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

2. 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

3. 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?

4. 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, (5): p )
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)

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Pelvic Derived Varicosities Anatomy of Round Ligament

12. Pelvic Derived Varicosities Anatomy of Round Ligament

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

14. Pelvic Derived Varicosities Venogram of Round Ligament Vein

15. 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

16. Pelvic Derived Varicosities MRI of Round Ligament Varicosities

17. 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