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Szkodziak F, Wozniak S, Szkodziak PR, Pyra K, Paszkowski T. Noninvasive diagnostic imaging of pelvic venous disorders. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024. [PMID: 38325406 DOI: 10.1055/a-2263-7193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
It is estimated that chronic pelvic pain (CPP) may affect up to 24% of women. Unfortunately, very often, despite extensive diagnostics, the cause of CPP remains unknown. The pathophysiology of CPP could be explained to a large extent by the occurrence of pelvic venous disorders (PVD). Although pelvic venography is still considered the gold standard for the diagnosis of PVD, noninvasive diagnostic imaging techniques seem to be instrumental in the initial identification of patients with PVD. This literature review aimed to analyze and evaluate the usefulness of noninvasive diagnostic imaging techniques like transvaginal ultrasonography, transabdominal ultrasonography, magnetic resonance, and computed tomography in the diagnosis and identification of patients with PVD. Forty-one articles published between 1984 and 2023 were included in this literature review. Based on this literature review, we conclude that the clinical application of noninvasive diagnostic techniques in the diagnosis of PVD seems to be very promising. Future studies investigating the role of noninvasive diagnostic imaging techniques in the diagnosis of PVD are required.
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Affiliation(s)
- Filip Szkodziak
- 3rd Chair and Department of Gynaecology, Medical University of Lublin, Lublin, Poland
| | - Slawomir Wozniak
- 3rd Chair and Department of Gynaecology, Medical University of Lublin, Lublin, Poland
| | | | - Krzysztof Pyra
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
| | - Tomasz Paszkowski
- 3rd Chair and Department of Gynaecology, Medical University of Lublin, Lublin, Poland
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Barros FS, Storino J, Cardoso da Silva NA, Fernandes FF, Silva MB, Bassetti Soares A. A comprehensive ultrasound approach to lower limb varicose veins and abdominal-pelvic connections. J Vasc Surg Venous Lymphat Disord 2024; 12:101851. [PMID: 38360403 DOI: 10.1016/j.jvsv.2024.101851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/12/2024] [Accepted: 01/30/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Pelvic venous reflux may be responsible for pelvic venous disorders and/or lower-limb (LL) varicose veins. Ultrasound investigation with Doppler allows a complete study of the entire infra-diaphragmatic venous reservoir. The aim of this study was to guide and standardize the investigation of the pelvic origin of venous reflux in female patients with LL varicose veins. METHODS In this case-control study, we applied a comprehensive ultrasound investigation protocol, which involved four steps: (1) venous mapping of the lower limbs; (2) transperineal and vulvar approach; (3) transabdominal approach; and (4) transvaginal approach. RESULTS Forty-four patients in group 1 (patients with LL varicose veins and pelvic escape points [PEPs]) and 35 patients in group 2 (patients with LL varicose veins without PEPs [control group]) were studied, matched by age. The median age was 43 years in both groups. The calculated body mass index was lower in group 1 (23.4 kg/m2) compared with the control group (25.4 kg/m2), and this difference reached statistical significance (P < .001). The presence of pelvic varicose veins (PVs) by transvaginal ultrasound was 86% in group 1 and 31% in group 2. Perineal PEPs were the most prevalent, being found in 35 patients (79.5%), more frequent on the right (57.14%) than on the left (42.85%) and associated with bilateral PVs 65.7% of the time. In group 1, 23 patients (52%) reported recurrent varicose veins vs eight patients (23%) in the control group (P = .008). Regarding the complaint of dyspareunia, a significant difference was identified between the groups (P = .019), being reported in 10 (23%) patients in group 1 vs one patient (2.9%) in the control group. The median diameters in the transabdominal approach of the left gonadal veins were 6.70 mm for group 1 and 4.60 mm for group 2 (P < .001). In patients with PVs in group 1, the median diameter of PEPs at the trans-perineal window was 4.05 mm. In the transvaginal examination, the mean diameter of the veins in the peri uterine region was 8.71 mm on the left and 7.04 mm on the right. CONCLUSIONS The identification of PEPs by venous mapping demonstrates the pelvic origin of the reflux and its connections with the LL varicose veins. For a more adequate treatment plan, we suggest a complete investigation protocol based on the transabdominal and transvaginal study to rule out venous obstructions, thrombotic or not, and confirm the presence of varicose veins in the pelvic adnexal region.
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Affiliation(s)
| | - Joana Storino
- Department of Vascular Surgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil.
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Shahat M, Abdelbaqy OMA, AbdelHakam AM, Ali SH, Attalla K. Can cross-sectional imaging replace diagnostic venography in pelvic venous disorder (PeVD)? J Vasc Surg Venous Lymphat Disord 2024; 12:101724. [PMID: 38135217 DOI: 10.1016/j.jvsv.2023.101724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The primary etiology of pelvic venous disorder is multifactorial and challengeable in vascular surgery as it mandates multidisciplinary team cooperation for its evaluation and management. METHODS All patients investigated for pelvic venous disorder in a high-volume, tertiary referral university hospital were identified and analyzed retrospectively during the period (March 2021 through September 2022). Demographic and medical data were scored. Agreement between the noninvasive modalities (computed tomographic venography [CTV] or magnetic resonance venography [MRV]) and diagnostic venography in detecting the refluxing pelvic veins was analyzed. Sensitivity, specificity, and diagnostic accuracy are also measured. No patients' treatments were reported in this study as the treatment is scheduled in other sessions in some cases and is out of the scope of this article. All patients had a diagnostic venogram regardless of the axial imaging modality. The main goal was to compare cross-sectional imaging with diagnostic venography. RESULTS The total number of patients was 120 with a mean age of 34.4 ± 7.1 years; 86.7% were multiparous. All patients presented chronic pelvic pain with vulvoperineal and/or atypical lower limb varicosities. Then patients were divided into two groups: those with CTV and those with MRV. Sensitivity, specificity, and diagnostic accuracy of CTV were 50%, 33%, and 47% for the detection of incompetent ovarian veins, 83%, 33%, and 53% for the detection of incompetent internal iliac veins, and 50%, 40%, and 47% for the detection of incompetent pelvic plexus veins, respectively, whereas time-resolved MRV achieved sensitivity, specificity, and diagnostic accuracy of 73%, 25%, and 60% for the detection of incompetent ovarian veins, 75%, 46%, and 53% for the detection of incompetent internal iliac veins, and 67%, 33% and 60% for detection of incompetent pelvic plexus veins, respectively. CONCLUSIONS The desire to avoid the drawbacks of diagnostic venography led to an increase in the use of noninvasive imaging modalities. Our results achieved acceptable sensitivity, specificity, and diagnostic accuracy outcomes for cross-sectional imaging with the superiority of MRV over CTV in diagnosing PCS.
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Affiliation(s)
- Mohammed Shahat
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt.
| | - Omar M A Abdelbaqy
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
| | - Ahmed M AbdelHakam
- Department of Diagnostic and Interventional Radiology, Assiut University Hospitals, Assiut, Egypt
| | - Sahar H Ali
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
| | - Khaled Attalla
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
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Galea M, Brincat MR, Calleja-Agius J. A review of the pathophysiology and evidence-based management of varicoceles and pelvic congestion syndrome. HUM FERTIL 2023; 26:1597-1608. [PMID: 37190955 DOI: 10.1080/14647273.2023.2212846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 04/25/2023] [Indexed: 05/17/2023]
Abstract
Pelvic congestion syndrome (PCS) in females and varicoceles in males may be regarded as closely related conditions since the main pathophysiological cause for both processes is pelvic venous insufficiency. Varicoceles are more prevalent amongst sub-fertile males, with an approximate incidence of 15% in the general male population. PCS is commonly diagnosed amongst premenopausal multiparous women, representing one of the leading causes of chronic pelvic pain. Both conditions appear to be predominantly left-sided and are associated with oxidative stress and pro-inflammatory cascades with subsequent effects on fertility. Clinical examination and pelvic ultrasonography play an essential role in the assessment of varicoceles, PCS and chronic pelvic pain. Venography is generally considered as a gold-standard procedure for both conditions. There is still much debate on how these conditions should be managed. This review article provides a comparative analysis of the underlying pathophysiological mechanisms of both PCS and varicoceles, their impact on fertility, as well as their clinical management.
