Diagnosis and treatment of the pelvic congestion syndrome

Application of the Symptoms-Varices-Pathophysiology classification system in patients with pelvic venous disorders

Introduction: In 2021, the American Vein and Lymphatic Society convened a multi-disciplinary group to develop a valid and reliable discriminative instrument for the classification of patients suffering from pelvic venous disorders (PeVD) referred to as the Symptoms-Varices-Pathophysiology (SVP) system. Limited data exists regarding the utility of this instrument in the care of patients with PeVD. The goal of this investigation is to apply the SVP classification system to a group of patients treated for PeVDs. Methods: From January 2018 to January 2019, we retrospectively reviewed the records of 70 female patients treated for a PeVD at the Center for Vascular Medicine. Age, race, gender, medical/surgical histories, CEAP classification and intervention types were assessed and patients were categorized according to their SVP classification. The prevalence of each S and V class, their association with gonadal or iliac vein obstructive lesions and the prevalence of lower extremity varicosities was evaluated. Results: The average age of the entire cohort was 47.4 ± 13.4. The race distribution was as follows: African American (6), Hispanic (1), and Caucasian (63). Of the 140 limbs, 57% were C3 or greater with an average rVCSS score of 4.53. At the time of intervention, 54 patients (77%) demonstrated CEAP class 2 disease or greater with 25 patients (35%) demonstrating lower extremity varicosities. Medical co-morbidities included the following: Endometriosis (n = 1), Uterine Fibroids (n = 1), Ovarian cysts (n = 4), history of venous thrombosis (n = 2) and prior lower extremity venous procedures (n = 3). Overall, 47 patients (67.1%) demonstrated S2 disease secondary to dyspareunia, post-coital pain, or dysmenorrhea. S2 alone was observed in 17 patients (24.3%), S2,3a and S2,3a,3b in nine patients each (12.9%), and S2,3b was in 12 patients (17.1%). Thirteen patients presented with isolated extra-pelvic symptoms (19%); four (5.7%) were classified as S3a,3b, and nine (12.9%) were classified as S3b only. Finally, 10 patients (14%) had no pelvic symptoms and thus were classified as S0. V0 disease was observed in 17 patients (24.3%) secondary to a high incidence of iliac vein stenoses (IVS). V1 disease was observed in 1 patient (1.43%). V2 disease was observed in 53 patients (74.3%) secondary to iliac or ovarian vein reflux. Of these, 45 patients (64.3%) presented with reflux in the iliac veins. Sixteen patients had reflux in the common iliac veins, 17 patients exhibited reflux of the external iliac veins, and 41 patients demonstrated reflux of the internal iliac veins. Thirty-two patients (45.7%) presented with V2 disease secondary to reflux of the ovarian veins, 8 of whom presented with isolated ovarian vein reflux without IVS. Bilateral ovarian vein reflux was observed in 6 patients (9%) and unilaterally in 26 (37%) patients with concomitant ovarian vein reflux and IVS observed in 31 patients (44%). In patients with ovarian vein reflux, 89% had a concomitant iliac vein stenosis: (96.9% in the common iliac vein, 81.3% in the external iliac vein and 3.1% in the internal iliac vein). Conclusion: In our patient cohort, 70 women demonstrated 14 different SV classifications. The most common was S2V2, found in 10 patients. Chronic pelvic pain of venous origin, S2 disease, was the most common symptom, present in 47 patients (67.1%); followed by extra-pelvic symptoms as 22 patients demonstrated symptoms of the external genitalia (S3a), and 21 patients had symptoms secondary to the non-saphenous leg veins (S3b). Pelvic varicosities, V2, were also the most common variceal pattern seen in 53 patients, and 17 patients did not have any varices noted by venogram. Non-thrombotic IVS either alone or with ovarian vein reflux was the most common cause of PeVD in this cohort and may reflect referral patterns to our center. To determine the true incidence of these SVP patterns, larger cohort studies are necessary.

Interventional Therapy of Pelvic Venous Disorders (PeVD)

BACKGROUND

 Pelvic venous disorders (PeVD) are an underdiagnosed cause of chronic pelvic pain in women. They are caused by venous insufficiency of the pelvic or ovarian veins, leading to the development of mainly periuterine and periovarian varices. It is a progressive disease if left untreated and can cause swelling, dyspareunia, dysmenorrhea, and other symptoms, some non-specific, that affect the patient's quality of life. Interventional therapies are a central component of the treatment of PeVD, with a variety of techniques available for both diagnosis and treatment.

METHOD

 This review provides an overview of the pathophysiologic background, diagnosis, and, most importantly, interventional treatment options for PeVD.

RESULTS

 There is a lack of standardized nomenclature and internationally accepted diagnostic criteria for PeVD as well as randomized controlled trials demonstrating clinical success. However, in clinical trials, endovascular therapy for PeVD has been shown to be safe and effective. This review presents the various interventional techniques for the treatment of PeVD, including embolization, stenting, and sclerotherapy.

CONCLUSION

 The importance of PeVD is receiving growing recognition. Recent advances, such as the development of the Symptoms-Varices-Pathophysiology (SVP) classification, provide an impetus to standardize nomenclature and are the first step toward systematizing disease management. Interventional therapies provide a safe and tailored minimally invasive treatment option for patients with PeVD.

KEY POINTS

  · Pelvic venous disorders are an underdiagnosed condition with frequently delayed diagnosis and debilitating symptoms.. · Until now, the PeVD nomenclature has been imprecise, with terms like May-Thurner syndrome/Nutcracker syndrome.. · Interventional approaches are effective and play a central role in PeVD treatment..

CITATION FORMAT

· Dewald CL, Becker LS, Meyer BC. Interventional Therapy of Pelvic Venous Disorders (PeVD). Fortschr Röntgenstr 2024; 196: 921 - 927.

The Incidence and Characteristics of Pelvic-Origin Varicosities in Patients with Complex Varices Evaluated by Ultrasonography

OBJECTIVE

The purpose of this study was to evaluate the incidence of gonadal vein refluxes associated with lower-extremity varicose veins with Doppler ultrasonography (DUS).

METHOD

A total of 6279 patients with venous disease-related symptoms of the lower extremity were evaluated with DUS in the vascular lab. Gonadal vein reflux using abdominal ultrasound was further evaluated in patients with unusual varices, defined as varices in the inguinal, inner or upper thigh and the vulvar area without refluxes in the saphenofemoral junction (SPJ). Those patients who showed gonadal vein reflux were diagnosed as having pelvic-origin varicosity.

RESULTS

Unusual varices were found in a total of 237 patients (3.8%), and of these patients, pelvic-origin varicosity was discovered with transabdominal ultrasound in 156 (65.8%). A total of 66.7% (n = 38/57) of unusual varix patients with pelvic pain had gonadal vein reflux. The measurement of gonadal vein diameter was larger in ultrasonography than CT scans (8.835 vs. 8.81, p < 0.001). Two patients with severe symptoms but no obstructive venous diseases were treated with gonadal vein embolization.

