Pelvic Congestion Syndrome. Sophia A. Virani, HMS IV Gillian Lieberman, MD Beth Israel Deaconess Medical Center Department of Radiology May 2009

Pelvic Congestion Syndrome Sophia A. Virani, HMS IV Gillian Lieberman, MD Beth Israel Deaconess Medical Center Department of Radiology May 2009 Agen...
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Pelvic Congestion Syndrome Sophia A. Virani, HMS IV Gillian Lieberman, MD Beth Israel Deaconess Medical Center Department of Radiology May 2009

Agenda ƒ

Introduce index patient


Discuss pelvic congestion syndrome ƒ Etiology ƒ Menu of radiologic tests ƒ Treatment options


Review pelvic vasculature


Companion Cases

Let’s meet our patient …

Ms. C: Initial presentation ƒ

Ms. C is a 57 year old G3P2 post-menopausal woman who presents with one year of left lower quadrant pain ƒ Nagging pain ƒ Worse at night ƒ Often presents late in the afternoon after prolonged periods of standing

Chronic Pelvic Pain: Overview ƒ

Pelvic pain lasting greater than 6 months ƒ Not cyclical or intercourse related ƒ Often refractory to analgesic therapy with narcotics


Estimated cause of 10-40% of outpatient gynecologist visits


Etiology often elusive ƒ Patients can have extensive workups including laparoscopy in search of cause


Differential diagnosis is broad and includes endometriosis, adhesions, fibroids and pelvic varicosities

As part of her workup for pelvic pain, Ms. C had a transvaginal ultrasound which showed dilated pelvic veins, compatible with pelvic congestion syndrome

Pelvic Congestion Syndrome (PCS): Overview ƒ

Overview ƒ ƒ ƒ ƒ


Pathophysiology ƒ ƒ ƒ ƒ


Dilated pelvic veins with retrograde flow Stretch of engorged veins causes pain Can cause mass effect with symptoms such as constipation and bladder incontinence Can be bilateral, but left more often affected than right

Etiology ƒ ƒ ƒ


Dilated gonadal and pelvic veins determined as cause of chronic pelvic vein Affects primarily multiparous women of childbearing age Symptoms include pelvic pain, dyspareunia, thigh and vulvar varices Controversial as a diagnostic entity Æ mostly a diagnosis of exclusion

Poorly understood Hormonal factors are a likely contributor given that pre-menopausal women are primarily affected Mechanical factors ► Absent or incompetent valves ► Left renal vein variants associated with a higher incidence of pelvic varices

Treatment ƒ ƒ

No established medical treatments Surgical treatments include pelvic vein embolization and laparoscopic ligation of ovarian veins

Pelvic Congestion Syndrome is both diagnosed and treated radiologically. Let’s take a look at the imaging options for PCS

Pelvic Congestion: Menu of Radiologic Tests Test

Key Findings


ƒ ƒ ƒ

Contrast CT / CTA

ƒ ƒ


ƒ ƒ

Direct Venography

ƒ ƒ


Dilated ovarian veins Pelvic varices > 5mm Reversed flow with Doppler


Dilated ovarian veins Tortuous pelvic varices


Dilated ovarian veins Pelvic varices often hyperintense on T2


Dilated veins Reflux


ƒ ƒ


ƒ ƒ



Non invasive Readily available Can detect other causes of symptoms


Non operator dependent Can visualize vascular anatomy for possible etiology


Non invasive No contrast MRV becoming popular; can image pelvic venous system in 1 breath hold


Gold standard Can be done @ time of embolization


Operator dependent

Supine position can underestimate size of veins ƒ Contrast exposure Expense ƒ Patient comfort ƒ Supine position can underestimate size of veins ƒ Follow up limited for patients who have had embolization with metal coils Invasive ƒ Contrast

Ms. C: Dilated Pelvic Veins on TVUS * * * *


BIDMC PACS Sagittal Transvaginal Ultrasound images of left ovary with and without without Doppler


Markedly dilated pelvic veins adjacent to left ovary


Pelvic Congestion: US Findings ƒ

Both transvaginal and transabdominal ultrasound can be used in evaluation of pelvic congestion syndrome


