pelvic venous insufficiency: imaging diagnosis, …...2017/12/23 · ajr:204, february 2015 449...

448 AJR:204, February 2015

these symptoms in conjunction with a clinical examination finding of ovarian point tender-ness is 94% sensitive and 77% specific for the diagnosis of PCS [4].

Pelvic venous insufficiency (PVI) is the standardized definition that specifically re-fers to the pathophysiologic mechanism of retrograde flow through incompetent ovari-an and pelvic veins. The pathogenesis of PVI is multifactorial. Predisposing factors for the development of PVI include a family history of varicose veins, hormonal influences, previ-ous pelvic surgery, a retroverted uterus, and multiple pregnancies [1, 3]. Specifically, the increased demand on venous return as a re-sult of pregnancy and hormonal influences leads to chronic venous distention that can render the valves incompetent, leading to re-flux of blood down the ovarian veins and into the internal iliac veins of the pelvis. The accu-mulation of blood within the pelvic veins can cause further engorgement, thrombosis, and mass effect on nearby nerves, which can lead to worsening pelvic pain. Dilated pelvic veins are more commonly seen on the left, where the left ovarian vein drains into the left renal vein before reaching the inferior vena cava, whereas the right ovarian vein drains direct-ly into the inferior vena cava (Fig. 1). In ad-dition, venous outflow obstruction from ana-tomic variants, such as compression of the left renal vein by the superior mesenteric artery (nutcracker syndrome) may result in engorge-ment of the left ovarian vein. Portal hyper-tension and acquired inferior vena cava syn-drome may be related to the development of secondary pelvic venous congestion [2, 5, 6].

Pelvic Venous Insufficiency: Imaging Diagnosis, Treatment Approaches, and Therapeutic Issues

M.-Gracia Knuttinen1 Karen Xie Aarti Jani Alison Palumbo Tami Carrillo Winnie Mar

Knuttinen MG, Xie K, Jani A, Palumbo A, Carrillo T, Mar W

1All authors: Department of Radiology, University of Illinois Hospital and Health Sciences System, 1741 W Taylor St, MC 931, Chicago, IL, 60612. Address correspondence to M. G. Knuttinen ([email protected]).

Vascular and Inter vent iona l Radiolog y • Review

This article is available for credit.

AJR 2015; 204:448–458

0361–803X/15/2042–448

© American Roentgen Ray Society

Chronic pelvic pain is a common health problem that affects mil-lions of women worldwide, but it can be a difficult condition to ad-

dress. As many as 40% of all women seen in gynecology outpatient clinics report chronic pelvic pain. One fourth of all hysterectomies and one third of exploratory laparoscopic pro-cedures are performed to investigate chronic pelvic pain [1]. Pelvic congestion syndrome (PCS) is a diagnosis that should be considered in many women after other pelvic conditions have been ruled out. Imaging may aid in diag-nosis, and the imaging findings may facilitate precise preprocedure planning. We describe our current imaging workup for the diagnosis of PCS and the therapeutic approaches.

Description and TermsPelvic venous congestion is a common-

ly overlooked condition that can be severe-ly painful and debilitating for many women. The term “pelvic congestion syndrome” spe-cifically refers to the condition first described by Louis Alfred Richet in 1857 and character-ized by chronic, dull pelvic pain, pressure, and heaviness that persist for more than 6 months with no other cause [2]. These symptoms are thought to be attributable to dilated, tortuous, and congested veins within the pelvis [3–5]. PCS is analogous to varicocele in men, but because the pelvic varicosities are not exter-nally visible, the diagnosis can be overlooked. Symptoms are exacerbated with menses, pro-longed standing, and activities that increase abdominal pressure [3–5]. The symptoms are worse at the end of the day. The presence of

Keywords: embolization, ovarian vein, pelvic pain, varices, varix, venous insufficiency

DOI:10.2214/AJR.14.12709

Received February 7, 2014; accepted after revision September 1, 2014.

OBJECTIVE. The purposes of this article are to review the causes of pelvic congestion syndrome and the imaging used to make the diagnosis and to summarize the treatment options.

CONCLUSION. Pelvic congestion syndrome is one of many causes of chronic pelvic pain. It is thought to arise from ovarian and pelvic venous incompetence. Findings from vari-ous noninvasive imaging studies, such as Doppler ultrasound and MRI, in association with the clinical symptoms are critical in establishing the diagnosis.

