Pelvic Veins a Source For Lower Extremity Varicose Veins ACP Annual Congress 2016 Mel Rosenblatt, M.D. FACPh Connecticut Image Guided Surgery

Pelvic Veins A Source For Lower Extremity Varicosities Disclosures Pelvic Veins A Source For Lower Extremity Varicosities I have no pertinent disclosures related to the material that will be presented

Pelvic Derived Varicosities Introduction Pelvic vein reflux is an often unrecognized primary cause of lower extremity varicosities Pelvic reflux has also been recognized as a cause of recurrent varicosities Recurrence Persistence Diagnostic and treatment algorithms for symptomatic lower extremity varicosities derived from a pelvic source is ambiguous Sclerotherapy? Embolization? Ablation of affected truncal veins?

Pelvic Venous Reflux Prevalence of Extremity Varicosities The prevalence of varices in the perivulval area was reported as 4% in a large population study (Hobbs JT. Varicose veins arising from the pelvis due to ovarian vein incompetence. Int J Clin Pract 2005;59:1195–1203.) A CT and US review of 1350 cases demonstrated pelvic derived LE varicosities in 8.6% (Seung Chai Jung, MD, et al RadioGraphics 2009; 29:525–536) 34% of non-saphenous venous reflux is related to pelvic reflux (Labropoulos, N., et al., Nonsaphenous superficial vein reflux. Journal of Vascular Surgery, 2001. 34(5): p. 872-7.) Marsh and Whitely noted a 19.5% and 21.5% incidence of LE varicosities related to non-saphenous reflux with 81% caused by pelvic reflux (Phlebology 2009)

Pelvic Derived Varicosities Clinical Presentation Common Varicosities in the thighs Labial/buttock varicosities HASTI symptoms C3-C6 disease SVT Less Common Dyspareunia Positional pelvic pain Spontaneous hemorrhage

Pelvic Derived Varicosities Clinical Presentation Villavicencio et al described 42 women with pelvic varicosities Mean age 31.9 (20-45) Mean onset after the second pregnancy 43% had leg varicosities 26% had pelvic pain 74% had labial varicosities

Pelvic Derived Varicosities Iliac Vein Varicosities Pubis, Vulva, Labia majora Round ligament Obturator vein Inner thigh, Posterior vulva Internal pudendal Gluteal, Posteromedial thigh Gluteal Internal pudendal

Pelvic Derived Varicosities Pelvic Escape Points The anatomists, with whom I frequently disagree as their descriptions not infrequently disagree with modern imaging, like to refer to 4 points of leakage from the pelvic veins – two major, the P and and I points – and two minor, the G and O points. The “perineal or p” point connects the internal and external pudendal systems and communicates with the veins of the medial thigh and further with the sapehnofemoral junction. The “inguinal or I” point connects the ovarian vein and pelvic venous plexus with the saphenofemoral junction. The “obturator or O” point connects the obturator vein with the veins of the medial thigh and the “gluteal or g” point connects the gluteal veins with the sciatic and posteriro thisgh veins. This is where sciatic veins arise. Obturator Inguinal Perineal Gluteal

Pelvic Derived Varicosities Ovarian Vein Anatomy Drainage of parametrium, cervix, mesosalpinx and pampiniform plexus 2 - 3 trunks merge to form a single vein at L4 Right - IVC Left - L Renal Vein Extensive connections between the II veins the periuterine plexus Mean diameter 3.1 mm 2 - 3 valves Valvular incompetence in 47% of women

Pelvic Derived Varicosities Importance of Round Ligament Vein In most if not all instances of gonadal vein reflux resulting in lower extremity varicosities the pathway to the lower extremity is through the round ligament vein The round ligament vein is not a branch of the internal iliac veins This vein courses from the pelvis directly to the anterior abdominal wall and into the labia medial to the pubic symphysis Normally the round ligament vein is not easily imaged

Pelvic Derived Varicosities Anatomy of Round Ligament

Pelvic Derived Varicosities Anatomy of Round Ligament

Pelvic Derived Varicosities Venogram of Round Ligament Vein RT Gonadal vein LT Gonadal vein Round ligament vein Labial varicosities

Pelvic Derived Varicosities Venogram of Round Ligament Vein

Pelvic Derived Varicosities US of Round Ligament Varicosities If dilated varicosities are noted in the low abdominal wall just medial of the epigastric veins this is almost pathognomonic for a diagnosis of gonadal vein reflux

Pelvic Derived Varicosities MRI of Round Ligament Varicosities

Pelvic Derived Varicosities Conclusion Pelvic Derived Varicosities can arise from reflux in the internal iliac or the gonadal veins The pattern of reflux on the leg can given some hint as to the source of reflux The pathway for gonadal vein reflux into the lower extremity is almost always through the round ligament vein The presences of round ligament varicosities on ultrasound almost always indicates gonadal vein reflux Other imaging modalities may be helpful but are typically not needed if round ligament varicosities are present