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Affiliation(s)
- Matteo Galea
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Mark R Brincat
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
- Department of Obstetrics and Gynaecology, Mater Dei Hospital, Msida, Malta
| | - Jean Calleja-Agius
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
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Clark MR, Taylor AC. Pelvic Venous Disorders: An Update in Terminology, Diagnosis, and Treatment. Semin Intervent Radiol 2023; 40:362-371. [PMID: 37575340 PMCID: PMC10415053 DOI: 10.1055/s-0043-1771041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Pelvic venous disorder (PeVD) is a term that encompasses all the interrelated causes of chronic pelvic pain (CPP) and perineal/lower extremity varicose veins of pelvic venous origin historically known as nutcracker syndrome, pelvic congestion syndrome, and May-Thurner syndrome, resulting in a more precise diagnosis that accounts for the underlying pathophysiology and anatomy. PeVD manifests as CPP with associated vulvar and lower-extremity varicosities, left flank pain and hematuria, and lower extremity pain and swelling secondary to obstruction or reflux in the left renal, ovarian, or iliac veins. This article will focus specifically on the most current nomenclature, evaluation, and management of CPP of venous origin.
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Affiliation(s)
- Meghan R. Clark
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
| | - Amy C. Taylor
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
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Gavrilov SG, Mishakina NY, Grishenkova AS. Venous Thromboembolism After Interventions on the Ovarian Veins in Patients With Pelvic Venous Disorder. Ann Vasc Surg 2023; 91:191-200. [PMID: 36464150 DOI: 10.1016/j.avsg.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/07/2022] [Accepted: 11/12/2022] [Indexed: 12/03/2022]
Abstract
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.
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Affiliation(s)
- Sergey G Gavrilov
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia.
| | - Nadezhda Yu Mishakina
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Anastasiya S Grishenkova
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia
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Hemodynamic and neurobiological factors for the development of chronic pelvic pain in patients with pelvic venous disorder. J Vasc Surg Venous Lymphat Disord 2023; 11:610-618.e3. [PMID: 36781107 DOI: 10.1016/j.jvsv.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/18/2022] [Accepted: 01/05/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVE The study was aimed at the identification of hemodynamic and neurobiological factors for the development of chronic pelvic pain (CPP) in patients with pelvic venous disorder (PeVD) using ultrasound, radionuclide, and enzyme immunoassay methods. METHODS This cohort study included 110 consecutive patients with PeVD and 20 healthy controls. Seventy patients with PeVD had symptoms (CPP in 100% of cases, discomfort in hypogastrium, dyspareunia, vulvar varices, and dysuria), and 40 were asymptomatic. Patients underwent clinical examination, duplex ultrasound study of the pelvic veins and lower extremities, and single-photon emission computed tomography of the pelvic veins with in vivo labeled red blood cells. The prevalence, duration, severity, and pattern of reflux in the pelvic veins, as well as the severity of pelvic venous congestion, were evaluated. Healthy controls underwent only clinical and duplex ultrasound examination. All 130 patients were assessed using enzyme immunoassays to determine plasma levels of calcitonin gene-related peptide (CGRP) and substance P (SP). RESULTS Symptomatic patients with PeVD had a higher prevalence of reflux in the ovarian veins (OVs) than asymptomatic ones (45.7% vs 10%, respectively; P = .001) and a greater reflux duration (4.1 ± 1.7 seconds vs 1.4 ± 0.3 seconds; P = .002), although no differences in the OV diameter were found. Similar results were obtained when comparing the diameters of the parametrial veins (PVs) and the duration of reflux in them. Type II/III reflux (greater than 2 seconds) was identified in 41.4% of symptomatic and in only 5% of asymptomatic patients (P = .001). Among patients with CPP, 24.2% had a combined reflux in the OVs, PVs, and uterine veins, and 45.7% had a combined reflux in the OVs and PVs, whereas 90% of patients without CPP had only an isolated reflux in the PVs. The pelvic venous congestion was moderate or severe in 95.7% of patients with CPP and in only 15% patients without CPP (P = .001). In patients with PeVD, the presence of CPP was associated with higher levels of CGRP and SP compared with asymptomatic patients (CGRP: 0.48 ± 0.06 vs 0.19 ± 0.02 ng/mL, respectively, P = .001; SP: 0.38 ± 0.08 vs 0.13 ± 0.03 ng/mL, P = .001). CONCLUSIONS In patients with PeVD, significant hemodynamic and neurobiological factors for the CPP development were found to be reflux in the pelvic veins greater than 2 seconds, involvement of several venous collectors, and increased plasma levels of CGRP and SP.
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Sheikh AB, Fudim M, Garg I, Minhas AMK, Sobotka AA, Patel MR, Eng MH, Sobotka PA. The Clinical Problem of Pelvic Venous Disorders. Interv Cardiol Clin 2022; 11:307-324. [PMID: 35710285 DOI: 10.1016/j.iccl.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Pelvic venous disorders are inter-related pathologic conditions caused by reflux and obstruction in the pelvic veins. It can present a spectrum of clinical features based on the route of transmission of venous hypertension to either distal or caudal venous reservoirs. Imaging can help to visualize pelvic vascular and visceral structures to rule out other gynecologic, gastrointestinal, and urologic diseases. Endovascular treatment, owing to its low invasive nature and high success rate, has become the mainstay in the management of pelvic venous disorders. This article reviews the pathophysiology, clinical presentations, and diagnostic and therapeutic approaches to pelvic venous disorders.
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Affiliation(s)
- Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1021 Medical Arts Avenue NE, Albuquerque, NM 87102, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1021 Medical Arts Avenue NE, Albuquerque, NM 87102, USA
| | - Abdul Mannan Khan Minhas
- Department of Internal Medicine, Forrest General Hospital, 6051 US 49, Hattiesburg, MS 39401, USA
| | | | - Manesh R Patel
- Division of Cardiology, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA
| | - Marvin H Eng
- Division of Cardiology, University of Arizona, Banner University Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006, USA
| | - Paul A Sobotka
- The Ohio State University, 281 West Lane Avenue, Columbus, OH 43210, USA.
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Gavrilov SG, Grishenkova AS, Mishakina NY, Krasavin GV. Use of a novel Likert scale instrument to assess patient satisfaction following endovascular and surgical treatment of pelvic venous disorders. Phlebology 2022; 37:241-251. [DOI: 10.1177/02683555211053119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective The study was aimed at assessing satisfaction with endovascular and surgical treatment, using a novel Likert scale procedure satisfaction instrument, in patients with pelvic venous disorder (PeVD) caused by the gonadal vein reflux. Methods This prospective cohort study included 100 women with PeVD who underwent gonadal veins embolization with coils (GVE group, n = 71) or gonadal veins endoscopic resection (GVR group, n = 29) in 2012–2020. The GVE was performed under local anesthesia and sedation, and was left-sided in 61, right-sided in three, and bilateral in seven patients. The GVR was performed under general anesthesia through transperitoneal ( n = 19) or retroperitoneal ( n = 10) access with three access ports in both cases. The GVR was left-sided in 19, right-sided in one, and bilateral in nine patients. To assess satisfaction with GVE and GVR treatment of PeVD, patients were asked to evaluate statements related to their experience using a new Likert scale instrument. The responses for each item were compared between the groups at Day 7 (D7) and at Month 6 (M6) after the procedure, as was a summary score of all the responses at both time points. The summary score allowed categorization on a spectrum from “completely satisfied” to “completely dissatisfied.” Results The comparison between GVЕ and GVR groups at D7 showed that 80% and 100% of patients, accordingly, reported the overall summary satisfaction, 49% and 79% agreed with a complete pelvic pain relief by D7, 79% and 0% agreed with the absence of a significant discomfort during the first postoperative day, 71% and 100% reported no need for analgesics to relief pain in the assess area, 80% and 100% reported fast return to daily activity, and 19.7% and 100% still experienced pelvic pain at D7 (pain in the GVR group was more severe and required the use of analgesics) (all p < .05). At the same time, 94% and 96% patients were satisfied with the aesthetic result of the procedure at D7 ( p = n.s.). The comparison between GVЕ and GVR groups at M6 showed that 100% of patients in both groups reported overall satisfaction with treatment ( p = n.s.), 96% and 100% confirmed a complete pelvic pain relief by M6, 79% and 65% agreed with the absence of a significant discomfort after the procedure, 79% and 65% reported no need for analgesics, 83% and 100% reported about the return to daily activity (all p < .05), and 100% in both groups were satisfied with the aesthetic result of the procedure ( p = n.s.). Conclusions In patients with PeVD, both GVE and GVR are associated with a high, although not significantly different, overall treatment satisfaction in the long term and have advantages and disadvantages. GVE is associated with less severe post-procedural pain, while GVR provides faster relief of pelvic pain and a return to usual daily activity.
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Affiliation(s)
- Sergey G Gavrilov
- Faculty surgery N°1, Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moskva, Russia
| | - Anastasiya S Grishenkova
- Faculty surgery N°1, Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moskva, Russia
| | - Nadezhda Yu Mishakina
- Faculty surgery N°1, Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moskva, Russia
| | - Gennady V Krasavin
- Faculty surgery N°1, Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moskva, Russia
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Whiteley MS. Current Best Practice in the Management of Varicose Veins. Clin Cosmet Investig Dermatol 2022; 15:567-583. [PMID: 35418769 PMCID: PMC8995160 DOI: 10.2147/ccid.s294990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/27/2022] [Indexed: 12/01/2022]
Abstract
This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.
