Download Pelvic congestion syndrome: a simple procedure but a

Pelvic congestion syndrome: a simple procedure but a complex condition and a challenging diagnosis
Morteza Afrasiabi, Neda Noroozian, Kyriacos Patatas
Radiology Department, Northwick Park Hospital
Introduction:
There is a 15% prevalence of chronic pelvic pain in premenopausal women, and the cause remains undiagnosed in up to 60%. Pelvic congestion
syndrome can be responsible for chronic pelvic pain when pelvic venous insufficiency results in painful pelvic varicosities. However, patients with
pelvic congestion syndrome can also present with haemorrhoids, vulvoperineal or posterior upper thigh varices, or previous varicose vein
treatment failure.
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Endovascular treatment with pelvic and ovarian vein embolisation has been shown to be effective in providing significant symptomatic relief and
has been gaining increased acceptance.
There are challenges that can lead to difficulty in diagnosing the condition or treatment failure / partial response, especially the relatively low
sensitivity of different imaging modalities, variant anatomy and associated anatomic disorders.
Aims:
1. To demonstrate the anatomy of the interconnecting plexus of veins draining the pelvic organs and lower limb
2. To discuss the sensitivity of the different imaging modalities and objective findings on imaging for diagnosis
3. To demonstrate other anatomical disorders that can lead to failed result or partial response that progresses to failure
Anatomy
A detailed understanding of the relevant pelvic venous anatomy including common variants is essential for successful endovascular treatment.
Usually, blood in the left ovarian vein drains into the inferior vena cava (IVC) via the left renal vein (figure 1), whilst the right ovarian vein is
typically a direct tributary into the IVC variably between T12 and L2-3. There are anatomic variations for both the left and right ovarian vein, for
example the left ovarian can occasionally be a direct tributary from the IVC or the right ovarian arise from the right renal vein.
The internal iliac venous plexus has a far more variable appearance. The veins most commonly responsible for symptomatic reflux are the
tributaries of the anterior division of the internal iliac artery – incompetent internal pudendal and broad ligament parametrial branches are
associated with pelvic venous congestion, whilst incompetent branches of the obturator and circumflex femoral veins are often associated with
pelvic venous reflux into vulval or lower limb varicosities (figures 2 and 3). Incompetent ovarian veins may contribute to either clinical
manifestation.
It is important to be aware of variant anatomy. For example, the ovarian veins may be duplicated (figure 4), and the obturator vein which normally
has two draining tributaries into the anterior division of the internal iliac vein may have two single draining veins into both the internal and external
iliac vein s (figure 5). Failure to appreciate the former will lead to treatment failure, failure to appreciate the latter can lead to disastrous
consequence of non-target embolisation.
Figures 1 a & 1b:
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1a: Left renal venography shows free reflux to the significantly
dilated left ovarian vein. No patent venous valve is seen. Note
the extensive venous tributaries off the middle to distal portion of
the ovarian vein (arrow)
1b: Left ovarian venography shows stagnation of contrast
material in the dilated pelvic varices. Contrast refluxes across
the midline to the contralateral ovarian and internal iliac veins
(arrows)
Figures 3a & 3b:
3a: Refluxing right obturator vein
3b: Embolised obturator vein
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Figures 4a & 4b:
Duplicated left ovarian vein before and after embolisation
Imaging:
Magnetic resonance imaging (MRI), transabdominal ultrasound (US) and computed
tomography (CT) can be used to exclude intrinsic pelvic pathology, but all of these studies
are limited in their sensitivity for pelvic varices, in part because of the supine positioning,
and perhaps hydration and hormonal variation. The sensitivity for diagnosis of pelvic
congestion syndrome is low – not exceeding 60% with MRI currently considered the most
sensitive examination.
In experienced hands, transabdominal combined with transvaginal ultrasound has been
found to be useful in demonstrating both pelvic varices and pathological venous reflux.
Sonographic findings include enlarged ovarian veins greater than 6 mm in diameter with
reversed blood flow, presence of pelvic varicocele (> 5 mm) and dilated (> 5 mm) arcuate
veins crossing the uterine myometrium between pelvic varicoceles.
Despite negative findings on any of the above studies, venography (gold standard as
widely available and objectively comparable) is indicated when clinical suspicion for pelvic
congestion exists. It can be performed for confirmation of the condition, and treatment can
be performed at the same sitting.
Figure 5:
Obturator vein draining into both internal (catheter in
situ) and external iliac vein (arrow)
Associated anatomical disorders (figures 6 and 7)that may be responsible for the dilated pelvic veins and will lead to failure of
embolisation if unrecognised or left untreated (commonly require stenting prior to embolisation of pelvic veins)
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Figure 6
Nutcracker
phenomenon – left
renal vein
compression by
overarching superior
mesenteric artery
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Figure 7
May-Thurner syndrome –
compression of the left
common
Iliac vein against the
lumbar spine by the
overlying right common
iliac artery.
Figures 2a & 2b:
2a: Refluxing internal iliac venous branches with vulval
varicosities
2b: Refluxing internal iliac venous branches with lower
limb varicosities
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Conclusion:
In the appropriately selected/diagnosed patients, embolisation for pelvic congestion syndrome can achieve significant
symptomatic improvement provided that meticulous attention has been paid to anatomy to identify variation or associated
anatomic disorders.
References:
1. Pelvic congestion syndrome; patient information. British Society of Interventional Radiology
2. Kim HS et al. Embolotherapy for pelvic congestion syndrome: long term results. J Vasc Interv Radiol 2006; 17: 289-297
3. Lopez A. Female pelvic vein embolisation: indications, techniques, and outcomes. CVIR 2015; 38: 806-820
4. Durham JD, Machan LM. Pelvic congestion syndrome. Semin Intervent Radiol 2013; 30: 372-380
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Contacts:
Dr. Morteza Afrasiabi MD,MSc
[email protected]
Dr.Neda Noroozian MD,MRCP [email protected]