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Pelvic Venous Disorders

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Pelvic Venous Disorders PELVIC VENOUS DISORDERS Anatomy and Pathophysiology Two Abdomino-Pelvic Compression Syndromes DIAGNOSIS of ABDOMINOO-PELVICP z Nutcracker Syndrome 9 Compression of the left renal vein COMPRESSIONCO SS O SYNDROMES S O with venous congestion of the left (with Emphasis on Duplex Ultrasound) kidney and left ovarian vein reflux R. Eugene Zierler, M.D. z May-Thurner Syndrome 9 Compression of the left common iliac vein by the right common The DD.. EE.. StrandnessStrandness,, JrJr.. Vascular Laboratory iliac artery with left lower University of Washington Medical Center extremity venous stasis and left DivisionDivision of Vascular Surgery internal iliac vein reflux University of Washington, School of Medicine ABDOMINO-PELVIC COMPRESSION Nutcracker Syndrome Left Renal Vein Entrapment z Grant 1937: Anatomical observation “…the left renal vein, as it lies between the aorta and superior mesenteric artery, resembles a nut between the jaws of a nutcracker.” X z El-Sadr 1950: Described first patient with the clinical syndrome X z De Shepper 1972: Named the disorder “Nutcracker Syndrome” Copy Here z Nutcracker Phenomenon z Nutcracker Syndrome 9 Anatomic finding only 9 Hematuria, proteinuria 9 Compression of left renal 9 Flank pain vein - medial narrowing 9 Pelvic pain/congestion with lateral (hilar) dilation 9 Varicocele ABDOMINO-PELVIC COMPRESSION ABDOMINO-PELVIC COMPRESSION Nutcracker Syndrome - Diagnosis Nutcracker Syndrome z Anterior Nutcracker z Posterior Nutcracker z Evaluate the left renal vein for aorto-mesenteric compression 9 Compression between 9 Compression between 9 Identify the left renal vein in SMA and aorta aorta and vertebral body the space between the SMA 9 Can also involve the 3rd 9 Retroaortic or and aorta portion of duodenum* circumaortic renal vein 9 Measure diameters and velocities in on the IVC side, at the SMA/aorta, and on the kidney side (hilum) 9 Measure the aorto-mesenteric angle * May be associated with compression of duodenum by the SMA (Wilkie syndrome) ABDOMINO-PELVIC COMPRESSION ABDOMINO-PELVIC COMPRESSION Nutcracker Syndrome - Diagnosis Diagnosis – General Approach z Duplex ultrasound is the preferred first imaging test 9 Fasting patient (as for other abdominal vascular ultrasound exams – visualization may be limited by bowel gas) Left Renal Vein Diameter 9 Low frequency curved-array (2-4 MHz) transducer Kidney Side (hilum) 1.02 cm 9 Settings for slow venous flow Aorta/SMA ≤ 0.22 cm z IVC Side 0.35 cm Components of the exam for Pelvic Venous Disorders: 9 Inferior vena cava and common/external iliac veins LongitudinalDiameter Ratio 1.02/0.22Transverse = 4.6 9 Nutcracker syndrome (left renal vein) 9 May-Thurner syndrome (left common iliac vein) 9 Internal iliac veins 9 Gonadal (ovarian) veins 9 Evaluation for pelvic varicosities ABDOMINO-PELVIC COMPRESSION ABDOMINO-PELVIC COMPRESSION Nutcracker Syndrome – Duplex Criteria Nutcracker Syndrome - Diagnosis z Diameterr Ratioo >5.00 (hilum/Aortataa-SMA) Sensitivity – 69% Specificity – 89% z Velocity Ratioo >5.00 (Aortataa-SMA/hilumm) Sensitivity – 80% Specificity – 94% z Aortoto-mesenteric Angle <23ºº – 35º Left Renal Vein Peak Velocity Sensitivity – 95.7% IVC Side (or site of compression) 102.8 cm/s Specificity – 69.2% Kidney Side (hilum) 13.8 cm/s Velocity Ratio 102.8/13.8 = 7.5 ABDOMINO-PELVIC COMPRESSION ABDOMINO-PELVIC COMPRESSION May-Thurner Syndrome Nutcracker Syndrome - Diagnosis Left Common Iliac Vein Compression z Aortomesenteric angle* z Virchow 1851: Observed increased frequency of left leg DVT associated with compression of left iliac vein between right iliac artery and 5th lumbar vertebrae 58° z McMurrich 1908: 30% prevalence of “congenital” obstructions in the left iliac vein (cadaver study) z Ehrich 1943: 24% prevalence