Solved on SIR Connect By Allison Tan, MD, Patrick Moran, MD, Jackson Bennett, MD, and Sudhen B. Desai, MD, FSIR
Feedback on pelvic venous disorders
Original post, lightly edited for fl ow:
My patient was a 37-year-old female, G0P0, with severe, debilitating chronic pelvic pain classic for pelvic venous disorder. Her pain was so severe that she was on disability and unable to work.
Ultrasound imaging confi rmed large left pelvic varices and CT demonstrated a signifi cantly dilated left ovarian vein with extensive pelvic varices. CT also identifi ed a retroaortic left renal vein, which raised concern for nutcracker physiology. The patient did not have fl ank pain or hematuria.
Diagnostic venogram performed with IVUS demonstrated a severely stenotic central left renal vein requiring prolonged wire and catheter manipulation to traverse what felt like a web or chronic changes. Nearly all of the left renal venous outfl ow was through a dilated left ovarian vein and pelvic plexus which received contribution from a large refl uxing intraparenchymal renal vein. Simulated ovarian vein occlusion with a balloon catheter was performed and resulted in an increase in left renal vein pressure from 6 mmHg to 16 mmHg.
Based on the venogram results, and after thorough discussion of all the options, I ultimately recommended surgical consultation and intervention. Surgery consultations off ered splenorenal shunt creation, left renal auto transplant or nephrectomy for donation. The patient sought an additional web-based opinion from a vascular surgeon who recommended ovarian vein embolization.
Due to confusion caused by the variety of opinions, this case was posted on SIR Connect for additional input from the IR community. Based on all of the gathered information, the patient ultimately chose to proceed with donor nephrectomy.
Thank you in advance.
AUTHOR NAME Allison Tan, MD
What is your general workup for patients referred to you for pelvic venous congestion? Many patients who are referred to me have already undergone extensive workup from our vulvovaginal specialist colleagues. Workup includes an extensive history and physical examination, including a pelvic exam by the patient’s gynecologist. Imaging studies help support the diagnosis and can include a pelvic ultrasound, CT or MRI, keeping in mind that negative imaging does not rule out a pelvic venous disorder. Venography is the gold standard to evaluate for the presence of ovarian vein refl ux and has the benefi t of being dynamic, allowing imaging with and without Valsalva maneuvers. However, due to the overlapping symptoms of pelvic venous disorders with other pelvic pathology, it is important to rule out other potential contributors to symptoms such as pelvic prolapse, genitourinary dysfunction and gastrointestinal issues.
Have you had experience with renal vein stenting in the setting of nutcracker or a retroaortic renal vein? If so, what are the important considerations and possible complications? I personally have not had experience with renal vein stenting. Renal vein
Disclaimer: This column represents the work and opinions of the contributing authors and do not necessarily refl ect the views or policies of SIR. SIR assumes no liability, legal, fi nancial or otherwise, for the accuracy of information in this article or the manner in which it is used. The statements made in the column are not intended to set a standard of care and should not be treated as medical advice nor as a substitute for independent, professional judgment. Please note: Due to recent law changes, certain procedures detailed within this article may not be legally permitted in your state. Please be sure to confer with your institution’s legal advisers.
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