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Print this pageReflux Patterns In Patients With Pelvic Venous Insufficiency And Varicose Veins
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Bruno Geier, MD1, Achim Mumme, MD, PhD1, Thomas von Rothenburg, MD2, Odo Koster, MD, PhD2, Letterio Barbera, MD, PhD3.
1Department of Vascular Surgery, St.Josef-Hospital, Ruhr-University, Bochum, Germany, 2Department of Diagnostic and Interventional Radiology, St.Josef-Hospital, Ruhr-University, Bochum, Germany, 3Division of Vascular Surgery, Hospital Bremen-Mitte, Bremen, Germany. Reflux patterns in patients with pelvic venous insufficiency and varicose veins
Objective: Venous reflux originating in the pelvic veins can contribute to the development of primary or recurrent varicose veins of the legs. In the present study, patients with varicose veins who in addition had clinical and/or duplex ultrasound findings suspicious of pelvic venous insufficiency (PVI) underwent selective retrograde catheter phlebography of the pelvic veins in order to detect the presence and pattern of reflux in the pelvic veins.
Methods: 101 patients (all female, mean age 49.3 years) underwent selective phlebography of the pelvic veins at our institution between October of 1999 and December of 2003. The decision to perform the examination was based on clinical (atypical location of the varicose veins, increase of congestion symptoms related to the menstrual period, dyspareunia ) and duplex-ultrasound (reflux in the groin originating from epigastric as well as pubic and pudendal veins) findings. The examination was performed on an outpatient basis. The right femoral vein was cannulated under local anaesthesia and both ovarian and hypogastric veins were selectively visualised using angiography catheters. The procedure was performed with the patient in a 40° anti-trendelenburg position at rest as well as during a valsalva manoeuvre. The presence and the extent of any insufficiency were documented and the ovarian and pelvic veins affected by the reflux were recorded.
Results: The standardized examination protocol was successfully completed in all cases. There were no adverse events due to the contrast agents nor where there any cases of bleeding or pelvic vein thrombosis. In three patients an injury of the pelvic veins occurred (in two cases the left ovarian vein and in one case the left hypogastric vein), but in all patients the injury resolved without the need for further intervention. The retrograde selective plebography demonstrated a PVI in 75 patients (74.2%). The left ovarian vein and the right hypogastric vein were most frequently affected by reflux (n = 41, 54.6%, respectively). The left hypogastric vein was insufficient in 35 patients (46.6%) and the right ovarian vein only in three cases (4%). In about half the patients with PVI reflux was demonstrated in more then one of the main pelvic veins (ovarian veins and hypogastric veins, n = 38, 50.6%).
An extension of the reflux into varicose veins of the groin or lower leg was demonstrated in 44 patients (58.6%).
Conclusions: Selective retrograde catheter phlebography is a safe and effective examination to detect pelvic venous reflux. Such a reflux was present in 75% of our study population. Therefore, a high level of suspicion of PVI and a low threshold to perform catheter phlebography should be assumed in patients with typical clinical and/or duplex findings.
The possible treatment options for PVI (ligation of the ovarian vein, coil embolisation, foam sclerotherapy) need further study.
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Bruno Geier, MD1, Achim Mumme, MD, PhD1, Thomas von Rothenburg, MD2, Odo Koster, MD, PhD2, Letterio Barbera, MD, PhD3.
1Department of Vascular Surgery, St.Josef-Hospital, Ruhr-University, Bochum, Germany, 2Department of Diagnostic and Interventional Radiology, St.Josef-Hospital, Ruhr-University, Bochum, Germany, 3Division of Vascular Surgery, Hospital Bremen-Mitte, Bremen, Germany. Reflux patterns in patients with pelvic venous insufficiency and varicose veins
Objective: Venous reflux originating in the pelvic veins can contribute to the development of primary or recurrent varicose veins of the legs. In the present study, patients with varicose veins who in addition had clinical and/or duplex ultrasound findings suspicious of pelvic venous insufficiency (PVI) underwent selective retrograde catheter phlebography of the pelvic veins in order to detect the presence and pattern of reflux in the pelvic veins.
Methods: 101 patients (all female, mean age 49.3 years) underwent selective phlebography of the pelvic veins at our institution between October of 1999 and December of 2003. The decision to perform the examination was based on clinical (atypical location of the varicose veins, increase of congestion symptoms related to the menstrual period, dyspareunia ) and duplex-ultrasound (reflux in the groin originating from epigastric as well as pubic and pudendal veins) findings. The examination was performed on an outpatient basis. The right femoral vein was cannulated under local anaesthesia and both ovarian and hypogastric veins were selectively visualised using angiography catheters. The procedure was performed with the patient in a 40° anti-trendelenburg position at rest as well as during a valsalva manoeuvre. The presence and the extent of any insufficiency were documented and the ovarian and pelvic veins affected by the reflux were recorded.
Results: The standardized examination protocol was successfully completed in all cases. There were no adverse events due to the contrast agents nor where there any cases of bleeding or pelvic vein thrombosis. In three patients an injury of the pelvic veins occurred (in two cases the left ovarian vein and in one case the left hypogastric vein), but in all patients the injury resolved without the need for further intervention. The retrograde selective plebography demonstrated a PVI in 75 patients (74.2%). The left ovarian vein and the right hypogastric vein were most frequently affected by reflux (n = 41, 54.6%, respectively). The left hypogastric vein was insufficient in 35 patients (46.6%) and the right ovarian vein only in three cases (4%). In about half the patients with PVI reflux was demonstrated in more then one of the main pelvic veins (ovarian veins and hypogastric veins, n = 38, 50.6%).
An extension of the reflux into varicose veins of the groin or lower leg was demonstrated in 44 patients (58.6%).
Conclusions: Selective retrograde catheter phlebography is a safe and effective examination to detect pelvic venous reflux. Such a reflux was present in 75% of our study population. Therefore, a high level of suspicion of PVI and a low threshold to perform catheter phlebography should be assumed in patients with typical clinical and/or duplex findings.
The possible treatment options for PVI (ligation of the ovarian vein, coil embolisation, foam sclerotherapy) need further study.
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