“PEARLS”in the

DUPLEX EVALUATION of

PELVIC VENOUS DISORDERSR. Eugene Zierler, M.D.

The D. E. Strandness, Jr. Vascular LaboratoryUniversity of Washington Medical Center

Division of Vascular SurgeryUniversity of Washington, School of Medicine

DISCLOSURE INFORMATION

No relevantfinancial or commercial

relationships to declare

R. Eugene Zierler, M.D.

Thanks to Sara Skjonsberg BS, RVT, RPhS for images, etc.

Pelvic Congestion Syndrome Pain, dyspareunia, dysuria Multiparous premenopausal women

Pelvic Varices Gluteal, perineal, vulvar

Pelvic venous drainage includes ovarian internal iliac, and femoral veins

Multiple interconnections and drainage across the pelvis

Diagnosis is based on correlation of the clinical presentation with findings of reflux or obstruction (or both)

Anatomy and PathophysiologyPELVIC VENOUS DISORDERS

Ovarian and internal iliac veins contain valves Dilation of ovarian veins (pregnancy, hormones) leads to

valvular incompetence and retrograde flow (reflux) Obstruction can result from: Compression of the left common iliac vein

(May-Thurner syndrome) with internal iliac vein reflux Compression of the left renal vein (Nutcracker syndrome)

with left ovarian vein reflux Retro-aortic left renal vein (1%-2%)

Anatomy and PathophysiologyPELVIC VENOUS DISORDERS

Fasting patient (like visceral vascular exams) Low frequency curved-array (2-4 MHz) transducer Settings for slow venous flow Specific components of the exam: Inferior vena cava and common/external iliac veins May-Thurner syndrome (left common iliac vein) Nutcracker syndrome (left renal vein) Internal iliac veins Gonadal (ovarian) veins Evaluation for pelvic varicosities

Ultrasound Examination - ProtocolPELVIC VENOUS DISORDERS

1. IVC and common iliac veins evaluated in reverse Trendelenburg position Look for left CIV compression by the right CIA B-mode image, velocity changes, distal waveforms

2. Measure internal iliac vein diameters and look for reflux with Valsalva Color Doppler and spectral waveforms

3. Evaluate the external iliac and common femoral veins Reflux, obstruction, prominent collaterals

Ultrasound Examination - ProtocolPELVIC VENOUS DISORDERS

4. Ovarian veins identified above the psoas muscle Followed to confluence with the IVC (right) or left

renal vein (left) Measure diameters Look for reflux with Valsalva

5. Evaluate the left renal vein for aorto-mesenteric compression Image in the angle between the SMA and aorta Measure diameters and velocities in on the IVC side,

at the SMA/aorta, and on the kidney side

PELVIC VENOUS DISORDERSUltrasound Examination - Protocol

6. Accuracy may be improved by repeating some measurements in the standing position (especially internal iliac veins, ovarian veins, and left renal vein)

7. If lower extremity varicose veins are present Look for “pelvic escape points” Inguinal canal (I), perineum (P), obturator (O), gluteal (G)

8. Evaluate for uterine/para-uterine varicosities Fundus of uterus and uterine veins (“uterus sweep”) Full bladder can help

PELVIC VENOUS DISORDERSUltrasound Examination - Protocol

Inferior Vena CavaPELVIC VENOUS DISORDERS

Left Common Iliac Vein (Normal)

Transverse View

PELVIC VENOUS DISORDERS

Left CIV Diameter VelocityProximal 1.10 cm 20 cm/sMid (at right CIA) 0.38 cm 45 cm/sDistal 1.35 cm 16 cm/s

PELVIC VENOUS DISORDERSLeft Common Iliac Vein (Compressed): May-Thurner

Velocity Ratio 45/16 = 2.8

Internal Iliac Veins

Left

PELVIC VENOUS DISORDERS

Right

External Iliac Veins

Occlusive Left External Iliac DVT

PELVIC VENOUS DISORDERS

Left Ovarian VeinPELVIC VENOUS DISORDERS

EIA

EIV

Left Renal Vein (Compressed): NutcrackerPELVIC VENOUS DISORDERS

Left Renal Vein Diameter VelocityRenal Hilum 0.65 cm 14 cm/sKidney Side 1.02 cm 14 cm/sAorta/SMA ≤ 0.22 cm No FlowIVC Side 0.35 cm 15 cm/s

Diameter Ratio 1.02/0.22 = 4.6

Uterine/Para-uterine VeinsPELVIC VENOUS DISORDERS

Uterine – Near fundus Para-uterine – between uterus

and ovaries

Varicosities Visualized with Power Doppler

Common Iliac Veins (May-Thurner) Absent or reduced respiratory phasicity in the left EIV or

CFV (vs. the right side) Diameters – Compare proximal left CIV with distal left CIV

and proximal right CIV Stenotic to pre-stenotic peak velocity ratio >2.5

(90% sensitivity for detection of >50% venous stenosis) Left Renal Vein (Nutcracker) Diameter ratio (kidney side, at SMA, cava side) >5.0

(69% sensitivity, 89% specificity) Peak velocity ratio (kidney side, at SMA, cava side) >5.0

(80% sensitivity, 94% specificity)

Ultrasound Examination - Criteria for CompressionPELVIC VENOUS DISORDERS

Nutcracker Syndrome Peak velocity in left renal vein

103 cm/s - site of compression14 cm/s - kidney side

Velocity ratio 103/14 = 7.4

Ultrasound Examination - Criteria for CompressionPELVIC VENOUS DISORDERS

Internal Iliac Veins Abnormal >0.5 or >0.7 cm (? Normal values) Retrograde flow ± Valsalva (reflux)

Ovarian Veins Measure proximal, mid, and distal Normal 0.3 – 0.4 cm with antegrade flow Abnormal >0.6 cm with retrograde flow ± Valsalva

Ultrasound Examination – Diameter CriteriaPELVIC VENOUS DISORDERS

Reflux is based on venous diameters and presence of retrograde flow with Valsalva

Left ovarian vein 0.79 cm in women with pelvic congestion vs. 0.49 cm in those with other pathology Ovarian vein diameter of >0.6 cm is consistent with reflux

Duplex has 100% sensitivity and 57% specificity for detection of left ovarian vein dilation (67% and 90% for right ovarian vein)

Retrograde flow in the left ovarian vein is found in 100% of women with pelvic congestion vs. 25% of those without

Duration of reflux flow is not diagnostic, but is usually >2 sec

Ultrasound Examination - Criteria for RefluxPELVIC VENOUS DISORDERS

Summary - Worksheet and ReportIMPRESSION

1. EVALUATION FOR NUTCRACKER SYNDROMEThere is evidence of left renal vein compression between the superior mesenteric artery and aorta with reflux (retrograde) flow throughout the left ovarian vein.

2. EVALUATION FOR MAY-THURNER (IVC/ILIAC VEINS)There is evidence of left common iliac vein compression by the right common iliac artery.

3. EVALUATION OF INTERNAL ILIAC VEINSRight: Right internal iliac vein is dilated; reflux is not identified.Left: Right internal iliac vein is dilated; reflux is not identified

4. EVALUATION OF GONADAL/OVARIAN VEINSRight: The right ovarian vein is identified and appears to be dilated, but reflux is not present.Left: The left ovarian vein is identified and appears to be significantly dilated with reflux throughout.

5. EVALUATION FOR PELVIC VARICOSITIESProminent left uterine veins are identified.

PELVIC VENOUS DISORDERS

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