Incapacitating pelvic congestion syndrome in a patient with a history of May-Thurner syndrome and left ovarian vein embolization

Familiar Disposition of May-Thurner Syndrome-A Case Series

May-Thurner syndrome is a venous compression syndrome of the pelvic vessels that represents a relevant risk factor for thrombus formation. The standard procedure to secure a diagnosis is venography, followed by endovascular therapy as the preferred treatment choice if the patient is symptomatic. In our case series, there are three related patients with May-Thurner syndrome. A 16-year-old female was admitted with pulmonary embolism, dyspnoea and hip pain. The compression syndrome was diagnosed with interventional venography, and the patient received venous stent implantation. Due to her family history, we also suspected her mother to be affected by the syndrome and elucidated the diagnosis shortly afterwards by invasive venography. Subsequently, we examined the patient's 19-year-old brother, and magnetic resonance imaging confirmed May-Thurner syndrome. A similar case series has not been published before. In this case, the family relation indicates a possible hereditary aspect of May-Thurner syndrome. This hypothesis should be the subject of further research. In conclusion, it is essential to assess family history thoroughly when treating patients with May-Thurner syndrome.

[Diagnosis of arteriovenous compression in small pelvic varicose veins]

AIM

The study was aimed at assessing the incidence of arteriovenous compression in women with chronic venous insufficiency of the inferior vena cava and at developing an optimal diagnostic algorithm.

PATIENTS AND METHODS

During the period 2019-2020, we performed a cross-sectional study including a total of sixty-six 18-to-55-year-old (mean 33.5±5.0) women with clinical manifestations of chronic venous insufficiency of the basin of the inferior vena cava. A diagnostic algorithm included questionnaire, transvaginal ultrasound examination, multislice computed tomography, direct phlebography in combination with phlebotonometry.

RESULTS

Chronic venous insufficiency of lower limbs was diagnosed in 66 (100%) cases and was presented by the following clinical classes according to the CEAP classification: C0 - 4.5%, C1 - 60.6%, C2 - 27.2%, C3 - 3%. Symptoms of pelvic venous plethora were revealed in 36 (55.5%) examined patients. Arteriovenous compression syndrome according to the findings of multislice computed tomography was verified in 16 (24%) women, including May-Turner syndrome in 5 (7.6%), aortomesenteric compression syndrome in 8 (12%) women, with a combination of both syndromes observed in 3 cases; the frequency of their detection did not differ statistically in subgroups of women with and without clinical signs pelvic varicose veins. Direct phlebography in combination with phlebotonometry was performed in 9 women, the diagnosis of arteriovenous compression (May-Thurner syndrome) was confirmed in 1 case only.

CONCLUSION

In women with signs of chronic venous insufficiency in the system of the inferior vena cava the frequency of detecting arteriovenous compression on multislice computed tomography may reach 24% and does not depend on the presence of symptoms of pelvic venous plethora. The proportion of arteriovenous compression according to the findings of direct phlebography and phlebotonometry in the structure of causes of the development of pelvic varicose veins did not exceed 11%. An algorithm for diagnosing arteriovenous compression syndromes should obligatorily include multislice computed tomography, direct phlebography and phlebotonometry.

Role of trans-abdominal and trans-perineal venous duplex ultrasound in cases of pelvic congestion syndrome

Background

For evaluation the role of trans-abdominal and trans-perineal venous duplex ultrasound in cases of pelvic congestion syndrome, fifty patients with pelvic congestion syndrome were included in the current research. All were evaluated by trans-abdominal and trans-perineal venous duplex.

Results

An incompetent left gonadal vein was detected in all cases with a mean diameter (± SD) = 7.9 ± 1.1 mm. The right gonadal vein was incompetent in 4 cases (8%) with a mean diameter (± SD) 5.9 ± 0.4 mm.

A refluxing proximal internal iliac vein was detected in 3cases (6%). Left renal vein nutcracker was present in 41cases (82%) while the left common iliac vein compression was present in 3 cases (6%).

Vulvoperineal varicosities were seen in all cases {right side = (36%, n = 18), left side = (30%, n = 15), and bilateral = (34%, n = 17)}.Thigh extension of the vulvoperineal varicosities was present in (74%, n = 37).

Round ligament varicosities were present in (6%, n = 3).

Conclusions

Trans-abdominal and trans-perineal venous duplex offer a simple, noninvasive, and quick technique that can help in an accurate evaluation of the ovarian vein reflux, diameters as well as the presence of vulvoperineal, and round ligament varicosities, Moreover, it is useful in the assessment of the left renal and iliac veins compression.

Pelvic congestion syndrome and embolization of pelvic varicose veins

Pelvic congestion syndrome (PGS) is defined as chronic pelvic pain for more than 6 months associated with perineal and vulvar varicose veins caused by reflux or obstruction in gonadal, gluteal, or parauterine veins. PGS accounts for 16-31% of cases of chronic pelvic pain, and is usually diagnosed in the third and fourth decades of life. Interest in this condition among vascular surgeons has been increasing over recent years because of its association with venous insufficiency of the lower limbs. Despite its significant prevalence, PGS is still poorly diagnosed in both gynecology and angiology offices. Therefore, in this article we review the etiology and diagnosis of this condition and the outcomes of the different types of treatment available.

Slippery Stents: A Case Report and Review of the Literature Describing Patients with May-Thurner Syndrome That Experienced Stent Migration

Endovascular stent placement is an effective treatment for relieving chronic venous obstruction in patients with May-Thurner Syndrome (MTS) with or without the presence of thrombotic lesions. Stent migration is a rare but potentially life-threatening complication of endovascular stenting. Herein, we describe a case of stent migration from the left common iliac vein into the right heart, requiring open-heart surgery. We also completed a literature review of MTS patients with stent migration in hopes of raising awareness of this rare and life-threatening complication.

