Pelvic Vein Incompetence Research Articles

Pelvic escape points: Bottom- up is the way to go!

Varicose veins (VVs) of pelvic origin are one of the clinical presentations of pelvic venous disorders (PeVD) and are increasingly being diagnosed in patients in phlebological offices these days. To investigate VVs potentially resulting from pelvic vein incompetence (PVI), a usual full duplex ultrasonography (DUS) of lower extremity veins in the upright position is recommended as well as DUS for evaluation of pelvic escape points (PELVs). Seven PELVs have been described, connecting the pelvic veins to the veins of the genital region and/or legs. There are two possible treatment options for pelvic origin VVs, top-down treatment such as pelvic vein embolization or treatment of iliac/renal vein compression if it is the cause of PVI and bottom-up treatment of PELVs and related VVs. The idea of the latter approach is to treat the causes of the external pelvic VVs in the genital region and VVs in the legs without having to treat asymptomatic pelvic veins within the pelvis. The most common methods of bottom- up treatment are sclerotherapy, surgical ligation and miniphlebectomy. The efficacy of such treatment approach for VVs of pelvic origin has been reported in the literature, whereas studies have failed to demonstrate good results of top- down treatment in the context of eliminating VVs of pelvic origin as well as minimizing the risk of VVs recurrence. Bottom-up treatment is a useful option to avoid unnecessary and more expensive pelvic vein embolization and should be considered as an initial therapeutic approach. Only if bottom-up treatment fails, if the VVs recur rapidly, or if the patient develops pelvic symptoms due to PVI, pelvic veins embolization can be considered.

Pelvic vein incompetence and chronic pelvic pain: a case-control study.

To investigate the association between chronic pelvic pain (CPP) and pelvic vein incompetence (PVI) or pelvic varices. Case-control study. Gynaecology and vascular surgery services in two teaching hospitals in north-west England. A total of 328 premenopausal women (aged 18-54 years), comprising 164 women with CPP and 164 matched controls with no history of CPP. Symptom and quality-of-life questionnaires and transvaginal duplex ultrasound for PVI and pelvic varices. Venous reflux of >0.7 s in the ovarian or internal iliac veins (primary outcome) and presence of pelvic varices (secondary outcome). Statistical analysis compared the prevalence of PVI between women with and without CPP using the two-sided chi-square test. Logistic regression was used to compare the odds of having PVI and pelvic varices between women with and without CPP. Pelvic vein incompetence was found on transvaginal duplex ultrasound in 101/162 (62%) women with CPP, compared with 30/164 (19%) asymptomatic controls (OR 6.79, 95% CI 4.11-11.47, p < 0.001). Forty-three of 164 (27%) women with CPP had pelvic varices compared with three of 164 (2%) asymptomatic women (OR 18.9, 95% CI 5.73-62.7, p < 0.001). There was a significant association between PVI, as detected by transvaginal duplex imaging, and CPP. Pelvic varices were strongly associated with CPP and were infrequently seen in control patients. These results justify further evaluation of PVI and its treatment in well-designed research.

Ovarian vein surgical ablation versus endovascular technique for treatment of pelvic vein incompetence

