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Case report: Pelvic pain syndrome-successful treatment of a case by ovarian vein embolization
ClinicalRadiology(1993) 47, 429-431
Case Report: Pelvic Pain Syndrome- Successful Treatment of a Case by Ovarian Vein Embolization R. D. E D W A R D S ,
I. R. R O B E R T S O N ,
A. B. M a c L E A N *
a n d A. P. H E M I N G W A Y t
Departments of Radiology and *Gynaecology, Western Infirmary, Glasgow, and ~fDepartment of Radiology, Hammersmith Hospital, London Pelvic pain syndrome, without an apparent organic cause, is a common gynaecological complaint. Investigations, including laparoscopy are frequently negative but ovarian venography has demonstrated that pelvic varices are a consistent finding in these patients. The aetiology of pelvic varices has been the subject of debate, but it has recently been suggested that the primary problem is venous reflux in dilated, incompetent ovarian veins. Surgical ligation of the ovarian veins has been used effectively in small series of patients with this condition. We report a patient with the clinical and radiological features of this syndrome in which treatment by bilateral ovarian venous embolization produced prolonged symptomatic relief. E d w a r d s , R . D . , R o b e r t s o n , I . R . , M a c L e a n , A . B . & H e m i n g w a y , A . P . (1993). Clinical
Radiology
47, 4 2 9 - 4 3 1 . C a s e R e p o r t : Pelvic P a i n S y n d r o m e Case by Ovarian Vein Embolization
Pelvic c o n g e s t i o n o r p e l v i c p a i n s y n d r o m e ( P P S ) is a common gynaecological complaint which presents a difficult d i a g n o s t i c a n d t h e r a p e u t i c p r o b l e m . P e l v i c p a i n is t h e c o m m o n e s t r e a s o n f o r l a p a r o s c o p y in the U K , b u t in 7 5 % o f cases, n o c a u s e is f o u n d [1]. V a r i o u s i m a g i n g m o d a l i t i e s h a v e b e e n e m p l o y e d in t h e d i a g n o s i s o f this c o n d i t i o n , b u t selective o v a r i a n v e n o g r a phy provides the most anatomical information. Although a n a s s o c i a t i o n b e t w e e n pelvic v a r i c e s a n d P P S h a s b e e n k n o w n f o r m a n y y e a r s [2], u n c e r t a i n t y r e g a r d i n g its aetiology has resulted in different therapeutic a p p r o a c h e s , p r o d u c i n g v a r i a b l e results. H o b b s [3] a n d L e c h t e r [4] h a v e i n d e p e n d e n t l y c o n c l u d e d t h a t t h e p r i m a r y p r o b l e m is r e t r o g r a d e f l o w in i n c o m p e t e n t o v a r i a n v e i n s a n d h a v e successfully t r e a t e d s m a l l series o f p a t i e n t s by o v a r i a n v e n o u s l i g a t i o n . W e r e p o r t a c a s e in w h i c h o v a r i a n v e n o u s e m b o l i z a t i o n w a s u s e d f o r t h e t r e a t m e n t o f this c o n d i t i o n . W e a r e n o t a w a r e o f a p r e v i o u s r e p o r t o f this f o r m o f t r e a t m e n t . C A S E REPORT A 40-year-old woman was referred to the gynaecology clinic with a 2 year history of chronic pelvic pain, dyspareunia and dysmenorrhoea. Her symptoms were aggravated by prolonged standing and were worse during menstruation. She was para 2+0 and following her last pregnancy had undergone laparoscopic sterilization. There was no previous history of pelvic inflammatory disease. Transabdominal ultrasound examination (US) was normal and at laparoscopy, the only abnormality seen was a prominent vein in the broad ligament. In view of the persistent nature and severity of her symptoms, she was referred for selective ovarian venography. Following selective catheterization, the patient was placed in the semi-erect position and 20 ml of Iopamido1300 mg/ml was injected to opacify the ovarian venous plexus. The proximal portion of the right and left ovarian veins measured 7-8 mm in diameter (normal < 5 mm) and no competent valves were demonstrated. Moderate congestion of the ovarian venous plexus was seen bilaterally with retrograde filling of the internal iliac system (Fig. 1). This combination of features is consistent with the pelvic congestion syndrome. No vulval or thigh varicosities were identified. Correspondence to: Dr R. D. Edwards, Department of Diagnostic Radiology, Hammersmith Hospital, Du Cane Road, London W 12 0HS.
