The role of duplex ultrasound in the workup of pelvic congestion syndrome

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Malgor RD, Adrahtas D, Spentzouris G, Gasparis AP, Tassiopoulos AK, Labropoulos N. J Vasc Surg: Venous and Lym Dis. 2014;2:34-38.

This article reports on an evaluation of using duplex ultrasound (DU) as a diagnostic technique in the diagnosis and follow-up of pelvic congestion syndrome (PCS) due to its noninvasive nature that contrasts with other standard techniques, such as conventional venography (CV). To asses this study, the authors performed a comparative study using patients imaged with DU, computed tomography venography (CTV), and CV in order to measure the accuracy of DU in the PCS diagnosis. Their results showed that DU has a high sensitivity to identify abnormalities in the left ovarian vein, but not in the case of the right ovarian vein, reducing, in that case, both sensitivity and accuracy. They did not find significant differences between the accuracy of the different imaging modalities.

The introduction of this work is simple and straightforward. However, they should have focused more on the presentation of their purpose, giving more data on the problems concerning PCS diagnosis and workup algorithms and comparing among these algorithms. In our unit, contrary to the authors, we do not separate DU and transvaginal ultrasound (TVUS), but consider these tests complementary, performing both if necessary.

The authors did not mention the presence of varicose veins in the lower limbs, but just discussed the appearance of edema; however later on they discussed lower limb symptoms. They also do not mention vulva-perineum leaks or gluteal, which, for us, is the most frequent. Particularly, different authors have described, in detail, the functional unit of the pelvis and lower limbs, but Malgor et al mostly ignore this discussion.

In our clinic, we use a different approach. First, after a normal gynecological exam to rule out PCS signs or symptoms related to gynecological causes and after discarding causes related to any column disease, we perform a TVUS to confirm the presence of pelvic varicose veins, as well as the presence or absence of a compression syndrome (which could be identified by noncontinuous or continuous venous flow). If we suspect a compression syndrome, then a transabdominal DU is performed. We use either CTV or magnetic resonance venography for identifying gonadal vein size or reflux as routine procedures.

If PCS treatment is planned, a super selective venography by brachial access is performed. This allows us to identify LRVC or IVC, pelvic varices, and the leak point to lower limb varices, and to treat these anomalies in the same session, thereby minimizing the patient’s disturbance. In addition, with a brachial approach, we obtain a better access to the ovarian veins due to the working angles for catheterization, and find no significant differences in the access to the left or right ovarian vein.