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Pelvic Pain in Reproductive Age: US Findings. Diagnostics (Basel) 2022; 12:diagnostics12040939. [PMID: 35453987 PMCID: PMC9026765 DOI: 10.3390/diagnostics12040939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Relationships of Pelvic Vein Diameter and Reflux with Clinical Manifestations of Pelvic Venous Disorder. Diagnostics (Basel) 2022; 12:diagnostics12010145. [PMID: 35054312 PMCID: PMC8774919 DOI: 10.3390/diagnostics12010145] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 12/16/2022] Open
Abstract
The causes of chronic pelvic pain (CPP) in patients with pelvic venous disorder (PeVD) are not completely understood. Various authors consider dilation of pelvic veins (PeVs) and pelvic venous reflux (PVR) as the main mechanisms underlying symptomatic forms of PeVD. The aim of this study was to assess relationships of pelvic vein dilation and PVR with clinical manifestations of PeVD. This non-randomized comparative cohort study included 80 female patients with PeVD who were allocated into two groups with symptomatic (n = 42) and asymptomatic (n = 38) forms of the disease. All patients underwent duplex scanning and single-photon emission computed tomography (SPECT) of PeVs with in vivo labeled red blood cells (RBCs). The PeV diameters, the presence, duration and pattern of PVR in the pelvic veins, as well as the coefficient of pelvic venous congestion (CPVC) were assessed. Two groups did not differ significantly in pelvic vein diameters (gonadal veins (GVs): 7.7 ± 1.3 vs. 8.5 ± 0.5 mm; parametrial veins (PVs): 9.8 ± 0.9 vs. 9.5 ± 0.9 mm; and uterine veins (UVs): 5.6 ± 0.2 vs. 5.5 ± 0.6 mm). Despite this, CPVC was significantly higher in symptomatic versus asymptomatic patients (1.9 ± 0.4 vs. 0.7 ± 0.2, respectively; p = 0.008). Symptomatic patients had type II or III PVR, while asymptomatic patients had type I PVR. The reflux duration was found to be significantly greater in symptomatic versus asymptomatic patients (median and interquartile range: 4.0 [3.0; 5.0] vs. 1.0 [0; 2.0] s for GVs, p = 0.008; 4.0 [3.0; 5.0] vs. 1.1 [1.0; 2.0] s for PVs, p = 0.007; and 2.0 [2.0; 3.0] vs. 1.0 [1.0; 2.0] s for UVs, p = 0.04). Linear correlation analysis revealed a strong positive relationship (Pearson's r = 0.78; p = 0.007) of CPP with the PVR duration but not with vein diameter. The grade of PeV dilation may not be a determining factor in CPP development in patients with PeVD. The presence and duration of reflux in the pelvic veins were found to be predictors of the development of symptomatic PeVD.
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Identification of Pelvic Congestion Syndrome Using Transvaginal Ultrasonography. A Useful Tool. Tomography 2022; 8:89-99. [PMID: 35076614 PMCID: PMC8788446 DOI: 10.3390/tomography8010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/20/2021] [Accepted: 12/27/2021] [Indexed: 11/18/2022] Open
Abstract
The gold standard for the diagnosis of pelvic congestion syndrome (PCS) is venography (VG), although transvaginal ultrasound (TVU) might be a noninvasive, nonionizing alternative. Our aim is to determine whether TVU is an accurate and comparable diagnostic tool for PCS. An observational prospective study including 67 patients was carried out. A TVU was performed on patients, measuring pelvic venous vessels parameters. Subsequentially, a VG was performed, and results were compared for the test calibration of TVU. Out of the 67 patients included, only 51 completed the study and were distributed in two groups according to VG results: 39 patients belonging to the PCS group and 12 to the normal group. PCS patients had a larger venous plexus diameter (15.1 mm vs. 12 mm; p = 0.009) and higher rates of crossing veins in the myometrium (74.35% vs. 33.3%; p = 0.009), reverse or altered flow during Valsalva (58.9% vs. 25%; p = 0.04), and largest pelvic vein ≥ 8 mm (92.3% vs. 25%). The sensitivity and specificity of TVU were 92.3% (95% CI: 78.03–97.99%) and 75% (95% CI: 42.84–93.31%), respectively. In conclusion, transvaginal ultrasonography, with the described methodology, appears to be a promising tool for the diagnosis of PCS, with acceptable sensitivity and specificity.
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Doganci S. Poorly Understood Pelvic Venous Disorders Require a Multidisciplinary Approach. PHLEBOLOGIE 2021. [DOI: 10.1055/a-1521-5995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractPelvic venous diseases encompasses all chronic pathologies of pelvic veins caused by venous hypertension and retrograde flow in pelvic veins. It is commonly unexplained and often underdiagnosed cause of chronic pelvic pain in women of productive age. Pelvic venous pathologies are a part of multidisciplinary problem that should be considered in a holistic approach. Newly offered SVP classification may help correctly classifying patients and using the same nomenclature. Endovascular treatment options are highly effective with good long-term results. Patients with inconclusive gynecologists examinations should be referred to a specialist for the investigation of pelvic venous disorders.
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Affiliation(s)
- Suat Doganci
- Health Sciences University, Gulhane School of Medicine, Department of Cardiovascular Surgery Ankara/Turkey
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15
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Stratification of pelvic venous reflux in patients with pelvic varicose veins. J Vasc Surg Venous Lymphat Disord 2021; 9:1417-1424. [PMID: 34023538 DOI: 10.1016/j.jvsv.2021.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We investigated the association between the pattern and duration of pelvic venous reflux (PVR) and pelvic pain severity in patients with pelvic varicose veins (PVVs). METHODS The present retrospective study included 600 female patients with PVVs. Of the 600 patients, 453 had had PVVs and pelvic congestion syndrome (group 1) and 147 had had an asymptomatic disease course (group 2). Pelvic venous pain (PVP) was assessed using a visual analog scale. All the patients had undergone duplex ultrasound of the left and right renal veins, external, internal, and common iliac veins, and parametrial, uterine, gonadal, and vulvar veins (PV, UV, GV, and VV, respectively), with an assessment of their patency and diameter and the presence and duration of reflux. Reflux in the pelvic veins was considered pathologic if it lasted for >1 second. RESULTS In group 1, PVR type I (1-2 seconds), II (3-5 seconds), and III (>5 seconds or spontaneous reflux in the absence of a loading test) was found in 31%, 58%, and 11% of the patients, respectively. Moderate and severe reflux (types II and III) was associated with severe PVP (mean score, 8.3 ± 0.5) in 69% of the group 1 patients. A combination of reflux in the GV, PV, UV, and internal iliac vein was associated with severe PVP (mean score, 8.1 ± 0.3) in 51% of these patients. A combination of reflux in the PVs, UVs, and VVs was associated with moderate pain (mean score, 5.3 ± 0.2) in 49.2% of group 1. In group 2, PVR type I, II, and III was present in 95%, 4%, and 1% of the patients, respectively, and was observed in the PV only in patients with type I; in the GVs, PVs, UVs, and internal iliac veins in those with type II; and in the PVs and GVs in the patients with type III reflux. Reflux in the GVs and UVs was significantly more prevalent in group 1 than in group 2 (GVs, 51% vs 6%; P = .0001; UVs, 57% vs 7%; P = .0001). A combination of reflux in the GVs and UVs was a predictor of severe PVVs (odds ratio, 19.7; 95% confidence interval, 11.3-34.6). CONCLUSIONS In patients with PVVs, the presence and severity of pelvic pain will be determined by the type of PVR and its distribution in the pelvic veins. The combination of moderate to severe reflux (types II and III) in the PVs, UVs, and GVs was a predictor of severe PVP. Patients with asymptomatic PVVs were characterized by mild reflux (type I) in the PVs, with rare involvement of the GVs and UVs.
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Topper SR, Winokur RS. Imaging of Pelvic Venous Disorders (PeVD); Should Every Patient Get an MRI? Tech Vasc Interv Radiol 2021; 24:100731. [PMID: 34147189 DOI: 10.1016/j.tvir.2021.100731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pelvic venous disease (PeVD) is part of the broad differential diagnosis of chronic pelvic pain with a challenging diagnosis and clinical workup to identify those patients that are most likely to benefit from intervention. Ultrasound, MRI, CT, venography, and intravascular ultrasound can all provide information to aid in the diagnostic algorithm. The purpose of this article is to review imaging as a component of the outpatient workup of patients with chronic pelvic pain to guide appropriate understanding and use of imaging modalities to accurately identify patients suffering from PeVD. A favored approach is to begin with transabdominal sonography with selective use of MRI/MRV in specific patient populations.