Successful Treatment of a
She remained persistently symptomatic and after a period of 9 months
was referred for bilateral ovarian vein embolization. Surgical ligation was considered hazardous in view of her obesity. Using the right femoral venous route, the left ovarian vein was catheterized with a 7 F 'spermatic vein' catheter (Cordis Ltd). A 0.035 in. Rosen wire was advanced distally and the catheter was exchanged for a 7 F Headhunter 1 embolotherapy catheter (Cook Ltd). The Rosen wire was replaced by a 0.18 in Nitinol wire (Ultraselect, Microvena Corp.), which enabled catheterization of the two main venous tributaries, while allowing injection of contrast media. The tributaries were embolized with 3 mm diameter steel coils (Cook Ltd) and 5 mm coils were placed above their confluence. Our initial aim was to perform distal embolization only, and therefore at this point, embolization of the right ovarian vein was performed. The right ovarian vein was catheterized with a 7 F Sidewinder III catheter and a more distal position achieved by advancing a T3 coaxial catheter (Cook Ltd) over the 0.018 in guide wire. On this side two venous tributaries were present and a plexiform venous pattern was seen distally. Embolization was performed in a similar manner to the left side, with 0.025 in calibre steel coils. The middle section of the right ovarian vein was duplicated and towards the end of the procedure clot was visible within one branch. Proximal embolization was therefore performed with larger diameter coils (Fig. 2). Left ovarian venography was then repeated and a column of thrombus was demonstrated within the vessel. In addition, a small vein communicating with the inferior mesenteric vein (IMV) was opacified (Fig. 3), probably as a result of increased peripheral venous resistance following distal embolization. A further coil was placed at this level and although a small amount of thrombus remained present proximally, further embolization was not attempted in view of the proximity to the left renal vein. The patient tolerated the procedure well and at discharge the following day was free from pain. At 6 months follow-up she has remained asymptomatic, her menstrual cycle is now regular and she no longer complains of dysmenorrhoea. Repeat ovarian venography performed 1 month after embolization demonstrated complete occlusion of both ovarian veins and internal iliac venography showed no evidence of reflux into the ovarian venous plexus. DISCUSSION Pelvic p a i n s y n d r o m e (PPS), w i t h o u t e v i d e n c e o f pelvic i n f l a m m a t i o n o r o t h e r o b v i o u s p a t h o l o g y , is a c o m m o n g y n a e c o l o g i c a l p r o b l e m . T h e a s s o c i a t i o n o f pelvic v a r i cosities w i t h p e l v i c c o n g e s t i o n o r P P S has b e e n r e c o g n i z e d for m a n y y e a r s [2]. A s s e s s m e n t o f the d e g r e e o f p e l v i c
430
CLINICAL RADIOLOGY
(a)
Fig. 2 - Thrombus is seen in the duplicated section o f the right ovarian vein. Coils have been placed proximal to this. A small amount of extravasation is seen due to catheter manipulation.
(b) Fig. 1 - Right (a) and left (b) ovarian venograms showing dilated ovarian veins and tortuous pelvic varices. Reflux occurs into both internal iliac veins.
congestion using a venographic scoring system has shown that patients with PPS have significantly higher scores than patients with other pelvic pathology or controls [5]. The clinical features of PPS include pelvic pain of variable intensity which is exacerbated by postural changes and walking. Congestive dysmenorrhoea, dyspareunia, post-coital ache and urinary symptoms are common features of PPS. This condition affects women of reproductive age and is more common in the mulfiparous patient [6]. Vulval varices and atypical varicosities of the thigh or buttock may be part of the clinical presentation and are caused by reflux from the dilated pelvic veins [4]. The various imaging techniques employed in the diagnosis of PPS have been recently reviewed [7] and include ultrasonography, vulval varicography, transuterine venography and selective ovarian venography.
