and pelvis without signs of malignant disease; normal electrocar-
diographic Holter monitoring and transthoracic and transesopha-
geal echocardiography; and unremarkable blood count with
differential (including a normal eosinophil count).
The patient initiated further investigations at an outside insti-
tution in her home state, including patch testing for metals that
revealed an allergy to nickel and palladium, both components of
the coils used. Hypersensitivity to these metals was thought to
be a possible cause of the systemic symptoms. The patient’s deci-
sion was to attempt treatment of her recurrent pelvic congestion
surgically and by all means to remove the coils that caused her po-
tential allergic reaction and that were also suspected to be a cause
of the additional pelvic pain after the initial intervention. She did
not take a trial of antihistamines or corticosteroids.
Her preoperative evaluation included contrast venography and
plain abdominal radiography. These demonstrated a large amount
of coils in both ovarian and internal iliac veins and also confirmed a
partially recanalized right ovarian vein, occluded left ovarian vein
(Fig 1), and numerous persistent venous collaterals originating
from the mostly occluded and coiled internal iliac and iliolumbar
veins. Ten months after the initial placement of the coils, open sur-
gical treatment was performed that included hysterectomy and
salpingo-oophorectomy with resection of the surrounding varicose
veins and surgical excision of both ovarian veins (Fig 2), together
with the coils. In addition, all coils were removed, one by one,
from both thrombosed internal iliac veins. The tips of some of
these coils were firmly embedded in thrombosed venous tribu-
taries, and removal of all metal fragments took several hours and
necessitated ligation of small pelvic arteries and veins to access
the area deep in the pelvis. Before closure, removal of all metal
fragments was confirmed by radiography (Fig 1, B). Six months af-
ter surgery, the patient reported marked improvement in pelvic
319
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320 Fahrni et al
Fig 1. A, Preoperative venogram shows reflux in partially recanalized right ovarian vein with coils. Multiple coils are
visible in both ovarian and internal iliac veins. B, Intraoperative completion abdominal radiograph after removal of all
coils.
symptoms with only minor residual pain and resolution of systemic
allergic symptoms.
DISCUSSION
Hypersensitivity to nickel affects up to 15% of the general
population.1 Type IV hypersensitivity is a T cell-mediated re-
action that is provoked by contact with the substance in ques-
tion in subjects who have been previously sensitized. The
onset of type IV reactions is typically delayed by at least
48 hours, sometimes up to weeks after exposure. With the
increasing number of endovascular devices being implanted,
concerns about allergic reactions to the implanted materials
have been raised. The most commonly used stents are
made of stainless steel or nitinol, both of which contain
nickel. Most publications have focused either on coronary
stents or on patent foramen ovale or atrial septal defect
occluder devices. In coronary stents, an association of nickel
hypersensitivity and in-stent restenosis was postulated in a
retrospective study published in 2000.2 However, this associ-
ation was not confirmed by others.3-6
There are several case reports of patients after implanta-
tion of patent foramen ovale occluder devices who developed
generalized symptoms, such as dermatitis, dyspnea, fever, and
edema, or more local symptoms (ie, chronic chest pain) as a
possible hypersensitivity reaction to the device.7-10 In two
cases in which the device was surgically removed and symp-
toms subsequently resolved, histologic findings pointing to
an allergic reaction, however, could not be demonstrated.7,8
One paper reported resolution of symptoms in a patient
after more than 3 months of systemic treatment with corti-
costeroids, without removal of the device.10 Possibly, the
exposure to nickel from the implanted occluder device
decreased sufficiently after several months, as suggested by
July 2015
another publication that measured systemic nickel levels in
nonallergic patients after device implantation and showed
that levels increase in the first month with a return to preim-
plantation levels within 12 months.11
Reports of possible hypersensitivity to devices in the
peripheral vasculature are scarce. In a case report of a pa-
tient who had a nitinol stent placed in the superficial
femoral artery and who developed severe generalized
dermatitis, the symptoms resolved after excision of the
stent.12 In another case, after coil embolization of gonadal
veins because of varicocele, a patient developed various
symptoms, including recurring urticaria. After positive al-
lergy testing to tungsten, one of the metals in the coils,
the coils were removed and the symptoms consequently
resolved.13 One patient was reported to have developed se-
vere pruritus and generalized eczematous lesions after
endovascular surgery with implantation of an endoprosthe-
sis for abdominal aortic aneurysm.14 Symptoms were well
controlled by oral antihistamine and topical hydrocorti-
sone, and removal of the endoprosthesis was not performed
because of the risks associated with the reintervention.
In those case reports that specify the time to onset of
symptoms after placement of the device, it was between
1 day and 2 months.
Although it is generally difficult to establish an associa-
tion between symptoms occurring after implantation of a
device containing nickel and nickel hypersensitivity, in
our case the time of onset as well as the relief of allergic
symptoms after removal of the allergen-containing coils
makes such a causal relationship likely.
Because of the high prevalence of nickel hypersensitiv-
ity in the general population and inconclusive evidence of
an association with adverse outcomes after device
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
Volume 3, Number 3
Fig 2. Resected right and left ovarian veins with coils in the vessel
and additional coils removed from pelvic veins.
implantation, patch testing for nickel sensitivity currently
does not seem to be indicated before planned implantation
of endovascular devices containing nickel. Pre-existing
known metal allergies, however, should be assessed before
device placement by thorough history. Even though cur-
rent evidence does not show that devices containing nickel
should be avoided in patients who have established hyper-
sensitivity, knowledge thereof can raise awareness should
such symptoms arise. Current guidelines on coronary stent-
ing,15 interventional occlusion of patent foramen ovale and
atrial septal defect,16 and interventional treatment of pe-
ripheral arterial disease17,18 do not address the issue.
In patients in whom there is a high suspicion for allergic
reaction after placement of the device and severe symptoms,
removal may be the only good option for treatment.
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Submitted Jan 6, 2014; accepted Apr 27, 2014.