of obstructive lesions in the left common iliac vein comprised of collagen and elastin 22° that were more likely acquired (cadaver study) * May vary with patient position; patient examined supine reverse Trendelenburg ABDOMINO-PELVIC COMPRESSION ABDOMINO-PELVIC COMPRESSION May-Thurner Syndrome - Diagnosis May-Thurner Syndrome Left Common Iliac Vein Compression z Evaluate the left common iliac vein for compression by the z May and Thurner 1957: right common iliac artery (also look for other sites of iliac vein compression) 9 22% of 430 cadavers had “spurs” in the left common iliac vein 9 These spurs were attributed to chronic compression of the 9 IVC and common iliac veins evaluated left common iliac vein by the right common iliac artery in reverse Trendelenburg position 9 Categorized spurs by location and size 9 Identify velocity and waveform changes z Cockett and Thomas1965: across sites of compression 9 Described “Iliac Compression Syndrome” in 29 patients 9 Measure vein diameters 9 Noted that the iliac lesions could remain asymptomatic due to 9 Evaluate external iliac and common formation of venous collaterals femoral veins for reflux and obstruction 9 Recognized variations in compressing structures, including right-sided and bilateral iliac vein obstructions ABDOMINO-PELVIC COMPRESSION ABDOMINO-PELVIC s May-Thurner Syndrome - Diagnosis May-Thurner Syndrome - Presentation z Normal left common iliac vein z Pathologic compression of the left common iliac vein by the right common iliac artery, resulting in left lower extremity pain, swelling, and deep venous thrombosis z More prevalent in women with female:male ratio of 2:1 z Mean age at presentation 42 years z Clinical stages: 9 Stage I - Asymptomatic iliac vein compression 9 Stage II - Formation of an intraluminal spur 9 Stage III - Left iliac DVT Transverse View ABDOMINO-PELVIC COMPRESSION ABDOMINO-PELVIC COMPRESSION Nutcracker and May-Thurner Syndrome May-Thurner Syndrome - Diagnosis Other Diagnostic Studies* z Compressed left common iliac vein z Duplex ultrasound is used for screening and initial diagnosis z Other imaging modalities reserved for intervention planning and procedural guidance 9 CT venography 9 MR venography 9 IVUS 9 Catheter venography Left CIV Diameter Velocity and direct pressure Proximal 1.10 cm 20 cm/s measurement VelocityVelocity Ratio Mid (at right CIA) 0.38 cm 45 cm/s 45/16 = 2.8 Distal (pre-obstruction) 1.35 cm 16 cm/s * Patient body position and volume status can also affect imaging results ABDOMINO-PELVIC COMPRESSION May-Thurner Syndrome – Duplex Criteria z Multiple threshold criteria for significant iliac vein stenosis have been evaluated: 9 Common femoral vein velocity ratio 9 Common femoral vein volume flow ratio 9 Common iliac vein diameter ratio 9 Common iliac vein velocity ratio z Common Iliac Vein Velocity Ratio ≥2.5 9 Sensitivity – 76% 9 Specificity – 100% Max velocity at site of compression Max pre-obstruction velocity ABDOMINO-PELVIC COMPRESSION Nutcracker Syndrome - Diagnosis Left Renal Vein Peak Velocity IVC Side (or site of compression) 61.9 cm/s Kidney Side (hilum) 3.3 cm/s Velocity Ratio 61.9/3.3 = 18.8 PELVIC VENOUS DISORDERS ABDOMINO-PELVIC COMPRESSION Anatomy and Pathophysiology May-Thurner Syndrome - Diagnosis Two Clinical Presentations z Other Findings z Pelvic Congestion 9 Pain, dyspareunia, dysuria z Pelvic Varices 9 Gluteal, perineal, vulvar z Pelvic venous drainage includes IVC, left renal, common iliac, internal iliac, and ovarian veins (multiple interconnections and drainage across the pelvis) z Diagnosis is based on correlation of the clinical Retrograde flow (reflux) in Occlusive left external presentation with findings of reflux or obstruction (or both) the left internal iliac vein iliac DVT ABDOMINO-PELVIC COMPRESSION Vascular lab worksheet and protocol with criteria (a work-in-progress).
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