Fig. 3 - Repeat venogram shows thrombus within the proximal, left ovarian vein. A small vein (arrowhead) communicating with the inferior mesenteric vein (arrow) is opacified.
Selective ovarian venography performed in the semierect position provides more anatomical information than the other techniques and can also demonstrate vulval and thigh varicosities. The venographic features of pelvic congestion include: an ovarian venous diameter of 10 mm at its widest point, uterine venous engorgement, moderate or severe congestion of the ovarian plexus, filling of veins across the midline or filling of vulval and/or thigh varices. Any one of these features is suggestive of PPS and the presence of several strongly supports the diagnosis [7]. Refinements in ultrasound techniques include colour Doppler imaging (CDI), utilizing specific anatomical windows [8] or the transvaginal approach [9]. The importance of imaging in the erect position should be stressed as filling of the pelvic veins is inadequate when the patient is supine. Laparoscopy in the Trendelenburg
PELVIC PAIN SYNDROME position favours venous drainage from the pelvis and the degree o f pelvic congestion is therefore underestimated. It has been suggested recently that the primary problem is that o f venous reflux in incompetent, dilated ovarian veins [3,4]. Anatomical studies have shown that ovarian venous valves are absent in 15% o f w o m e n on the left side and in 6% on the right [10]. Valvular incompetence is c o m m o n and m a y occur on either side, in 35-43% [11]. The capacity o f ovarian veins m a y increase by 60 times during pregnancy and changes m a y persist for up to 6 m o n t h s after delivery [12]. This m a y explain why PPS is m o r e c o m m o n in multiparous women. O n the basis o f these findings, surgical ligation and resection o f the dilated ovarian veins has been performed in small series o f patients. This appears to be a relatively simple, safe procedure which provides an effective cure for PPS [3,4]. E n c o u r a g e d by this approach, we decided to treat our patient in an analogous fashion by transcatheter embolization. Certain similarities exist with the male varicocoele for which transcatheter embolization is an established treatment [13]. However, several differences in ovarian a n a t o m y necessitate a modified embolization technique. C o m m u n i c a t i o n s m a y exist between the left ovarian vein
431
and the inferior mesenteric, splenic vein and ureteric veins [3]. F o r this reason, the use o f liquid sclerosants m a y be hazardous and should be avoided. The venous calibre in PPS is generally greater than that seen in the male varicocoele and distal venous blockade alone m a y lead to significant a m o u n t s o f t h r o m b u s in the proximal vein, as was seen in this case. The potential complication o f p u l m o n a r y embolism should be avoided by embolization o f the proximal vessel also (Fig. 4). Steel coils are available in a variety o f sizes, but large diameter vessels m a y require coaxial placement o f several coils to achieve effective occlusion. In this situation, a single detachable balloon m a y be more appropriate, but the choice o f embolic agent will depend on the individual venous anatomy. Coaxial catheter systems have extended the range o f therapeutic embolization and facilitate access to the ovarian venous tributaries. Platinum microcoils are m o r e radiopaque than steel coils o f similar calibre, and their enhanced visibility is particularly helpful in the obese patient. The effect o f venous embolization on ovarian function is u n k n o w n , but ovarian venous drainage is unlikely to be impaired, due to c o m m u n i c a t i o n s with the uterine plexus and hence the internal iliac vein. In our case, the patient's menstrual s y m p t o m s improved and her cycle became regular. Clearly, large series are necessary to determine the efficacy o f this procedure.