Knuttinen et al.Pelvic Venous Insufficiency: Imaging and Treatment

Vascular and Interventional RadiologyReview

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AJR:204, February 2015 449

Pelvic Venous Insufficiency: Imaging and Treatment

Disturbances in hormonal regulation also play a role in the development of PVI. Stones [7] found that in mice from which the ova-ries had been removed, the uterine and ovar-ian veins selectively enlarged in response to estradiol administration with no change in the caliber of the femoral or iliac veins or the vena cava [7]. This finding suggests that the ovarian and uterine veins are selectively sen-sitized to ovary-produced hormones. During menstruation, the ovarian veins are exposed to a markedly larger concentration of estrone and estradiol than is present in the peripheral plasma. The symptoms of PVI are known to be exacerbated during menses and pregnan-cy but generally diminish with menopause. This theory is also supported by the accepted medical treatment of PVI by pharmacologic ovarian suppression [4, 8].

Clinical CharacteristicsPatients with PVI are typically of child-

bearing age and multiparous [1, 3–5, 9, 10]. Women often present with unilateral or bilat-eral lower abdominal and pelvic pain, which is generally chronic and dull, but acute and severe pain may also occur. The pain, de-scribed as heaviness and fullness in the lower pelvis, vulvar region, and thighs, is exacer-bated during menses and may be associated with dyspareunia. Patients may present with atypical nonsaphenous pudendal, vulvar, and perilabial varicosities. Incompetent pel-vic varices also can collateralize along the pos tero lateral thigh and gluteal regions [11]. Signs of PVI include postcoital ache, dyspa-reunia, dysmenorrhea, perineal pain, urgen-cy, and vulval and lower extremity varicosi-ties [2, 9, 11–13]. Depression and anxiety are common comorbidities, in part owing to a prolonged time to diagnosis, but may also be physiologic. In response to the shearing and stretching of the congested ovarian veins, en-dothelial and smooth-muscle cells release va-sodilator substances, which play a key role in regulating emotions and stress [1]. Because of the negative psychosocial associations with the term pelvic congestion syndrome, pelvic venous insufficiency is now the pre-ferred term because it describes the actual pathophysiologic mechanism [11].

Imaging DiagnosisVarious imaging modalities are useful

in the evaluation of PVI, revealing multiple imaging features, such as ovarian vein size, flow velocity, flow direction, and the anatom-ic relations between the ovarian vein and the

surrounding structures. Although transcath-eter venography remains the standard for di-agnosing dilation and congestion of veins, other, less invasive modalities exist to indi-cate the presence of pelvic vein engorgement and suggest the diagnosis of PVI. Further-more, it is important to rule out other poten-tial pathologic conditions that could account for chronic pelvic pain. We discuss the imag-ing findings of ultrasound, MRI, and venog-raphy (Table 1). CT should not be a primary modality for imaging women of childbearing age, but its findings are similar to MRI find-ings and are discussed in the MRI section.

UltrasoundUltrasound is widely available and does

not involve radiation exposure. Multiple di-lated tubular structures around the uterus and ovaries can be identified with transvag-inal ultrasound. Color Doppler ultrasound technique is used for real-time analysis of arterial and venous flow. Three distinguish-ing sonographic criteria are important to adequately suggest the diagnosis of PVI: a dilated tortuous pelvic vein with a diame-ter greater than 4 mm, slow blood flow (≤ 3 cm/s), and a dilated arcuate vein in the myo-metrium that communicates with the pelvic varicosities [5] (Fig. 2).

Doppler ultrasound is important because the gray-scale sonographic appearance of dilated veins can be similar to that of cys-tic adnexal masses [14, 15]. During a Valsal-va maneuver or upright positioning, Doppler waveforms in the dilated pelvic veins may stop or reverse. Transabdominal sonographic measurement of the left ovarian vein with

evaluation for reflux can also be performed [16]. The positive predictive value of a left ovarian vein diameter of 5 mm was 71%, and of 6 mm was 83%. Patients with PVI also tend to have polycystic ovaries, a larger uterus, and a thicker endometrium [17]. The sensitivity, specificity, and accuracy of ultra-sound have not been reported, to our knowl-edge. Ultrasound has its limitations, depend-ing on patient factors such as habitus and the presence of bowel gas, and is operator depen-dent. Furthermore, normal findings at ultra-sound examination do not exclude the diag-nosis of pelvic varices.

