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)