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Affiliation(s)
- Stephen R Topper
- Department of Radiology, Division of Interventional Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Ronald S Winokur
- Department of Radiology, Division of Interventional Radiology, Thomas Jefferson University Hospital, Philadelphia, PA.
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Meissner MH, Khilnani NM, Labropoulos N, Gasparis AP, Gibson K, Greiner M, Learman LA, Atashroo D, Lurie F, Passman MA, Basile A, Lazarshvilli Z, Lohr J, Kim MD, Nicolini PH, Pabon-Ramos WM, Rosenblatt M. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. Phlebology 2021; 36:342-360. [PMID: 33849310 PMCID: PMC8371031 DOI: 10.1177/0268355521999559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This Practice Guidelines document has been co-published in
Phlebology [DOI: 10.1177/0268355521999559] and Journal of
Vascular Surgery: Venous and Lymphatic Disorders [DOI:
10.1016/j.jvsv.2020.12.084]. The publications are
identical except for minor stylistic and spelling differences in keeping
with each journal’s style. The contribution has been published under a
Attribution-Non Commercial 4.0 International (CC BY-NC 4.0), (https://creativecommons.org/licenses/by-nc/4.0/)
With the support of the American College of Obstetricians and
Gynecologists, the American Vein & Lymphatic Society, the American
Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and
Interventional Radiology Society of Europe, the European Venous Forum, the
International Pelvic Pain Society, the International Union of Phlebology,
the Korean Society of Interventional Radiology, the Society of
Interventional Radiology, and the Society for Vascular Surgery
As the importance of pelvic venous disorders (PeVD) has been increasingly
recognized, progress in the field has been limited by the lack of a valid and
reliable classification instrument. Misleading historical nomenclature, such as
the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to
recognize the interrelationship of many pelvic symptoms and their underlying
pathophysiology. Based on a perceived need, the American Vein and Lymphatic
Society convened an international, multidisciplinary panel charged with the
development of a discriminative classification instrument for PeVD. This
instrument, the Symptoms-Varices-Pathophysiology (“SVP”) classification for
PeVD, includes three domains—Symptoms (S), Varices (V), and Pathophysiology (P),
with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H),
and Etiologic (E) features of the patient’s disease. An individual patient’s
classification is designated as SVPA,H,E. For patients with pelvic
origin lower extremity signs or symptoms, the SVP instrument is complementary to
and should be used in conjunction with the
Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP
instrument accurately defines the diverse patient populations with PeVD, an
important step in improving clinical decision making, developing
disease-specific outcome measures and identifying homogenous patient populations
for clinical trials.
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Affiliation(s)
- Mark H Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Neil M Khilnani
- Department of Radiology (Interventional Radiology) Weill Cornell Medicine-New York Presbyterian Hospital, New York, USA
| | - Nicos Labropoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, USA
| | - Antonios P Gasparis
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, USA
| | | | - Milka Greiner
- Interventional Radiology, Hopital Americain de Paris, Paris, France
| | - Lee A Learman
- Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Roanoke, USA
| | - Diana Atashroo
- Department of Obstetrics and Gynecology, Stanford Medicine, Palo Alto, USA
| | - Fedor Lurie
- Department of Surgery, Jobst Vascular Institute, Promedica, Toledo, USA
| | - Marc A Passman
- Department of Surgery, University of Alabama School of Medicine, Birmingham, USA
| | - Antonio Basile
- Department of Interventional Radiology, University of Catania, Catania, Italy
| | | | - Joann Lohr
- Department of Surgery, University of South Carolina School of Medicine, Columbia, USA
| | - Man-Deuk Kim
- Department of Radiology, Yonsei University School of Medicine, Seoul, South Korea
| | | | - Waleska M Pabon-Ramos
- Department of Radiology (Interventional Radiology), Duke University School of Medicine, Durham, USA
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Amin TN, Wong M, Foo X, Pointer SL, Goodhart V, Jurkovic D. The effect of pelvic pathology on uterine vein diameters. Ultrasound J 2021; 13:7. [PMID: 33599877 PMCID: PMC7892655 DOI: 10.1186/s13089-021-00212-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transvaginal ultrasound (TVS) is a sensitive tool for detecting various conditions that contribute to pelvic pain. TVS can be also used to assess blood flow and measure the size of pelvic veins. Pelvic venous congestion (PVC) is characterised by enlargement of the pelvic veins and has been recognised as a cause of chronic pelvic pain. The reference ranges for uterine venous diameter in women with normal pelvic organs have been established, but there is no information regarding the potential effect of pelvic pathology on the uterine venous diameters. The aim of this study was to examine the size of uterine venous plexus in women with evidence of pelvic abnormalities on TVS and to determine whether the reference ranges need to be adjusted in the presence of pelvic pathology. A prospective, observational study was conducted in our gynaecological outpatient clinic. Morphological characteristics of all pelvic abnormalities detected on TVS and their sizes were recorded. The uterine veins were identified and their diameters were measured in all cases. The primary outcome measure was the uterine venous diameter. Regression analyses were performed to determine factors affecting the uterine venous size in women with pelvic pathology. RESULTS A total of 1500 women were included into the study, 1014 (67%) of whom were diagnosed with pelvic abnormalities. Women with pelvic pathology had significantly larger uterine venous diameters than women with normal pelvic organs (p < 0.01). Multivariable analysis showed that pre-menopausal status, high parity, presence of fibroids (p < 0.001) and Black ethnicity were all associated with significantly larger uterine vein diameters. Based on these findings modified reference ranges for uterine venous diameters have been designed which could be used for the diagnosis of PVC in women with uterine fibroids. CONCLUSIONS Our findings show that of all pelvic pathology detected on TVS, only fibroids are significantly associated with uterine venous enlargement. Factors known to be associated with enlarged veins in women with normal pelvic organs, namely parity and menopausal status, also apply in patients with pelvic pathology. Future studies of uterine venous circulation should take into account the presence and size of uterine fibroids when assessing women for the signs of PVC.
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Affiliation(s)
- T N Amin
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK.
| | - M Wong
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - X Foo
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - S-L Pointer
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - V Goodhart
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - D Jurkovic
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
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19
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Meissner MH, Khilnani NM, Labropoulos N, Gasparis AP, Gibson K, Greiner M, Learman LA, Atashroo D, Lurie F, Passman MA, Basile A, Lazarshvilli Z, Lohr J, Kim MD, Nicolini PH, Pabon-Ramos WM, Rosenblatt M. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disord 2021; 9:568-584. [PMID: 33529720 DOI: 10.1016/j.jvsv.2020.12.084] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/05/2020] [Indexed: 12/26/2022]
Abstract
As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVPA,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.
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Affiliation(s)
- Mark H Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Wash.
| | - Neil M Khilnani
- Department of Radiology (Interventional Radiology) Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY
| | - Nicos Labropoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY
| | - Antonios P Gasparis
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY
| | | | - Milka Greiner
- Interventional Radiology, Hopital Americain de Paris, Paris, France
| | - Lee A Learman
- Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Roanoke, Va
| | - Diana Atashroo
- Department of Obstetrics and Gynecology, Stanford Medicine, Palo Alto, Calif
| | - Fedor Lurie
- Department of Surgery, Jobst Vascular Institute, Promedica, Toledo, Ohio
| | - Marc A Passman
- Department of Surgery, University of Alabama School of Medicine, Birmingham, Ala
| | - Antonio Basile
- Department of Interventional Radiology, University of Catania, Catania, Italy
| | | | - Joann Lohr
- Department of Surgery, University of South Carolina School of Medicine, Columbia, Ohio
| | - Man-Deuk Kim
- Department of Radiology, Yonsei University School of Medicine, Seoul, South Korea
| | | | - Waleska M Pabon-Ramos
- Department of Radiology (Interventional Radiology), Duke University School of Medicine, Durham, NC
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20
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Gavrilov SG, Vasilyev AV, Krasavin GV, Moskalenko YP, Mishakina NY. Endovascular interventions in the treatment of pelvic congestion syndrome caused by May-Thurner syndrome. J Vasc Surg Venous Lymphat Disord 2020; 8:1049-1057. [DOI: 10.1016/j.jvsv.2020.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/08/2020] [Indexed: 11/17/2022]
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21
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Gavrilov SG, Vasilyev AV, Moskalenko YP, Mishakina NY. Diagnostic value of pelvic venography in female patients with pelvic varicose veins and vulvar varicosities. INT ANGIOL 2020; 39:452-460. [PMID: 32594669 DOI: 10.23736/s0392-9590.20.04402-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Instrumental diagnosis of pelvic-perineal reflux is based on the use of ultrasound and radiological methods; however, the volume of their use represents a stumbling block for various researchers. The study aimed to determine the diagnostic value and reasonability of ovarian and pelvic venography in female patients with pelvic varicose veins (PVV) and vulvar varicosities (VV). METHODS A total of 62 women with PVV were examined and allocated into two groups with or without the pelvic congestion syndrome (PCS) symptoms. Patients of group 1 with the PCS symptoms (N.=30) had concomitant VV (13.3%) and valvular incompetence of the left (83.3%) or right (16.7%) gonadal veins, parametrial (100%) and uterine (70%) veins, according to the duplex ultrasound scanning (DUS). Patients of group 2 without the PCS symptoms (N.=32) had valvular incompetence of the left gonadal vein (9.4%), parametrial (100%), uterine (3.1%) and vulvar veins (100%), according to the DUS. All patients underwent ovarian and pelvic venography (OPV) for imaging of the pelvic-perineal reflux. RESULTS In group 1, dilation and valvular incompetence of the gonadal and parametrial veins were confirmed by the OPV in 100% of patients. The imaging of the obturator vein (OV) was obtained in 6.6% patients and internal pudendal vein (IPV) in 6.6% patients; no reflux of the contrast agent in the vulvar veins was observed. In group 2, the OPV confirmed the valvular incompetence of the left gonadal vein in 9.4% patients and parametrial vein in 100% patients. The contrast agent in the OV was found in 9.4%, and in the IPV in 6.3% patients, while no reflux of the contrast agent in the dilated vulvar veins was observed. CONCLUSIONS Pelvic venography is a not mandatory component of the examination of women with pelvic and vulvar varicose veins without varicose veins of the lower extremities, who do not have symptoms of the PCS and valvular incompetence of the gonadal veins according to the DUS.