CONCLUSION

The incidence of pelvic-origin varicosities was 2.5% (n = 156/6279). However, more than half of the patients with unusual varices had gonadal vein reflux and 24.4% of these patients also presented with pelvic pain. The evaluation of pelvic-origin varicosities should be performed in patients who present with unusual forms of varices of the lower extremity.

A scoping review of scores or grading systems for pelvic venous disorders

BACKGROUND

Pelvic venous disorders (PeVD) encompass a variety of conditions linked to chronic pelvic pain in women. However, PeVD remain underdiagnosed due to the absence of universally accepted diagnostic criteria. The complexity of PeVD classifications across specialties leads to delays in treatment. This scoping review aims to fill a gap in PeVD diagnosis and management by identifying all existing scoring or grading systems to lay the foundation for standardized clinical scoring tools for PeVD.

METHODS

This scoping review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews. Online databases were searched up to April 2023. Studies implementing a scoring or grading system for patients with confirmed or suspected PeVD were included. Scores or grading systems were classified into four main categories based on their use in the study: screening, diagnosis, measure of disease severity, and measure of response to treatment.

RESULTS

Of the 2976 unique records identified, 82 were reviewed in full, and 20 were included in this study. The publication dates ranged from 1984 to 2023 (median, 2018; interquartile range, 2003-2022). A total of 21 scores and/or grading systems were identified. Of these 21 scores, 10 (47.6%) were clinical scores, and 10 (47.6%) were scores based on radiological findings; one study included a score that used both clinical and radiological findings. The identified scores were used in various settings. Of the 21 scores, 2 (9.52%) were used for screening in a tertiary care setting; 3 (14.3%) were used to establish the PeVD diagnosis; 8 (38.1%) were used to assess disease severity; and 8 (38.1%) were used as measures of response to treatment. Of the eight scores assessing disease severity, four (50.0%) assessed the degree of dilatation of pelvic veins and four (50%) assessed the severity of reflux. Only three of the scores were validated.

CONCLUSIONS

This scoping review identified a range of scoring and grading systems for PeVD. We note a lack of a validated scoring system, both clinical and radiological, for screening and assessment of disease severity. This is an important first step in developing validated disease-specific scoring systems for patient screening, appropriate referral, assessment of symptom severity, and assessment of the response to treatment.

Successful Ovarian Vein Embolization of a Multiparous Woman with Pelvic Congestion Syndrome

Pelvic congestion syndrome (PCS) is a clinical syndrome supported by specific findings, such as ovarian vein's dilatation, that cause pelvic vein congestion. Although many theories are explaining the pathophysiologies of this condition, the underlying cause remains unknown. The clinical manifestations of PCS are various including chronic pelvic pain (CPP), voiding disturbances, or ureteral obstruction. Imaging modality, such as ultrasonography, computed tomography (CT scan), magnetic resonance imaging (MRI), and venography, are needed to confirm and exclude the differential diagnosis. Currently, American venous forum guidelines recommended endovascular therapy which is percutaneous embolization as the first option therapy of PCS. Here, we reported a 35-year-old woman with PCS who underwent successful percutaneous embolization therapy.

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Transabdominal ultrasound accurately identifies a significant iliac vein area-reducing lesion in patients with pelvic venous insufficiency

BACKGROUND

In patients with pelvic venous disorders secondary to pelvic venous insufficiency (PVI), the optimal imaging modality is ill-defined. Transabdominal ultrasound (TAU) is widely used to identify the presence of iliac vein stenosis. The purpose of the present investigation is to determine the accuracy of TAU for determining the presence of an iliac vein area-reducing lesion compared with intravascular ultrasound (IVUS).

METHODS

From January to December 2020, a retrospective review of prospectively collected data from 96 patients treated for symptomatic PVI at the Center for Vascular Medicine was performed. All patients had complete history and physical examination findings, demographics, CEAP (clinical, etiologic, anatomic, pathophysiologic), revised venous clinical severity score, and TAU, diagnostic venography, and IVUS measurements recorded in our electronic medical record system. All TAU measurements were performed by the same ultrasound technician with the patient in the supine position. Iliac vein diameters of the common femoral, external iliac, and common iliac veins and the inferior vena cava were obtained. Differences in body habitus were normalized by dividing the minimum diameter measurement of the stenotic vessel with that of the ipsilateral common femoral vein, subtracting this number from 1 and multiplying by 100 (stenosis = [1 - minimal diameter/common femoral diameter] × 100). The normalized stenoses were then compared with the IVUS-derived area reducing measurements. A receiver operating characteristic curve was created, and logistic regression analysis for the probability of predicting an area-reducing lesion of >50% and >60% with TAU was performed. The sensitivity, specificity, and positive and negative predictive values were calculated.

RESULTS

The average age of the entire cohort was 49.8 ± 13.5 years, with 69 women and 27 men. The CEAP distribution was as follows: C0, 5%; C1, 5%; C2, 10%; C3, 40%; C4a,b, 30%; C5, 7%; and C6, 3%. The average revised venous clinical severity score was 6.2 ± 2.6. The indications for intervention were leg symptoms alone in 43%, pelvic symptoms alone in 3%, and combined leg and pelvic symptoms in 54%. TAU identified a stenosis of ≥50% in 92 of the 96 patients (96%). For a ≥50% stenosis, a normalized diameter of ≤3 mm demonstrated a sensitivity, specificity, and positive and negative predictive value of 75%, 75%, 98%, and 12%, respectively. Logistic regression analysis indicated that TAU was significant in predicting the presence of a ≥60% area-reducing lesion (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P = .009). The area under the receiver operating characteristic curve (c-statistic) was 68.6%. The sensitivity, specificity, and positive and negative predictive values were 66.7%, 66.7%, 81.5%, and 47.6%, respectively, for a normalized diameter of ≥4 mm.

CONCLUSIONS

The ability of TAU to identify an iliac vein stenosis of ≥50% is 96%. The positive predictive value for TAU to identify a ≥60% iliac vein area-reducing lesion is high, with moderate sensitivity and specificity. For patients with symptoms consistent with pelvic venous disorders secondary to PVI, TAU is a good preintervention screening modality for properly trained vascular imaging specialists with findings that correlate well with IVUS measurements.

Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review

Pelvic venous disorders (PeVD), previously known by various imprecise terms including pelvic congestion syndrome, have historically been underdiagnosed as a cause of chronic pelvic pain (CPP), a significant health problem associated with reduced quality of life. However, progress in the field has helped to provide heightened clarity with respect to definitions relating to PeVD, and evolution in algorithms for PeVD workup and treatment has been accompanied by new insights into the causes of a pelvic venous reservoir and associated symptoms. Ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for PeVD. Both treatments have been shown to be safe and effective for patients with CPP of venous origin, regardless of age. Current therapeutic protocols for PeVD exhibit significant heterogeneity owing to limited prospective randomized data and evolving understanding of the factors driving successful outcomes; forthcoming clinical trials are anticipated to improve understanding of CPP of venous origin as well as algorithms for PeVD management. This Expert Panel Narrative Review provides a contemporary update relating to PeVD, summarizing the entity's current classification, diagnostic workup, endovascular treatments, management of persistent or recurrent symptoms, and future research directions.

