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Superficial thrombophlebitis of pubic collateral veins after gynecological surgery: a case report
European Journal of Obstetrics & Gynecology and Reproductive Biology 86 (1999) 207–209
Case report
Superficial thrombophlebitis of pubic collateral veins after gynecological surgery: a case report a, a b a Ignace F.J. Tielliu *, Marianne G.R. De Maeseneer , Wiebren A.A. Tjalma , Paul E.Y. Van Schil , a Erik J.M. Eyskens a
University Hospital of Antwerp, Department of Surgery, Division of Vascular and Thoracic Surgery, Wilrijkstraat 10, 2650 Edegem, Belgium b University Hospital of Antwerp, Department of Gynecology, Wilrijkstraat 10, 2650 Edegem, Belgium Received 30 December 1998; received in revised form 9 February 1999; accepted 19 March 1999
Abstract Superficial pubic collateral veins are the result of iliac vein occlusion due to previous thrombosis. They can be accompanied by deep crossover veins. We present a patient with thrombophlebitis of superficial pubic collateral veins after a hysteroscopic procedure. 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Deep venous thrombosis; Iliac vein occlusion; Crossover collateral veins; Pelvic surgery; Suprapubic varicosities
1. Case A 38-year-old woman was admitted to the hospital because of vascular complications 6 weeks after a hysteroscopic procedure. Her medical history started at the age of 2, when she underwent an appendectomy. It was a complicated procedure, resulting in a long hospital stay. She first presented at the out-patient clinic 5 years ago with varicose veins of the right leg and groin, extending to the suprapubic area. Colour-coded duplex scan revealed an occlusion of the right iliac vein. This finding was confirmed on ascending contrast phlebography. An extensive collateral circulation had developed via three pathways: superficial suprapubic veins, deep visceral veins and a presacral venous plexus (Fig. 1a). Waist-length elastic stockings were prescribed and sclerotherapy of varicose veins was performed regularly. The recent history of this woman started 6 weeks before admission when she underwent a hysteroscopic resection of a leiomyoma of the uterus. This resection was laborious and the patient remained immobilized during 2 h. She *Corresponding author. Tel.: 132-3-821-3148; fax: 132-3-825-1308.
received subcutaneous injections of low-molecular-weight heparin (nadroparin) on the morning of the operation (0.3 ml) and postoperatively (0.3 ml once a day for 3 days and 0.6 ml once a day for 2 weeks). During this period she wore thigh-length elastic stockings. Six weeks after the hysteroscopy she presented with a painful suprapubic swelling and oedema of the right leg. Clinical examination revealed superficial thrombophlebitis of the pubic collateral veins. Colour-coded duplex scan showed thrombosis of the crossover pubic collateral veins, from the right groin to the left suprapubic area. The left iliac and right common femoral vein were patent. The right iliac vein remained occluded. An ascending phlebography confirmed this change in collateral circulation (Fig. 1b). Two collateral pathways could be distinguished: one via the perivesical, periuterine and periovarial veins to the left internal iliac vein, and one via the presacral plexus. The third pathway via the superficial pubic collateral veins could not be opacified anymore. Laboratory screening revealed no underlying coagulation disorders. The patient was treated with nadroparin (0.6 ml twice a day for 10 days, followed by 0.6 ml once a day for 1 month) and naproxen. The symptoms of thrombophlebitis
0301-2115 / 99 / $ – see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115( 99 )00076-7
208
I.F. J. Tielliu et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 86 (1999) 207 – 209
Fig. 1. (a) Phlebography 5 years before admission, showing occlusion of the right iliac vein. Extensive collateral circulation: superficial suprapubic, deep visceral and presacral collateral pathways; (b) digital substraction phlebography showing occlusion of the right iliac vein and of the pubic crossover collateral veins.
I.F. J. Tielliu et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 86 (1999) 207 – 209
of the collateral pubic veins gradually disappeared. Further recovery was uneventful.
