Ovarian Vein Reflux Research Articles

Randomized Double-Blinded Study Comparing Clinical Versus Endovascular Treatment of Iliac Vein Obstruction.

Randomized Double-Blinded Study Comparing Clinical Versus Endovascular Treatment of Iliac Vein Obstruction.

Nonthrombotic Venous Obstructions Cause Pelvic Congestion Syndrome.

Pelvic congestion syndrome (PCS) usually is attributed to ovarian or internal iliac vein reflux. Until recently, nonthrombotic iliac vein obstruction and left renal vein obstruction rarely have been reported as causes of PCS.

Diagnosis and treatment of the pelvic congestion syndrome.

Chronic pelvic pain accounts for up to 30% of outpatient gynecologic visits in the United States, potentially affecting up to 40% of the female population during their lifetime. Pelvic congestion syndrome (PCS) is defined as chronic pelvic pain resulting from reflux or obstruction of the gonadal, gluteal, or periuterine veins, sometimes associated with perineal or vulvar varices. It can also be caused by compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta, also known as the nutcracker syndrome. Whereas PCS accounts for up to 30% of patients presenting with chronic pelvic pain, it is frequently underdiagnosed. We reviewed the literature to investigate the current state of the diagnosis and treatment of this disorder. An online database search was performed with MEDLINE. MeSH headings included PCS, chronic pelvic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies. Our MEDLINE search revealed more than 3756 references to chronic pelvic pain. Specific references to PCS, pelvic chronic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies, however, included only 260 references. Thirty-seven references were small series including fewer than 50 patients or individual case reports documenting medical, surgical, or endovascular treatment of PCS. The majority of these papers demonstrated successful treatment of symptoms from PCS with embolization of one or both ovarian veins in addition to treatment of refluxing internal iliac vein branches. In addition, open surgery and, more recently, endovascular stenting of LRV obstruction have shown some promise in alleviating symptoms attributed to nutcracker syndrome. Diagnosis of PCS requires a careful history, physical examination, and noninvasive imaging. Several large case series have demonstrated the efficacy of embolotherapy in the reduction of pelvic pain; thus, it is the most favored treatment option for patients with PCS. For patients with outflow obstruction due to nutcracker syndrome, a limited number of studies have demonstrated remission of symptoms with stenting of the LRV as an alternative to open surgery.

Pelvic Congestion Syndrome

Patients with pelvic congestion syndrome present with otherwise unexplained chronic pelvic pain that has been present for greater than 6 months, and anatomic findings that include pelvic venous insufficiency and pelvic varicosities. It remains an underdiagnosed explanation for pelvic pain in young, premenopausal, usually multiparous females. Symptoms include noncyclical, positional lower back, pelvic and upper thigh pain, dyspareunia, and prolonged postcoital discomfort. Symptoms worsen throughout the day and are exacerbated by activity or prolonged standing. Examination may reveal ovarian tenderness and unusual varicosities-vulvoperineal, posterior thigh, and gluteal. Diagnosis is suspected by clinical history and imaging that demonstrates pelvic varicosities. Venography is usually necessary to confirm ovarian vein reflux, although transvaginal ultrasound may be useful in documenting this finding. Endovascular therapy has been validated by several large patient series with long-term follow-up using standardized pain assessment surveys. Embolization has been shown to be significantly more effective than surgical therapy in improving symptoms in patients who fail hormonal therapy. Although there has been variation in approaches between investigators, the goal is elimination of ovarian vein reflux with or without direct sclerosis of enlarged pelvic varicosities. Symptom reduction is seen in 70 to 90% of the treated females despite technical variation.

The role of duplex ultrasound in the workup of pelvic congestion syndrome.

Pelvic congestion syndrome (PCS) imaging workup algorithms are not well-defined. The purpose of our study is to gauge the impact and accuracy of duplex ultrasound (DU) to assist in the diagnosis of PCS. We reviewed the records of 48 patients with PCS seen at a vein center from June 2010 to June 2012. All patients had DU plus either computed tomography venography (CTV) or conventional venography (CV). Measurements of the left (LOV) and right ovarian vein (ROV) diameter and the presence or absence of ovarian vein reflux were obtained using DU and compared with either CTV or CV to assess sensitivity and specificity. An ovarian vein diameter >6 mm was considered abnormal. All patients were female (29 Caucasians, 18 Hispanic, and 1 Asian). The mean number of pregnancies was 3 (range, 1-5). All patients had lower extremity varicose veins, and 14 (29%) had vulvar varicosities. Thirty-four (71%) patients reported pelvic pain, 22 (46%) dyspareunia, 2 (4%) dysuria, and 1 (2%) hematuria. The median diameter of the LOVs and ROVs measured using DU compared with either CTV/CV were similar (DU, 8.6 and 5.6; CTV/CV, 8.3 and 6). The sensitivity and specificity of DU to demonstrate a dilated LOV were 100% and 57%, and for the ROV were 67% and 90%. Pelvic varicosities were identified in all but one patient with good correlation between DU and CV. DU has a high sensitivity to identify an abnormal LOV diameter that is greatly reduced when evaluating the ROV; however, the latter can be evaluated with another imaging modality such as CTV especially when DU results areequivocal or negative. A moderate specificity was found todetermine both LOV and ROV abnormal diameters. All three imaging modalities are equally accurate to show the presence of pelvic varices.