Surgical and endovascular treatment of pelvic venous disorder: Results of a multicentre retrospective cohort study

OBJECTIVE

In the present study, we investigated the clinical outcomes after gonadal vein resection (GVR) and gonadal vein embolization (GVE) with coils in patients with pelvic venous disorder (PeVD). We also assessed the rates of procedural complications and disease recurrence.

METHODS

Our multicenter retrospective cohort study included 361 female patients with PeVD-related chronic pelvic pain (CPP) and gonadal vein reflux who underwent GVR (n = 184) or GVE with coils (n = 177) from 1999 to 2020. The clinical outcomes (ie, presence and severity of CPP, procedural complications, disease recurrence) were assessed at 1 month and 1, 3, and 5 years after intervention. The pain intensity before and after treatment was assessed using a visual analog scale. All the patients underwent duplex ultrasound after GVR and GVE, and those with persistent CPP and suspected perforation of the gonadal vein by the coils were also evaluated by multiplanar pelvic venography.

RESULTS

GVR and GVE was associated with the reduction or elimination of CPP at 1 month after treatment in 100% and 74% of patients and postprocedural complications in 14% and 37% of patients, respectively (Р < 0.01 for both). The most common complication after either GVR or GVE was pelvic vein thrombosis (11% and 22% patients, respectively; P < .01 between groups). GVE was associated with postembolization syndrome in 20%, coil protrusion in 6%, and coil migration in 1% of patients. The long-term recurrence rate after GVR and GVE was 6% and 16%, respectively (P < .01).

CONCLUSIONS

Both GVR and GVE were found to be effective in treating patients with PeVD. However, GVR was associated with better efficacy in the relief of CPP and lower rates of procedural complications and disease recurrence.

Venous Thromboembolism After Interventions on the Ovarian Veins in Patients With Pelvic Venous Disorder

BACKGROUND

Ovarian vein resection (OVR) and ovarian vein embolization (OVE) are effective options for treating patients with pelvic venous disorder (PeVD). However, due to in an abrupt cessation of blood flow in the ovarian veins (OVs), these interventions can be complicated by pelvic vein thrombosis (PVT). The aim of this study was to assess venous thromboembolism (VTE) rates after OVR and OVE in patients with PeVD.

METHODS

This retrospective cohort study included 272 patients with PeVD who underwent OVR (n = 122) or OVE with coils (n = 150). The rates and clinical manifestations of VTE were assessed in each group on days 1 and 3 after the intervention using duplex ultrasonography. Vein patency, blood flow velocity, and localization of thrombi in the pelvic (parametrial, uterine, and ovarian), iliac, superficial, and deep veins of the lower extremities were examined. PVT was defined as the formation of blood clots in nontarget (i.e. not intended to intervention) veins of the pelvis (parametrial, uterine veins, or tributaries of the internal iliac veins).

RESULTS

VTE after OVR and OVE was identified in 52 (19%) out of 272 patients. In the OVR group, PVT and calf deep vein thrombosis were detected in 9% and 1% of patients, accordingly, while in the OVE group their rates were almost three times higher (24% and 3%; both P = 0.001). In both groups, the most common VTE was PVT. The odds ratio for developing VTE with coils was 10 times higher (95% confidence interval: 2.35-56.43) after OVE than after OVR. Clinical manifestations of PVT were observed in 2.5% of patients, and the rest patients were asymptomatic. No cases of pulmonary embolism occurred.

CONCLUSIONS

VTE after interventions of the ovarian vein in patients with PeVD occurs in every fifth patient. OVE is associated with a higher incidence of PVT.

Retrospective Analysis of Complications After Gonadal Vein Interventions for Pelvic Venous Disorder

INTRODUCTION

To investigate and compare complications after gonadal vein embolization (GVE) with coils and gonadal vein resection (GVR) in patients with pelvic venous disorder (PeVD).

METHODS

This single-center retrospective cohort study included 277 female patients with PeVD who underwent GVE with coils (n = 150) or GVR (n = 122) in the period from 2000 to 2020. The participants were selected from a cohort of 4975 patients with chronic pelvic pain (CPP), of whom 1107 suffered from the PeVD-related CPP and 305 underwent surgical or endovascular intervention on the gonadal veins. The GVR technique was open retroperitoneal in 92, endoscopic transperitoneal in 18, and retroperitoneal in 12 patients. Clinical outcomes included 30-day complication rates and 3-year PeVD recurrence rates. The pain intensity was assessed before and after the procedure using a visual analogue scale. All patients underwent duplex ultrasound after the procedure, and those with persisting pain and suspected gonadal vein perforation with coil were also examined using computed tomographic venography.

RESULTS

A substantial pelvic pain relief was achieved within 30 d after GVE and GVR in 73% and 100% patients, accordingly (Р = 0.001). Complications after GVE were identified in 85 (56%) patients. The major complications included pelvic vein thrombosis (PVT) and calf deep vein thrombosis (24%), postembolization syndrome (22%), and coil protrusion (5.3%). Complications after GVR occurred in 14 (11%) patients and consisted of PVT (10%) and ileus (1.6%). The 3-year recurrence rates after GVE and GVR were 11% and 5%, accordingly (P = 0.04).

CONCLUSIONS

In patients with PeVD, the gonadal vein embolization with coils is associated with a high complication rate, which can be reduced with further development of the GVE technique, the use of new embolic agents, and the selection of a treatment method based on the patient's body composition.

Nitinol stents placed in iliac veins are not associated with prolonged back pain

INTRODUCTION

Endovascular stenting is the standard of care for the management of symptomatic chronic venous obstruction. The increased radial resistive force and longer lengths of Nitinol stents have led to questions over persistent post-operative back pain. The purpose of this investigation was to assess the incidence and severity of post-operative back pain of Nitinol stents compared to Wallstents.

METHODS

A retrospective review of data at the Center for Vascular Medicine was performed. Patient demographics, pre-operative, one week, three-, six,- and 12 month visual analog pain scores (VAS) for back pain, stent type, diameter, length, and vein locations were assessed.

RESULTS

From April 2014 to November 2021, 627 (412 women/215 men) patients were assessed for the presence of post-operative back pain after an initial iliac vein stent placement. Stents utilized were Wallstents (n = 114), Venovo (n = 342), and Abre (n = 171). The most common Nitinol stent diameter and lengths were 14 mm, 16 mm, and 120 mm, respectively (p ≤ .03). The incidence of back pain at one week was 66% (411/627). VAS scores at one week and one, three, and six months post-operatively were the following: Wallstents-2.6 ± 3 (n = 66), 1.7 ± 2.6 (n = 43) 0.7 ± 2 (n = 51), and 0 ± 0 (n = 27); Abre-3.5 ± 3 (n = 130), 3.8 ± 3 (n = 19), 1.2 ± 2.5 (n = 12), and 1 ± 2 (n = 5); and Venovo- 2.5 ± 3 (n = 216), 2.4 ± 3 (n = 70), 0.9 ± 2 (n = 68), and 0.6 ± 1.7 (n = 49). There was no difference in the severity of back pain at any time point (p ≥ .99). The development of back pain was unrelated to stent type, diameter, length, or covered vein territory.

