V. Pelvic disorders

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Diagnosis and pelvic disorders

The session started with a keynote lecture by Wassila Taha Elkashishi (Egypt) on duplex criteria and patient selection in modern vein therapy. This talk provided an excellent review of the potential of duplex ultrasound in skillful hands and the role of this examination in modern phlebology. Today, this is a mandatory diagnostic tool for planning venous procedures in both chronic and acute conditions. Vimalin Samuel (India) discussed the anatomical variations of the saphenous fascia in the Indian population. In 72% of legs, the saphenous fascia belongs to the so-called I-type, and the great saphenous vein lies completely between two layers of the fascia (saphenous eye). These findings are valuable for local practitioners who use endovenous ablation.

Pier Luigi Antignani (Italy) presented his work using transbrachial endovascular foam sclerotherapy of incompetent gonadal veins with 10 mL of 3% sodium tetradecyl sulphate foam in 59 women with chronic pelvic venous pain and pelvic varicose veins. The treatment showed an excellent success with complete resolution of symptoms in 58 patients. After 12 months, further treatment was required in only 1 patient.

An interesting study using air plethysmography was presented by Yosuke Shiraishi (Japan). In some cases, there was an inaccuracy observed in the venous filling index (VFI) due to the arterial inflow rate. VFI is a very precise tool to assess hemodynamic disorders in patients with chronic venous disease. The author invented a more accurate, original, and pure regurgitation index (RI) that can be calculated as: RI = (standing VFI – supine VFI)/body mass index.

Stenting of the superior vena cava obstruction is a very rare procedure. Ravul Jindal (India) has performed 40 such interventions on patients undergoing hemodialysis who developed central venous obstruction. Technical success was 82% and the primary patency rates were 90%, 80%, and 52% at 3, 6, and 12 months, respectively. Stent placement in such patients provides excellent results and helps preserve vascular access for a substantial period.

Diagnosis of pelvic venous insufficiency
Mark Meissner, USA

The diagnosis of pelvic venous insufficiency is not simple. Chronic pelvic pain (>6 months) represents 10% of all outpatient gynecology visits. The most common causes of chronic pelvic pain is endometriosis (39%), pelvic congestion syndrome (31%), pelvic inflammatory disease (11%), and adhesion (10%). A high prevalence of depression (25% to 50%) and anxiety (10% to 20%) is observed in association with chronic pelvic pain. Pelvic venous disorders have two clinical manifestations– pelvic congestion syndrome and pelvic varices. In the pelvic congestion syndrome, the patient complains of pain, dyspareunia, and dysuria, and in pelvic varices, the patient relates the presence of varices in gluteal, perineal, and vulvar regions.

For a correct diagnosis, an understanding of the anatomy of the ovarian veins, internal iliac veins, and saphenous femoral junctions, and the connection between them, is very important. The ultrasound must be applied with a low-frequency transducer (2-4 mHz) in a reverse Trendelemburg position to evaluate ovarian reflux and diameter (>6 mm) and internal iliac reflux and diameter. In addition, a transvaginal ultrasound should be done to observe the presence of crossing veins (>5 mm). The ultrasound diagnosis must exclude iliac venous compression and aortomesenteric renal vein compression. The definitive diagnosis is composed of selective venography (left renal vein, bilateral ovarian veins, and bilateral internal iliac veins), intravascular ultrasound to exclude real and iliac compression, and measurements of pullback pressure.

It is important to treat any obstruction first (via angioplasty and stenting) and then treat pelvic reflux with selective embolization and sclerotherapy. In the management of pelvic venous disease, we must be aware of the interconnected venous systems, ovarian veins, internal iliac veins, and saphenous femoral junction.