Successful ultrasound-guided foam sclerotherapy for vulval and leg varicosities secondary to ovarian vein reflux: a case study

Pelvic varicose veins secondary to ovarian vein reflux are common and can present with clinical pelvic congestion syndrome (PCS). After assessment with duplex ultrasound and venography, treatment often involves surgical ovarian vein ligation and more recently embolization of the ovarian vein(s) followed by ultrasound-guided foam sclerotherapy (UGFS) of the pelvic tributaries. This paper presents one out of many PCS patients treated with UGFS of the pelvic tributaries alone, with clinically symptomatic improvement.

Time-resolved imaging of contrast kinetics three-dimensional (3D) magnetic resonance venography in patients with pelvic congestion syndrome

The purpose of this study was to assess the role of magnetic resonance venography (MRV) with time-resolved imaging of contrast kinetics (TRICKS) in dynamically evaluating ovarian vein dilation, reflux and direction of flow in patients with suspected pelvic congestion syndrome (PCS). The hypotheses tested were: (i) That conspicuity scores of the ovarian veins across three raters was greater using TRICKS MRV compared with T2W or T(2)* imaging; (ii) That three key MR variables (ovarian vein diameter, timing and grade of reflux) correlated across all raters. We carried out a retrospective study of 13 patients undergoing T2W and TRICKS MRI and pelvic sonography (n = 4) or catheter venography (n = 5). Three observers rated conspicuity, vessel diameter, timing and grade of ovarian vein reflux for T(2)/T2*W and TRICKS MRI. The mean left ovarian diameter for all patients with reflux was 7.9 mm (range 2.2-12 mm). There was high inter-observer agreement for ovarian vein diameter for both sequences. TRICKS showed significantly greater conspicuity than T(2)/T2*W imaging (TRICKS: T(2)/T2* mean (SD) = 7.80 (3.20):5.50 (1.97), F (1,12) = 5.80, p < 0.05). TRICKS MRV demonstrated high inter-observer correlation for timing and grade of reflux (r (36) = 0.77,0.71,0.79, p < 0.01). TRICKS MRA/V was significantly degraded by breathing artefact in two patients. We conclude that TRICKS MRV accurately and dynamically demonstrates ovarian vein reflux in patients with PCS but requires quiet respiration. TRICKS MRV has better image conspicuity than T(2)/T2*W imaging and sufficient temporal resolution to distinguish between Grade I, II and III reflux.

Time-Resolved MR Angiography as a Useful Sequence for Assessment of Ovarian Vein Reflux

The purpose of this retrospective study was to assess the imaging characteristics of ovarian vein reflux using time-resolved MR angiography (TR-MRA). One hundred consecutive female patients underwent TR-MRA of the pelvis to evaluate suspected or known pelvic pathology. Findings of ovarian vein reflux, ovarian vein dilation, and periuterine varices were analyzed and correlated with symptoms of pelvic pain. Overall, TR-MRA is a useful sequence for the assessment of ovarian vein reflux, which may aid the evaluation of pelvic congestion syndrome.

What is the significance of ovarian vein reflux detected by computed tomography in patients with pelvic pain?

Chronic pelvic pain (CPP) is a common gynecological complaint. CPP is nonmenstrual pain localized in the anatomic pelvis of at least 6 months' duration without any identifiable organic cause that is severe enough to cause functional disability and require treatment. Pelvic congestion syndrome (PCS) is a poorly understood disorder and often overlooked cause of pelvic pain. Ovarian vein reflux (OVR) and pelvic varicosities are a cause of PCS. On the other hand, OVR can be seen in asymptomatic women, typically parous. OVR has a characteristic appearance at enhanced computed tomography (CT). Contrast medium retrogradely fills the ovarian veins and parauterine veins during the arterial phase after intravenous contrast administration. CT is not the ideal modality to evaluate all the causes of pelvic pain, but CT is a commonly used diagnostic modality to screen patient who presents with abdominal and pelvic pain. CT can demonstrate abnormal ovarian venous flow as well as tortuous and dilated ovarian and pelvic veins. Ovarian vein reflux is important to recognize and when correlated with patient clinical presentation may help in the diagnosis of PCS.

