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Interventional Radiology
Procedures
Venous, Portal, and Lymphatic Procedures
Venous Interventions
Pelvic Venous Disorders (PeVD)
Pelvic Venous Disorders (PeVD)
Jennifer R. Buckley, MD, MBA; Brandt C. Wible, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Pelvic venous disorders (PeVD): Spectrum of clinical disorders presenting with chronic pelvic pain and varicosities related to pelvic venous incompetence (PVI) caused by venous reflux or nonthrombotic venous obstruction
              • Syndromic nomenclature, sites of pathology, and common mechanism of disease
                • Nutcracker syndrome (NS): Left renal vein (LRV); compression between aorta and superior mesenteric artery
                • May-Thurner syndrome (MTS): Common iliac vein (CIV); compression between spine and contralateral common iliac artery
                • Pelvic congestion syndrome (PCS): Gonadal vein (GV) ± internal iliac vein (IIV); reflux due to incompetent valves
                • Varicocele: Pampiniform plexus dilation; reflux of spermatic/GV
            • PeVD/PVI etiology: Often multifactorial
              • Primary valvular insufficiency due to absent/incompetent valves
              • Venous outflow obstruction
                • Anatomic: Nutcracker or May-Thurner anatomy; causes venous compression, elevated venous pressure, possible thrombosis or reflux
                  • Presence of anatomic findings does not always mean patient will be symptomatic (i.e., nutcracker phenomenon vs. NS)
                • Pathologic: Retroperitoneal or pelvic mass causing venous obstruction
                  • Particularly of concern with new right unilateral varicocele
              • Anatomic variants
                • Retroaortic LRV may elevate venous pressure/may cause GV reflux
              • Dysfunctional vasomotor hormonal regulation [uterine/ovarian veins (OV) are hormonally sensitive]

          • Clinical Presentation

            • NS: Hematuria and left flank pain
              • Can lead to additional findings of PCS
                • Due to increased reflux/pressure within left GV (LGV), which acts to decompress obstructed LRV
              • May need additional work-up (such as cystoscopy) to exclude other causes of hematuria
            • PCS: Chronic pelvic pain lasting > 6 months due to PVI and associated venous distention
              • Most often due to retrograde flow through incompetent valves in dilated ovarian/IIVs, causing tortuous, congested pelvic/periuterine veins
                • Can occur primarily or as secondary result of other anatomic abnormalities (such as NS)
                • Risk factors: Heredity, hormonal influence, pelvic surgery, retroverted uterus, history of varicose veins, and multiple pregnancies
              • Pelvic pain, pressure, or heaviness that is often worsened with movement, posture, and activities that increase abdominal pressure
                • Symptoms often worsen throughout day and are relieved with supine positioning
              • Superficial varicosities of vulva or lower extremities
              • Dyspareunia (71%), dysmenorrhea (66%)
              • Bladder irritability, urinary frequency
              • Symptoms typically disappear after menopause
            • Varicocele
              • Asymptomatic (common)
              • Palpable lump ("bag of worms"), scrotal thickening
              • Testicular pain, heaviness
              • Infertility/subfertility
                • Most common abnormality found in infertile men
                  • Affects 40% of infertile men but only 15% of general male population
                  • 75% of men with varicocele have normal fertility
                • Etiology: Elevation of testicular temperature
                  • Other proposed causes: Reflux of toxic metabolites, hypoxia from venous stasis