ObjectiveChronic pelvic pain in women is a disorder brought on by pelvic vein incompetence (PVI). In this prospective, randomized study, the effects of percutaneous coil embolization and surgical ovarian vein ligation and division combined with retrograde sclerotherapy were compared with regard to ovarian vein occlusion, improvement of pelvic congestion symptoms, and their influence on estradiol level after intervention. MethodsA total of 50 patients with PVI were enrolled, with a mean age of 31.9 ± 4.7 years and a pain score of 9 (range, 0-10; from 0 [no pain] to 10 [the highest level of pain]). Both percutaneous coil embolization of ovarian veins (endovascular group) and surgical ovarian vein ablation with retrograde sclerotherapy were offered to the patients at random. ResultsIn the open group, the pain level decreased to 2, whereas in the endovascular group, it decreased to 1 (range, 0-10). Estradiol levels were 224 (range, 9-612) in the open group and 478 (range, 18-613) in the endovascular group before the intervention, with no significant change (P = .1120). After 1 week of intervention, estradiol levels in the open group were 89 (range, 18-243) and 124 (range, 22-298) in the endovascular group, respectively, with statistical insignificance (P = .225). After 1 month of intervention, the endovascular group's estradiol level was 101 (range, 20-196) and the open group's was 89 (range, 15-190) (P = .382). After 3 months of intervention, the open group's estradiol level was 78 (range, 12-132) and the endovascular group's was 65 (range, 18-110) (P = .045). ConclusionsIn addressing PVI, both methods seemed to have promising results. Nevertheless, endovascular management was more effective at decreasing estrogen levels and relieving discomfort. Three months should be the time at which estradiol levels are measured, because this is when they are at their lowest. In both the open and endovascular groups as well as in the pooled data, there was a significant association between estradiol level from before the intervention and improvement in pain scores (P = .005). Because it was linked to a lower pain score, the high preoperative estradiol level can be used to predict postintervention improvement.

Operative therapy of lower extremity varicose vein disease in women with pelvic congestion syndrome

Background: Approximately a third of women of fertile age suffer from chronic pelvic pain. 20% of gynecological encounters are associated with this exact problem. Within the structure of reasons of chronic pelvic pain pelvic vein incompetence (pelvic congestion syndrome) takes up to 30%, however, patients are correctly diagnosed only in 2–4% of the cases. Operative treatment helps solve the problem completely, but high disease reoccurrence and post-surgery complications rate remain relevant. Materials and Methods: 62 women with lower limb varicose vein disease aged from 22 to 48, including 20 women diagnosed with pelvic congestion, were examined and assigned into two groups (main group – 32, comparison group – 30). The main group was applied operative therapy based on the developed method of insufficient communicant vein dissection and, in case of pelvic congestion, – surgical intervention aiming at its elimination. Assessment of the result was conducted through the determination of post-surgery complications and with the varicose vein disease severity (VCSS) method. The aim: To decrease the frequency of the lower limb varicose vein disease reoccurrence after operative therapy of the pathology.

Endovascular treatment for pelvic congestion syndrome associated with inferior vena cava anomaly

Introduction: Pelvic congestion syndrome is described as chronic pelvic pain arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence and pelvic pain is not established. Embolization appears to provide symptomatic relief in the majority of women and is safe. Case report: We report the case of a young woman affected by pelvic congestion syndrome associated with a rare venous anomaly, duplicity of inferior vena cava with azygos vein continuation. Endovascular treatment consisted of detachable coil embolization of the right ovarian vein, as pelvic pain was prevalently on this side. Technical and clinical outcome were positive with a significant improvement of quality of life. Conclusion: This is the first reported case of a pelvic congestion syndrome associated with inferior vena cava anomaly and effectively treated with ovarian vein embolization.

Pelvic vein incompetence: clinical perspectives.

Chronic pelvic pain (CPP) affects 24% of premenopausal women, accounts for 20%–30% of UK gynecology outpatient appointments, and has an annual pan-European economic cost of €3.8 billion. Despite extensive investigation, often including laparoscopy, up to 55% of women do not receive a diagnosis and endure persistent symptoms. In these patients, clinical management focuses on symptom control rather than treatment. It is possible that pelvic vein incompetence (PVI) is a cause of CPP, although the quality of studies investigating an association is generally low. PVI may develop during and after pregnancy, as uterine blood flow increases significantly, pushing venous valve leaflets apart, and enabling retrograde venous flow. Analogies with varicose veins of the lower limb are helpful, and symptoms are similar. Women with symptomatic PVI report a dull pelvic ache that is worse on standing and sitting and persists throughout the day. It can be relieved by lying down. Early treatments for PVI included laparoscopic ligation; however, since the advent of endovascular occlusive techniques, treatments have lower risk and lower cost, and can be undertaken without sedation or anesthetic. However, there have been no high-quality randomized controlled trials of interventions and, therefore, the evidence is limited to single-center case series.