CONCLUSIONS

Post-operative back pain was observed in 66% of patients at one week. The average pain score at one week for the entire cohort was three, which declined to less than one at one month. No difference in the severity of back pain between groups was observed at any time point, and the development of back pain is unrelated to stent type, diameter, length, or covered vein territory.

Insights into pelvic venous disorders

Pelvic venous disorders (PeVD), sometimes referred to as pelvic congestion syndrome (PCS), widely impact affected patients-mainly young women's quality of life, causing puzzling, uncomfortable symptoms sometimes requiring months or years to get an explanation, while simply remaining undiagnosed in other cases. Because pelvic pain is a non-specific symptom, an appropriate diagnosis requires a careful patient workup, including a correlation between history and non-invasive imaging. Invasive imaging is frequently required to confirm the diagnosis and plan treatment. Current therapeutic approaches principally rely on minimally invasive techniques delivered through endovascular access. However, while comprehensive descriptive classifications such as the symptoms-varices-pathophysiology (SVP) classification exist, universally accepted guidelines regarding therapy to apply for each SVP category are still lacking. This review strongly focuses on PeVD imaging and discusses available therapeutic approaches with regard to pathophysiological mechanisms. It proposes a new classification scheme assisting clinical decision-making about endovascular management to help standardize the link between imaging findings and treatment.

Proximal coil occlusion preceding distal sclerotherapy in patients with pelvic congestion syndrome: A multicenter, retrospective study

OBJECTIVE

We investigated the efficacy, feasibility, and safety of proximal coil occlusion preceding distal sclerotherapy (PCODS) for patients with pelvic congestion syndrome (PCS).

METHODS

We performed a multicenter, retrospective cohort study of 94 patients with PCS who had undergone PCODS and 53 patients who had undergone standard endovascular embolization (control group) between June 2014 and April 2020. The primary end point was the clinical remission rate and the secondary end points were the operative time, total fluoroscopy time, radiation dose, overall length of coils used per case, and adverse events. The patients were followed up at 1, 3, 6, and 12 months.

RESULTS

PCODS was successfully performed in 94 patients (100%). The clinical remission rates were significantly higher in the PCODS group than in the control group at 1, 6, and 12 months (P = .036, P = .032, and P = .032). The operative time and total fluoroscopy time were shorter for the PCODS group than for the control group (48.3 ± 5.2 minutes and 37.7 ± 4.4 minutes vs 53.9 ± 4.8 minutes and 42.6 ± 4.1 minutes, respectively; P < .001 for both). The radiation dose was significantly lower in the PCODS group than in the control group (362,634.69 ± 41,533.13 mGy·cm² vs 421,578.30 ± 49,517.93 mGy·cm²; P < .001). The overall length of coils used per case was 19.8 ± 6.0 cm in the PCODS group and 31.7 ± 8.5 cm in the control group (P < .001). Migration of n-butyl cyanoacrylate to the renal vein occurred in two patients in the control group.

CONCLUSIONS

We found PCODS was feasible with a higher clinical remission rate and mild adverse effects in patients with PCS.

Comprehensive overview of the venous disorder known as pelvic congestion syndrome

Pelvic venous disorders (PeVD) also known as Pelvic Congestion Syndrome (PCS) affect a great number of women worldwide and often remain undiagnosed. Gynecological symptoms caused by vascular background demand a holistic approach for appropriate diagnosis. This is a relevant cause of chronic pelvic pain and atypical varicose veins. The diagnosis is based on imaging studies and their correlation with clinical presentation. Although the aetiology of PCS still remains unclear, it may result from a combination of factors including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension and dilatation. The following paper describes an in-depth overview of anatomy, pathophysiology, symptoms, diagnosis and treatment of PCS. In recent years, minimally invasive interventions have become the method of first choice for the treatment of this condition. The efficacy of a percutaneous approach is high and it is rarely associated with serious complications.Key MessagesPelvic venous disorders demand a holistic approach for appropriate diagnosis.This article takes an in-depth look at existing therapies of Pelvic Congestion Syndrome and pathophysiology of this condition.Embolisation is an effective and safe treatment option.

Venous Anatomy and Collateral Pathways of the Pelvis: An Angiographic Review

The pelvic venous system is complex, with the potential for numerous pathways of collateralization. Owing to stenosis or occlusion, both thrombotic and nonthrombotic entities in the pelvis may necessitate alternate routes of venous return. Although the pelvic venous anatomy and collateral pathways may demonstrate structural variability, a number of predictable paths often can be demonstrated on the basis of the given disease and the level of obstruction. Several general categories of collateral pathways have been described. These pathway categories include the deep pathway, which is composed of the lumbar and sacral veins and vertebral venous plexuses; the superficial pathway, which is composed of the circumflex and epigastric vessels; various iliofemoral collateral pathways; the intermediate pathway, which is composed of the gonadal veins and the ovarian and uterine plexuses; and portosystemic pathways. The pelvic venous anatomy has been described in detail in cadaveric and anatomic studies, with the aforementioned collateral pathways depicted on CT and MR images in several imaging studies. A comprehensive review of the native pelvic venous anatomy and collateralized pelvic venous anatomy based on angiographic features has yet to be provided. Knowledge of the diseases involving a number of specific pelvic veins is of clinical importance to interventional and diagnostic radiologists and surgeons. The ability to accurately identify common collateral patterns by using multiple imaging modalities, with accurate anatomic descriptions, may assist in delineating underlying obstructive hemodynamics and diagnosing specific occlusive disease entities. ^©RSNA, 2022.

Pelvic Pain in Reproductive Age: US Findings

Pelvic pain in reproductive age often represents a diagnostic challenge due to the variety of potential causes characterized by overlapping clinical symptoms, including gynecological and other disorders (e.g., entero-colic or urological). It is also necessary to determine if there is a possibility of pregnancy to rule out any related complications, such as ectopic pregnancy. Although ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are strongly integrated, the choice of which is the ideal diagnostic tool should be guided both by clinical suspicion (gynecological vs. non-gynecological cause) and by the risk ratio–benefit (ionizing radiation and instrumental costs), too. The didactic objective proposed by this review consists in the diagnosis of the cause and differential of pelvic pain in reproductive age by describing and critically analyzing the US diagnostic clues of the most frequent adnexal, uterine, and vascular causes.

Varicose Veins and Chronic Venous Disease

Chronic venous disease is a worldwide problem associated with significant morbidity and is expected to increase in prevalence as the current population ages. This is a comprehensive review of the anatomy, pathophysiology, genomics, clinical classification, and treatment modalities of chronic venous disease.