2. Discussion The patient initially presented with extensive superficial pubic collateral veins. Although crossover pubic collateral veins are a very rare phenomenon, they are a telltale clinical sign of iliac vein occlusion, most likely secondary to a previous deep venous thrombosis [1]. They present as varicosities in the suprapubic region. Recent population surveys suggest that the incidence of deep venous thrombosis is between 50 and 150 cases per 100 000 of the population per year [2]. Prolonged immobilization, especially during and after surgery, is one of the main risk factors for developing thrombosis. After gynecological surgery the incidence of thrombosis varies between 14% and 29% [3]. Occlusion of the iliac vein will lead to formation of a superficial and deep collateral circulation. Superficial collateral veins develop via enlarged external pudendal, superficial epigastric and superficial circumflex iliac veins. These are visible and palpable. The deep collateral circulation is installed via inferior epigastric, obturator and parametrial veins, and via the perivesical and sacral plexus. These are visualised on phlebography [1,4]. Our patient developed thrombosis of superficial collateral veins. This causes symptoms of superficial thrombophlebitis with swollen, hard and painful pubic veins. These varicose collateral veins are peculiarly prone to thrombosis, as they are thin-walled and vulnerable. Immobilization over a prolonged period gives almost complete stagnation of venous flow, possibly leading to thrombus formation in the varicose collateral pubic veins. In the presence of occlusion of the iliac vein, the venous drainage of the leg fully depends on the superficial and deep collateral veins. When additional thrombosis of these collaterals occurs, all the symptoms of leg thrombosis may arise. It is important to recognize patients with chronic iliac vein occlusion after previous deep venous thrombosis. A history of unilateral swelling of the leg, caused by prolonged bedrest, pregnancy, malignant disease, pelvic surgery or trauma is suspicious [5]. Clinical examination
209
may reveal post-thrombotic changes in the leg, suggesting venous hypertension. In such case the patient should be examined for telltale pubic varicosities. Duplex sonography and contrast phlebography will provide additional illustration of collateral venous pathways. If a gynecological operation has to be performed in a patient with chronic iliac vein occlusion, care should be taken to avoid damage to the collateral veins crossing the pelvis. Damaging the deep collateral veins may cause massive peroperative bleeding. In addition, peroperative surgical manipulation and prolonged immobilization in leg supports may lead to thrombosis of the deep or superficial collateral venous circulation. For this reason a ‘hanging stirrup’ may be preferred in patients at risk for thrombotic complications. Interruption of one or more of the collateral pathways may result in deterioration of the preexisting post-thrombotic syndrome in the leg. Postoperative deep venous thrombosis of the leg or thrombophlebitis of the superficial crossover veins should further be avoided by adequate prophylactic measures. Recent evidence suggested that the risk of proximal deep vein thrombosis continued for at least 3 weeks after surgery [6]. Therefore it seems advisable to continue prophylaxis with anti-thromboembolism stockings and with low-molecular-weight heparin for at least 3 weeks in patients at risk.
References [1] Tibbs DJ. Obstructed venous outlet syndrome: iliac vein occlusion. In: Varicose veins and related disorders, Oxford: ButterworthHeinemann, 1992, pp. 180–94. [2] Carter CJ, Anderson FA, Wheeler HB. Epidemiology and pathophysiology of venous thromboembolism. In: Venous thromboembolisms, New York: Futura, 1996, Chapter 1. [3] Browse NL, Burnand KG, Irvine AT, Wilson NM. Deep vein thrombosis: pathology. In: Diseases of the veins, London: Arnold, 1999, pp. 249–89. [4] Lea Thomas M, Fletcher EW, Cockett FB, Negus D. Venous collaterals in external and common iliac vein obstruction. Clin Radiol 1967;18:403–11. ¨ B. Etiological spectrum in acute [5] Plate G, Einarsson E, Eklof iliofemoral venous thrombosis. Int Angiol 1986;5:59–64. [6] Planes A, Vochelle N, Darmon JY et al. Risk of deep venous thrombosis after hospital discharge in patients having undergone total hip replacement. Double blind randomized trial of enoxaparin versus placebo. Lancet 1996;348:224–8.