Using trans-vaginal duplex ultrasound to detect pelvic vein incompetence in women: A diagnostic readability and interobserver variability study

Using trans-vaginal duplex ultrasound to detect pelvic vein incompetence in women: A diagnostic readability and interobserver variability study

Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review

PurposeChronic pelvic pain (CPP) in the presence of dilated and refluxing pelvic veins is often described as pelvic congestion syndrome (PCS), although the causal relationship between pelvic vein incompetence and CPP has not been established. Percutaneous embolization is the principal treatment for PCS, with high success rates cited. This study was undertaken to systematically and critically review the effectiveness of embolization of incompetent pelvic veins. Materials and MethodsA comprehensive search strategy encompassing various terms for pelvic congestion, pelvic pain, and embolization was deployed in 17 bibliographic databases, with no restriction on study design. Methodologic quality was assessed. The quality and heterogeneity generally precluded meta-analysis. Results were tabulated and described narratively. ResultsTwenty-one prospective case series and one poor-quality randomized trial of embolization (involving a total of 1,308 women) were identified. Early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility, but no concerns were noted. Transient pain was common following foam embolization, and there was a < 2% risk of coil migration. ConclusionsEmbolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.

The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness

Pelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence (PVI) and CPP is not established. Non-invasive screening methods such as Doppler ultrasound and magnetic resonance venography are used before confirmation by venography. Percutaneous embolisation has become the principal treatment for PCS, with high success rates often cited. Our proposal aimed to systematically and critically review the definitions and diagnostic criteria of PCS, the association between PVI and CPP, the accuracy of various non-invasive imaging techniques and the effectiveness of embolisation for PVI; and to identify factors associated with successful outcome. We also wished to survey clinicians and patients to assess awareness and management of PCS and gauge the enthusiasm for further research. A comprehensive search strategy encompassing various terms for pelvic congestion, pain, imaging techniques and embolisation was deployed in 17 bibliographic databases, including MEDLINE, EMBASE and Web of Science. There was no restriction on study design. Methodological quality was assessed using appropriate tools. Online surveys were sent to clinicians and patients. The quality and heterogeneity generally precluded meta-analysis and so results were tabulated and described narratively. We identified six association studies, 10 studies involving ultrasound, two studies involving magnetic resonance venography, 21 case series and one poor-quality randomised trial of embolisation. There were no consistent diagnostic criteria for PCS. We found that the associations between CPP and PVI were generally fairly similar, with three of five studies with sufficient data showing statistically significant associations (odds ratios of between 31 and 117). The prevalence of PVI ranged widely, although the majority of women with PVI had CPP. Transvaginal ultrasound with Doppler and magnetic resonance venography are both useful screening methods, although the data on accuracy are limited. Early substantial relief from pain symptoms was observed in approximately 75% of women undergoing embolisation, a figure which generally increased over time and was sustained. Reintervention rates were generally low. Transient pain was a common occurrence following foam embolisation, while there was a < 2% risk of coil migration. Confidence in the embolisation technique is reasonably high, although there is a desire to strengthen the evidence base. Even among women with CPP, fewer than half had any knowledge about PCS. The data supporting the diagnosis and treatment of PCS are limited and of variable methodological quality. There is some evidence to tentatively support a causative association, but it cannot be categorically stated that PVI is the cause of CPP in women with no other pathology, as the six most pertinent drew on clinically disparate populations and defined PVI inconsistently. Embolisation appears to provide symptomatic relief in the majority of women and is safe. However, the majority of included studies of embolism were relatively small case series and only the randomised controlled trial was considered at risk of potential biases. There is scope and demand for considerable further research. The question of the association of PVI and CPP requires a well-designed and well-powered case-control study, which will also provide data to derive a diagnostic standard. An adequately powered randomised trial is essential to provide evidence on the effectiveness of embolisation, but this faces methodological challenges. This study is registered as PROSPERO CRD42012002237 and CRD42012002238. The National Institute for Health Research Health Technology Assessment programme.