Pelvic Congestion Syndrome in a Postmenopausal Female

This study reports the case of a 53-year-old postmenopausal woman and explores her unique experience with pelvic congestion syndrome (PCS). PCS is a relatively newly recognized entity and is still a diagnosis of exclusion. We analyze the presenting symptoms and imaging findings on CT and ultrasonography. We also examine the potential causes of this ambiguous prognosis. This case is unusual in that PCS usually presents in premenopausal rather than postmenopausal women.

Advances of Laparoscopy for the Diagnosis of Pelvic Congestion Syndrome

The objective of this review is to describe the effectiveness of laparoscopy in the diagnosis and treatment of pelvic congestion syndrome (PCS). PCS is a cause of chronic pelvic pain (CPP) and is associated with dysfunction of the pelvic venous system. PCS is more common in women of reproductive age, and hormonal changes are associated with its development along with other reasons (e.g., working and living habits). There is an urgent need to establish an effective algorithm for the diagnosis and treatment of CPP, which could have a dramatic effect in patients' everyday life. This algorithm should be able to overcome known issues that lead to the underdiagnosis of PCS, such as the overlap of its symptoms with other diseases. Here, we present our findings from literature articles about the methods used in practice today for the diagnosis of this syndrome. We also compare the methods to propose the most promising technique for providing a diagnosis with high accuracy. In our understanding, laparoscopy is superior when compared to other methods. It can provide a diagnosis of PCS while excluding or identifying other comorbidities and can also lead toward the next steps for the treatment of PCS.

Pregnancy after iliac vein stenting for pelvic venous insufficiency

BACKGROUND

The use of iliac vein stenting for the treatment of pelvic pain secondary to pelvic venous insufficiency has significantly increased. In women of childbearing age, the effect of the gravid uterus on stent function and patency is unclear. The purpose of this investigation was to determine the effect of pregnancy on stent patency and reintervention rate in women with iliac vein stents.

METHODS

A retrospective chart review and email survey was performed to identify women treated at the Center for Vascular Medicine who were treated with iliac vein stenting and who had subsequent pregnancies. Medical and surgical comorbidities, stent type, location, length, number of stents, reintervention rates, number of pregnancies after stenting, anticoagulation usage during pregnancy, and type of delivery were assessed.

RESULTS

From January 2014 to December 2020, 15 women with 16 iliac vein stents and who had 17 subsequent pregnancies were identified. The average age at stenting was 35.3 ± 4.13 years. The average interval between stenting and conception was 350 ± 287 days. Before pregnancy, stent location was in the right common/right external iliac veins in 1 patient and left common/external iliac veins in 14 patients. The average stent diameter and length were 19.6 ± 3 and 79.5 ± 20.3 mm, respectively. Thirteen Boston Scientific Wallstents and three Bard Venovo stents were used before pregnancy. One patient with a Wallstent required a stent extension before pregnancy and one patient had two stents placed at the initial procedure. Two women were pregnant twice after stenting for a total of 17 pregnancies. There were 16 term and 1 premature delivery of single infants. Patients were treated with enoxaparin (Lovenox) for stent-related thrombosis prophylaxis in 11 of 17 pregnancies, 5 had no prophylaxis, and the status of 1 pregnancy is unknown. One asymptomatic patient underwent a stent venoplasty after delivery.

CONCLUSIONS

Iliac vein stents tolerate a gravid uterus well. No stents thrombosed during or after pregnancy and none required reintervention secondary to pregnancy-related compression. Anticoagulation with low-molecular-weight heparin should be considered for stent thrombosis prophylaxis. Potential pregnancy should not be considered a contraindication to iliac vein stenting for the treatment of symptomatic pelvic venous insufficiency.

[Diagnosis of arteriovenous compression in small pelvic varicose veins]

AIM

The study was aimed at assessing the incidence of arteriovenous compression in women with chronic venous insufficiency of the inferior vena cava and at developing an optimal diagnostic algorithm.

PATIENTS AND METHODS

During the period 2019-2020, we performed a cross-sectional study including a total of sixty-six 18-to-55-year-old (mean 33.5±5.0) women with clinical manifestations of chronic venous insufficiency of the basin of the inferior vena cava. A diagnostic algorithm included questionnaire, transvaginal ultrasound examination, multislice computed tomography, direct phlebography in combination with phlebotonometry.

RESULTS

Chronic venous insufficiency of lower limbs was diagnosed in 66 (100%) cases and was presented by the following clinical classes according to the CEAP classification: C0 - 4.5%, C1 - 60.6%, C2 - 27.2%, C3 - 3%. Symptoms of pelvic venous plethora were revealed in 36 (55.5%) examined patients. Arteriovenous compression syndrome according to the findings of multislice computed tomography was verified in 16 (24%) women, including May-Turner syndrome in 5 (7.6%), aortomesenteric compression syndrome in 8 (12%) women, with a combination of both syndromes observed in 3 cases; the frequency of their detection did not differ statistically in subgroups of women with and without clinical signs pelvic varicose veins. Direct phlebography in combination with phlebotonometry was performed in 9 women, the diagnosis of arteriovenous compression (May-Thurner syndrome) was confirmed in 1 case only.

CONCLUSION

In women with signs of chronic venous insufficiency in the system of the inferior vena cava the frequency of detecting arteriovenous compression on multislice computed tomography may reach 24% and does not depend on the presence of symptoms of pelvic venous plethora. The proportion of arteriovenous compression according to the findings of direct phlebography and phlebotonometry in the structure of causes of the development of pelvic varicose veins did not exceed 11%. An algorithm for diagnosing arteriovenous compression syndromes should obligatorily include multislice computed tomography, direct phlebography and phlebotonometry.

Is the Prevalence of Estimated Pelvic Congestion Higher Than Examined? A Retrospective Study of Consecutive Abdominopelvic Computed Tomography Analyses

BACKGROUND

Chronic pelvic pain (CPP) is a common complaint in women, and is the key factor in the diagnosis of pelvic congestion syndrome (PCS).

INTRODUCTION

Consecutive abdominal and pelvic computed tomography (CT) scans in adult female patients not diagnosed with PCS and collected over a period of 3 years were evaluated retrospectively to determine the prevalence of underestimated pelvic congestion (PC).

METHODS

500 consecutive abdominal and pelvic CT scans collected from female patients aged 18-80 years were retrospectively analyzed for the presence of PC.

RESULTS

90 of the CT scans examined showed the presence of PC (18 %). These patients were divided into two groups: Group I had 52 scans with unilateral PC, while Group II had 38 scans with the bilateral enlarged ovarian vein (OV). Left and right OV diameters were measured as 7.14±2.15 and 5.56±1.87 mm, respectively. Co-occurrence of additional vascular anomalies, such as nutcracker-type compression of the left renal vein, and May Thurner, was significantly higher in Group I than Group II (p<0.001). The diameter of the OV remained wide irrespective of age in Group I, but showed a decrease with increasing age in Group II. The most common complaint was abdominal pain; these patients required an average of six referrals to two different clinics (primarily general surgery and internal medicine) before being diagnosed with PC.