Case report
Superficial thrombophlebitis of pubic collateral veins after gynecological surgery: a case report a, a b a Ignace F.J. Tielliu *, Marianne G.R. De Maeseneer , Wiebren A.A. Tjalma , Paul E.Y. Van Schil , a Erik J.M. Eyskens a
University Hospital of Antwerp, Department of Surgery, Division of Vascular and Thoracic Surgery, Wilrijkstraat 10, 2650 Edegem, Belgium b University Hospital of Antwerp, Department of Gynecology, Wilrijkstraat 10, 2650 Edegem, Belgium Received 30 December 1998; received in revised form 9 February 1999; accepted 19 March 1999
Abstract Superficial pubic collateral veins are the result of iliac vein occlusion due to previous thrombosis. They can be accompanied by deep crossover veins. We present a patient with thrombophlebitis of superficial pubic collateral veins after a hysteroscopic procedure. 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Deep venous thrombosis; Iliac vein occlusion; Crossover collateral veins; Pelvic surgery; Suprapubic varicosities
1. Case A 38-year-old woman was admitted to the hospital because of vascular complications 6 weeks after a hysteroscopic procedure. Her medical history started at the age of 2, when she underwent an appendectomy. It was a complicated procedure, resulting in a long hospital stay. She first presented at the out-patient clinic 5 years ago with varicose veins of the right leg and groin, extending to the suprapubic area. Colour-coded duplex scan revealed an occlusion of the right iliac vein. This finding was confirmed on ascending contrast phlebography. An extensive collateral circulation had developed via three pathways: superficial suprapubic veins, deep visceral veins and a presacral venous plexus (Fig. 1a). Waist-length elastic stockings were prescribed and sclerotherapy of varicose veins was performed regularly. The recent history of this woman started 6 weeks before admission when she underwent a hysteroscopic resection of a leiomyoma of the uterus. This resection was laborious and the patient remained immobilized during 2 h. She *Corresponding author. Tel.: 132-3-821-3148; fax: 132-3-825-1308.
received subcutaneous injections of low-molecular-weight heparin (nadroparin) on the morning of the operation (0.3 ml) and postoperatively (0.3 ml once a day for 3 days and 0.6 ml once a day for 2 weeks). During this period she wore thigh-length elastic stockings. Six weeks after the hysteroscopy she presented with a painful suprapubic swelling and oedema of the right leg. Clinical examination revealed superficial thrombophlebitis of the pubic collateral veins. Colour-coded duplex scan showed thrombosis of the crossover pubic collateral veins, from the right groin to the left suprapubic area. The left iliac and right common femoral vein were patent. The right iliac vein remained occluded. An ascending phlebography confirmed this change in collateral circulation (Fig. 1b). Two collateral pathways could be distinguished: one via the perivesical, periuterine and periovarial veins to the left internal iliac vein, and one via the presacral plexus. The third pathway via the superficial pubic collateral veins could not be opacified anymore. Laboratory screening revealed no underlying coagulation disorders. The patient was treated with nadroparin (0.6 ml twice a day for 10 days, followed by 0.6 ml once a day for 1 month) and naproxen. The symptoms of thrombophlebitis
0301-2115 / 99 / $ – see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115( 99 )00076-7
208
I.F. J. Tielliu et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 86 (1999) 207 – 209
Fig. 1. (a) Phlebography 5 years before admission, showing occlusion of the right iliac vein. Extensive collateral circulation: superficial suprapubic, deep visceral and presacral collateral pathways; (b) digital substraction phlebography showing occlusion of the right iliac vein and of the pubic crossover collateral veins.
I.F. J. Tielliu et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 86 (1999) 207 – 209
of the collateral pubic veins gradually disappeared. Further recovery was uneventful.