Is pelvic vein incompetence associated with symptoms of chronic pelvic pain in women? A pilot study

ObjectivePelvic vein incompetence (PVI) affects 15–20% of all women, yet we know little about how it affects sufferers. The aim of this prospective pilot study was to explore symptoms experienced by women with PVI, and determine its impact on quality of life and NHS costs. Study designCase-control study at a UK University teaching hospital conducted over an eight-month period. Cases were 40 premenopausal women aged 18–49 years with PVI and varicose veins (VV). There were two age-matched controls groups: (i) 40 healthy women with no PVI but with VV, and (ii) 40 healthy women with no PVI and no VV. Subjects were asked to complete a structured questionnaire on disease specific outcomes, health status and use of healthcare resources. ResultsMean age (range) was 39.8 (24–47) years for cases, 39.1 (24–49) for VV controls and 38 (25–49) for healthy controls. Pelvic pain was reported by 38 of 40 (95%) PVI cases, compared with 25 of 40 (62%) VV controls, and 26 of 40 (65%) healthy controls (p=0.001). The median (range) EQ-5D utility score for PVI cases was 0.80 (0.29–1.0) compared with 0.80 (0.09–1.0) for VV controls and 1.0 (0.62–1.0) for healthy controls (p=0.002). Of the 40 PVI cases, 35 (88%) visited a consultant in the previous 12 months compared with 12 of 40 (30%) VV controls, and 14 of 40 (35%) healthy controls (p<0.001). ConclusionsWomen with PVI report a greater frequency of pelvic pain with reduced health status and increased use of healthcare resources compared with matched controls.

Effects of endothelin receptor antagonism in an experimental model of renal transplantation