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Affiliation(s)
- Sergey G Gavrilov
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia -
| | - Alexey V Vasilyev
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Yekaterina P Moskalenko
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Nadezhda Y Mishakina
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia
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22
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Toh MR, Tang TY, Lim HHMN, Venkatanarasimha N, Damodharan K. Review of imaging and endovascular intervention of iliocaval venous compression syndrome. World J Radiol 2020; 12:18-28. [PMID: 32226586 PMCID: PMC7061234 DOI: 10.4329/wjr.v12.i3.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/04/2020] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
Iliocaval venous compression syndrome (ICS) is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra. Chronic compression can lead to venous stenosis and stasis, which manifests as chronic venous disease and treatment resistance. Therefore, early recognition of ICS and prompt treatment are essential. Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies. The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass, which is followed by computed tomography (CT) or magnetic resonance (MR) venography. CT and MRI can identify the anatomical causes for venous compression. In patients with high clinical suspicion for ICS, negative findings on CT and MR venography would still warrant further investigations. Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality. In this review paper, we will discuss the evidence, utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.
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Affiliation(s)
- Ming Ren Toh
- Duke-NUS Medical School, Singapore 544886, Singapore
| | - Tjun Yip Tang
- Department of Vascular surgery, Singapore General Hospital, Singapore 169608, Singapore
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Bookwalter CA, VanBuren WM, Neisen MJ, Bjarnason H. Imaging Appearance and Nonsurgical Management of Pelvic Venous Congestion Syndrome. Radiographics 2020; 39:596-608. [PMID: 30844351 DOI: 10.1148/rg.2019180159] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Candice A Bookwalter
- From the Department of Radiology, Mayo Clinic Rochester, 200 First St SW, Rochester, MN 55905
| | - Wendaline M VanBuren
- From the Department of Radiology, Mayo Clinic Rochester, 200 First St SW, Rochester, MN 55905
| | - Melissa J Neisen
- From the Department of Radiology, Mayo Clinic Rochester, 200 First St SW, Rochester, MN 55905
| | - Haraldur Bjarnason
- From the Department of Radiology, Mayo Clinic Rochester, 200 First St SW, Rochester, MN 55905
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Baz AA. Role of trans-abdominal and trans-perineal venous duplex ultrasound in cases of pelvic congestion syndrome. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0099-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
For evaluation the role of trans-abdominal and trans-perineal venous duplex ultrasound in cases of pelvic congestion syndrome, fifty patients with pelvic congestion syndrome were included in the current research. All were evaluated by trans-abdominal and trans-perineal venous duplex.
Results
An incompetent left gonadal vein was detected in all cases with a mean diameter (± SD) = 7.9 ± 1.1 mm. The right gonadal vein was incompetent in 4 cases (8%) with a mean diameter (± SD) 5.9 ± 0.4 mm.
A refluxing proximal internal iliac vein was detected in 3cases (6%). Left renal vein nutcracker was present in 41cases (82%) while the left common iliac vein compression was present in 3 cases (6%).
Vulvoperineal varicosities were seen in all cases {right side = (36%, n = 18), left side = (30%, n = 15), and bilateral = (34%, n = 17)}.Thigh extension of the vulvoperineal varicosities was present in (74%, n = 37).
Round ligament varicosities were present in (6%, n = 3).
Conclusions
Trans-abdominal and trans-perineal venous duplex offer a simple, noninvasive, and quick technique that can help in an accurate evaluation of the ovarian vein reflux, diameters as well as the presence of vulvoperineal, and round ligament varicosities, Moreover, it is useful in the assessment of the left renal and iliac veins compression.
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Abstract
This review presents modern information on the anatomy of pelvic veins, mechanisms of development of pelvic congestion syndrome (PCS) and venous pelvic pain (VPP), methods for verifying the venous nature of pelvic pain, as well as opportunities of various surgical interventions on the gonadal veins in treatment of PCS and relief of its most severe symptom, VPP. A comparative analysis of resection and embolization treatment methods and their effects on VPP, as well as rates of postprocedural complications, was carried out. The issues of elimination of specific compression syndromes causing occurrence of VPP, by using open, endoscopic and endovascular techniques are addressed.
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Affiliation(s)
- S G Gavrilov
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University , Moscow , Russia
| | - O I Efremova
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University , Moscow , Russia
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26
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Amin TN, Wong M, Pointer S, Goodhart V, Bean E, Jurkovic D. Reference ranges for uterine vein dimensions in non-pregnant women with normal pelvic organs. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:403-411. [PMID: 30834625 DOI: 10.1002/uog.20254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/25/2019] [Accepted: 02/27/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To establish reference ranges for uterine vein (UtV) diameters in non-pregnant women with normal pelvic organs. METHODS This was a prospective study of all women attending the general gynecological clinic of a university teaching hospital in the UK, between August 2015 and December 2016. All women aged ≥ 18 years underwent a transvaginal ultrasound examination in accordance with the study protocol. In women with normal pelvic organs, the largest trunk of the uterine venous plexus was identified in the transverse plane on each side. The maximum anteroposterior vessel diameter was measured by placing the calipers on the inner walls of the vein, and the mean of three measurements was used as the representative value. Inter- and intraobserver variability was assessed in a subgroup of 30 women. Maximum UtV diameter was compared between right and left UtVs and between pre- and postmenopausal women. Factors associated with UtV diameter were assessed and reference ranges were constructed. RESULTS Of 1500 women examined, 486 (32%) had normal pelvic organs on ultrasound scan and were included in the final analysis. In all women, the uterine venous trunk was clearly visualized and there was no significant difference between the maximum median left and right UtV diameters (P = 0.37). UtV diameters were generally lower in postmenopausal, compared with premenopausal, women, with the difference being statistically significant for the right UtV and the average of left and right UtVs. There was a gradual increase in UtV diameter with advancing age, with a peak observed in women aged 41-50 years and decreasing values in older age groups. Univariable analysis showed that parity, menopausal status and age were associated significantly with UtV diameters (P < 0.01). On multivariable analysis, only higher parity was significantly associated with increasing venous size in both pre- and postmenopausal women. Reference ranges were constructed separately for nulliparous and parous premenopausal women aged between 18 and 45 years. CONCLUSION UtVs can be identified and measured consistently in all women with normal pelvic organs using transvaginal ultrasound. Parity was the main factor influencing the maximum mean UtV diameter, which had to be taken into account when constructing reference ranges. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- T N Amin
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - M Wong
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - S Pointer
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - V Goodhart
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - E Bean
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - D Jurkovic
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
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Antignani PL, Lazarashvili Z, Monedero JL, Ezpeleta SZ, Whiteley MS, Khilnani NM, Meissner MH, Wittens CH, Kurstjens RL, Belova L, Bokuchava M, Elkashishi WT, Jeanneret-Gris C, Geroulakos G, Gianesini S, de Graaf R, Krzanowski M, Al Tarazi L, Tessari L, Wikkeling M. Diagnosis and treatment of pelvic congestion syndrome: UIP consensus document. INT ANGIOL 2019; 38:265-283. [PMID: 31345010 DOI: 10.23736/s0392-9590.19.04237-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
| | | | - Javier L Monedero
- Unity of Vascular Pathology, Ruber Internacional Hospital, Madrid, Spain
| | - Santiago Z Ezpeleta