          • Anatomic Considerations

            • Anatomic findings of venous compression may be incidentally present without associated syndrome
            • Left-sided disease significantly more common than right side due to pattern of drainage
              • LGV → LRV → inferior vena cava (IVC)
                • LGV may also communicate with inferior mesenteric vein
              • Right GV → IVC
                • Enters below right renal vein
            • Complex venous communications common between GVs and internal iliac varices
              • Between GV and IIV
                • May cause OVs to be decompressed despite significant reflux
                • Normal-sized OVs (< 10 mm) does not exclude venous incompetence
              • Between uterine veins and OV or right and left endometrial veins
                • Incomplete embolization may result in persistent symptoms via uteroovarian arcade pelvic varices
            • GV anomalies common (both ovarian and spermatic)
              • Absent GV valves on left (15%) more common than right (6%)
              • Multiple LGV branches draining into LRV in 10-20%
              • Multiple right GV branches draining into right renal vein in 20-25%
            • Alternative drainage pathways may develop after varicocele embolization
              • External pudendal vein → greater saphenous vein
              • Ductus deferens vein → superior vesicular vein → IIV
              • Cremasteric vein (a.k.a. external spermatic vein) → inferior epigastric vein

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Equipment Preparation

                      • Procedure Steps

                        • Alternative Procedures/Therapies

                          POST PROCEDURE

                          • Things to Do

                            • Things to Avoid

                              OUTCOMES

                              • Complications

                                • Expected Outcomes

                                  Selected References

                                  1. Broe MP et al: Spermatic vein embolization as a treatment for symptomatic varicocele. Can Urol Assoc J. 15(11):E569-73, 2021
                                  2. Chait J et al: Nutcracker syndrome: how to diagnose it and when/how should it be treated in the pelvic venous disease population. Tech Vasc Interv Radiol. 24(1):100734, 2021
                                  3. Gavrilov S et al: Stratification of pelvic venous reflux in patients with pelvic varicose veins. J Vasc Surg Venous Lymphat Disord. 9(6):1417-24, 2021
                                  4. Joh M et al: Ovarian vein embolization: how and when should it be done? Tech Vasc Interv Radiol. 24(1):100732, 2021
                                  5. Khilnani NM et al: Clinical presentation and evaluation of pelvic venous disorders in women. Tech Vasc Interv Radiol. 24(1):100730, 2021
                                  6. Velasquez CA et al: A systematic review on management of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 6(2):271-8, 2018
                                  7. Borghi C et al: Pelvic congestion syndrome: the current state of the literature. Arch Gynecol Obstet. 293(2):291-301, 2016
                                  8. Halpern J et al: Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Asian J Androl. 18(2):234-8, 2016
                                  9. Lorenc T et al: The value of ultrasonography in the diagnosis of varicocele. J Ultrason. 16(67):359-70, 2016
                                  10. Rotker K et al: Recurrent varicocele. Asian J Androl. 18(2):229-33, 2016
                                  11. Favard N et al: Comparison of three different embolic materials for varicocele embolization: retrospective study of tolerance, radiation and recurrence rate. Quant Imaging Med Surg. 5(6):806-14, 2015
                                  12. Lurvey R et al: Adolescent varicocele: a large multicenter analysis of complications and recurrence in academic programs. J Pediatr Urol. 11(4):186.e1-6, 2015
                                  13. Alkaram A et al: Varicocele and its effect on testosterone: implications for the adolescent. Transl Androl Urol. 3(4):413-7, 2014
                                  14. Koo S et al: Pelvic congestion syndrome and pelvic varicosities. Tech Vasc Interv Radiol. 17(2):90-5, 2014
                                  15. Kwak N et al: Imaging and interventional therapy for varicoceles. Curr Urol Rep. 15(4):399, 2014
                                  16. Masson P et al: The varicocele. Urol Clin North Am. 41(1):129-44, 2014
                                  17. Vanlangenhove P et al: Pathophysiology, diagnosis and treatment of varicoceles: a review. Minerva Urol Nefrol. 66(4):257-82, 2014
                                  18. Laborda A et al: Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Intervent Radiol. 36(4):1006-14, 2013
                                  19. Iaccarino V et al: Interventional radiology of male varicocele: current status. Cardiovasc Intervent Radiol. 35(6):1263-80, 2012
                                  20. Monedero JL et al: Pelvic congestion syndrome can be treated operatively with good long-term results. Phlebology. 27 Suppl 1:65-73, 2012
                                  21. Diegidio P et al: Review of current varicocelectomy techniques and their outcomes. BJU Int. 108(7):1157-72, 2011
                                  22. Black CM et al: Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol. 21(6):796-803, 2010
                                  23. Tu FF et al: Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 65(5):332-40, 2010
                                  24. Cayan S et al: Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl. 30(1):33-40, 2009
                                  25. Gandini R et al: Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol. 31(4):778-84, 2008
                                  26. Ratnam LA et al: Pelvic vein embolisation in the management of varicose veins. Cardiovasc Intervent Radiol. 31(6):1159-64, 2008
                                  27. Reiner E et al: Initial experience with 3% sodium tetradecyl sulfate foam and fibered coils for management of adolescent varicocele. J Vasc Interv Radiol. 19(2 Pt 1):207-10, 2008
                                  28. Koc Z et al: Association of left renal vein variations and pelvic varices in abdominal MDCT. Eur Radiol. 17(5):1267-74, 2007
                                  29. Kwon SH et al: Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol. 30(4):655-61, 2007
                                  30. Liddle AD et al: Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 22(3):100-4, 2007
                                  31. Kim HS et al: Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 17(2 Pt 1):289-97, 2006
                                  32. Pavkov ML et al: Quantitative evaluation of the utero-ovarian venous pattern in the adult human female cadaver with plastination. World J Surg. 28(2):201-5, 2004
                                  33. Venbrux AC et al: Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 13(2 Pt 1):171-8, 2002
                                  34. Venbrux AC et al: Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol. 11(4):395-9, 1999
                                  35. Dubin L et al: Varicocele. Urol Clin North Am. 5(3):563-72, 1978
                                  Related Anatomy
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                                  Related Differential Diagnoses
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                                  References
                                  Tables