s / International Journal of Surgery 23 (2015) S15eS134 S21 Conclusion: Our results indicate the existence of a mitochondrial stress environment with a lasting negative impact on residual kidney-function at day 30 likely reflecting a renal-tubular dysfunction in the remaining kidney. Further biochemical analyses are ongoing to confirm the nature of this dysfunction allowing the targeting of timely interventions. 0598: EFFECTS OF ENDOTHELIN RECEPTOR ANTAGONISM IN AN EXPERIMENTAL MODEL OF RENAL TRANSPLANTATION K. Shah, S. Hosgood, M. Patel, M. Nicholson. University of Leicester, UK Aim: Uncontrolled Donation after Circulatory Death (uDCD) donors provide a large potential source of kidneys but there is reluctance to use them due to prolonged warm ischaemic times. Endothelin-1, a potent vasoconstrictor, is a major contributor to ischaemic injury. This study aimed to investigate the benefit of endothelin receptor blockade in an experimental model of uDCD transplantation. Methods: Porcine kidneys underwent 60 minutes warm ischaemia and 2 hours cold ischaemia followed by 3 hours of reperfusion with autologous blood without (control, n 1⁄4 6) and with (n 1⁄4 6) 500mg BQ-123, a selective ETA endothelin receptor antagonist. Markers of renal function and injury were analysed. Results: Renal blood flow was significantly higher in the experimental group at 15e30 minutes of reperfusion (29.6e37.7 vs. 13.1e18.2 ml/min/ 100 g, p 1⁄4 0.02), after which, although higher throughout, statistical significance was lost. Urine output, creatinine clearance and oxygen consumption were also higher in the experimental group throughout but statistical significance was only seen in the 1st hour urine output (83 vs. 32 ml/hr, p 1⁄4 0.01). Urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL) levels were not different between the groups. Conclusion: Kidneys can recover from warm ischaemic injury. BQ-123 appeared to improve perfusion and function initially but did not have a sustained effect or significant overall benefit. Association of Surgeons of Great Britain & Ireland Short Paper Session 0002: SURGICAL AND TRANSCATHETER CLOSURE OF CONGENITAL CORONARY FISTULAE: OUTCOMES FROM A NATIONAL AUDIT D. Fudulu, D. Dorobantu, M. Caputo, S. Stoica. Bristol Children's Hospital, UK Aim: To report short and long term outcomes after surgical and transcatheter correction of congenital coronary fistulas (CCF). Methods: Using data from the UK Central Cardiac Audit Database we performed a retrospective analysis of all patients undergoing surgical or transcatheter correction of CCF between 2000 and 2012. Results: Out of 81 patients (48.2% Male, 51.8% Female), 34 (42%) underwent surgical repair and 47 (58%) had transcatheter procedures. The median ages were 12.6 years for surgery (range, 0.08e68.2) and 7.8 years (range, 0.01e77.8) in the catheterization group. Mean follow-up times were: 5.3 years (range, 0e13.0) for the surgical group and 4.6 years (range, 0e12.7) for the catheter group. Therewas no 30-daymortality in the entire cohort. One-year mortality for the surgical group was 7.41 % vs. 2.94 % for the catheter group (p 1⁄4 0.58). In the catheter group 4 patients (8.51%) required one or more reinterventions, compared to no reinterventions in the surgical cohort (p 1⁄4 0.13). Conclusions: CCF repair via transcatheter or surgical approach is attainable with no early mortality and good medium-term results. Careful patient selection would have to be partly responsible for these excellent national results Reintervention is overall infrequent and it appears to be higher after transcatheter embolisation. 0418: TRANS-VAGINAL DUPLEX ULTRASOUND FOR DETECTING PELVIC VEIN INCOMPETENCE IN WOMEN: A PILOT STUDY V. Hansrani, D. Kotecha, K. Norse, C. McCollum. University of Manchester, UK Aim: Pelvic vein incompetence (PVI) is diagnosed by reflux venography. This is invasive, nephrotoxic and involves ionizing radiation in young women. Trans-vaginal duplex ultrasound (TVU) is a non-invasive and entirely safe alternative. We compared TVUwith reflux venography for the detection of PVI. Methods: Womenwith clinical suspicion of PVI who attended for TVU and reflux venography were included in this study (n 1⁄4 20). Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were calculated for TVU with reflux venography as the ‘gold standard’. Results: 40-paired TVU and reflux venography images were analysed from 20women, mean (range) age 45 (25e55). PVI was detected in all 20 images with TVU and 19 of 20 (95%) images with reflux venography. The sensitivity and PPV of TVU to detect PVI was 100% and 95% respectively. TVU identified left ovarian vein incompetence with a sensitivity and specificity of 78.6% and 66.7%; right ovarian vein incompetence with sensitivity and specificity of 71.4% and 100%; left internal iliac vein incompetence with sensitivity and specificity of 91.7% and 100%, and right internal iliac vein incompetence sensitivity and specificity of 70% and 90% respectively. Conclusion: TVU is accurate and safe alternative to reflux venography in diagnosing of PVI. 0719: LIVING KIDNEY DONATION IN THE ELDERLY: THE UK EXPERIENCE R. Tamburrini, Z. Ahmed, A. Shafi, N. Kessaris, N. Mamode. Guy's Hospital,

Trans-vaginal duplex ultrasound for detecting pelvic vein incompetence in women: A pilot study

Trans-vaginal duplex ultrasound for detecting pelvic vein incompetence in women: A pilot study

Haemorrhoids are associated with internal iliac vein reflux in up to one-third of women presenting with varicose veins associated with pelvic vein reflux.

