Summary: A 39-year-old female patient, SG, presented with painful varices in the
lower extremities and pubic region after having several failed saphenous
Dr. Siegel is the System Chief, Interventional Radiology
Services, North Shore LIJ Health System, and Associate Professor of
Radiology, Hofstra-North Shore LIJ School of Medicine, New Hyde Park,
A 39-year-old female patient,
SG, presented with painful varices in the lower extremities and pubic
region after having several failed saphenous vein procedures. Following
consultation and venography, diagnoses of pelvic congestion and iliac
vein compression, or May-Thurner Syndrome, were made. The latter was
treated successfully with stenting of the iliac vein; the gonadal veins
were embolized bilaterally after venographic confirmation of reflux.
Over the next 8 years, the patient underwent 11 additional procedures to
treat symptomatic recurrences. Although the patient’s symptoms
completely or nearly completely resolved following each successful
procedure, they were rarely in control for more than 6 to 8 months.
Pelvic congestion syndrome
As the patient’s varicosities recurred, it became increasingly more
difficult to obtain access to them and to perform sclerotherapy,
especially when they began to develop in the inferior pelvis, causing
pain and a burning sensation involving the pelvic floor. Pudendal veins,
cross pelvic collateral veins, recanalized portions of the saphenous
vein and many unnamed veins were accessed and/or treated in subsequent
sessions. An example is seen in Figure 1, a venogram from one of those
procedures. Injection of contrast is being performed via microcatheter,
which was manipulated into the visualized pelvic floor veins via the
vein of Giacomini. This was then used for sclerotherapy. Figure 2
demonstrates a direct puncture through the perineum, which was used for
access to some of the deep pelvic varices at a subsequent procedure.
this circumstance, direct access to a sizable pelvic vein for
sclerotherapy would be quite advantageous, but the issue is safely
guiding a needle to the mid-pelvis accurately and reliably to avoid
traversing any unwanted or dangerous pelvic structures. Figure 3,
obtained at the last procedure, is a venogrom obtained by direct
puncture of a posterior division branch of the left hypogastric vein
using the planning functionality of XperCT and XperGuide. Contrast
injection beautifully demonstrates the symptomatic pelvic venous plexi,
including the periuterine/periovarian plexus and the dilated veins
surrounding the urinary bladder, communicating with the deep peroneal
veins. Following this venogrom, 3% sodium tetradecyl was injected
through the needle and allowed to dwell in place with the patient in the
semi-upright position for 25 minutes. This procedure was performed
about 1 year prior to the preparation of this case report and the
patient has remained asymptomatic during that time, which is her longest
symptom-free interval since presentation.
Pelvic congestion syndrome, or ovarian venous incompetence, was originally described in 19581 and the name pelvic congestion syndrome first appeared in the literature in 1976.2
For many years, this was a misunderstood and underdiagnosed entity. The
confusion is primarily due to the variable clinical presentations and
the wide variations in response to endovascular therapy. As there are a
myriad of etiologies for pelvic pain and many patients are asymptomatic
with respect to their pelvic varices, treatment failures are not
uncommon. Additionally, many patients have simple ovarian vein
incompetence with involvement of one or both ovarian veins, while others
have some contribution from the internal iliac system.3 The
latter situation can lead to treatment failures or incomplete symptom
resolution following gonadal vein embolization alone.
Pelvic congestion syndrome is a complex condition, the hallmark of
which is ovarian vein reflux and symptomatic pelvic varices. This case
of recurrent pelvic varices after embolotherapy illustrates how XperCT
and XperGuide can support direct access for sclerotherapy after numerous
procedures have essentially eliminated the conventional vascular access
routes. While this specific situation is quite rare, it is the author’s
hope that practitioners will consider cone-beam CT and dedicated needle
guidance when faced with other situations where direct deep vascular
access would be advantageous.
- Topolanski-Sierra R. Pelvic phlebography. Am J Obstet Gynecl. 1958;76:44-45.
- Hobbs JT. The pelvic congestion syndrome. Practitioner. 1976; 41:41-46.
- Ignacio EA, Dua R, Sarin S, et al. Pelvic congestion syndrome: Diagnosis and treatment. Semin Intervent Radiol. 2008;25:361-368.