                                  Tables

                                  KEY FACTS

                                  • Terminology

                                    • Preprocedure

                                      • Post Procedure

                                        • Outcomes

                                          TERMINOLOGY

                                          • Definitions

                                            • Pelvic venous disorders (PeVD): Spectrum of clinical disorders presenting with chronic pelvic pain and varicosities related to pelvic venous incompetence (PVI) caused by venous reflux or nonthrombotic venous obstruction
                                              • Syndromic nomenclature, sites of pathology, and common mechanism of disease
                                                • Nutcracker syndrome (NS): Left renal vein (LRV); compression between aorta and superior mesenteric artery
                                                • May-Thurner syndrome (MTS): Common iliac vein (CIV); compression between spine and contralateral common iliac artery
                                                • Pelvic congestion syndrome (PCS): Gonadal vein (GV) ± internal iliac vein (IIV); reflux due to incompetent valves
                                                • Varicocele: Pampiniform plexus dilation; reflux of spermatic/GV
                                            • PeVD/PVI etiology: Often multifactorial
                                              • Primary valvular insufficiency due to absent/incompetent valves
                                              • Venous outflow obstruction
                                                • Anatomic: Nutcracker or May-Thurner anatomy; causes venous compression, elevated venous pressure, possible thrombosis or reflux
                                                  • Presence of anatomic findings does not always mean patient will be symptomatic (i.e., nutcracker phenomenon vs. NS)
                                                • Pathologic: Retroperitoneal or pelvic mass causing venous obstruction
                                                  • Particularly of concern with new right unilateral varicocele
                                              • Anatomic variants
                                                • Retroaortic LRV may elevate venous pressure/may cause GV reflux
                                              • Dysfunctional vasomotor hormonal regulation [uterine/ovarian veins (OV) are hormonally sensitive]