- Unity of Radiology for Vascular Diseases, Ruber Internacional Hospital, Madrid, Spain
| | | | - Neil M Khilnani
- Division of Interventional Radiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Mark H Meissner
- University of Washington School of Medicine, Seattle, WA, USA
| | - Cees H Wittens
- Department of Venous Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Ralph L Kurstjens
- Department of Obstetrics and Gynecology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Ludmila Belova
- Faculty of Medicine, Ulyanovsk State University, Ulyanovsk, Russia
| | - Mamuka Bokuchava
- Tbilisi State Medical University, N. Bokhua Memorial Cardiovascular Center, Tbilisi, Georgia
| | | | - Christina Jeanneret-Gris
- Department of Angiology, University Clinic of Internal Medicine, KSBL Bruderholz, Baselland, Switzerland
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, Athens, Greece
| | | | - Rick de Graaf
- Clinic for Diagnostic and Interventional Radiology/Nuclear Medicine, Clinical Center of Friedrichshafen, Friedrichshafen, Germany
| | | | - Louay Al Tarazi
- Varicose Veins and Vascular Polyclinic (VVVC), Damascus, Syria
| | - Lorenzo Tessari
- Bassi-Tessari Foundation, Veins&Lymphatics Association ONLUS, Varese, Italy
| | - Marald Wikkeling
- Department of Vascular Surgery Heelkunde Friesland, Location MCL and Nij Smellinghe Hospital, Drachten, the Netherlands
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28
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Campbell B, Goodyear S, Franklin I, Nyamekye I, Poskitt K. Investigation and treatment of pelvic vein reflux associated with varicose veins: Current views and practice of 100 UK vascular specialists. Phlebology 2019; 35:56-61. [PMID: 31084296 DOI: 10.1177/0268355519848621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective Management of pelvic vein disorders possibly contributing to leg varicose veins remains variable and controversial. This survey investigated practice in the UK. Methods Email questionnaire to 328 members of the Vascular Society. Results One hundred and four (32%) questionnaires were returned. Of 100 respondents treating varicose veins, 9% do not recognise pelvic vein reflux and 11% never investigate or treat it. Indications for investigation include labial (94%) and buttock/upper thigh (70%) varicose veins: 46% use magnetic resonance venography and only 16% transvaginal duplex. Treatments used are coil embolization (89%), sclerotherapy via thigh veins (47%) and transcatheter sclerotherapy (26%). Thirty-four per cent treat only ovarian veins (not internal iliac tributaries). Follow-up is by clinical response (100%): only 14% use duplex. Only 5% treat >10 patients annually. Conclusions There is substantial variation in the management of pelvic vein reflux in the UK. There is need for further consensus and good clinical trial evidence to guide practice.
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29
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Khilnani NM, Meissner MH, Learman LA, Gibson KD, Daniels JP, Winokur RS, Marvel RP, Machan L, Venbrux AC, Tu FF, Pabon-Ramos WM, Nedza SM, White SB, Rosenblatt M. Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2019; 30:781-789. [PMID: 30857986 DOI: 10.1016/j.jvir.2018.10.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022] Open
Abstract
Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.
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Affiliation(s)
- Neil M Khilnani
- Division of Interventional Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 2315 Broadway, Fourth Floor, New York, New York 10128.
| | - Mark H Meissner
- Division of Vascular Surgery, University of Washington Medical Center, Seattle, Washington
| | - Lee A Learman
- Department of Obstetrics and Gynecology, Charles A. Schmidt School of Medicine, Florida Atlantic University, Boca Raton, Florida
| | | | - Jane P Daniels
- Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Ronald S Winokur
- Division of Interventional Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 2315 Broadway, Fourth Floor, New York, New York 10128
| | | | - Lindsay Machan
- Departments of Radiology and Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony C Venbrux
- Division of Interventional Radiology, George Washington University School of Medicine, Washington, DC
| | - Frank F Tu
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois; Department of Obstetrics and Gynecology, North Shore University Medical Group, Skokie, Illinois
| | - Waly M Pabon-Ramos
- Division of Interventional Radiology, Duke University School of Medicine, Durham, North Carolina
| | - Susan M Nedza
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sarah B White
- Division of Interventional Radiology, Froedtert Hopsital, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mel Rosenblatt
- Connecticut Image-Guided Surgery, Fairfield, Connecticut
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30
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Riding DM, Pond EJ, McCollum C, Caress AL. Seeking consensus amongst UK-based interventional radiologists on the imaging diagnosis of pelvic vein incompetence in women with chronic pelvic pain: A modified Delphi study. Phlebology 2019; 34:486-495. [PMID: 30621525 DOI: 10.1177/0268355518821554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives This modified Delphi study of vascular interventional radiologists sought to achieve consensus statements on the optimal imaging strategy and definitions of important imaging diagnostic features in women with pelvic vein incompetence. Method The UK-based interventional radiologists with the experience of investigating and treating pelvic vein incompetence responded to up to three rounds of online questionnaires. Results Three consensus statements emerged from 27 responders: (1) catheter venography is the ‘gold standard’ investigation for the diagnosis of pelvic vein incompetence; (2) pelvic vein incompetence should be defined as ‘retrograde flow along the ovarian or internal iliac veins’; (3) pelvic varices should be defined as ‘tortuous, often dilated, vulval, adnexal, para-uterine veins arising from incompetent internal iliac or ovarian veins.’ Conclusion This study achieved consensus statements on imaging diagnosis in women with suspected pelvic vein incompetence. These can be used to minimise heterogeneity of research protocols, and represent baseline positions which can, themselves, be tested.
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Affiliation(s)
- David M Riding
- Academic Surgery Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Emma J Pond
- Academic Surgery Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Charles McCollum
- Academic Surgery Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ann L Caress
- Academic Surgery Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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31
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Santoshi RK, Lakhanpal S, Satwah V, Lakhanpal G, Malone M, Pappas PJ. Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency. J Vasc Surg Venous Lymphat Disord 2018; 6:202-211. [DOI: 10.1016/j.jvsv.2017.09.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/08/2017] [Indexed: 12/22/2022]
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32
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Whiteley MS. Objective measurements of pelvic venous reflux and stratification of severity of venous reflux in pelvic congestion syndrome due to pelvic venous reflux. Curr Med Res Opin 2017; 33:2089-2091. [PMID: 28521534 DOI: 10.1080/03007995.2017.1332987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Mark S Whiteley
- a The Whiteley Clinic , Guildford, Surrey , UK
- b Faculty of Health and Biomedical Sciences , University of Surrey , Surrey , UK
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33
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Beckett D, Dos Santos SJ, Dabbs EB, Shiangoli I, Price BA, Whiteley MS. Anatomical abnormalities of the pelvic venous system and their implications for endovascular management of pelvic venous reflux. Phlebology 2017; 33:567-574. [PMID: 29059022 DOI: 10.1177/0268355517735727] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Pelvic venous reflux is often treated with pelvic vein embolisation; however, atypical pelvic venous anatomy may provide therapeutic challenges. Methods We retrospectively reviewed seven patient files and reported symptoms, diagnostic imaging, aberrant anatomy and means by which the interventional radiologist successfully completed the procedure. Any follow-up data were included if available. Results Four anatomical abnormalities were found: internal iliac veins draining into the contralateral common iliac vein, duplicated inferior vena cava, reverse-angle renal veins with atypical left ovarian vein drainage and direct drainage of the internal iliac vein to the inferior vena cava. All patients were successfully treated with pelvic vein embolisation. Conclusion Abnormal embryologic development may cause variable pelvic venous anatomy. Knowledge of this will enable interventional radiologists to successfully treat such patients.