MRIMultiplanar pelvic MRI has superb image

quality, providing high tissue contrast and spatial resolution in depicting pelvic anatom-ic detail and vasculature. MRI may reveal ev-idence of other causes of chronic pelvic pain, such as endometriosis, which may not be vis-ible at ultrasound, or other uterine, adnexal, urologic, gastrointestinal, or musculoskeletal causes of pain. In one study [18], the sensi-tivity and specificity of MRI for congestion according to the criteria developed by Kaup-pila et al. [19] with venography as a refer-ence standard were 88% and 67% for ovarian veins, 100% and 38% for internal iliac veins, and 91% and 42% for the pelvic plexus. In another study [20], the sensitivity of time-resolved MR angiography for ovarian reflux ranged from 67% to 75%; the specificity was 100%; and the accuracy was 79–84%. At our institution, we use MRI of the abdomen and pelvis to identify the location and size of the ovarian veins and the presence of pelvic vari-

TABLE 1: Diagnostic Imaging Findings That Suggest Pelvic Venous Insufficiency

Modality Finding

Ultrasound Multiple dilated, tubular structures around the ovary and uterus

Three common criteria:

1. Dilated tortuous vein with diameter > 4 mm

2. Slow blood flow (≤ 3 cm/s)

3. Dilated arcuate vein in the myometrium that communicates with pelvic varicosities

Doppler technique helpful in differentiating pelvic varicosities from cystic adnexal masses

MRI T1-weighted images: serpentine flow voids

T2-weighted images: heterogeneous signal intensity due to slow flow in dilated veins

Contrast-enhanced images: delayed enhancement of the dilated, tortuous vessels

Venography Retrograde ovarian venography: ovarian vein measuring > 8–10 mm

Uterine venous engorgement

Filling of pelvic veins across midline or filling of vulvovaginal and thigh varicosities

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Knuttinen et al.

cosities. The diagnostic criteria for MRI and CT proposed by Coakley et al. [10] consist of at least four ipsilateral parauterine veins of varying caliber, at least one measuring more than 4 mm in diameter, or an ovarian vein di-ameter greater than 8 mm.

Ovarian vein and pelvic varices are hypoin-tense on T1-weighted images, appearing as flow voids. On T2-weighted images, dilated ovarian and pelvic veins are hyperintense and of decreased flow velocity [10]. On MR im-ages, pelvic varices appear as multiple dilated tubular structures around the uterus, ovaries, and pelvic sidewall. They are hypointense on T1-weighted images and hyperintense on T2-weighted images [10]. On contrast-enhanced T1-weighted gradient-echo MR images, di-lated ovarian and pelvic varices are best vi-sualized in the venous phase [15]. Subtracted maximum-intensity-projection reconstruction images are used for 3D visualization of the course of the dilated veins (Fig. 3).

Late arterial phase MRI can show retro-grade filling of the ovarian veins from the re-nal veins and early draining of the pelvic veins into the iliac veins. Pelvic varices can vary in size and number and may extend into the broad ligament, reach the pelvic sidewall, or extend inferiorly to communicate with the paravagi-nal and thigh venous plexus (Figs. 4 and 5).

VenographyTranscatheter venography is performed

when findings at noninvasive imaging are inconclusive for diagnosis in a patient with suspected PVI or when interventional treat-ment is pursued. Confirmatory venographic findings include dilated ovarian veins with diameters of at least 5 mm; retrograde ovar-ian vein reflux; uterine venous engorgement; and cross filling of pelvic veins across the midline with filling of vulvovaginal or thigh varicosities [11]. Although these findings are helpful, not all of them need be present in all patients being treated. Some authors [11] believe that strict diameter measurements should not preclude treatment. Conversely, correlation with clinical symptoms is essen-tial because dilatation of the ovarian veins and ovarian venous reflux were seen on CT images of as many as 47% of women without symptoms [21]. PVI therefore should not be diagnosed solely with imaging.

The venographic scoring system of Beard et al. [5] consists of three components: max-imum diameter of the ovarian vein, time to disappearance of contrast material, and degree of congestion. Each component is

scored from 1 to 3 on the basis of degree. A score of 5 or more has been found to be an objective measure of pelvic congestion, having 91% sensitivity and 89% specificity. Ovarian vein diameter was considered nor-mal if it measured 1–4 mm; moderate, 5–8 mm; and severe, greater than 8 mm. Time to disappearance after transuterine injection of contrast medium was scored on the basis of a time of 0, 20, or 40 seconds. Degree of con-gestion was determined as follows: Normal veins were small, straight, and easily seen. In moderate congestion, veins were tortuous with variable caliber. In severe congestion, veins were wide with great variation in cali-ber and were highly tortuous [19].