2. Discussion The patient initially presented with extensive superficial pubic collateral veins. Although crossover pubic collateral veins are a very rare phenomenon, they are a telltale clinical sign of iliac vein occlusion, most likely secondary to a previous deep venous thrombosis [1]. They present as varicosities in the suprapubic region. Recent population surveys suggest that the incidence of deep venous thrombosis is between 50 and 150 cases per 100 000 of the population per year [2]. Prolonged immobilization, especially during and after surgery, is one of the main risk factors for developing thrombosis. After gynecological surgery the incidence of thrombosis varies between 14% and 29% [3]. Occlusion of the iliac vein will lead to formation of a superficial and deep collateral circulation. Superficial collateral veins develop via enlarged external pudendal, superficial epigastric and superficial circumflex iliac veins. These are visible and palpable. The deep collateral circulation is installed via inferior epigastric, obturator and parametrial veins, and via the perivesical and sacral plexus. These are visualised on phlebography [1,4]. Our patient developed thrombosis of superficial collateral veins. This causes symptoms of superficial thrombophlebitis with swollen, hard and painful pubic veins. These varicose collateral veins are peculiarly prone to thrombosis, as they are thin-walled and vulnerable. Immobilization over a prolonged period gives almost complete stagnation of venous flow, possibly leading to thrombus formation in the varicose collateral pubic veins. In the presence of occlusion of the iliac vein, the venous drainage of the leg fully depends on the superficial and deep collateral veins. When additional thrombosis of these collaterals occurs, all the symptoms of leg thrombosis may arise. It is important to recognize patients with chronic iliac vein occlusion after previous deep venous thrombosis. A history of unilateral swelling of the leg, caused by prolonged bedrest, pregnancy, malignant disease, pelvic surgery or trauma is suspicious [5]. Clinical examination
209
may reveal post-thrombotic changes in the leg, suggesting venous hypertension. In such case the patient should be examined for telltale pubic varicosities. Duplex sonography and contrast phlebography will provide additional illustration of collateral venous pathways. If a gynecological operation has to be performed in a patient with chronic iliac vein occlusion, care should be taken to avoid damage to the collateral veins crossing the pelvis. Damaging the deep collateral veins may cause massive peroperative bleeding. In addition, peroperative surgical manipulation and prolonged immobilization in leg supports may lead to thrombosis of the deep or superficial collateral venous circulation. For this reason a ‘hanging stirrup’ may be preferred in patients at risk for thrombotic complications. Interruption of one or more of the collateral pathways may result in deterioration of the preexisting post-thrombotic syndrome in the leg. Postoperative deep venous thrombosis of the leg or thrombophlebitis of the superficial crossover veins should further be avoided by adequate prophylactic measures. Recent evidence suggested that the risk of proximal deep vein thrombosis continued for at least 3 weeks after surgery [6]. Therefore it seems advisable to continue prophylaxis with anti-thromboembolism stockings and with low-molecular-weight heparin for at least 3 weeks in patients at risk.
References [1] Tibbs DJ. Obstructed venous outlet syndrome: iliac vein occlusion. In: Varicose veins and related disorders, Oxford: ButterworthHeinemann, 1992, pp. 180–94. [2] Carter CJ, Anderson FA, Wheeler HB. Epidemiology and pathophysiology of venous thromboembolism. In: Venous thromboembolisms, New York: Futura, 1996, Chapter 1. [3] Browse NL, Burnand KG, Irvine AT, Wilson NM. Deep vein thrombosis: pathology. In: Diseases of the veins, London: Arnold, 1999, pp. 249–89. [4] Lea Thomas M, Fletcher EW, Cockett FB, Negus D. Venous collaterals in external and common iliac vein obstruction. Clin Radiol 1967;18:403–11. ¨ B. Etiological spectrum in acute [5] Plate G, Einarsson E, Eklof iliofemoral venous thrombosis. Int Angiol 1986;5:59–64. [6] Planes A, Vochelle N, Darmon JY et al. Risk of deep venous thrombosis after hospital discharge in patients having undergone total hip replacement. Double blind randomized trial of enoxaparin versus placebo. Lancet 1996;348:224–8.