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Affiliation(s)
- David Beckett
- 1 The Whiteley Clinic, Guildford, UK.,2 Department of Radiology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Scott J Dos Santos
- 1 The Whiteley Clinic, Guildford, UK.,3 Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | | | | | - Barrie A Price
- 1 The Whiteley Clinic, Guildford, UK.,3 Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Mark S Whiteley
- 1 The Whiteley Clinic, Guildford, UK.,3 Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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34
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Whiteley MS, Lewis-Shiell C, Bishop SI, Davis EL, Fernandez-Hart TJ, Diwakar P, Beckett D. Pelvic vein embolisation of gonadal and internal iliac veins can be performed safely and with good technical results in an ambulatory vein clinic, under local anaesthetic alone - Results from two years' experience. Phlebology 2017; 33:575-579. [PMID: 28992753 DOI: 10.1177/0268355517734952] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Pelvic vein embolisation is increasing in venous practice for the treatment of conditions associated with pelvic venous reflux. In July 2014, we introduced a local anaesthetic "walk-in walk-out" pelvic vein embolisation service situated in a vein clinic, remote from a hospital. Methods Prospective audit of all patients undergoing pelvic vein embolisation for pelvic venous reflux. All patients had serum urea and electrolytes tested before procedure. Embolisation coils used were interlock embolisation coils (Boston Scientific, USA) as they can be repositioned after deployment and before release. We noted (1) complications during or post-procedure (2) successful abolition of pelvic venous reflux on transvaginal duplex scanning (3) number of veins (territories) treated and number of coils used. Results In 24 months, 121 patients underwent pelvic vein embolisation. Three males were excluded as transvaginal duplex scanning was impossible and six females excluded due to lack of complete data. None of these nine had any complications. Of 112 females analysed, mean age 45 years (24-71), 104 were for leg varices, 48 vulval varices and 20 for pelvic congestion syndrome (some had more than one indication). There were no deaths or serious complications to 30 days. Two procedures were abandoned, one completed subsequently and one was technically successful on review. One more had transient bradycardia and one had a coil removed by snare during the procedure. The mean number of venous territories treated was 2.9 and a mean of 3.3 coils was used per territory. Conclusion Pelvic vein embolisation under local anaesthetic is safe and technically effective in a remote out-patient facility outside of a hospital.
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Affiliation(s)
- Mark S Whiteley
- 1 The Whiteley Clinic, Guildford, UK.,2 Faculty of Health and Biomedical Sciences, University of Surrey, Guildford, UK
| | | | | | - Eluned L Davis
- 1 The Whiteley Clinic, Guildford, UK.,3 The Whiteley Clinic, One Chapel Place, London, UK
| | - Tim J Fernandez-Hart
- 1 The Whiteley Clinic, Guildford, UK.,3 The Whiteley Clinic, One Chapel Place, London, UK
| | | | - David Beckett
- 1 The Whiteley Clinic, Guildford, UK.,3 The Whiteley Clinic, One Chapel Place, London, UK
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35
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Dabbs EB, Dos Santos SJ, Shiangoli I, Holdstock JM, Beckett D, Whiteley MS. Pelvic venous reflux in males with varicose veins and recurrent varicose veins. Phlebology 2017; 33:382-387. [PMID: 28857674 DOI: 10.1177/0268355517728667] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To report on a male cohort with pelvic vein reflux and associated primary and recurrent lower limb varicose veins. Methods Full lower limb duplex ultrasonography revealed significant pelvic contribution in eight males presenting with bilateral lower limb varicose veins. Testicular and internal iliac veins were examined with either one or a combination of computed tomography, magnetic resonance venography, testicular, transabdominal or transrectal duplex ultrasonography. Subsequently, all patients received pelvic vein embolisation, prior to leg varicose vein treatment. Results Pelvic vein reflux was found in 23 of the 32 truncal pelvic veins and these were treated by pelvic vein embolisation. Four patients have since completed their leg varicose vein treatment and four are undergoing leg varicose vein treatments currently. Conclusion Pelvic vein reflux contributes towards lower limb venous insufficiency in some males with leg varicose veins. Despite the challenges, we suggest that pelvic vein reflux should probably be investigated and pelvic vein embolisation considered in such patients.
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Affiliation(s)
| | - Scott J Dos Santos
- 1 The Whiteley Clinic, Guildford, Surrey, UK.,2 Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | - Irenie Shiangoli
- 1 The Whiteley Clinic, Guildford, Surrey, UK.,2 Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | | | - David Beckett
- 1 The Whiteley Clinic, Guildford, Surrey, UK.,3 Department of Radiology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Mark S Whiteley
- 1 The Whiteley Clinic, Guildford, Surrey, UK.,2 Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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36
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Whiteley MS, Smith VC. Exacerbation of alopecia areata: A possible complication of sodium tetradecyl sulphate foam sclerotherapy treatment for varicose veins. SAGE Open Med Case Rep 2017; 5:2050313X17712643. [PMID: 28616235 PMCID: PMC5459345 DOI: 10.1177/2050313x17712643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 05/08/2017] [Indexed: 01/12/2023] Open
Abstract
A 40-year-old woman with a history of alopecia areata related to stress or hormonal changes was treated for bilateral primary symptomatic varicose veins (CEAP clinical score C2S) of pelvic origin, using a staged procedure. Her first procedure entailed pelvic vein embolisation of three pelvic veins using 14 coils and including foam sclerotherapy of the tributaries, using 3% sodium tetradecyl sulphate. Following this procedure, she had an exacerbation of alopecia areata with some moderate shedding of hair. Subsequently, she underwent endovenous laser ablation under local anaesthetic without incident. Seven months after the pelvic vein embolisation, she underwent foam sclerotherapy of leg and labial varicose veins using sodium tetradecyl sulphate. Two days following this procedure, she had a severe exacerbation of alopecia areata with gross shedding of hair. These two episodes of exacerbation of alopecia areata appear to be associated with sodium tetradecyl sulphate foam sclerotherapy of veins.
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Affiliation(s)
- Mark S Whiteley
- The Whiteley Clinic, Guildford, UK.,Faculty of Health and Biomedical Sciences, University of Surrey, Guildford, UK
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37
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Dos Santos SJ, Whiteley MS. Pelvic congestion syndrome masquerading as osteoarthritis of the hip. SAGE Open Med Case Rep 2016; 4:2050313X16683630. [PMID: 27994874 PMCID: PMC5153020 DOI: 10.1177/2050313x16683630] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/14/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Pelvic congestion syndrome (PCS) is associated with pelvic vein reflux (PVR), occasionally secondary to venous compression. Its symptoms, usually intra-pelvic, are alleviated following the abolition of this reflux by pelvic vein embolisation (PVE). The objective of this report is to present two cases of left hip pain, erroneously diagnosed as osteoarthritis, which disappeared after successful PVE and abolition of PVR. METHODS Two females presented with lower limb varicose veins, and also had a history of left-sided hip pain. Both had previously been investigated for the hip pain and diagnosed as osteoarthritis despite minimal arthritic changes on pelvic X-rays. During investigation for lower limb varicose veins, both showed a pelvic origin for their leg veins and hence underwent transvaginal duplex ultrasound. This revealed PVR, and PVE was planned in both patients. RESULTS Both patients underwent PVE and reported 'miraculous' resolution of left hip pain and also PCS symptoms including pelvic pain, irritable bowel issues and the disappearance of pelvic dragging, with almost immediate disappearance of vulval and vaginal varicosities. One patient also noted reduced clitoral sensitivity. CONCLUSION Manifestations of PCS may vary in terms of intra- or extra-pelvic signs. PCS and PVR should be considered in the differential diagnosis of patients with arthritic symptoms in the hip without evident radiographic evidence.
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Affiliation(s)
- Scott J Dos Santos
- The Whiteley Clinic, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Mark S Whiteley
- The Whiteley Clinic, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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38
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Labropoulos N, Jasinski PT, Adrahtas D, Gasparis AP, Meissner MH. A standardized ultrasound approach to pelvic congestion syndrome. Phlebology 2016; 32:608-619. [PMID: 27799418 DOI: 10.1177/0268355516677135] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Nicos Labropoulos
- 1 Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Patrick T Jasinski
- 1 Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Demetri Adrahtas
- 1 Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Antonios P Gasparis
- 1 Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Mark H Meissner
- 2 Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
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39
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Lattimer CR, Mendoza E. Reappraisal of the Utility of the Tilt-table in the Investigation of Venous Disease †. Eur J Vasc Endovasc Surg 2016; 52:854-861. [PMID: 27789144 DOI: 10.1016/j.ejvs.2016.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 09/23/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Without gravity opposing drainage, most venous diseases would not exist. Therefore, manoeuvres that assess venous function should include gravity. The aim was to "dose" gravity in subjects using static positions and dynamic angulations on a tilt-table and to assess its effects with air plethysmography (APG) and duplex ultrasound over the femoral vein. METHODS Three groups (providing n = 11 legs each) were compared. (a) A control group, without clinical or duplex evidence of venous disease. (b) An obstruction group, with past iliofemoral deep vein thrombosis. (3) A reflux group, with primary varicose veins. A manually operated tilt-table ranging from -70° to 40° in the Trendelenburg position provided rapid tilting (<3 s). The changes in calf volume at -70° (almost standing), -45° (reclining), and 40° (legs-up) were recorded with APG, as well as the rate and duration of the changes. The minor diameter of the femoral vein was recorded at the three tilt positions. RESULTS The results were expressed as median (interquartile range). The total working venous volume (mL) in the reflux group was significantly increased: 202 (180-240) mL versus the controls at 138 (119-198) mL, p = .008, and versus the legs with obstruction at 117 (80-154) mL, p < .0005. The venous drainage index (VDI) in mL/second in the obstructed group was significantly reduced: 7 (6-9.6) mL/second, versus the controls at 17.4 (13.9-27.2) mL/second, p < .0005, and versus the legs with varicose veins at 28.1 (25.4-34.4) mL/second, p < .0005. The venous filling index (VFI) in mL/second in the reflux group was significantly increased: 8.1 (4.2-10) mL/second versus the controls at 1.8 (1-2.1) mL/second, p < .0005. The VDI cut-off point discriminating obstruction was ≤10.8 mL/second and the VFI discriminating reflux was ≥ 2.9 mL/second. The femoral vein diameter was reduced significantly with increasing leg elevation. CONCLUSIONS Manoeuvres using APG on a tilt-table have the potential to quantify the contributions of global obstruction and reflux (mL/second) in patients with venous disease.