CONCLUSION

The diagnosis of PCS remains to be an important problem for patients because of insufficient perception of physicians. PCS should be considered in female patients with complaints of chronic abdominal and pelvic pain and CT may be a valuable examination tool for diagnosis.

Nutcracker Syndrome: How to Diagnose It and When/How Should It Be Treated in the Pelvic Venous Disease Population

With wider recognition of left renal vein compression / obstruction, especially as an incidental finding, the significance as it relates to the patient's symptoms needs to be evaluated in light of variable practices and results of treatment. This communication deals with problems of diagnosis, clinical significance, options and indications for treatment.

Ovarian Vein Embolization: How and When Should It Be Done?

Pelvic Venous Disease (PeVD) is characterized by pelvic varicosities and chronic pelvic pain, defined as noncyclic pelvic pain that persists for more than 6 months. Pain and discomfort related to PeVD typically worsen with upright positioning and occur more frequently in multiparous and premenopausal women. The most common cause of PeVD is pelvic venous insufficiency (PVI) due to incompetent valves. Noninvasive imaging modalities such as ultrasound, computed tomography, or magnetic resonance imaging, and invasive catheter-based venography can help characterize varicosities and venous insufficiency, supporting the diagnosis of PeVD. In patients with PeVD, ovarian and/or internal iliac vein embolization demonstrate excellent technical and clinical success rates with relatively low complication rates and should be considered as standard management, in conjunction with medical therapy. Appropriate diagnostic work-up and patient selection are important prior to any intervention for achieving therapeutic success, as multiparous women have a higher success rate compared to patients with dyspareunia after embolization therapy. Post-procedure follow-up is critical for assessing symptom improvement and need for repeat intervention. However, further research is needed to identify additional predictors of successful outcomes after embolization therapy. This article aims to provide an overview of patient selection, interventional technique, challenges, and outcomes of ovarian vein embolization.

Pelvic venous insufficiency secondary to iliac vein stenosis and ovarian vein reflux treated with iliac vein stenting alone

BACKGROUND

We have previously reported that in women with a pelvic venous disorder secondary to pelvic venous insufficiency, 56% will present with an iliac vein stenosis (IVS) and ovarian vein reflux (OVR). The purpose of the present investigation was to determine whether women with combined disease can be treated using iliac vein stenting alone.

METHODS

A retrospective review of prospectively collected data at the Center for Vascular Medicine was performed. We investigated women with pelvic pain or dyspareunia secondary to combined IVS and OVR who had undergone stenting alone. The patient demographics, pre- and 6-month postoperative visual analog scale (VAS) for pain scores, stent type, stent diameter, stent length, and ovarian vein diameters were assessed. All patients had undergone diagnostic venography of their pelvic veins, left ovarian veins, and pelvic reservoirs and intravascular ultrasonography of their iliac veins.

RESULTS

From May 2016 to October 2019, 82 patients with a pelvic venous disorder secondary to IVS and OVR were identified. The present data analysis focused on 38 patients with complete pre- and postoperative VAS scores and duplex scan stent patency data at 6 months. The pelvic and dyspareunia VAS scores at the initial and 6-month follow-up visits were as follows: 6.83 ± 3.19 and 4.24 ± 2.65 and 1.72 ± 2.01 and 0.05 ± 2.0, respectively (P ≤ .001). At 6 months, 29 of the 38 women (76%) reported complete resolution of all symptoms, 26 of 28 (93%) reported complete resolution of their dyspareunia, 5 of 38 (13%) reported significant improvement, and 4 of 38 (10%) reported no improvement. The average ovarian vein diameter was 6.7 ± 2.5 mm. The average stent size and length was 18.20 ± 1.6 mm and 92.41 ± 18.5 mm, with 25 placed in the left common iliac, 2 in the right common iliac vein, and 3 bilaterally. Of the 38 patients, 7 required reintervention (18%). An untreated pelvic reservoir was observed in 17 of the 38 patients (44%). One of the two with no response and six of the patients with improvement had OVR and an untreated pelvic reservoir. The remaining 10 patients with a pelvic reservoir had experienced complete resolution of their symptoms with stenting alone.

CONCLUSIONS

Of the 38 women with pelvic pain secondary to combined IVS and OVR, 76% achieved complete symptom resolution with iliac vein stenting alone. Most of the women with a pelvic reservoir were asymptomatic and reported full symptom resolution after stenting alone. However, these data suggest that in some women, a relationship might exist between the presence of a pelvic reservoir and the persistence of symptoms. Therefore, for women with combined IVS and OVR, we recommend iliac vein stenting alone and staged ovarian vein embolization only for women with persistent symptoms.

[Immediate and remote results of endovascular embolization of ovarian veins]

Presented in the article is a prospective study of endovascular embolization of ovarian veins in female patients suffering from primary pelvic varicose veins, with the assessment of the immediate and remote results, as well as a 1-year follow up.

AIM

The aim of our investigation was a comprehensive clinical and instrumental assessment of efficacy of endovascular embolization in women with pelvic varicose veins.

PATIENTS AND METHODS

Our single-centre study included a total of 29 female patients presenting with pelvic varicose veins and undergoing embolization of ovarian veins using microcoils, in 5 cases the procedure was supplemented with injecting a foam sclerosant.

RESULTS

The technical success of endovascular occlusion of ovarian veins amounted to 100%. Two women immediately after the operation were subjected to a redo intervention: in one case - resection of the ovarian vein and in the second case - repositioning of the microcoils. In the remote period, one patient due to recurrent relapses underwent repeat embolization followed by retroperitoneal resection of the ovarian vein. The findings of the clinical methods of examination demonstrated a decrease in the intensity of manifestations of pelvic varicose veins according to the pelvic venous clinical severity score and visual analogue scale, as well as improvement of the women's quality of life.

CONCLUSION

Endovascular occlusion of ovarian veins is a highly effective, minimally invasive, and safe method of treatment of female patients with incompetent ovarian veins. Endovascular treatment may be regarded as a method of choice in management of the primary form of pelvic varicose veins.

Presentation patterns in women with pelvic venous disorders differ based on age of presentation

BACKGROUND

The prevalence and presentation patterns in women with pelvic venous disorders (PeVD) secondary to pelvic venous insufficiency (PVI) at various ages are ill-defined. The purpose of this investigation was to determine if the types of symptoms, interventions, and treatment outcomes of women with PeVD varied with age progression.