Principles and Selection of Treatment

Multiple methods of therapy for PVI have been used, including medical management with hormone analogues and surgical op-tions, such as ligation of the ovarian veins and hysterectomy with or without bilateral salpingo-oophorectomy. Less invasive and more modern approaches to treatment in-clude transcatheter embolization of the ovar-ian or internal iliac veins.

Medical OptionsThe medical treatment of PVI consists

in treating the entity as one of ovarian dys-function. Proponents of this theory argue that estrogen is a venous dilator and that counteracting this effect can resolve symp-toms. A review of the literature spans the use of hormone therapies, such as medroxy-progesterone acetate (MPA) and goserelin, a gonadotropin-releasing hormone analogue, in an effort to suppress ovarian function or increase venous contraction [9, 22]. MPA acts as an agonist of progesterone, causing an inhibitory effect on estrogen levels through suppression of the hypothalamic-pituitary axis. The net effect is to suppress ovarian function. The long-term benefits of MPA with doses of 30 mg/d for 4–6 months have been found to produce an optimal hormon-al milieu of hypoestrogenism [17, 23] with success in pelvic pain reduction. Soysal et al. [22] performed a randomized controlled trial of MPA and goserelin in a group of 47 women with symptoms suggestive of PVI. They looked at the longer-term effects after 6 months of medical treatment in either the MPA (30-mg/d regimen) or the goserelin ac-etate (3.6 mg/mo) arm. Comparative objec-tives (peruterine venography) and subjec-

tive measures (symptom improvement) were measured at 6 months and 1 year. Goserelin was found to be more effective: Subjective improvements in pelvic symptoms persisted for 1 year after treatment [22]. The authors did not report on adverse effects. It remains unclear whether a temporary artificial meno-pausal state of 6 months can effectively yield a permanent cure of PVI. The limitations of gonadotropin-releasing hormone analogues are the side effects, cost, and lack of feasi-bility of long-term use because of the risk of menopausal symptoms and osteoporosis.

In a 2014 Cochrane review [24], 13 ran-domized controlled trials were evaluated to assess the effectiveness and safety of nonsur-gical interventions for women with chron-ic pelvic pain, which included women with PVI or adhesions. The authors conclud-ed that there is evidence of moderate qual-ity to support progestogen as an option for the treatment of chronic pelvic pain. How-ever, the authors stated that the limitations of this therapy are the adverse side effects, such as weight gain and bloating. The quality of evidence was considered very low for most comparisons of medical treatments because they involved single small studies. Further-more, it is difficult to draw meaningful con-clusions about quality-of-life and functional outcomes because of the large variation in outcome measures used in these studies.

The efficacy of a synthetic steroid consist-ing of a single-rod nonbiodegradable implant containing and releasing the desogestrel me-tabolite etonogestrel (Implanon, Merck) has been evaluated for the treatment of pelvic pain in women with PVI [25]. This implant has been widely used for long-term contra-ception. It inhibits follicle-stimulating hor-mone activity and thus ovulation and pro-duces a hypoestrogenic state. In this small study, which included only 23 women, near-ly 80% of the women with PVI who received the implant were satisfied with symptom re-lief after only 3 months of treatment. It is difficult to compare this device with other medical treatment options, because the other options are used for a shorter duration than the implant. The etonogestrel implant is a vi-able option for long-term medical treatment of PVI, but a long-term study with more sub-jects is necessary to evaluate the effective-ness and recurrence of PVI after removal.

Surgical OptionsSurgical treatment options are based on

counteracting the mechanical factors that af-

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fect pelvic varicosities. A marked increase in the capacity and laxity of pelvic veins later in gestation causes these vessels to become more vulnerable to enlargement and venous incompe-tence. This increased dilatation with venous sta-sis likely results in the chronic pelvic pain that women may feel. In the 1980s Rundquist et al. [26] found that resection of the left ovarian vein for PVI had a positive effect in relieving PVI symptoms. More recently, laparoscopic ligation of the ovarian veins also has had positive effects, but only a few case studies are available [7, 27]. Damage to nearby pelvic nerves and the devel-opment of collateral channels are risk factors. Hysterectomy was initially considered 100% curative, but several studies have shown resid-ual pain in 30% of women and a 20% recur-rence rate [28]. Overall, surgery is rarely used because more modern endovascular treatments are much more effective and less invasive.