Non-invasive, often first-line imaging


Can identify other causes of pelvic pain


Findings include: ƒ Dilated ovarian vein > 5 mm ƒ Tortuous pelvic veins around ovary and uterus > 5 mm ƒ Dilated arcuate veins crossing uterine myometrium ƒ Slow or reversed (caudal) flow with Doppler ƒ Changes with Valsalva ► Increase

in size of varices

► Variable

duplex waveform

Ms. C: Dilation of Pelvic Veins on TVUS before Valsalva


PrePre-Valsalva TVUS of left adnexa

Pre-Valsalva Dilated pelvic vein Diameter = 8.4 mm

Ms. C: Dilation of Pelvic Veins on TVUS with Valsalva


PostPost-Valsalva TVUS of left adnexa

Post-Valsalva Dilated pelvic vein Diameter = 8.8 mm

Anatomy Review: Gonadal Veins

Gray Anatomy online; Accessed 5/19/2009.

ƒ ƒ ƒ

Right ovarian vein drains into IVC Left ovarian vein drains into left renal vein Left renal vein courses anteriorly to aorta

Volume-rendered MDCT image of left and right ovarian veins. From Karaosmanoglu et. al. “MDCT of the Ovarian Vein: Normal Anatomy and Pathology.” AJR 192: January 2009

Ms. C: Dilated Ovarian Vein on MRI

dilated left ovarian vein measuring 9 mm prominent adnexal veins


T2 Weighted MRI, Coronal MIP Reconstruction

Pelvic Congestion: MRI Findings ƒ

Multi-planar imaging allows good visualization of pelvic anatomy and vasculature


Appearance of varices: ƒ Flow voids on T1 ƒ Can be hypo-intense, iso-intense or hyper-intense on T2 depending on velocity of blood flow ƒ High signal intensity on gradient echo


Time of flight sequences can assess direction of blood flow ƒ Technique that optimizes signal from flowing blood and diminishes signal from stationary tissue

Ms. C: Retrograde Flow in Left Ovarian Vein on Time-of-Flight MRI BIDMC PACS


C+ Limited axial MRI TOF images; arterial phase



left ovarian vein


Time-of-Flight demonstrates reversed flow in left ovarian vein ƒ left ovarian vein has flow in the same direction as aorta ƒ No flow seen in image selected for venous flow

C+ Limited axial MRI TOF images; venous phase

Ms. C: Clinical Course ƒ

Given the imaging findings, pelvic congestion syndrome was thought to be the etiology of Ms. C’s pelvic pain.


She elected to undergo pelvic vein embolization.

Pelvic Vein Embolization ƒ

Overview ƒ Transcatheter embolization using coils and/or sclerosing agents to occlude ovarian vein ƒ Venograms performed during procedure to verify anatomy and assess extent of collaterals ► Collaterals between ovarian and internal iliac venous plexus may cause recurrence of symptoms ƒ Can perform balloon embolization of internal iliac veins to visualize collaterals


Effectiveness ƒ Studies have demonstrated symptomatic relief in 70-80% of patients ƒ Long-term effects not well characterized ► Recent study by Kim et. al ƒ 127 patients with pelvic congestion syndrome who underwent embolization ƒ 83% reported clinical improvement at 4-year follow up


Risks ƒ Ovarian vein thrombophlebitis, recurrence of varices, radiation exposure, migration of embolic material


Areas of debate ƒ Unilateral vs. bilateral embolization ƒ Internal iliac embolization

Ms. C: Ovarian Venogram During Embolization Tip of catheter in left ovarian vein showing RETROGRADE flow toward ovary

Dilated and tortuous left ovarian vein and collaterals

Congestion of veins in pelvis


Left ovarian venogram, venogram, digital subtraction image

Ms. C: Left Ovarian Vein Coiling

Amplatzer vascular occlusion device within left ovarian vein


Fluoroscopy image of left ovarian vein embolization

Ms. C: Post-Embolization Venogram Pre-embolization left ovarian venogram

Post-embolization left ovarian venogram

Occluded left ovarian vein


Left ovarian venogram, venogram, DSA


PostPost-embolization ovarian venogram, venogram, DSA

Ms. C reported significant pain relief at her two-week follow up visit

Ms. C’s case demonstrated pelvic vein congestion without an identified anatomic etiology. Let’s move on to see features of pelvic congestion secondary to anatomic anomalies in two companion patients