METHODS

From January 2015 to December 2019, we retrospectively reviewed prospectively collected data on 1,280 women with PeVD from our electronic medical record at the Center for Vascular Medicine (CVM). Medical and surgical comorbidities, past medical history, presenting pelvic and lower extremity symptoms, Clinical, Etiology, Anatomy, Pathophysiology (CEAP) class, revised Venous Clinical Severity Score (rVCSS), visual analog pain score (VAS) and types of interventions were assessed. Patients were grouped into five categories based on age of initial presentation: 20-29, 30-39, 40-49, 50-59, and greater than or equal to 60. Patients were also subcategorized according to their course of treatment: Iliac venous stenting alone, ovarian vein embolization (OVE) alone, simultaneous iliac vein stenting and ovarian vein embolization, and staged iliac vein stenting and ovarian vein embolization. Differences in groups were analyzed utilizing chi square, analysis of variance and regression analysis with Graphpad Prism 8 (San Diego, CA) and SAS Studio 3.8 (Cary, NC) statistical software.

RESULTS

From January 2015 through December 2019, 1,280 women were treated for PeVD. The average ages in each group were the following: 26.53 ± 2.90 (n = 57), 35.80 ± 2.84 (n = 238), 44.98 ± 2.78 (n = 345), 54.67 ± 2.90 (n = 324) and 68.39 ± 8.44 (n = 316) respectively. The prevalence of PVI by age group was 4.45%,18.59%, 26.95%, 25.31% and 24.70% respectively (p < 0.05). The prevalence of diabetes, hypertension, coronary artery disease (CAD) and hypercholesterolemia differed between age groups (p < 0.05). Significant differences in the prevalence of pelvic pain, dyspareunia, dysmenorrhea, vulvar varices, leg pain, leg edema, leg heaviness, restless legs, varicose veins, and leg ulcers were observed across treatment groups (p < 0.05). CEAP distribution differed by age with CEAP 0-2 decreasing with age, CEAP 3 progressively increasing with age and CEAP 4-6 predominantly observed in patients older than 50. Analysis of variance indicated that with each decile increase in age, the prevalence of leg symptoms increased (p < 0.05) with a reciprocal decrease in pelvic symptoms (p < 0.05). All intervention types were infrequent in twenty year old's. There was a linear increase in stenting with each decile increase in age. The prevalence of OVE was similar across all age groups. There was an overall improvement in VAS scores for all treatment and age groups. For patients in their 20 s, an initial improvement in VAS scores was observed with moderate recurrence of pain observed after three months.

CONCLUSION

PeVD presents as a spectrum of signs and symptoms, with pelvic and leg symptoms being inversely related according to age. The prevalence of PeVD is lowest in patients in their twenties with differences in presentation observed with increasing age. Venous stenting progressively increases with each decile of age whereas the prevalence of OVE is similar regardless of age. There is overall improvement in symptoms post intervention, although women in their 20 s do not respond as well to intervention as women in other age groups. Future investigations will focus on determining which pelvic venous lesion is the predominant factor that needs correction to achieve maximal pain reduction.

Imaging Appearance and Nonsurgical Management of Pelvic Venous Congestion Syndrome

Pelvic venous congestion syndrome (PVCS) is a challenging and complex cause of chronic pelvic pain in female patients. PVCS due to incompetent vein valves is the combination of gonadal vein reflux and pelvic venous engorgement in patients with chronic pelvic pain without other causes. However, pelvic venous engorgement and gonadal vein reflux can be seen in patients without pelvic pain, which makes obtaining a detailed history and physical examination important for workup and diagnosis. The underlying cause of PVCS may be incompetent gonadal vein valves or structural causes such as left renal vein compression with an incompetent gonadal vein valve (nutcracker syndrome) or iliac vein compression (May-Thurner configuration) with reflux into the ipsilateral internal iliac vein. Venography is considered the criterion standard for imaging diagnosis; however, more recently, US and MRI have been shown to provide adequate accuracy for diagnosis. Noninvasive imaging studies aid in the diagnosis of PVCS and also aid in pretreatment planning. When PVCS is caused by incompetent gonadal vein valves, treatment typically is performed by means of embolization via a minimally invasive catheter with excellent technical and clinical success rates. When PVCS is caused by venous obstruction, the obstruction must be treated first before gonadal vein embolization and sclerotherapy are considered. ^©RSNA, 2019 Online supplemental material is available for this article.

Symptoms in Dilating Venous Disease

Lower extremity venous diseases or insufficiency include clinically deteriorating conditions with morphological and functional alterations of the venous system, including venous hypertension, vascular wall structural abnormality, and venous valvar incompetency in association with an inflammatory process. In fact, the same pathophysiological processes are the main underlying mechanisms of other venous insufficiencies in different vascular territories such as Peripheral Varicose Vein (PVV), varicocele, Pelvic Varicosities or Congestion Syndrome (PCS) and Hemorrhoidal Disease (HD). Regarding the anatomical continuity of lower extremity venous system, urogenital system (pampiniform plexus in male and broad ligament and ovarian veins in female) and anorectal venous system, it is reasonable to expect common symptoms such as pain, burning sensation, pruritis, swelling, which arise directly from the involved tissue itself. High coexistence rate of PVV, varicocele/PCS and HD between each other underlines not only the same vascular wall abnormality as an underlying etiology but also the existence of common symptoms originating from the involved tissue in dilating venous disease. Accordingly, it might be reasonable to query the common symptoms of venous dilating disease in other venous vascular regions in patients with complaints of any particular venous territory.

Pelvic congestion syndrome and embolization of pelvic varicose veins

Pelvic congestion syndrome (PGS) is defined as chronic pelvic pain for more than 6 months associated with perineal and vulvar varicose veins caused by reflux or obstruction in gonadal, gluteal, or parauterine veins. PGS accounts for 16-31% of cases of chronic pelvic pain, and is usually diagnosed in the third and fourth decades of life. Interest in this condition among vascular surgeons has been increasing over recent years because of its association with venous insufficiency of the lower limbs. Despite its significant prevalence, PGS is still poorly diagnosed in both gynecology and angiology offices. Therefore, in this article we review the etiology and diagnosis of this condition and the outcomes of the different types of treatment available.

May-Thurner syndrome presenting as pelvic congestion syndrome and vulvar varicosities in a nonpregnant adolescent

May-Thurner syndrome (MTS) refers to compression of the left common iliac vein (CIV) by the common iliac artery. Although this is typically manifested as acute left lower extremity deep venous thrombosis, MTS is a rare cause of pelvic congestion syndrome. A 17-year-old girl presented with a 5-year history of worsening painful vulvar and labial varicosities. Venography demonstrated pelvic collateralization and left CIV stenosis consistent with MTS. The left CIV was stented with complete radiographic resolution. At 1-year follow-up, the patient is asymptomatic with a widely patent stent. This case highlights the role of endovascular therapy for patients presenting with MTS causing pelvic congestion syndrome.

Incidence and distribution of lower extremity reflux in patients with pelvic venous insufficiency

Introduction

Women with pelvic venous insufficiency often present with lower extremity symptoms and manifestations of chronic venous disorders. The purpose of this investigation was to determine the incidence of lower extremity chronic venous disorders and the types and distribution of lower extremity veins involved in patients with a known diagnosis of pelvic venous insufficiency.