Interventional OptionsTranscatheter pelvic vein embolization was

pioneered in 1993 by Edwards et al. [12] and has developed into a well-recognized proce-dure that is safe and efficacious in the treat-ment of women with PVI [11]. Numerous studies have shown clinical success rates ranging from 60% to 80% in reducing chronic pelvic pain. In one long-term study, Kim et al. [29] found that 83% of women had significant improvement in overall pain perception in a mean of 45 months. The goal of transcathe-ter embolization is to occlude the diseased, re-fluxing veins, which eliminates the increased hydrostatic pressure in the pelvis and resolves the varicosities. After occlusion of the reflux-ing vein, follow-up pelvic venography is per-formed to document resolution of the reflux into the varicosities. Clinical success is mea-sured by long-term symptomatic relief.

Embolization MaterialsEdwards et al. [12] described the first case

of transcatheter embolization of ovarian var-ices in 1993. They used coils as the embol-ic agent. Today, embolizing agents include coils, sclerosants, and glue alone or in var-ious combinations. Although the literature reports data on the use of different embol-ic agents, to our knowledge, no controlled studies have directly compared embolic agents for the treatment of PVI. Therefore, the choice of embolic agent is largely deter-mined by the operator and institution. A re-view of the literature [30] shows that a com-bination of coils and sclerosing agents seems to be the most frequently reported method.

Historically, mechanical occlusion with metallic coils is one of the most common techniques of permanent blood vessel occlu-sion in endovascular therapy. Typical coils comprise either a stainless steel or platinum core and synthetic thrombogenic fibers fan-ning out from the core. Coils come in a vari-ety of shapes and sizes and are typically used to treat vessels wider than 2 mm in diameter. Once deployed from the catheter, the coil as-sumes its shape in the vessel and causes me-chanical occlusion and thrombosis, which lead to sclerosis and eventual permanent oc-clusion of the vessel [31, 32]. The optimal size and number of coils used for embolization are determined by the size of the ovarian vein be-ing treated. Coil size can be 1–3 mm great-er than the diameter of the vein to be emboli-zed. Kwon et al. [33] in 2006 reported results of a study of 67 patients treated for PVI by coil embolization alone with an average of 5.8 coils per ovarian vein (Figs. 6 and 7).

Sodium tetradecyl sulfate (STS) and sodi-um morrhuate are commonly used sclerosing agents. Detergent-based chemicals act on the lipid molecules in the cells of the vein wall, causing intimal inflammation and thrombus formation, which lead to sclerosis and com-plete vessel occlusion. Sclerosing agents can be delivered in a variety of forms, including liquid, foam, or a slurry of sclerosant and gelatin foam sponge. When the agent is used in liquid form, small aliquots of the scle-rosant (2 mL) are injected slowly with bal-loon occlusion of the proximal vessel until coagulation of the vessel is achieved. Often, metallic coils are placed behind to the scle-rosant to ensure the sclerosant stays in place and to contribute to complete vessel occlu-sion [34]. The preparation and use of STS foam for the treatment of varicose veins was introduced by Tessari in France in 1999 [35]. Using STS in the form of foam takes advan-tage of the fact that foam spreads on the en-dothelium so that there is larger surface con-tact, which induces more effective sclerosis. In addition, owing to its high viscosity, STS foam is associated with lower risk of extrav-asation and allows use of smaller quantities of sclerosing agent, thereby reducing the rate of systemic dispersion and adverse reactions. Gandini et al. [36] reported that the mallea-ble nature of the foam allows complete fill-ing of the varices via the ovarian vein, elimi-nating the need for selective catheterization of the internal iliac veins for embolization of eventual collaterals. Gandini et al. also stat-ed that use of STS foam eliminated the need

for concomitant use of metallic coils, so that the procedure is less invasive with overall less fluoroscopic time and therefore a lower radiation dose.