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Affiliation(s)
- C R Lattimer
- Josef Pflug Vascular Laboratory, Ealing Hospital, Middlesex, UK; Department of Surgery and Cancer, Imperial College, London, UK; West London Vascular & Interventional Centre, Northwick Park Hospital, Harrow, UK.
| | - E Mendoza
- Venenpraxis-Wunstorf, Wunstorf, Germany
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40
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Hansrani V, Dhorat Z, McCollum CN. Diagnosing of pelvic vein incompetence using minimally invasive ultrasound techniques. Vascular 2016; 25:253-259. [PMID: 27688293 DOI: 10.1177/1708538116670499] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Pelvic vein incompetence is a cause for pelvic pain and recurrent varicose veins in women. The gold standard diagnostic method is reflux venography involving radiation, nephrotoxic contrast and jugular puncture. Trans-vaginal ultrasound (TVU) is increasingly being used as a diagnostic tool for pelvic vein incompetence. Methods Fifty women with clinical suspicion of pelvic vein incompetence and aged between 18 and 55 years were recruited prospectively over two years at a large UK University Teaching Hospital. Trans-vaginal ultrasound was performed using a standardised protocol which included assessment of the ovarian and internal iliac veins bilaterally in the supine and semi-standing position with provocative manoeuvres. Diagnostic readability and inter-observer variability was determined. Results Mean (range) age of 43 (23-51). Visibility of all four pelvic veins was better in the supine position compared with semi-standing position (76% vs 64%). Pelvic vein incompetence was identified in 34 of 50 (68%) women in the supine position compared with 38 of 50 (76%) women in the semi-standing position. Pelvic vein incompetence was demonstrated in 35 of 50 (70%) women with Valsalva manoeuvre. Inter-observer variability was 0.84 (kappa, very good agreement, p = 0.001). Conclusion Trans-vaginal ultrasound is effective at demonstrating pelvic vein incompetence. All trans-vaginal ultrasound protocols should include assessment of pelvic veins in the supine and semi-standing position with Valsalva manoeuvre.
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Affiliation(s)
- Vivak Hansrani
- Institute of Cardiovascular Sciences, University of Manchester, Academic Surgery Unit, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| | - Zainab Dhorat
- Institute of Cardiovascular Sciences, University of Manchester, Academic Surgery Unit, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| | - Charles N McCollum
- Institute of Cardiovascular Sciences, University of Manchester, Academic Surgery Unit, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
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Dos Santos SJ, Holdstock JM, Harrison CC, Whiteley MS. The effect of a subsequent pregnancy after transjugular coil embolisation for pelvic vein reflux. Phlebology 2016; 32:27-33. [PMID: 26769721 DOI: 10.1177/0268355515623898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Pelvic venous reflux has been proven to contribute to the development of primary and recurrent varicose veins, vulval/labial varicose veins and pelvic congestion syndrome. It is associated with lower limb varicose veins in 20% of patients who have a history of at least one prior vaginal delivery. Pelvic vein embolisation is known to be a safe and effective treatment for the abolition of pelvic venous reflux. However, the effect of a subsequent pregnancy on a previously embolised patient remains largely unknown. This study aims to report the effect of pregnancy on patients that have undergone pelvic vein embolisation. Methods Patients that had previously undergone pelvic vein embolisation for pelvic venous reflux at our unit were sent a questionnaire asking if they had had a pregnancy and subsequently delivered post-embolisation. Patients responding positively were invited to attend our unit for transvaginal duplex ultrasonography of their pelvic veins. Post-pregnancy transvaginal duplex ultrasonography results were compared to pre-embolisation and 6-week post-embolisation scans. Results Eight women, aged 32-48 years (mean 38.8), were retrospectively analysed. Parity prior to embolisation ranged from 1 to 5 (mean 2.8). Initial outcomes at 6 weeks Pelvic venous reflux was completely eliminated in five patients, two patients achieved complete elimination of truncal reflux with very minor vulval reflux and one patient had persistent, mild reflux in the right internal iliac vein. Post-pregnancy outcomes Pelvic venous reflux was completely eliminated in three patients and five patients displayed pelvic venous reflux in at least one truncal vein, with or without concurrent vulval reflux. No patient showed any coil displacement or embolisation as a result of the pregnancy. Conclusions Pregnancy is associated with recurrent reflux in the pelvic veins in women who had previously been treated with coil embolisation. Following recovery from pregnancy, repeat embolisation can eliminate recurrent reflux. Pregnancy appears to be safe following coil embolisation of pelvic veins.
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Affiliation(s)
- Scott J Dos Santos
- 1 The Whiteley Clinic, Stirling House, Guildford, Surrey, UK.,2 Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | | | | | - Mark S Whiteley
- 1 The Whiteley Clinic, Stirling House, Guildford, Surrey, UK.,2 Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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Brinegar KN, Sheth RA, Khademhosseini A, Bautista J, Oklu R. Iliac vein compression syndrome: Clinical, imaging and pathologic findings. World J Radiol 2015; 7:375-381. [PMID: 26644823 PMCID: PMC4663376 DOI: 10.4329/wjr.v7.i11.375] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 08/03/2015] [Accepted: 09/16/2015] [Indexed: 02/06/2023] Open
Abstract
May-Thurner syndrome (MTS) is the pathologic compression of the left common iliac vein by the right common iliac artery, resulting in left lower extremity pain, swelling, and deep venous thrombosis. Though this syndrome was first described in 1851, there are currently no standardized criteria to establish the diagnosis of MTS. Since MTS is treated by a wide array of specialties, including interventional radiology, vascular surgery, cardiology, and vascular medicine, the need for an established diagnostic criterion is imperative in order to reduce misdiagnosis and inappropriate treatment. Although MTS has historically been diagnosed by the presence of pathologic features, the use of dynamic imaging techniques has led to a more radiologic based diagnosis. Thus, imaging plays an integral part in screening patients for MTS, and the utility of a wide array of imaging modalities has been evaluated. Here, we summarize the historical aspects of the clinical features of this syndrome. We then provide a comprehensive assessment of the literature on the efficacy of imaging tools available to diagnose MTS. Lastly, we provide clinical pearls and recommendations to aid physicians in diagnosing the syndrome through the use of provocative measures.
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Dos Santos SJ, Holdstock JM, Harrison CC, Lopez AJ, Whiteley MS. Ovarian Vein Diameter Cannot Be Used as an Indicator of Ovarian Venous Reflux. Eur J Vasc Endovasc Surg 2015; 49:90-4. [PMID: 25457295 DOI: 10.1016/j.ejvs.2014.10.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/17/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Previous research into pelvic venous reflux has suggested that the size of the ovarian veins indicates the presence or absence of reflux. It is already known that vessel diameter is not an indicator of reflux in the great saphenous vein. However, to this day, physicians still use vein size to plan treatment of refluxing ovarian veins. The authors aimed to investigate whether or not vessel diameter can be used as an indicator of reflux in the ovarian veins. METHODS Nineteen female patients (mean 40.2 years, range 29-60) presenting to a specialist vein unit with leg varicose veins underwent duplex ultrasonography (DUS). All were found to have a significant pelvic contribution to their leg reflux on transvaginal duplex ultrasonography (TVS) and were referred to an interventional radiologist for treatment by transjugular coil embolization. During the procedure, the diameter of the ovarian veins was measured using digital subtraction venography. RESULTS Thirty-four ovarian veins were measured (17 right, 17 left) and of these 18 were found to be non-refluxing while 16 displayed reflux. The mean diameter of the non-refluxing veins was 7.2 mm (range 3-13 mm)and that of the refluxing veins was 8.5 mm (range 4-13 mm). This difference was found to be insignificant at a 95% confidence level (Student t test, p = .204). CONCLUSIONS There is no significant difference between the diameters of competent and refluxing ovarian veins and, as such, techniques that measure vein diameter may not be suitable for the diagnosis of venous reflux in the ovarian veins.
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