v. 2014.01.13

“Yes”

Pelvic vein insufficiency relates to imaging findings where venous valves are incompetent (usually ovarian veins but internal iliac vein branches can contribute) whereas pelvic congestion syndrome implies that this pelvic vein insufficiency causes symptoms.

Question 1 Answer

1) Inferior mesenteric vein 2) (Deep and superficial) external pudendal veins. 3) Superior Gluteal vein 4) Obturator vein

2) Obturator vein

4) (Deep and superficial) external pudendal veins.

Question 2 Answer

Pelvic congestion syndrome is usually overlooked at laparoscopy because of the patient's position, which is usually a Tredelenburg position, leading to unfilling of the varicose veins by gravity. Also, there is CO2 insufflation during laparoscopy, which leads to compression of the varicose veins and therefore missing the diagnosis.

Question 3 Answer

1,3,4,5,6,7,8

Dyspareunia or pelvic pain of unknown etiology (Dull ache or heaviness, increased standing/pregnancy/post-sexual intercourse)

- Perimenstrual variation in symptoms (increased pre-menstrual )

- Multiparous ( > 2/3)

- History of vaginal varicosities during pregnancy

- Recurrent lower extremity varices

- Varicose veins in atypical location (groin, buttocks, posteromedial thigh)

Question 4 Answer

1) May-Thurner syndrome which is compression of the left common iliac vein by the right common iliac artery

2) Nutcracker syndrome which is compression of the left renal vein in between the aorta and the superior mesenteric artery and hematuria

Links: Andrew K. Kurklinsky, MD, MACP and Thom W. Rooke, MD Nutcracker Phenomenon and

Nutcracker Syndrome, Mayo Clin Proc. 2010 June; 85(6): 552–559. doi: 10.4065/mcp.2009.0586 PMCID: PMC2878259

May-Turner Syndrome: Radiopaedia reference

Question 5 Answer

A) Glue

B) Particles

C) Coils

D) A mixture of sclerosing agent and mechanical agents

D) mix of sclerosing agent (for the varicosities themselves) and mechanical agents (for the main refluxing veins); for example, the peri-uterine varices can be embolized with a foam (STS 3%/Lipiodol/Air) and the ovarian vein would be closed with coils &/or Amplatzer plugs.

Question 6 Answer

Doppler/ultrasound, contrast CT, MRI and phlebography can all be used to diagnose a radiological pelvic congestion syndrome, on their own or in combination. However, the best test is a venous phlebography, ideally with Valsalva maneuver &/or table tilting.

Question 7 Answer

1) 95-100% 2) 40 to 100% 3) 75-80%

1) 60-80% 2) 100% 3) 30%

1) 55-75% 2) 35% 3) 65-75%

1) Technical success :95-100%

2) Clinical success :The subjective positive outcome is quite variable, from 40 to 100% but most studies report 68-100% improvement with follow-up between 1 and 48 months

3) Clinical success on lower extremity symptoms: There is very little literature about this but in the few series published, patients report improvement/satisfaction in 75-80% of embolized cases

Question 8 Answer

Perforation of ovarian vein, hypotension, venous thrombosis (at puncture site/venous drainage from embolization site)/Pulmonary emboli.

Post-embolization syndrome, but others are very few real complication and usually, these complications are not serious

Post-embolization syndrome, Perforation of ovarian vein, venous spasm, veni-puncture site hematoma, coil migration , venous thrombosis , Pulmonary emboli .

Post-embolization syndrome, Perforation of ovarian vein, venous spasm, veni-puncture site hematoma, coil migration

Most patients will experience a post-embolization syndrome but thers are very few real complication and usually, these complications are not serious:

Perforation of ovarian vein, venous spasm, veni-puncture site hematoma, coil migration (2%), venous thrombosis (at puncture site/venous drainage from embolization site)/Pulmonary emboli (very rare).

Question 9 Answer

- Non-invasive imaging recommended in selected patients with symptoms of PCS or symptomatic varices in pubis, labia, perineum or buttocks: 1C

- Recommended retrograde ovarian and internal iliac venoography in patients with pelvic venous disease, confirmed or suspected by non-invasive imaging, in whom intervention is planned: 1C

- Treatment of PCS and pelvic varices with coils, plugs, sclerotherapy: 2B

- If less invasive treatment is unavailable or has failed, surgical ligation and excision of ovarian veins: 2B

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Question 10 Answer