Methods

Between January 2012 and December 2015, we retrospectively reviewed the charts of 227 women with pelvic venous insufficiency as well as their lower extremity venous duplex investigations. Presenting symptoms, Clinical, Etiology, Anatomy, Pathophysiology (CEAP) class, initial revised Venous Clinical Severity Score (rVCSS) and the types of lower extremity veins with reflux and their locations were noted. Patients were also subcategorized according to their primary pelvic disorder as follows: Entire cohort (PVI), Ovarian vein reflux (OVR), Iliac vein stenosis (IVS) or both (OVR + IVS).

Results

The study group consisted of 227 women (454 limbs) with documented pelvic venous insufficiency. The average age was 44.71 ± 10.2 years. In decreasing order, patients presented with the following lower extremity symptoms: pain (66%), swelling (32%), heaviness (26%), limb fatigue (13%), itching (13%), leg cramps (10%), skin changes or Superficial Venous Thrombosis (SVT) (2%) and ulceration or bleeding (0.08%). Table 1 outlines the CEAP class for 215 of the 227 patients. For the entire cohort, 48% of right and 50% of left limbs demonstrated C0 or C1 disease. The incidence and type of symptomatic lower extremity veins were as follows: any axial vein, 32%; great saphenous vein (GSV), 21%; small saphenous vein (SSV), 11%; GSV and SSV, 5%; non-saphenous tributaries, 15%; saphenous tributaries, 12%; posterior or postero-lateral thigh distribution, 5%; vulvar distribution, 4%; perforators, 4%; deep veins, 2%; and anterior accessory saphenous veins, 1%. For the GSV and SSV, the following patterns of reflux were observed: entire GSV, 4%; entire above knee GSV, 2%; entire below knee GSV, 2%; above knee segmental GSV, 20%; below knee segmental GSV, 21%; above and below knee GSV segmental disease, 1%; entire SSV, 4%; and SSV segmental disease, 12%. The incidence of reflux in any axial vein, the GSV and anterior accessory GSV was greater in the OVR group compared to IVS or OVR + IVS (p ≤ 0.03). In addition, 64 of 227 (28%) patients had a history of prior lower extremity venous ablations: OVR (10/39, 26%), IVS (15/50, 30%) and OVR + IVS (39/127, 9%). The number of ablations per patient was as follows—OVR: 1.48 ± 0.5, IVS: 1.7 ± 0.7 and OVR + IVS: 1.65 ± 0.7.

Conclusion

At least 50% of patients with pelvic venous insufficiency present with lower extremity venous disease. The incidence of reflux in any axial vein is greatest in the OVR group suggesting a correlation with hormonal fluctuations and pregnancy. The majority of symptomatic patients present with segmental axial GSV or SSV disease. Although vulvar and gluteal escape veins are highly associated with pelvic venous insufficiency, they are infrequently observed. In patients who experience residual or persistent symptoms after treatment for chronic venous disorders, a pelvic venous ultrasound should be performed to assess the presence of pelvic venous insufficiency.

Evaluating the frequency and severity of ovarian venous congestion on adult computed tomography

PURPOSE

While pelvic congestion syndrome and chronic pelvic pain are relatively common in women, no large- or medium-sized studies have been conducted to our knowledge to evaluate the frequency and severity of ovarian vein dilatation (OVD) on computed tomography (CT). The purpose of our study was therefore to analyze a large number of consecutive abdominal and pelvic CT scans in adult women to determine OVD frequency and severity.

METHODS

An IRB-approved, single-institution retrospective analysis of 1042 consecutive abdominal and pelvic CT scans in women ages 25-65 was performed. Scans were evaluated for the presence and severity of OVD and association with "nutcracker anatomy." A gradation scheme was developed based on quartile analysis.

RESULTS

143 of the CT scans had OVD (13.7%). Of the positive scans, 96 were bilateral, 29 were left-side only, 18 were right-side only, and 18 had nutcracker-type compression of the left renal vein (14.4% of scans with left or bilateral OVD). In positive scans, the mean and median left OVD were 7.5 and 7 mm, respectively, and right-side were 7.2 and 7 mm, respectively. Based on quartile analysis, OVD grading was mild (< 6 mm), moderate (6-8 mm), or severe (> 8 mm), with moderate including the middle 50% of patients.

CONCLUSIONS

OVD was found on 13.7% of 1042 consecutive female abdominal and pelvic CT scans, with "nutcracker anatomy" present in 14.4% of the scans with left OVD. Moderate dilatation was defined as an OVD of 6-8 mm at the iliac crests.

Diagnosis and treatment of the Nutcracker syndrome: a review of the last 10 years

The nutcracker syndrome is characterized by a group of clinical manifestations caused by compression of the Left Renal Vein. The main symptoms are: macro and micro hematuria, proteinuria, and flank pain. Diagnosis is usually made after excluding other causes, because there are no clinical criteria for diagnosis. Confirmation is by Doppler ultrasonography or computed tomography. Treatment can vary, depending on patient characteristics and the severity of the symptoms, while conservative treatment, open surgery, and endovascular surgery may be employed. Currently, open surgery is still the first-line treatment, but some less invasive approaches are gaining acceptance.

Sensitivity and specificity of clinical findings for the diagnosis of pelvic congestion syndrome in women with chronic pelvic pain

Background

Pelvic congestion syndrome is among the causes of pelvic pain. One of the diagnostic tools is pelvic venography using Beard’s criteria, which are 91% sensitive and 80% specific for this syndrome.

Objective

To assess the diagnostic performance of the clinical findings in women diagnosed with pelvic congestion syndrome coming to a Level III institution.

Methods

Descriptive retrospective study in women with chronic pelvic pain taken to transuterine pelvic venography at the Advanced Gynecological Laparoscopy and Pelvic Pain Unit of Clinica Comfamiliar, between August 2008 and December 2011, analyzing social, demographic, and clinical variables.

Results

A total of 132 patients with a mean age of 33.9 years. Dysmenorrhea, ovarian points, and vulvar varices have a sensitivity greater than 80%, and the presence of leukorrhea, vaginal mass sensation, the finding of an abdominal mass, abdominal trigger points, and positive pinprick test have a specificity greater than 80% when compared with venography.

Conclusion

This study may be considered as the first to evaluate the diagnostic performance of the clinical findings associated with pelvic congestion syndrome in a sample of the Colombian population. In the future, these findings may be used to create a clinical score for the diagnosis of this condition.

A standardized ultrasound approach to pelvic congestion syndrome

Pelvic congestion syndrome is one of the many causes of chronic pelvic pain and is often diagnosed based on exclusion of other pathologies. Over the past decades, pelvic congestion syndrome was recognized to be a more common cause of chronic pelvic pain. Multiple diagnostic modalities including pelvic duplex ultrasonography, transvaginal ultrasonography, computed tomography, and magnetic resonance were studied. In the current literature, selective ovarian venography, an invasive imaging approach, is believed to be the gold standard for diagnosing pelvic congestion syndrome.