REFERENCES
I Beard RW, Reginald PW, Pearce S. Pelvic pain in women. British Medical Journal 1986;293:1160-1162. 2 Topolanski-Sierra R. Pelvic phlebography. American Journal of Obstetrics and Gynaecology 1958;76:44~45. 3 Hobbs JT. The pelvic congestion syndrome. British Journal of Hospital Medicine 1990;43:200-206. 4 Lechter A, Alvarez A. Pelvic varices and gonadal veins. In: Negus D & Jantet G, eds. Phlebology '85. London: John Libbey, 1986:225 228. 5 Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984;ii:946-949. 6 Beard RW, Reginald PW, Wadsworth J. Clinical features of women with chronic lower abdominal pain and pelvic congestion. British Journal of Obstetrics and Gynaecology 1988;95:153-161. 7 Kennedy A, Hemingway A. Radiology of ovarian varices. British Journal of Hospital Medicine 1990;44:38 43. 8 Richardson GD, Beckwith TC, Sheldon M. Ultrasound windows to abdominal and pelvic veins. Phlebology 1991;6:111-125. 9 Giacchetto C, Cotroneo GB, Marincolo F, Camisulu F, Caruso G, Catizone F. Ovarian varicocele: ultrasound and phlebographic evaluation. Journal o f Clinical Ultrasound 1990;18:551-555. 10 Ahlberg NE, Bartley O, Chidekel N. Circumference of the left gonadal vein. An anatomical and statistical study. Acta Radiologica 1965;3:503-512.
Fig. 4 - Abdominal radiograph shows sites of proximal and distal embolization (arrows). The smaller calibre steel coils are obscured by the bony pelvis.
11 Ahlberg NE, Bartley O, Chidekel N. Right and left gonadal veins. An anatomical and statistical study. Acta Radiologica 1966;4:593 601. 12 Hodgkinson CP. Physiology of the ovarian veins during pregnancy. Obstetrics and Gynaecology 1953;1:26-37. 13 White RI, Kaufman SL, Barth KH, Kadir S, Smyth JW, Walsh PC. Occlusion of varicoceles with detachable balloons. Radiology 1981;139:327-334.
Case Report: Pelvic Pain Syndrome- Successful Treatment of a Case by Ovarian Vein Embolization R. D. E D W A R D S ,
I. R. R O B E R T S O N ,
A. B. M a c L E A N *
a n d A. P. H E M I N G W A Y t
Departments of Radiology and *Gynaecology, Western Infirmary, Glasgow, and ~fDepartment of Radiology, Hammersmith Hospital, London Pelvic pain syndrome, without an apparent organic cause, is a common gynaecological complaint. Investigations, including laparoscopy are frequently negative but ovarian venography has demonstrated that pelvic varices are a consistent finding in these patients. The aetiology of pelvic varices has been the subject of debate, but it has recently been suggested that the primary problem is venous reflux in dilated, incompetent ovarian veins. Surgical ligation of the ovarian veins has been used effectively in small series of patients with this condition. We report a patient with the clinical and radiological features of this syndrome in which treatment by bilateral ovarian venous embolization produced prolonged symptomatic relief. E d w a r d s , R . D . , R o b e r t s o n , I . R . , M a c L e a n , A . B . & H e m i n g w a y , A . P . (1993). Clinical
Radiology
47, 4 2 9 - 4 3 1 . C a s e R e p o r t : Pelvic P a i n S y n d r o m e Case by Ovarian Vein Embolization
Pelvic c o n g e s t i o n o r p e l v i c p a i n s y n d r o m e ( P P S ) is a common gynaecological complaint which presents a difficult d i a g n o s t i c a n d t h e r a p e u t i c p r o b l e m . P e l v i c p a i n is t h e c o m m o n e s t r e a s o n f o r l a p a r o s c o p y in the U K , b u t in 7 5 % o f cases, n o c a u s e is f o u n d [1]. V a r i o u s i m a g i n g m o d a l i t i e s h a v e b e e n e m p l o y e d in t h e d i a g n o s i s o f this c o n d i t i o n , b u t selective o v a r i a n v e n o g r a phy provides the most anatomical information. Although a n a s s o c i a t i o n b e t w e e n pelvic v a r i c e s a n d P P S h a s b e e n k n o w n f o r m a n y y e a r s [2], u n c e r t a i n t y r e g a r d i n g its aetiology has resulted in different therapeutic a p p r o a c h e s , p r o d u c i