Pelvic Congestion Syndrome Anatomy and Pathologic Anatomy S. Lakhanpal MD, FACS President & CEO Center for Vein Restoration

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In this presentation – The attendee should be able to: Definition of Pelvic Congestion Syndrome. Anatomy of the pelvic-abdominal venous system. Pathology leading to Pelvic Congestion Syndrome Pathologic anatomy of the pelvic, abdominal and Saphenous and non saphenous varicosities – their relationship with pelvic venous congestion and pelvic escape veins Pathologic physiology of pelvic venous congestion Diagnosis of PVC Clinical presentation Imaging PVC and fertility Treatment Medical therapy Interventions Fertility & post intervention pregnancies

What is Pelvic Congestion Syndrome? Chronic pelvic pain is described as the presence of lower abdominal pain for longer than 6 months Pelvic congestion Syndrome is defined as chronic pelvic pain resulting from reflux or obstruction of the gonadal, gluteal or peri-uterine veins. PCS is characterized by dysmenorrhea, dysuria, and dyspareunia It can often be found in conjunction with vulvar and pelvic varices in women and varicocele in men. In addition to physical pain and discomfort it is associated with high levels of anxiety, stress and depression.

Incidence of PVC: The magnitude of the challenge Chronic pelvic pain: Responsible for 30% of outpatient Gyn. visits in the US Potentially affecting up to 40% of the female population during their lifetime Pelvic Congestion Syndrome: PCS accounts for 30% of the patients presenting with Chronic pelvic pain. For patients with lower extremity varicose veins: 10-15% have non saphenous varicosities

It is essential to treat the infra-diaphragmatic venous system as one functional unit, and to understand the hemodynamic behavior of the normal centripetal venous circulation, and of the centripetal and centrifugal flow patterns in chronic venous insufficiency Perrin M, Gobin JP, Nicolini P. Recurrent varicose veins in the groin after surgery. J Mal Vasc. 1997;22:303-312

The Anatomy of the Veins of the Pelvis and Abdomen

Veins of the Abdomen and Pelvis Ext iliac vein: Begins at the inguinal ligament, courses along the pelvic brim, ends anterior to the SI joint by joining the internal iliac vein to form the common iliac vein. Tributaries, these anastomose freely with the corresponding superficial veins and the obturator veins: Deep Inferior Epigastric veins Deep External pudendal veins(pubic veins) Deep Circumflex iliac veins

Veins of the Abdomen & Pelvis Internal iliac vein: Short trunk formed by the union of its Extrapelvic (Gluteal{superior& inferior}), internal pudendal and obturator) … (mostly Parietal) Intrapelvic tributaries(parietal {lateral sacral}, visceral{rectal[middle hemorrhoidal], vesical, uterine and vaginal}. They drain the presacral venous plexus and the pelvic visceral plexus. These plexus and the additional superficial plexus provide free communication across the midline 30% of the times IIV drains by means of two separated veins Valves are infrequent in Int. Iliac Veins (10% - main trunk and tributaries)

Veins of the Abdomen & Pelvis Common Iliac vein From the SI joint to the right side of the fifth lumbar vertebrae RCIV – only tributary is the Rt. Ascending lumbar vein(collects blood from the lumbar veins and drains into the Azygos vein) LCIV – Left ascending lumbar vein(same as right) and the median sacral vein

Anatomy of the Inferior Vena Cava It is the largest venous trunk in the body. It is formed by the union of the two common iliac veins in front of the right side of the body of the fifth lumbar vertebra about two and a half centimeters (one inch) to the right of the median plane. In its ascent, it lies upon the bodies of the lower three lumbar vertebrae, the right lumbar and renal arteries, and the right crus of the diaphragm, by which it is separated from the aorta. It passes through the caval opening in the diaphragm opposite the eighth thoracic vertebra, pierces the pericardium and immediately enters the right atrium of the heart. In its upward course it receives the lumbar, the right testicular or ovarian, the renal, the right phrenic, the right suprarenal, and the hepatic veins. The veins tributary to the inferior vena cava generally follows the same course as the corresponding arteries. Because of the position of the inferior vena cava to the right of the media n line, the veins entering it from the left are longer than those from the right side.