The effect of the ovarian varicose vein on the DNA methylation in the rat's oocyte

Objective(s):

We intended to determine whether the ovarian varicose which is one of the common etiologies of the pelvic congestion syndrome, has the ability to interfere with the DNA methylation reprogramming in the oocyte and thereby affect the oocyte quality or not.

Materials and Methods:

Varicose model was induced according to the Turner’s method in the rats. Briefly, a 20-gauge needle was placed on the left renal vein and a thread was tied over both the needle and the renal vein medial to the insertion of the ovarian vein, and then the needle was removed. Evaluation of prooxidant-antioxidant balance (PAB) was assessed using specific kits and the expression level of the DNA methyltransferase genes Dnmt1, Dnmt3a and Dnmt3L was assessed by Real-time PCR. Immunofluorescent staining for 5-methylcytosine in the oocytes evaluated the global DNA methylation.

Results:

A significant PAB increase in the ovaries from varicose group was seen. Real-time PCR demonstrated a remarkable decrease in the expression of the Dnmt3a and Dnmt3L which are responsible for de novo DNA methylation in the oocytes. Immunofluorescent staining for 5-mC showed a reduction in the fluorescence intensity in the oocytes collected from the varicose group.

Conclusion:

Our findings from Real-time PCR and immunocytochemistry suggest that the epigenetic parameters in the oocyte could be affected by varicose induction and these epigenetic alteration has the potential to affect the oocyte quality. We suggest that the epigenetic changes could happen in the oocytes after the induction of ovarian varicose and lead to the oocyte quality reduction or even infertility.

Iliac Vein Compression Syndrome (IVCS): An Under-Recognized Risk Factor for Left-Sided Deep Venous Thrombosis (DVT) in Old Hip Fracture Patients

BACKGROUND The aim of this study was to identify whether iliac vein compression syndrome (IVCS) is a risk factor for left-sided deep venous thrombosis (DVT) in hip fracture patients and the influence IVCS may have on the treatment of DVT. MATERIAL AND METHODS A retrospective study was carried out among 424 hip fracture patients admitted to our hospital from 2011 to 2016. Clinical data were analyzed, and all patients were classified into the DVT group and the non-DVT group based on plasmin D-Dimer concentration and results of Doppler ultrasound of the left lower limb. Also, a 50% intraluminal constriction of the left iliac vein in the venography image was considered as IVCS. Comparison of IVCS prevalence was made between the DVT group and the non-DVT group. Patients in the DVT group were further divided into the DVT+/IVCS+ group and the DVT+/IVCS- group to evaluate the influence IVCS may have on the treatment of DVT. RESULTS There were 204 patients in the DVT group and 220 patients in the non-DVT group. No statistically significant differences were found regarding the mean age, sex distribution, fracture type, and accompanying risk factors between the two groups. A total of 70 patients (34.3%) were diagnosed with IVCS in the DVT group, while confirmed IVCS was found in 52 patients (23.6%) in the non-DVT group (P=0.02). Postoperatively, the incidence of symptomatic DVT in the DVT+/IVCS+ group and the DVT+/IVCS- group was 30.0% and 11.9%, respectively (P=0.002). CONCLUSIONS IVCS is an under-recognized risk factor for left-sided DVT in hip fracture patients. What's more, anticoagulation alone is insufficient for the treatment of DVT when it is complicated with IVCS. More aggressive measures have to be taken to achieve a favorable outcome.

Nutcracker syndrome: A rare cause of left flank pain that can also manifest as unexplained pelvic pain

Nutcracker syndrome (NCS) is symptomatic unilateral renal venous hypertension due to compression of the left renal vein between the superior mesenteric artery and aorta (anterior NCS) or between the aorta and spine (posterior NCS). The left ovarian or spermatic vein empties into the left renal vein and is an additional site of venostasis in about half the cases of NCS. The presenting symptom of NCS in about half the cases is atypical left flank pain suggesting a disorder of the lower ribs or thoracolumbar spinal junction, particularly as the pain worsens with standing and increased lumbar lordosis. NCS may be suggested by any combination of the following manifestations: hematuria, which is often only microscopic; orthostatic proteinuria; varicocele and infertility; dyspareunia and other gynecological symptoms; varicose veins in the pelvis, buttocks, or upper thighs; orthostatic hypotension and fatigue; and abdominal pain. Narrowing of the left renal vein on imaging studies is required but far from sufficient to establish the diagnosis. Several converging clinical findings and a marked pressure gradient between the left renal vein and inferior vena cava must be present also. Urological procedures and vascular surgery are being superseded by endovascular stenting with or without simultaneous treatment of the acquired gonadal vein insufficiency by embolization.

Left ovarian vein dilation or pelvic congestion syndrome secondary to abdominal aortic dissection: incidental findings on CT angiography

BACKGROUND

In the study, we describe eight cases in which pelvic congestion syndrome (PCS) was a direct complication of abdominal aortic dissection (AD).

METHODS

We recorded computed tomographic (CT) details of the AD and PCS. The patterns of pelvic varices and reflux were identified as well.

RESULTS

All eight had abdominal AD (diameter, 23.44-33.98 mm). The compressed left renal vein revealed stenosis in situ (diameter, 1.17-2.69 mm). CT also revealed dilation of left ovarian vein with left pelvic varices in all cases.

CONCLUSIONS

Some cases of PCS and dilation of the left ovarian vein can be directly correlated with abdominal AD.