To determine the prevalence of haemorrhoids in women with pelvic vein reflux, identify which pelvic veins are associated with haemorrhoids and assess if extent of pelvic vein reflux influences the prevalence of haemorrhoids. Females presenting with leg varicose veins undergo duplex ultrasonography to assess all sources of venous reflux. Those with significant reflux arising from the pelvis are offered transvaginal duplex ultrasound (TVS) to evaluate reflux in the ovarian veins and internal Iliac veins and associated pelvic varices in the adnexa, vulvar/labial veins and haemorrhoids. Patterns and severity of reflux were evaluated. Between January 2010 and December 2012, 419 female patients with leg or vulvar varicose vein patterns arising from the pelvis underwent TVS. Haemorrhoids were identified on TVS via direct tributaries from the internal Iliac veins in 152/419 patients (36.3%) and absent in 267/419 (63.7%). The prevalence of the condition increased with the number of pelvic trunks involved. There is a strong association between haemorrhoids and internal Iliac vein reflux. Untreated reflux may be a cause of subsequent symptomatic haemorrhoids. Treatment with methods proven to work in conditions caused by pelvic vein incompetence, such as pelvic vein embolisation and foam sclerotherapy, could be considered.

The Outcome of Treatment for Pelvic Congestion Syndrome

Pelvic congestion syndrome is one of many causes of chronic pelvic pain. It is generally accepted that this is attributable to ovarian and pelvic vein incompetence which may result in varices in the lower limb leading to presentation in varicose vein clinics. However, far more patients have pelvic varices associated with varicose veins in the lower limb than have pelvic congestion syndrome. Magnetic resonance imaging and computed tomographic venography are usually used in the diagnosis of this condition and criteria have been established to identify pelvic varices. Many different treatments have been used to manage the symptoms of pelvic congestion. Hysterectomy combined with oophrectomy, open surgical ligation of ovarian veins and laparoscopic vein ligation have been used in the past. The most common treatments used currently involve embolization of pelvic and ovarian veins. The results of this treatment have been published in a limited number of clinical series, usually with fairly short follow-up periods. These treatments may be complicated by migration of embolization of coils used to occlude veins. The longest duration of follow-up currently reported is five years. Limited clinical evidence supports the use of embolotherapy in the management of pelvic congestion syndrome.

Surgery for Recurrent Varicose Veins: Toward a Less-Invasive Approach?

Redo surgery for recurrent varicose veins, involving the saphenofemoral junction (SFJ) or saphenopopliteal junction has a bad reputation because it is a laborious, time-consuming intervention, characterized by a high incidence of postoperative complications. Moreover, outcome is worse than after primary surgery. This is illustrated by long-term (5 years) prospective follow-up of 235 reoperated limbs after redo procedure at the SFJ, all performed at the University Hospital of Antwerp between 1991 and 2009. Such invasive redo procedures will soon belong to the past because, nowadays, many less-invasive alternatives are available: phlebectomies without reopening the groin, focusing on the "varicose reservoir"; limited redo surgery with combined with foam sclerotherapy; endovenous ablation of a residual refluxing saphenous trunk; ultrasound-guided foam sclerotherapy; embolization treatment of pelvic vein incompetence; and treatment of an underlying deep-venous obstruction. All these interventions can be performed in an ambulatory setting, without need for general anesthesia.

Pelvic vein incompetence influences pain levels in patients with lower limb varicosity

To detect the influence of pelvic vein incompetence (PVI) on pain levels in patients with varicosity of the lower limb. Women of child-bearing age with symptomatic primary or recurrent varicosity of the greater saphenous vein (GSV) were prospectively included in two groups depending on the presence or absence of phlebographic signs of PVI. Pain assessment was carried out with the help of a visual analogue scale (VAS). Forty women were included in the study. Nineteen of them had phlebographic evidence of PVI (group A), whereas 21 were included in the control group (group B). Patients of group A reported a higher median total pain level than patients of group B (group A median 62, range 25-100; group B median 32, range 0-100; P = 0.001). In group A, patients experienced a median level of pain of 67.2 at the lower limb in the standing position (range 40-100) versus a median of 50.3 (range 36-81) in patients of group B (P = NS). The median level of leg pain in the sitting position was 41.2 (range 0-67) in patients of group A and 38.1 (range 0-46) in women of group B (P = NS). Pelvic pain level in the standing position was higher (P = NS) in patients of group A (median 72.2, range 50-91), than in women of group B (median 20.1, range 0-41). In patients of group A, statistically significant (P = 0.0001) higher VAS scores for pelvic pain level in sitting (group = A median 67.2, range 59-71; group B median 18.1 range 0-35) were reported. In a small population of patients with GSV varicosity, overall pain levels were significantly higher in a subgroup of patients with phlebographic signs of PVI. This finding suggests that the presence of PVI might influence the intensity of varicosity symptoms.