n g v a r i a b l e results. H o b b s [3] a n d L e c h t e r [4] h a v e i n d e p e n d e n t l y c o n c l u d e d t h a t t h e p r i m a r y p r o b l e m is r e t r o g r a d e f l o w in i n c o m p e t e n t o v a r i a n v e i n s a n d h a v e successfully t r e a t e d s m a l l series o f p a t i e n t s by o v a r i a n v e n o u s l i g a t i o n . W e r e p o r t a c a s e in w h i c h o v a r i a n v e n o u s e m b o l i z a t i o n w a s u s e d f o r t h e t r e a t m e n t o f this c o n d i t i o n . W e a r e n o t a w a r e o f a p r e v i o u s r e p o r t o f this f o r m o f t r e a t m e n t . C A S E REPORT A 40-year-old woman was referred to the gynaecology clinic with a 2 year history of chronic pelvic pain, dyspareunia and dysmenorrhoea. Her symptoms were aggravated by prolonged standing and were worse during menstruation. She was para 2+0 and following her last pregnancy had undergone laparoscopic sterilization. There was no previous history of pelvic inflammatory disease. Transabdominal ultrasound examination (US) was normal and at laparoscopy, the only abnormality seen was a prominent vein in the broad ligament. In view of the persistent nature and severity of her symptoms, she was referred for selective ovarian venography. Following selective catheterization, the patient was placed in the semi-erect position and 20 ml of Iopamido1300 mg/ml was injected to opacify the ovarian venous plexus. The proximal portion of the right and left ovarian veins measured 7-8 mm in diameter (normal < 5 mm) and no competent valves were demonstrated. Moderate congestion of the ovarian venous plexus was seen bilaterally with retrograde filling of the internal iliac system (Fig. 1). This combination of features is consistent with the pelvic congestion syndrome. No vulval or thigh varicosities were identified. Correspondence to: Dr R. D. Edwards, Department of Diagnostic Radiology, Hammersmith Hospital, Du Cane Road, London W 12 0HS.
Successful Treatment of a
She remained persistently symptomatic and after a period of 9 months
was referred for bilateral ovarian vein embolization. Surgical ligation was considered hazardous in view of her obesity. Using the right femoral venous route, the left ovarian vein was catheterized with a 7 F 'spermatic vein' catheter (Cordis Ltd). A 0.035 in. Rosen wire was advanced distally and the catheter was exchanged for a 7 F Headhunter 1 embolotherapy catheter (Cook Ltd). The Rosen wire was replaced by a 0.18 in Nitinol wire (Ultraselect, Microvena Corp.), which enabled catheterization of the two main venous tributaries, while allowing injection of contrast media. The tributaries were embolized with 3 mm diameter steel coils (Cook Ltd) and 5 mm coils were placed above their confluence. Our initial aim was to perform distal embolization only, and therefore at this point, embolization of the right ovarian vein was performed. The right ovarian vein was catheterized with a 7 F Sidewinder III catheter and a more distal position achieved by advancing a T3 coaxial catheter (Cook Ltd) over the 0.018 in guide wire. On this side two venous tributaries were present and a plexiform venous pattern was seen distally. Embolization was performed in a similar manner to the left side, with 0.025 in calibre steel coils. The middle section of the right ovarian vein was duplicated and towards the end of the procedure clot was visible within one branch. Proximal embolization was therefore performed with larger diameter coils (Fig. 2). Left ovarian venography was then repeated and a column of thrombus was demonstrated within the vessel. In addition, a small vein communicating with the inferior mesenteric vein (IMV) was opacified (Fig. 3), probably as a result of increased peripheral venous resistance following distal embolization. A further coil was placed at this level and although a small amount of thrombus remained present proximally, further embolization was not attempted in