Ovarian Vein Incompetence: A Potential Cause of Chronic Pelvic Pain in Women

Conclusion: Ovarian vein incompetence is a cause of chronic pelvic pain in women and responds to ovarian vein sclerotherapy. Summary: For many years investigators have suggested pelvic varices can be responsible for otherwise unexplained pelvic pain. Venographic studies have demonstrated dilation of major pelvic veins with congestion of the ovarian plexus and broad ligaments in a high percentage of women with chronic pelvic pain and normal laparoscopy. It appears retrograde flow in incompetent ovarian veins may be the primary mechanism for dilation of pelvic veins and congestion of surrounding tissues leading to chronic pelvic pain. The clinical utility of ovarian vein occlusion and the treatment of such women are controversial. The authors evaluated 22 women with laparoscopy aged 19-50 years who had chronic pelvic pain and no recognized pelvic pathology. All did have evidence of reflux and dilated pelvic veins on transvaginal color Doppler ultrasound and subsequently underwent retrograde ovarian vein venography and sclerotherapy of incompetent ovarian veins. Outcomes were assessed by a symptom questionnaire and visual analog pain scales at 3, 6, and 12 months. Serial ultrasound examinations were used to evaluate changes in pelvic circulation after sclerotherapy. Venography showed 20 of the 22 women had incompetent ovarian veins, and they subsequently received sclerotherapy, which was not associated with immediate or late complications. Symptom improvement of varying magnitude was observed in 85% of the 20 treated women at a mean follow-up of 12 months. Marked or complete relief occurred in 15 patients and mild to moderate relief in two patients, with three women (15%) having no improvement in symptoms. Median visual analog pain scales at 3, 6, and 12 months were significantly lower than at baseline: 2.0, 2.5, and 3.0 at 3, 6, and 12 months vs 8.0 at baseline (P < .001). Follow-up ultrasound examinations demonstrated recurrence of venous reflux in three patients at 3 months. Comment: All the women in this study underwent laparoscopy. In fewer than half were pelvic varices detected by laparoscopy, indicating the absence of pelvic varicosities at laparoscopy does not rule out the diagnosis. Ovarian vein reflux as a cause of so-called pelvic congestion syndrome will remain controversial. The data do suggest, in patients who have had a thorough history, clinical evaluation, and negative results on standard diagnostic tests, that ovarian venography should be considered with the idea of possibly treating underlying ovarian vein reflux.

Retroaortic left renal vein fistula masquerading as pelvic congestion syndrome: Case report

This case study shows how aorto-left renal vein fistula in a female can present with left-sided pelvic pain secondary to ovarian vein reflux, a symptom of pelvic congestion syndrome, next to typical features such as epigastric and back pain.

Association of left renal vein variations and pelvic varices in abdominal MDCT

The aim of this study was to determine whether left renal vein (LRV) variation is associated with pelvic varices and left ovarian vein (LOV) reflux. Routine abdominal multidetector-row computed tomography scans of 324 women without symptoms of pelvic congestion syndrome were analyzed. Presence and type of LRV variants (circumaortic [CLRV] or retroaortic [RLRV]) were recorded. Diameters of the LRV, ovarian veins (OVs), and parauterine veins were measured and a specific LRV diameter ratio was calculated for each patient. Presence and severity of pelvic varices and LOV reflux were noted. Pelvic varices were detected in 59 (18%) of the total of 324 women, in 7 (37%) of the 19 women with RLRVs, in 7 (29%) of the 24 women with CLRVs, and in 45 (16%) of the 281 women with normal LRVs. The frequency of pelvic varices in the women with LRV variation was significantly higher than that in the group with normal LRV anatomy (33 vs. 16%; p=0.009). The frequency of pelvic varices in the women with RLRVs was also significantly higher than that in the group with normal LRV anatomy (p=0.02). LRV diameter ratio was correlated with presence of pelvic varices and presence of LOV reflux (p=0.0001 for both). This study revealed an association between pelvic varices and LRV variations in a population of predominantly multiparous women.

Right ovarian vein drainage variant: Is there a relationship with pelvic varices?

Objective To correlate right ovarian vein (ROV) variations that drain into the right renal vein (RRV) with the presence of pelvic varices. Materials and methods Routine abdominal multidetector-row computed tomography scans of 324 women were analyzed for the presence and type of ROV variations in this retrospective study. The subjects were divided into 2 groups: those with ROV variations and those without such variations. The diameters of the subjects’ ROV, left ovarian vein (LOV), and parauterine veins were measured. Pelvic varices and the presence and degree of ovarian vein reflux were noted and compared between the 2 groups. The χ 2-test and the Pearson correlation test were used for statistical analysis. Results Thirty-two (9.9%) of 324 women studied exhibited ROV variant that drained into the right renal vein, and the remaining subjects (90.1%) exhibited a normal pattern of ROV drainage that flowed directly into the inferior vena cava. Pelvic varices were identified in 59 (18%) of the subjects. Reflux was not observed in any patient without pelvic varices. Fifty-seven of 59 women exhibited ovarian vein reflux. In 56 of those 57 individuals, reflux occurred only in the LOV, and in 1 subject, reflux was noted predominantly in the ROV. No significant relationship between the presence of an ROV that drained into the right renal vein and pelvic varices was noted. Conclusion Although right-sided pelvic varices associated with right ovarian vein drainage variations are rare, anatomic variations of the right ovarian vein are not. This study did not find an association between the presence of right ovarian vein and pelvic varices.

Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome: Lessons learned from the first five cases

Compression of the left renal vein between the aorta and the superior mesenteric artery is a rare but possibly underestimated condition. Surgical correction (42 cases reported in the literature) can be performed by means of a variety of different techniques. Although endovascular stenting is well accepted for iliocaval occlusive disease, it has been poorly evaluated in this indication. We describe five patients who were treated for nutcracker syndrome by using stenting and analyze the nine cases previously reported. From November 2002 to September 2004, five women (mean age, 34.7 years) were admitted for endovascular treatment of a nutcracker syndrome. They all had incapacitating pelvic congestion syndrome, including two with a history of left ovarian vein embolization; moreover, two had left lumbar pain, and three had hematuria. The mean preoperative venous disability score was 2.4. The patients underwent a gynecologic examination and laparoscopy to eliminate other causes of pelvic pain. The laparoscopy revealed large pelvic varicose veins and no signs of endometriosis. Duplex scan, computed tomographic scan, and iliocavography revealed left renal vein compression, with proximal distention and collateral pathways, with dilatation and permanent reflux in the left ovarian vein in the three patients who had not had prior embolization. The mean renocaval pullback gradient was 4.3 mm Hg. A percutaneous endovascular procedure, during in which a self-expanding metallic stent was implanted, was performed under general anaesthesia. Technical success was achieved in all cases. One case of stent migration occurred: the stent was pulled down in the inferior vena cava, with uneventful follow-up (mean, 14.3 months). One month later, patients were all improved and stents were patent at the duplex scan examination, without restenosis. The mean venous disability score was 1. No further left ovarian vein reflux was evident at duplex scan in patients who did not have prior embolization. Pelvic pain recurred in one patient who had initially improved, and endometriosis was diagnosed 15 months after the procedure. Two other patients, who received 40-mm-long stents, had a secondary recurrence of the symptoms caused by stent dislodgement. The two other patients were asymptomatic. This study shows that stenting is feasible, but some guidelines should be followed, mainly the use of long stents protruding into the inferior vena cava. Stenting can eliminate the symptoms of the condition, and the technique is only very slightly invasive. Further experience and follow-up are needed before accepting such a procedure for treatment of the nutcracker syndrome.

Reflux in the Left Ovarian Vein: Analysis of MDCT Findings in Asymptomatic Women

The aim of this study was to clarify the CT features of ovarian vein reflux in asymptomatic women and to determine the possible cause of the reflux. One hundred ten multiparous or uniparous and 41 nulliparous asymptomatic women were examined on MDCT. Degree, pathway, and associated findings of ovarian vein reflux were evaluated. We measured the diameters of the left renal vein (LRV), the ovarian veins, and the parauterine veins. Ratios of LRV diameters (lateral-aortomesenteric) were obtained. These data were then compared between the women with reflux and those without reflux. Reflux was found in 44% (48/110) of parous and 5% (2/41) of nulliparous women. Reflux flowed into the right ovarian vein through the parauterine and uterine veins in 25 women. Twenty-four of these 25 women were multiparous. In these cases, the parauterine veins showed varicose dilation (5.9 +/- 1.6 mm [mean +/- SD]). There was a statistically significant difference in left ovarian vein diameter (8.3 +/- 2.1 mm vs 4.9 +/- 1.3 mm, p < 0.0001) between parous women with reflux and those without reflux, respectively. The LRV diameter ratio (lateral-aortomesenteric) was also statistically significant (3.6 +/- 1.3 vs 1.7 +/- 0.7, p < 0.0001) between the same two groups. Reflux into the left ovarian vein is seen up into the contralateral ovarian plexus by passing through the dilated parauterine and uterine veins. This CT finding is common in asymptomatic multiparous women. Narrowing of the LRV at its aortomesenteric portion can be one of the causes of such reflux.

Ovarian Vein Embolization for Pelvic Congestion Syndrome

Pelvic congestion syndrome is a controversial entity consisting of varying degrees of pelvic heaviness or pain caused by retrograde flow in one or both ovarian veins. It has to date been unevenly accepted by clinicians and relatively poorly studied. Nevertheless, approximately 50% of patients with otherwise unexplained pelvic pain have ovarian vein reflux and 73.7 to 88.9% of women have symptomatic improvement after ovarian vein embolization.