The use of glue as a venous embolic agent in the treatment of PVI has also been de-scribed in the literature. In 2000, Maleux et al. [37] reported the use of a mixture of 0.5 mL enbucrilate and 0.4 mL iodized oil, in-jecting approximately 2 mL of the mixture into each ovarian vein, occluding from distal to proximal. This technique was used in con-junction with coil embolization. Flushing the catheter with a 10% dextrose solution both before and after injection of the glue helps to prevent immediate coagulation of glue in the catheter. In very large ovarian veins (> 2 cm), a sandwich technique with both glue and coils has been described [37]. The ad-vantages of using glue include its ability to reflux into various branches of any eventual collaterals owing to its liquid state and its lo-cal inflammatory effect on the veins them-selves, which contribute to effective throm-bosis. The disadvantage of using glue for venous occlusion is the risk of migration of glue fragments. One of the more dangerous outcomes is pulmonary embolus.

Although numerous studies have shown the efficacy of percutaneous transcatheter embolization for the treatment of PVI, to our knowledge no study has directly compared the choices of embolic agents. Therefore, this choice is based more on the experience and preference of the operator than on objective data directly related to embolic treatment of PVI. A randomized clinical trial is warrant-ed to further investigate the efficacy of vari-ous embolic agents in the treatment of PVI.

Technique for Pelvic Vein EmbolizationPreoperative image analysis (ultrasound

and MRI) is crucial for delineating the ovar-ian venous anatomy and for documenting the pelvic varicosities. Localized pelvic vari-ces from dilated ovarian veins are the sim-plest to treat. Contribution to pelvic vari-ces via the internal iliac veins may require a staged approach. Before embolization, ade-quate visualization of pelvic varicosities and their contributors is critical. We perform our transcatheter embolization technique with moderate sedation using fentanyl and mid-azolam with adequate monitoring by nursing staff. The ovarian veins are approached from either a femoral or a jugular route; we pre-fer the jugular approach. A 7-French sheath is placed into the inferior vena cava, and a

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5-French guiding catheter is used to select the left renal vein. A guidewire is then ma-nipulated caudally into the left ovarian vein, and digital subtraction venography is per-formed. The ovarian venous plexus is then coiled. Other embolic agents have been de-scribed in the literature, such as a slurry of gelatin foam sponge and sodium morrhuate, as described previously.

Embolization materials can be used ei-ther individually or in combination. Anoth-er popular technique is to sandwich foamed sclerosant between the mechanical occlusions (coils) of the proximal and distal ends of the ovarian vein. The entire length of the ovarian vein should be treated to prevent residual in-competent patent segments from recanalizing. After gonadal vein embolization, repeat left renal venography from the renal hilum should be performed to confirm gonadal vein occlu-sion. From the inferior vena cava, the right ovarian vein is subsequently catheterized with a multipurpose B or cobra 2 catheter. The em-bolization procedure is repeated. Venography of the inferior vena cava should be performed after embolization to confirm occlusion of the right ovarian vein (Figs. 8 and 9).

Because of the communications that ex-ist from the ovarian veins to the internal ili-ac system, it is important to perform internal iliac venography to document contributions to pelvic varicosities. Internal iliac varicosi-ties can be identified by selecting the internal iliac vein and performing venography with and without a Valsalva maneuver. If reflux is identified, the varicosities can be individ-ually selected and coiled. If necessary, vul-var and vaginal varicosities can be individu-ally selected and coiled. However, care must be taken when embolizing a superficial vari-cosity with coils: Some patients describe a palpable sensation of the coil under the skin, which can be irritating.

It is important to understand the varicosi-ties in a particular patient before the exam-ination, to localize the feeding vein. Vari-cosities can originate in the inguinal region, arising from the external iliac vein. It is fre-quently noted that internal iliac vein reflux documented before gonadal vein emboliza-tion resolves after embolization of the go-nadal vein. In such cases, we are conser-vative about localizing and embolizing the varicosities arising from the internal iliac vein. The primary refluxing vein, the gonad-al vein, has been obliterated, eliminating the problem of excessive blood flow within the pelvis. If the patient experiences persistent

pelvic discomfort, she can return for further embolization of the hypogastric varicosities.

Follow-UpAfter the procedure, patients may expe-

rience mild to moderate pain that is signifi-cantly less than that of arterial embolization. Access to oral or IV pain medication may be needed. Embolization procedures are typi-cally performed in an outpatient setting. In a small cohort study (24 patients), Creton et al. [38] reported a high rate of technical success and clinical improvement in 80% of patients 3 years after embolization. Complications are rare, occurring at a rate of 0–4%, and include migration of coils to the pulmonary bed and thrombophlebitis and pain [39, 40].