view of the proximity to the left renal vein. The patient tolerated the procedure well and at discharge the following day was free from pain. At 6 months follow-up she has remained asymptomatic, her menstrual cycle is now regular and she no longer complains of dysmenorrhoea. Repeat ovarian venography performed 1 month after embolization demonstrated complete occlusion of both ovarian veins and internal iliac venography showed no evidence of reflux into the ovarian venous plexus. DISCUSSION Pelvic p a i n s y n d r o m e (PPS), w i t h o u t e v i d e n c e o f pelvic i n f l a m m a t i o n o r o t h e r o b v i o u s p a t h o l o g y , is a c o m m o n g y n a e c o l o g i c a l p r o b l e m . T h e a s s o c i a t i o n o f pelvic v a r i cosities w i t h p e l v i c c o n g e s t i o n o r P P S has b e e n r e c o g n i z e d for m a n y y e a r s [2]. A s s e s s m e n t o f the d e g r e e o f p e l v i c
430
CLINICAL RADIOLOGY
(a)
Fig. 2 - Thrombus is seen in the duplicated section o f the right ovarian vein. Coils have been placed proximal to this. A small amount of extravasation is seen due to catheter manipulation.
(b) Fig. 1 - Right (a) and left (b) ovarian venograms showing dilated ovarian veins and tortuous pelvic varices. Reflux occurs into both internal iliac veins.
congestion using a venographic scoring system has shown that patients with PPS have significantly higher scores than patients with other pelvic pathology or controls [5]. The clinical features of PPS include pelvic pain of variable intensity which is exacerbated by postural changes and walking. Congestive dysmenorrhoea, dyspareunia, post-coital ache and urinary symptoms are common features of PPS. This condition affects women of reproductive age and is more common in the mulfiparous patient [6]. Vulval varices and atypical varicosities of the thigh or buttock may be part of the clinical presentation and are caused by reflux from the dilated pelvic veins [4]. The various imaging techniques employed in the diagnosis of PPS have been recently reviewed [7] and include ultrasonography, vulval varicography, transuterine venography and selective ovarian venography.
Fig. 3 - Repeat venogram shows thrombus within the proximal, left ovarian vein. A small vein (arrowhead) communicating with the inferior mesenteric vein (arrow) is opacified.
Selective ovarian venography performed in the semierect position provides more anatomical information than the other techniques and can also demonstrate vulval and thigh varicosities. The venographic features of pelvic congestion include: an ovarian venous diameter of 10 mm at its widest point, uterine venous engorgement, moderate or severe congestion of the ovarian plexus, filling of veins across the midline or filling of vulval and/or thigh varices. Any one of these features is suggestive of PPS and the presence of several strongly supports the diagnosis [7]. Refinements in ultrasound techniques include colour Doppler imaging (CDI), utilizing specific anatomical windows [8] or the transvaginal approach [9]. The importance of imaging in the erect position should be stressed as filling of the pelvic veins is inadequate when the patient is supine. Laparoscopy in the Trendelenburg
PELVIC PAIN SYNDROME position favours venous drainage from the pelvis and the degree o f pelvic congestion is therefore underestimated. It has been suggested recently that the primary problem is that o f venous reflux in incompetent, dilated ovarian veins [3,4]. Anatomical studies have shown that ovarian venous valves are absent in 15% o f w o m e n on the left side and in 6% on the right [10]. Valvular incompetence is c o m m o n and m a y occur on either side, in 35-43% [11]. The capacity o f ovarian veins m a y increase by 60 times during pregnancy and changes m a y persist for up to 6 m o n t h s after delivery [12]. This m a y explain why PPS is m o r e c o m m o n in multiparous women. O n the basis o f these