Diagnostic Approach to Abdominal
/ Pelvic Venous Disorders
Mark H. Meissner, MDPeter Gloviczki Professor of Venous & Lymphatic Disease
University of Washington School of Medicine
Seattle, WA
Mark H. Meissner, MD
I Have No Disclosures Relevant To This
Presentation
Disclosures
Abdominal-Pelvic Venous Disorders
Four Clinical
Presentations
Leg
Symptoms•Pain
•Swelling•Venous
Claudication
Chronic
Pelvic Pain
•Pain •Dyparunia•Dysuria
Renal
Symptoms
•Flank Pain •Hematuria
Pelvic
Source
Varices
•Gluteal•Perineal•Vulva
Leg
Symptoms• Pain
• Swelling• Venous
Claudication
Chronic
Pelvic Pain
• Pain • Dyparunia• Dysuria
Renal
Symptoms
• Flank Pain • Hematuria
Pelvic Source
Varices
• Gluteal• Perineal• Vulva
L Renal Vein
CompressionOvarian Vein
Reflux
Reflux Obstruction
Iliac Vein
Obstruction
Internal Iliac
Reflux
Diagnosis of Chronic Pelvic Venous Disorders
I. History
II. Transabdominal Ultrasound
III.Definitive Imaging - Venograpy
I. The History – Key Elements
Pregnancy history 1º reflux uncommon in nulliparous women
Gynecologic history 1º reflux uncommon in post-menopausal women
DVT history Consider iliac obstruction
Leg symptoms (swelling, claudication) Consider iliac obstruction
Left flank symptoms Consider L renal vein compression
Body habitus
Consider L renal vein compressionHematuria
Compressive lesions common in aesthenic pts
Axial (GSV, SSV)varices Is there a type II (competent) junction
Pelvic origin varices Labial, perineal, gluteal distribution
Edema, skin changes
Consider venous malformationOther vascular (e.g capillary) lesions
Consider iliac obstruction
History
Physical Exam
II. Transabdominal Ultrasound
Exclude iliac venous compression
Diminished CFV respiratory variation
Velocity ratio > 2.5
Iliac venous diameters (B mode)
Exclude L renal vein compression
PSV ratio (Ao-SMA angle to hilum) > 5.0
Diameter ratio (hilum to Ao-SMA) > 5.0
Hilar varices & collaterals Evaluate IIV & ovarian reflux
Vein diameter
Flow direction +/- Valsalva Evaluate pelvic varices
• Transuterine crossing veins > 5 mm• Change in waveform with Valsalva
Definitive DiagnosisContrast Venography
• L renal vein evaluation
• Selective bilateral ovarian venography
• L iliac evaluation
• Bilateral internal iliac vein balloon occlusion venography
The Complete Venographic Evaluation
Complete evaluation modified based on clinical
assessment and ultrasound
Step 1 - Left Renal Vein Evaluation
• Flush venography – AP & 360º rotational views
• Signs of renal vein compression
• Contrast stagnation
• Contrast attenuation
• Renal hilar varices
• Collateral drainage pattern and rate
• Hemiazygous pathways
• Gonadal veins
• Intravascular ultrasound
• Pullback pressures
Step 2 – Selective Bilateral Ovarian Venography
Tilt table with 30º reverse Trendelenburg
Selective imaging
R & L ovarian veins
Pelvic venous plexus
4 diagnostic criteria (Beard, 1984)
Ovarian vein diameter ≥ 6 mm
Contrast retention > 20 sec
Pelvic venous congestion / Filling of IIV
Filling of vulvar / thigh varicosities
Step 3 – Evaluation for Iliac Obstruction
Iliocaval venography
Intravascular ultrasound (IVUS)
Step 4 – Internal Iliac Venography
Requires balloon occlusion (13.2 mm compliant Berenstein balloon)
AP & LAO/RAO projections
Selective catheterization of refluxing tributaries (Know the anatomy!!!)
Approach to Interventional DiagnosisGuided by Clinical Suspicion and Ultrasound
Clinical
Suspicion
L Renal
Venography
L Renal
IVUS
Pullback
Pressures
L Ovarian
Venography
R Ovarian
Venography
L CIV
VenographyL CIV IVUS
Internal
Iliac
Venograpy
L Renal Vein
CompressionX XX X X X
1º Ovarian
Incompetence X X X X X
L Common
Iliac
CompressionX X X
• 4 interconnected systems• L renal vein• Ovarian veins• Internal iliac veins• Great saphenous vein
Great Saphenous
SEV
Superfical
External
Pudendal
Deep External
Pudendal• Initial clinical evaluation guides subsequent work-up• Trans-abdominal U/S is initial imaging test of choice• Invasive evaluation guided by clinical & U/S evaluation• Venography (± IVUS) is the definitive evaluation• Requires excellent knowledge of pelvic venous anatomy• Requires good selective catheter-guidewire techniques
Conclusions
Approach to Interventional DiagnosisHow I Do It
Common iliac venography
Pigtail catheter at femoral head
AP and LAO / RAO projections
IVUS over amplatz wire
Internal iliac venography
Requires thorough knowledge of pelvic anatomy
Internal internal iliac selection in LAO / RAO projections
Calibrate balloon to vein size
Initial imaging with balloon at EIV / IIV confluence
Progressive selection of varicose tributaries
Approach to Interventional DiagnosisHow I Do It
R internal jugular access
Ultrasound guided, micropuncture access
0.035” Rosen wire
8 Fr X 35 cm braided, curved sheath to L1
Bilateral ovarian venography
L ovarian – Kumpe catheter
R ovarian – Kumpe, C2, Simmons1, microcatheter
30º reverse trendelenberg
Catheter in proximal ovarian vein and at SI joint
L renal venography
65 cm Kumpe / 0.035” glide wire
Anchor in L ovarian vein if necessary
Exchange for 0.035” Rosen vs Amplatz wire
5 Fr pigatail (venography)
8.2 Fr IVUS
Straight end-hole catheter (Pullback pressures)
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