Companion Patient #1: Dilated Ovarian Vein and Pelvic Varices on CT ƒ

42 year old G2P2 with six months of left lower quadrant pain and a normal ultrasound BIDMC PACS


C+ axial CT of pelvis

pelvic varices C+ axial CT, coronal reconstruction

dilated left ovarian

Companion Patient #1: Left Renal Vein Compression on CT

SMA Left Renal Vein



C+ axial CT

Left renal vein compressed between aorta and SMA

Nutcracker Syndrome: Overview ƒ

Left renal vein (LRV) entrapment syndrome



ƒ LRV compressed between aorta and SMV ► “anterior” nutcracker phenomenon ƒ Retro-aortic LRV compressed between aorta and spinal cord ► “posterior” nutcracker phenomenon ƒ Circum-aortic LRV


Clinical consequences

ƒ Increased pressure between LRV and IVC ► Can cause rupture of small veins into collecting system ƒ Hematuria ƒ Flank pain ƒ Venous obstruction and symptoms of pelvic congestion syndrome


Treatment options

ƒ Surgery ƒ Stents ► Can cause fibromuscular dysplasia ƒ Embolization

Companion Patient #2: Pelvic Congestion due to Retro-aortic Left Renal Vein

retroaortic left renal vein, compressed

pelvic varices

Axial MIP CT images From: Koc et al. “Association of left renal vein variations and pelvic varices varices in abdominal MDCT.” Eur Radiology 2007: 17: 12671267-1274

Companion Patient #1 underwent ovarian vein embolization. Let’s take a look at the images from her procedure

Companion #1: Left Ovarian Venogram Pre- and Post-Embolization Pre-embolization ovarian venogram

Post-embolization ovarian venogram

dilated left ovarian vein

Coils Occluded left ovarian vein

BIDMC PACS Fluoroscopy prior to ovarian vein embolization

BIDMC PACS Fluoroscopy post to ovarian vein embolization

Companion Patient #1: Clinical Course ƒ

Companion Patient #1 continued to have pain after her embolization procedure. One possible explanation for her residual pain is the presence of large collateral pelvic varices.


She did not undergo internal iliac vein balloon occlusion during her procedure.

Let’s move on to see how internal iliac balloon occlusion can identify additional varices in a companion patient.

Anatomy Review: Pelvic Venous Plexus

When there is reflux in the ovarian vein, collateral vessels can form that drain into the iliac vein

Umeoka et. al “Vascular Dilation in the Pelvis: Identification with MR and CT Imaging.” Radiographics 2004: 24:193-208.

Companion Patient #3: Dilated Ovarian Varices on Venogram ƒ ƒ

38 year old multiparous woman with symptoms of pelvic congestion syndrome Bilateral ovarian venograms demonstrate dilated ovarian varices and some reflux across midline

Left ovarian venogram

Right ovarian venogram

Coiled left ovarian vein

Courtesy Dr. Tim Killoran Left ovarian venogram; venogram; DSA

Courtesy Dr. Tim Killoran Right ovarian venogram; venogram; DSA

Companion Patient #3: Bilateral Ovarian Vein Coiling

Left and right ovarian veins embolized with platinum coils

Courtesy Dr. Tim Killoran Fluoroscopy, bilateral ovarian veins

Companion Patient #3: Right Internal Iliac Vein Balloon Occlusion

Catheter in right internal iliac

Courtesy Dr. Tim Killoran Right internal iliac balloon occlusion venography; venography; DSA


Balloon occlusion of internal iliac vein prevents flow out of varices that drain into iliac vein


Allows visualization of additional collaterals that may cause recurrent symptoms


No significant varices identified on right internal iliac occlusion

Companion Patient #3: Left Internal Iliac Vein Balloon Occlusion

multiple pelvic varices

Courtesy Dr. Tim Killoran Left internal iliac balloon occlusion prepre-embolization venography, venography, DSA

Companion Patient #3: Clinical Course ƒ

Companion Patient #3’s left internal iliac balloon occlusion demonstrated significant pelvic collaterals.