Patients are usually seen in an outpatient facility within 1 week for short-term clinical follow-up and again within 3–6 months to confirm and document symptom relief. Clin-ical improvement markers to be reported be-fore and after treatment should include over-all pelvic pain level, pelvic and leg pain on standing and lying down, dyspareunia, men-strual pain, and the use of pain medications. The primary clinical endpoint should be to improve a woman’s quality of life through relief of chronic pelvic pain. Embolization of the ovarian veins should cause the pelvic varicosities to shrink within a few weeks. Only recently have a few prospective obser-vational studies, conducted with a visual an-alog scale, shown relief of pelvic pain symp-toms [32, 41]. Further studies conducted with objective scores are needed to determine the long-term beneficial effect of endovascular embolotherapy on symptom improvement.

ConclusionPVI is difficult to diagnose in many

women. Its identification is based on the presence of typical symptoms and imaging findings with various diagnostic modalities and parameters. The diagnostic and thera-peutic approach to PVI must be individually tailored and must take into account the se-verity of symptoms. Multiple treatment ap-proaches, varying from medical therapies to aggressive surgical options, have been used in the past. More recently, there have been encouraging technical and clinical success rates for selective endovascular emboliza-tion of incompetent veins. However, ad-ditional clinical studies are needed to ad-dress the long-term outcomes and to clarify which patients may benefit from each treat-ment approach.

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(Figures start on next page)

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Fig. 1—Drawing depicts ovarian venous anatomy. Right ovarian vein (v.) drains directly into inferior vena cava and courses inferiorly in relation to pelvic venous plexus. Left ovarian vein drains into left renal vein and then courses inferiorly. Internal iliac veins also communicate with pelvic venous plexus. (Courtesy of Natalie Doolittle, Medical Illustrator and Animator)

AFig. 2—45-year-old woman with pelvic venous insufficiency.A and B, Gray-scale (A) and color Doppler (B) ultrasound images show dilated left adnexal veins (arrow, B).

B

(Fig. 2 continues on next page)

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CFig. 2 (continued)—45-year-old woman with pelvic venous insufficiency.C–E, CT images show dilated left pelvic veins (white arrow) and left ovarian vein (black arrow).

ED

AFig. 3—48-year-old woman with pelvic venous insufficiency.A–C, Venous phase (A and B) and maximum-intensity-projection MR angiographic (C) images show dilated left gonadal vein (arrow, A and C) and dilated pelvic collaterals (arrows, B) consistent with pelvic venous insufficiency.

CB

A

Fig. 4—48-year-old woman with pelvic venous insufficiency.A and B, Late arterial phase MR images show retrograde filling of ovarian veins (white arrow) from renal vein (black arrow).

B

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AFig. 5—49-year-old woman with pelvic venous insufficiency.A–C, Thigh varicose veins (arrows, A), vulvar varicose veins (arrow, B), and dilated internal iliac veins and pelvic veins (arrows, C).

B

C

AFig. 6—48-year-old woman with pelvic venous insufficiency.A, Maximum-intensity-projection MR angiogram shows enlarged left ovarian vein coursing inferiorly in pelvis.B, Transcatheter venogram confirms dilatation of left ovarian vein.C, Transcatheter venogram shows dilated ovarian vein with several collateral pelvic veins and cross filling into right internal iliac venous system.

CB

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A

Fig. 7—48-year-old woman with pelvic venous insufficiency.A, Venogram shows enlargement of right ovarian vein with engorgement of uterine veins.B, Venogram obtained with catheter in left renal vein shows coils within right ovarian vein extending to origin from inferior vena cava and retrograde reflux down left ovarian vein.

B

A

Fig. 8—48-year-old woman with pelvic venous insufficiency.A, Venogram obtained with catheter advanced distally into left ovarian vein shows engorged uterine venous plexus.B, Venogram shows aftermath of coil embolization of left ovarian vein up to its origin with left renal vein.

B

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A

Fig. 9—39-year-old woman with pelvic venous insufficiency.A, Venogram shows large collateral pelvic vein arising from left internal iliac vein.B, Venogram shows aftermath of coil embolization performed for venous varicosity.

B

F O R Y O U R I N F O R M A T I O N

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pelvic venous insufficiency: imaging diagnosis, …...2017/12/23 · ajr:204, february 2015 449...

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