                                          • Clinical Presentation

                                            • NS: Hematuria and left flank pain
                                              • Can lead to additional findings of PCS
                                                • Due to increased reflux/pressure within left GV (LGV), which acts to decompress obstructed LRV
                                              • May need additional work-up (such as cystoscopy) to exclude other causes of hematuria
                                            • PCS: Chronic pelvic pain lasting > 6 months due to PVI and associated venous distention
                                              • Most often due to retrograde flow through incompetent valves in dilated ovarian/IIVs, causing tortuous, congested pelvic/periuterine veins
                                                • Can occur primarily or as secondary result of other anatomic abnormalities (such as NS)
                                                • Risk factors: Heredity, hormonal influence, pelvic surgery, retroverted uterus, history of varicose veins, and multiple pregnancies
                                              • Pelvic pain, pressure, or heaviness that is often worsened with movement, posture, and activities that increase abdominal pressure
                                                • Symptoms often worsen throughout day and are relieved with supine positioning
                                              • Superficial varicosities of vulva or lower extremities
                                              • Dyspareunia (71%), dysmenorrhea (66%)
                                              • Bladder irritability, urinary frequency
                                              • Symptoms typically disappear after menopause
                                            • Varicocele
                                              • Asymptomatic (common)
                                              • Palpable lump ("bag of worms"), scrotal thickening
                                              • Testicular pain, heaviness
                                              • Infertility/subfertility
                                                • Most common abnormality found in infertile men
                                                  • Affects 40% of infertile men but only 15% of general male population
                                                  • 75% of men with varicocele have normal fertility
                                                • Etiology: Elevation of testicular temperature
                                                  • Other proposed causes: Reflux of toxic metabolites, hypoxia from venous stasis

                                          • Anatomic Considerations

                                            • Anatomic findings of venous compression may be incidentally present without associated syndrome
                                            • Left-sided disease significantly more common than right side due to pattern of drainage
                                              • LGV → LRV → inferior vena cava (IVC)
                                                • LGV may also communicate with inferior mesenteric vein
                                              • Right GV → IVC
                                                • Enters below right renal vein
                                            • Complex venous communications common between GVs and internal iliac varices
                                              • Between GV and IIV
                                                • May cause OVs to be decompressed despite significant reflux
                                                • Normal-sized OVs (< 10 mm) does not exclude venous incompetence
                                              • Between uterine veins and OV or right and left endometrial veins
                                                • Incomplete embolization may result in persistent symptoms via uteroovarian arcade pelvic varices
                                            • GV anomalies common (both ovarian and spermatic)
                                              • Absent GV valves on left (15%) more common than right (6%)
                                              • Multiple LGV branches draining into LRV in 10-20%
                                              • Multiple right GV branches draining into right renal vein in 20-25%
                                            • Alternative drainage pathways may develop after varicocele embolization
                                              • External pudendal vein → greater saphenous vein
                                              • Ductus deferens vein → superior vesicular vein → IIV
                                              • Cremasteric vein (a.k.a. external spermatic vein) → inferior epigastric vein