She underwent left internal iliac embolization to treat these varices

Companion Patient #3: Venogram After Left Internal Iliac Embolization

Significant decrease in size of varices

Courtesy Dr. Tim Killoran Left internal iliac balloon occlusion postpost-embolization venography, venography, DSA

Summary Pelvic congestion syndrome is a potentially overlooked cause of chronic pelvic pain ƒ Radiologic diagnosis ƒ

ƒ Ultrasound, MRI/MRV and CT can demonstrate dilated ovarian veins and pelvic varices ƒ Venography is gold standard ƒ

Ovarian vein embolization is an effective and promising therapy for this condition


Jay Pahade, MD ƒ Tim Killoran, MD ƒ

Gillian Lieberman, MD ƒ Maria Levantakis ƒ

References 1.


3. 4. 5.

6. 7. 8. 9. 10.




Ahmed K, Sampath R, Khan MS. “Current Trends in the Diagnosis and Management of Renal Nutcracker Syndrome: A Review” European Journal of Vascular and Endovascular Surgery, Volume 31, Issue 4, April 2006, Pages 410-416 Asciutto G, Mumme A, Marpe B, Köster O, Asciutto KC, Geier B. "MR venography in the detection of pelvic venous congestion." Eur J Vasc Endovasc Surg. 2008 Oct;36(4):491-6. Epub 2008 Aug 20.Click here to read Belenky A, Bartal G, Atar E, Cohen M, Bachar GN. "Ovarian varices in healthy female kidney donors: incidence, morbidity, and clinical outcome" AJR Am J Roentgenol. 2002 Sep;179(3):625-7. Ganeshan A., Upponi S., et al. "Chronic Pelvic Pain due to Pelvic Congestion Syndrome: The Role of Diagnostic and Interventional Radiology." Cardiovasc Intervent Radiol (2007) 30:1105–1111 Hartung O, Grisoli D, Boufi M, Marani I, Hakam Z, Barthelemy P, Alimi YS. "Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome: lessons learned from the first five cases" J Vasc Surg. 2005 Aug;42(2):275-80. Karaosmanoglu et. al. “MDCT of the Ovarian Vein: Normal Anatomy and Pathology.” AJR 192: (1) 295. January 2009 Kaufman J and Lee M. “Pelvic Congestion Syndrome.” Chapter in Vascular and Interventional Radiology: The Requisites. Mosby, Philadelphia PA 2004. Kim HS, Malhotra AD, Rowe PC, et al. “Emblotheraphy for pelvic congestion syndrome: Long-term results.” J Vasc Interv Radiol: 17: 289-297 (2006) Koc Z, Ulusan S, Oguzkurt L. "Association of left renal vein variations and pelvic varices in abdominal MDCT." Eur Radiol. 2007 May;17(5):1267-74. Epub 2006 Oct 13. Koc Z, Ulusan S, Tokmak N, Oguzkurt L, Yildirim T. "Double retroaortic left renal veins as a possible cause of pelvic congestion syndrome: imaging findings in two patients." Br J Radiol. 2006 Oct;79(946):e152-5. Kwon SH, Oh JH, Ko KR, Park HC, Huh JY. "Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome." Cardiovasc Intervent Radiol. 2007 JulAug;30(4):655-61. Epub 2007 Apr 28. Park SJ, Lim JW, Ko YT, Lee DH, Yoon Y, Oh JH, Lee HK, Huh CY. “Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography”. AJR Am J Roentgenol. 2004 Mar;182(3):683-8. Umeoka S, Koyama T, Togashi K, Kobayashi H, Akuta K. "Vascular dilatation in the pelvis: identification with CT and MR imaging." Radiographics. 2004 Jan-Feb;24(1):193-208. Review.

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