findings, surgical ligation and resection o f the dilated ovarian veins has been performed in small series o f patients. This appears to be a relatively simple, safe procedure which provides an effective cure for PPS [3,4]. E n c o u r a g e d by this approach, we decided to treat our patient in an analogous fashion by transcatheter embolization. Certain similarities exist with the male varicocoele for which transcatheter embolization is an established treatment [13]. However, several differences in ovarian a n a t o m y necessitate a modified embolization technique. C o m m u n i c a t i o n s m a y exist between the left ovarian vein
431
and the inferior mesenteric, splenic vein and ureteric veins [3]. F o r this reason, the use o f liquid sclerosants m a y be hazardous and should be avoided. The venous calibre in PPS is generally greater than that seen in the male varicocoele and distal venous blockade alone m a y lead to significant a m o u n t s o f t h r o m b u s in the proximal vein, as was seen in this case. The potential complication o f p u l m o n a r y embolism should be avoided by embolization o f the proximal vessel also (Fig. 4). Steel coils are available in a variety o f sizes, but large diameter vessels m a y require coaxial placement o f several coils to achieve effective occlusion. In this situation, a single detachable balloon m a y be more appropriate, but the choice o f embolic agent will depend on the individual venous anatomy. Coaxial catheter systems have extended the range o f therapeutic embolization and facilitate access to the ovarian venous tributaries. Platinum microcoils are m o r e radiopaque than steel coils o f similar calibre, and their enhanced visibility is particularly helpful in the obese patient. The effect o f venous embolization on ovarian function is u n k n o w n , but ovarian venous drainage is unlikely to be impaired, due to c o m m u n i c a t i o n s with the uterine plexus and hence the internal iliac vein. In our case, the patient's menstrual s y m p t o m s improved and her cycle became regular. Clearly, large series are necessary to determine the efficacy o f this procedure.
REFERENCES
I Beard RW, Reginald PW, Pearce S. Pelvic pain in women. British Medical Journal 1986;293:1160-1162. 2 Topolanski-Sierra R. Pelvic phlebography. American Journal of Obstetrics and Gynaecology 1958;76:44~45. 3 Hobbs JT. The pelvic congestion syndrome. British Journal of Hospital Medicine 1990;43:200-206. 4 Lechter A, Alvarez A. Pelvic varices and gonadal veins. In: Negus D & Jantet G, eds. Phlebology '85. London: John Libbey, 1986:225 228. 5 Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984;ii:946-949. 6 Beard RW, Reginald PW, Wadsworth J. Clinical features of women with chronic lower abdominal pain and pelvic congestion. British Journal of Obstetrics and Gynaecology 1988;95:153-161. 7 Kennedy A, Hemingway A. Radiology of ovarian varices. British Journal of Hospital Medicine 1990;44:38 43. 8 Richardson GD, Beckwith TC, Sheldon M. Ultrasound windows to abdominal and pelvic veins. Phlebology 1991;6:111-125. 9 Giacchetto C, Cotroneo GB, Marincolo F, Camisulu F, Caruso G, Catizone F. Ovarian varicocele: ultrasound and phlebographic evaluation. Journal o f Clinical Ultrasound 1990;18:551-555. 10 Ahlberg NE, Bartley O, Chidekel N. Circumference of the left gonadal vein. An anatomical and statistical study. Acta Radiologica 1965;3:503-512.
Fig. 4 - Abdominal radiograph shows sites of proximal and distal embolization (arrows). The smaller calibre steel coils are obscured by the bony pelvis.
11 Ahlberg NE, Bartley O, Chidekel N. Right and left gonadal veins. An anatomical and statistical study. Acta Radiologica 1966;4:593 601. 12 Hodgkinson CP. Physiology of the ovarian veins during pregnancy. Obstetrics and Gynaecology 1953;1:26-37. 13 White RI, Kaufman SL, Barth KH, Kadir S, Smyth JW, Walsh PC. Occlusion of varicoceles with detachable balloons. Radiology 1981;139:327-334.