                                          PREPROCEDURE

                                          • Indications

                                            • Contraindications

                                              • Preprocedure Imaging

                                                • Getting Started

                                                  PROCEDURE

                                                  • Patient Position/Location

                                                    • Equipment Preparation

                                                      • Procedure Steps

                                                        • Alternative Procedures/Therapies

                                                          POST PROCEDURE

                                                          • Things to Do

                                                            • Things to Avoid

                                                              OUTCOMES

                                                              • Complications

                                                                • Expected Outcomes

                                                                  Selected References

                                                                  1. Broe MP et al: Spermatic vein embolization as a treatment for symptomatic varicocele. Can Urol Assoc J. 15(11):E569-73, 2021
                                                                  2. Chait J et al: Nutcracker syndrome: how to diagnose it and when/how should it be treated in the pelvic venous disease population. Tech Vasc Interv Radiol. 24(1):100734, 2021
                                                                  3. Gavrilov S et al: Stratification of pelvic venous reflux in patients with pelvic varicose veins. J Vasc Surg Venous Lymphat Disord. 9(6):1417-24, 2021
                                                                  4. Joh M et al: Ovarian vein embolization: how and when should it be done? Tech Vasc Interv Radiol. 24(1):100732, 2021
                                                                  5. Khilnani NM et al: Clinical presentation and evaluation of pelvic venous disorders in women. Tech Vasc Interv Radiol. 24(1):100730, 2021
                                                                  6. Velasquez CA et al: A systematic review on management of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 6(2):271-8, 2018
                                                                  7. Borghi C et al: Pelvic congestion syndrome: the current state of the literature. Arch Gynecol Obstet. 293(2):291-301, 2016
                                                                  8. Halpern J et al: Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Asian J Androl. 18(2):234-8, 2016
                                                                  9. Lorenc T et al: The value of ultrasonography in the diagnosis of varicocele. J Ultrason. 16(67):359-70, 2016
                                                                  10. Rotker K et al: Recurrent varicocele. Asian J Androl. 18(2):229-33, 2016
                                                                  11. Favard N et al: Comparison of three different embolic materials for varicocele embolization: retrospective study of tolerance, radiation and recurrence rate. Quant Imaging Med Surg. 5(6):806-14, 2015
                                                                  12. Lurvey R et al: Adolescent varicocele: a large multicenter analysis of complications and recurrence in academic programs. J Pediatr Urol. 11(4):186.e1-6, 2015
                                                                  13. Alkaram A et al: Varicocele and its effect on testosterone: implications for the adolescent. Transl Androl Urol. 3(4):413-7, 2014
                                                                  14. Koo S et al: Pelvic congestion syndrome and pelvic varicosities. Tech Vasc Interv Radiol. 17(2):90-5, 2014
                                                                  15. Kwak N et al: Imaging and interventional therapy for varicoceles. Curr Urol Rep. 15(4):399, 2014
                                                                  16. Masson P et al: The varicocele. Urol Clin North Am. 41(1):129-44, 2014
                                                                  17. Vanlangenhove P et al: Pathophysiology, diagnosis and treatment of varicoceles: a review. Minerva Urol Nefrol. 66(4):257-82, 2014
                                                                  18. Laborda A et al: Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Intervent Radiol. 36(4):1006-14, 2013
                                                                  19. Iaccarino V et al: Interventional radiology of male varicocele: current status. Cardiovasc Intervent Radiol. 35(6):1263-80, 2012
                                                                  20. Monedero JL et al: Pelvic congestion syndrome can be treated operatively with good long-term results. Phlebology. 27 Suppl 1:65-73, 2012
                                                                  21. Diegidio P et al: Review of current varicocelectomy techniques and their outcomes. BJU Int. 108(7):1157-72, 2011
                                                                  22. Black CM et al: Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol. 21(6):796-803, 2010
                                                                  23. Tu FF et al: Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 65(5):332-40, 2010
                                                                  24. Cayan S et al: Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl. 30(1):33-40, 2009
                                                                  25. Gandini R et al: Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol. 31(4):778-84, 2008
                                                                  26. Ratnam LA et al: Pelvic vein embolisation in the management of varicose veins. Cardiovasc Intervent Radiol. 31(6):1159-64, 2008
                                                                  27. Reiner E et al: Initial experience with 3% sodium tetradecyl sulfate foam and fibered coils for management of adolescent varicocele. J Vasc Interv Radiol. 19(2 Pt 1):207-10, 2008
                                                                  28. Koc Z et al: Association of left renal vein variations and pelvic varices in abdominal MDCT. Eur Radiol. 17(5):1267-74, 2007
                                                                  29. Kwon SH et al: Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol. 30(4):655-61, 2007
                                                                  30. Liddle AD et al: Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 22(3):100-4, 2007
                                                                  31. Kim HS et al: Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 17(2 Pt 1):289-97, 2006
                                                                  32. Pavkov ML et al: Quantitative evaluation of the utero-ovarian venous pattern in the adult human female cadaver with plastination. World J Surg. 28(2):201-5, 2004
                                                                  33. Venbrux AC et al: Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 13(2 Pt 1):171-8, 2002
                                                                  34. Venbrux AC et al: Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol. 11(4):395-9, 1999
                                                                  35. Dubin L et al: Varicocele. Urol Clin North Am. 5(3):563-72, 1978