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Approximately 15% of women aged 20-50 have pelvic vein insufficiency, with 60% of them being symptomatic. This condition typically affects the left side and is effectively treatable.
Symptoms
- Bloating
- Nausea
- Vaginal discharge
- Swelling in the pubic area
- Lower back pain
- Pain in the anal region
- Urge incontinence
- Hip pain
- Leg varicose veins
- Sexual arousal
- Dyspareunia
- Possible irritable bowel syndrome (IBS)
Presentation
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Anatomy
Risk factors
* Pregnancy
* Previous pelvic surgery
* Estrogen therapy
* Obesity, phlebitis
* Heavy lifting
* Venous anomalies
* Endometriosis, fibroids
* Tumors
* Genetic predispositions such as FOXC2, TIE2, NOTCH3
* Thrombomodulin
* Type 2 transforming growth factor-β receptor
* There is an association with polycystic ovaries
* During pregnancy, venous capacity increases by 60%, potentially leading to valve incompetence
Indications
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Type |
Description |
Treatment |
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I |
Venous insufficiency[colspan="2"] |
[null] |
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Ia |
Unilateral venous insufficiency |
Embolization |
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Ib |
Bilateral venous insufficiency |
Embolization |
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II |
Venous compression[colspan="2"] |
[null] |
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IIa |
May-Thurner syndrome |
Stenting ± embolization |
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IIb |
Nutcracker phenomenon |
Embolization ± stenting |
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IIc |
May-Thurner syndrome and nutcracker phenomenon |
Stenting, embolization |
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IId |
Other extrinsic venous compression |
Stenting |
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III |
Venous obstruction[colspan="2"] |
[null] |
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IIIa |
Common iliac vein obstruction |
Stenting |
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IIIb |
Inferior vena cava obstruction |
Stenting |
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IIIc |
Portal hypertension |
Stenting |
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IV |
Arteriovenous malformation or fistula |
Embolization |
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V |
Nutcracker syndrome |
Stenting or surgery |
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Contra Indications
Workup
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S - symptoms [colspan="2"] |
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S0 |
No symptoms |
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S1 |
Renal symptoms of venous origin |
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S2 |
Chronic pelvic pain of venous origin |
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S3 |
Extra-pelvic symptoms of venous origin
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V - varices [colspan="2"] |
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V0 |
No abdominal, pelvic, or pelvic origin extra-pelvic varices |
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V1 |
Renal hilar varices |
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V2 |
Pelvic varices |
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V3 |
Pelvic origin extra-pelvic varices
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P - pathophysiology [colspan="2"] |
[null] |
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Anatomy[colspan="2"] |
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IVC |
Inferior vena cava |
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LRV |
Left renal vein |
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LGV |
Left gonadal vein |
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LCIV |
Left common iliac vein |
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LEIV |
Left external iliac vein |
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IIV |
Internal iliac vein |
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PELV |
Pelvic escape veins
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Hemodynamics[colspan="2"] |
[null] |
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O |
Obstruction—thrombotic or nonthrombotic |
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R |
Reflux—thrombotic or nonthrombotic |
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Ethiology[colspan="2"] |
[null] |
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T |
Thrombotic—venous reflux or obstruction after a DVT |
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N |
Nonthrombotic—reflux arising from a degenerative process of the vein wall or proximal obstruction; obstruction arising from extrinsic compression |
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C |
Congenital—congenital venous or mixed vascular malformation |
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Multiple imaging modalities—ultrasound, venography (with or without intravascular ultrasound), computed tomography (CT), and magnetic resonance imaging (MRI)—are used to evaluate pelvic venous disorders. Because definitive anatomic and hemodynamic criteria for the PeVD spectrum remain lacking, no noninvasive imaging study alone should be used as the sole justification for intervention. Imaging findings must be interpreted cautiously and correlated carefully with the patient’s clinical symptoms.
- Transabdominal and transvaginal ultrasound
- Computed tomography venography (CTV)
- Magnetic resonance venography
Material
Essentials
- Ultrasound
- Chlorhexidine
- Standard angiography set
- Sterile drapes
- Lidocaine 1% 10 ml
- Contrast medium
- Heparine 5.000 IU/ml
- Heparinized saline (5.000 IU/l)
- 6F Introducer
- RIM catheter
- 25-45 cm 6F sheaths
- Stiff Terumo wire
- Floppy Terumo wire
- Cobra catheters
- Glubran2
- Coils, both pushable/detachable and 0.018" and 0.035"
Non Essentials
Write your text here
Positioning
- Head first
- Supine
Steps
- Time out
- Infiltration with Lidocaine
- Ultrasound-guided venous puncture
- Placement of a sheath
- Administration of Heparin (5000 IU)
- Selective catheterization of the left renal vein
- Deep renal vein series under Valsalva maneuver
- If possible direct catheterization of the left ovarian vein, and if insufficient embolization with Glubran2
- Identification of the right ovarian vein, same procedrue as left ovarian vein
- Selective catheterization of the iliac veins, if insufficient embolization with coils
- Closure by manual compression
Tips & Tricks
- In case of perforation, avoid gluing due to the risk of damaging the ureter
| Access site complications, hematoma, pseudoaneurysm, fistula | 0.4% | ||
| Testicular pain post-procedure, may last up to 10 days | |||
| Spasm, perforation | |||
| Coil migration, rare when the correct coil size is used | |||
| Pelvic vein thrombosis | |||
| Phlebitis, occurs only with sclerotherapy (typically begins 24-48 hours post-procedure) | |||
| Post-embolization syndrome | |||
| Recurrence | 2-24% | ||
- Bed rest for around 2 h
Follow up
- In case of recurrent or persistent symptoms
Folder
Literature
| File Name | Type | Permissions | Changed Date | Date | Size |
|---|
Combined size: 0 B
Report
Time out.
Wassen met chloorhexidine en steriel afdekken. Echografisch geen stenose in de VFCD. Antegrade toegang, met 6F sheath. 5000 IE Heparine.
Selectieve katheterisatie van de vene renalis links. Er wordt geen insufficient collateraal pad gezien vanuit diepe renale vene. De vene ovarica is sufficient.
De vene ovarica rechts wordt niet geidentificeerd en als sufficient beschouwd. Geen insufficiente konvoluten in de ilacale venen.
Manuele compressie.
Sign-out
Time-out.
Cleanse with chlorhexidine and drape sterilely. Ultrasound shows no stenosis in the common femoral vein. Obtained antegrade access and placed a 6F sheath. Administered 5,000 IU heparin.
Selective catheterization of the left renal vein was performed. No insufficient collateral pathway from the deep renal vein was identified. The left ovarian vein is competent.
The right ovarian vein was not visualized; it is presumed competent. No insufficient varicosities were seen in the iliac veins.
Manual compression applied.
Sign-out