Oestradiol Levels in Varicose Vein Blood of Patients with and without Pelvic Vein Incompetence (PVI): Diagnostic Implications

Purpose To assess the difference in the oestradiol levels of blood taken from varicose veins in patients with and without pelvic vein incompetence (PVI). Materials and methods Women of child-bearing age with symptomatic primary or recurrent varicose veins of the great saphenous vein (GSV) were included in a prospective study. Patients underwent duplex ultrasonography and pelvic vein phlebography. They were divided into a group with PVI (PVI group) and a control group with GSV reflux alone (VV group). Blood samples were collected from the GSV at the sapheno-femoral junction or lower in the thigh as well as from the arm. Oestradiol levels were determined by electroluminescence. Results Between January and December 2007, 40 women were studied, of which 19 showed phlebographic evidence of PVI (PVI group), while 21 were included in the VV group. Phlebography revealed an incompetent ovarian vein in 14 (74%) patients of the PVI group, dilated uterine and ovarian plexuses in 12 (63%) and an incompetent internal iliac vein in six cases (32%). In the PVI group, the median oestradiol level in GSV samples was 121 pg ml −1 (range: 12–4300), while in the VV group the median level was 75 pg ml −1 (range: 9–1177). In the upper limb, the PVI group patients had a median level of 78 pg ml −1 (range: 15–121) and the VV group patients 68 pg ml −1 (range: 13–568). The ratio of lower limb/upper extremity was significantly higher ( p < 0.002) in patients of PVI group (median: 1.9; range: 0.7–33) than in those of the VV group (median: 1.1; range: 0.8–13). A threshold ratio of 1.4 showed the highest combined sensitivity and specificity in differentiating patients with PVI from those without. Conclusions In patients with varicose veins arising from the GSV, oestradiol levels were significantly higher in the lower limb than in the upper extremity in the subgroup with associated PVI. It may be possible to use this observation as a diagnostic test in patients with suspected PVI. This deserves further study.

Pelvic Vein Embolisation in the Management of Varicose Veins

Pelvic vein incompetence is common in patients with atypical varicose veins, contributing to their recurrence after surgery. Therefore, refluxing pelvic veins should be identified and treated. We present our experience with pelvic vein embolisation in patients presenting with varicose veins. Patients presenting with varicose veins with a duplex-proven contribution from perivulval veins undergo transvaginal duplex sonography (TVUS) to identify refluxing pelvic veins. Those with positive scans undergo embolisation before surgical treatment of their lower limb varicose veins. A total of 218 women (mean age of 46.3 years) were treated. Parity was documented in the first 60 patients, of whom 47 (78.3%) were multiparous, 11 (18.3%) had had one previous pregnancy, and 2 (3.3%) were nulliparous. The left ovarian vein was embolised in 78%, the right internal iliac in 64.7%, the left internal iliac in 56.4%, and the right ovarian vein in 42.2% of patients. At follow-up TVUS, mild reflux only was seen in 16, marked persistent reflux in 6, and new reflux in 3 patients. These 9 women underwent successful repeat embolisation. Two patients experienced pulmonary embolisation of the coils, of whom 1 was asymptomatic and 1 was successfully retrieved; 1 patient had a misplaced coil protruding into the common femoral vein; and 1 patient had perineal thrombophlebitis. The results of our study showed that pelvic venous embolisation by way of a transjugular approach is a safe and effective technique in the treatment of pelvic vein reflux.