Abstract
The well-known purported response of Sherlock Holmes to a seemingly inane question of his assistant, Dr. John H. Watson-“It's elementary, my dear Watson!”-is often used to stress the simplicity of an obvious answer. In this issue, Greiner and Gilling-Smith's article documents the important role that unrecognized incompetence of the tributaries of the internal iliac vein plays in the recurrence of lower extremity varicose veins. The anatomic basis for this occurrence was recognized by Thomas and colleagues in 1967. 1
Chronic pelvic pain with or without accompanying vulval and lower extremity varicosities is found in approximately 10% of patients attending gynecologic clinics. 2 The symptoms comprising the pelvic venous syndromes are pelvic pain, dyspareunia, dysmenorrhea, dysuria, and vulvar congestion with or without vulvar varices. The hemodynamic factors responsible for these symptoms can be found in the following four anatomoclinical situations:
Insufficiency of the gonadal vein. This is most common in women who have had children and is produced by the gradual dilatation of the ovarian vein occurring during pregnancy. In nulliparous women, the internal diameter of the ovarian vein is 3 to 4 mm. On average, three usually competent valves are located along its course. After several term pregnancies, the ovarian vein gradually dilates, reaching an internal diameter ranging from 8 to 14 mm and becoming grossly incompetent after delivery.
The association of gonadal vein reflux with incompetence of the internal iliac vein tributaries. This single-axis incompetence produces massive reflux and severe symptoms. It is responsible for the so-called “pelvic dumping syndrome.” 3–5 The combination of reflux of the gonadal and the internal iliac venous tributaries transmits the large venous flow from the renal, gonadal, and pelvic veins down to the pelvic organs, vulva, and lower extremities, resulting in large varicosities extending typically over the posteromedial aspect of the thigh and legs.
Isolated insufficiency of the internal iliac vein and its tributaries. This clinical condition has been beautifully demonstrated in Greiner and Gilling-Smith's article. In this pathology, whose undeniable existence has been questioned by several investigators, 6,7 varicose veins appear in the territories of the tributaries of the internal iliac vein, such as the internal pudendal, obturator, round ligament, and gluteal veins. When the gluteal veins are incompetent, large varicose veins may be present in the buttocks. 5 Isolated incompetence of the internal iliac vein and its tributaries has its anatomic origin in the scarcity of valves in this vein. In a study of the pelvic valvular system performed in human cadaver dissections by Lepage and colleagues, it was found that the left internal iliac vein has a mean of 14% of valves versus 28% of the right. 4
Obstruction of the left gonadal vein outflow by mesoaortic compression of the left renal vein (nutcracker syndrome). The left renal vein may be compressed in the segment where it crosses between the abdominal aorta and the superior mesenteric artery, producing stagnation of the high-output renal and gonadal venous outflow, resulting in the typical symptoms of pelvic congestion, such as dysmenorrhea, dysuria, dyspareunia, and vulvar and pelvic varices in the female and varicocele in the male. 8 In this syndrome, there is also the important finding of hematuria, which most frequently is microscopic but occasionally may become very severe. 9–11
The etiology of chronic pelvic pain may be a very challenging diagnostic problem. A number of factors, hemodynamic, physiologic, and psychological, play an important role and must be considered individually. A thorough gynecologic examination to rule out endometriosis or other gynecologic syndromes must be carried out. Most of these disorders can be clinically suspected and documented by noninvasive and invasive diagnostic methods. A Doppler ultrasound examination with the patient in the upright position may demonstrate a loud reflux during Valsalva's maneuver when the probe is placed over the vulval varices or over the large varicosities in the upper posteromedial aspect of the thigh. Contrast computed tomography can clearly demonstrate mesoaortic compression of the left renal vein, as well as perirenal venous dilatation and development of venous collaterals in the retroperitoneum and pelvis. Whenever there is a clinical suspicion of a pelvic venous syndrome, the preferred diagnostic method is retrograde angiography. Selective retrograde catheterization of the gonadal circulation through the right common femoral vein or from above through the cephalic or jugular vein results in excellent visualization of the gonadal venous circulation, including its detailed anatomy and communications of the intra- and extrapelvic venous circulation. The left gonadal vein is selectively catheterized at the junction with the renal vein, and the renocaval gradient is determined in the supine position with and without Valsalva's maneuver. 12 The normal gradient is 0 to 2 mm Hg. The right ovarian vein is catheterized at its junction with the inferior vena cava using either a Cobra or a Sidewinder catheter (I, II, or III, Cordis Inc., Miami, FL). This procedure demonstrates, with precision, the anatomy of the ovarian circulation and often shows the complex gonadal plexus, which is formed by three to five trunks in the distal third of the vein. 5
The majority of patients with chronic pelvic vein pain of venous origin have subdiaphragmatic venous insufficiency, a term provided by Leal's group in Spain. 12 In their large series, these investigators documented the fact that among 530 studied patients, 96% demonstrated points of leakage from the internal iliac vein tributaries to the lower extremities. In 64% of these patients, the reflux was via the superficial and deep venous systems of the extremities. This important observation demonstrates the need to interrupt the intra- and extrapelvic communications in those individuals with varicose veins in an atypical location or in those patients with recurrent varicose veins in spite of appropriately performed surgical treatment of the lower extremity varicose veins.
Most of the published series recommend direct venographic evaluation with transcatheter embolization of the incompetent ovarian and pelvic varices in one single step, 12 as Greiner and Gilling-Smith recommend in their article. In the majority of cases, the embolization materials used are gianturco coils (steel coils introduced by Gianturco and Wallace, Cook Incorporated Bloomington, IN) of different sizes, either alone or in combination with sclerosants, either liquid or foam. The results of treatment using this form of therapy have improvement rates in the range of 50 to 100%. Most of these series are relatively small, and the follow-up period has also been relatively short. In the series of Leal and colleagues, in a group of patients studied from 1999 to 2003 (991 patients), 95.6% reported improvement after 6 months. In the series of 131 patients of Kim and colleagues, the mean follow-up period was 45 months and 83% of the patients showed clinical improvement at the long-term follow-up. 13 The series of Greiner and Gilling-Smith and Kim and colleagues are of specific interest because their treatment included a thorough evaluation of the incompetence of the internal iliac tributaries and their therapy included elimination of the points of leakage between the pelvis and the lower extremities. In Kim and colleagues' series, 108 of 127 patients (85%) had internal iliac embolization. This reveals an awareness of the importance of the incompetence of the internal iliac tributaries either as an isolated source of reflux or as a pathway of severe gonadal iliac venous insufficiency.