Ahlberg NE, Bartley O, Chidekel N. Right and left gonadal veins. An Ovarian Vein - Anatomy Provide drainage to the Parametrium, cervix, mesosalpinx, pampiniform plexus. Forms a rich anastomotic venous plexus with the; Paraovarian, uterine, vesical, rectal and vulvar plexus. 2-3 trunks form a single ovarian vein at L4. Left ovarian vein drains into the LRV Right Ovarian vein drains into the IVC 10% ROV’s drain into the RRV The ovarian veins have an average diam. of 5mm. Valves are present mainly in the distal third Absence of valves in 15% on the left side and 6% on the right side. Ahlberg NE, Bartley O, Chidekel N. Right and left gonadal veins. An anatomical and statistical study. Acta Radiol Diagn (Stockh) 1966;4: 593-601.

Pathological Anatomy Defining PCS Two anatomic findings define PCS: ovarian vein reflux & pelvic varicosities. Each may be seen without the other or both can be present in asymptomatic patients.

Pathological Anatomy of May Thurner’s Syndrome MTS was first described in 1957 when it was noted that 22% of 430 cadavers on autopsy possessed an anatomical variant in which an overriding right common iliac artery caused compression of the left common iliac vein against the lumbar spine More recently, a similar prevalence (22%–24%) of MTS was reported in a retrospective analysis of computed tomography scans . This compression is associated with intimal hyperplasia, which creates the potential for venous stasis and subsequent thrombosis, venous webs etc. that may add to the functional venous obstruction leading to venous hypertension in the left internal iliac vein .

Pathological Anatomy of Nutcracker Syndrome Most typical nutcracker morphologic features imply compression of the LRV between the aorta and the superior mesenteric artery (SMA)

Pathological Anatomy – Non Saphenous Varicosities Pelvic escape veins, from pelvic pain to achy tired heavy legs in the absence of saphenous varicosities.

Non Saphenous Varicosities of the Leg The non saphenous superficial system(superficial veins that do not drain into the small or great saphenous systems). Non-saphenous veins (NSV) are located in the watershed areas as: Pelvic escape non saphenous veins; Buttock(internal iliac system through the gluteal veins) Perineal veins Vulva(internal iliac system), Non pelvic escape –non saphenous varicosities: Postero-lateral thigh(internal iliac system through the femoral vein) Lower posterior thigh, popliteal fossa, knee(popliteal/femoral vein) Along the peripheral nerves such as the tibial and sciatic nerve(internal iliac through the gluteal veins)

Pelvic Escape: Non Saphenous Superficial Veins of the Leg The non saphenous superficial system(superficial veins that do not drain into the small or great saphenous systems). Pelvic escape; non-saphenous veins (NSV) are located in the watershed areas as: Vulvar (internal iliac system) Perineal Buttock (internal iliac system through the gluteal veins) Veins of the sciatic nerve

Escape Routes and Their Frequency When selective pelvic phlebography was performed in 552 patients, 310 patients (552/310, 56.16%) displayed 1 or 2 dilated avalvular gonadal vessels measuring more than 8 mm in diameter. 446 (552/446; 80.8%) patients presented significant venous lakes or pelvic varices, While 530 (552/530; 96.01%) patients displayed leakage points from the hypogastric vein to the lower limbs. Escape routes showed as follows: to the great saphenous vein or its tributaries in 66 patients (66/530; 12.45%); to the deep venous system, deep femoral veins in 84 patients (84/530; 15.85%) and to the residual embryonic sciatic veins in 38 patients (38/530; 7.17%). A high number of patients, 342 (342/530; 64.53%) displayed mixed reflux in both superficial and deep venous systems

Gluteal and Lower Posterior Thigh Veins

Vulvar & Perineal Varicosities

Varicosities of the Sciatic Nerve www.phlebolymphology.org Right gluteal vein to sciatic nerve vein

Non pelvic escape?

Postero-lateral Thigh Veins

Popliteal Fossa and Knee Veins

Valves in the Pelvic Veins The number of deep venous valves increases from cranial to caudal. Unlike the infrainguinal veins, the iliac veins rarely(10%) contain valves. The external iliac and common femoral vein above the saphenofemoral junction usually have one valve at most. The ovarian veins have valves in the distal third. 15% of the ovarian veins on the left have no valves while 6% have no valves on the right.

Please refer back to the complete presentation on Pelvic Congestion Syndrome.

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