The first treatment step was accomplished via a percutaneous access to the left femoral vein, with pelvic and abdominal phlebography confirming duplication of the IVC, with each common iliac vein draining into the respective inferior vena cava ( Figures 3 and 4) and an interiliac vein communicating between the right and left iliac systems, with a considerable number of large caliber pelvic varicose veins ( Figure 5). The treatment strategy planned was to eliminate proximal points of reflux by percutaneous embolization of pelvic varicose veins with deployment of fibered platinum coils, followed by chemical sclerotherapy of the varicose veins in the lower limbs. Investigation with imaging exams was conducted with venous duplex scan of the lower limbs, which found no significant disorders of the superficial or deep venous systems, and with angiotomography in venous phase, which confirmed presence of pelvic varicose veins, and detected duplication of the infrarenal IVC, forming a single vessel from the outflow of the left renal vein onwards ( Figures 1 and 2).Īngiotomography in venous phase, showing duplication of the inferior vena cava, forming a single vessel from the outflow of the left renal vein onwards. During history-taking, the patient described complaints compatible with PVC, such as dyspareunia and strong intensity pelvic pain during her menstrual period, in addition to recurrent urinary infections.
On physical examination of the patient, a large-caliber varicose vein was observed on the posterior-medial aspect of the upper third of the left thigh, in addition to varicules and telangiectasias distributed across both lower limbs. This bibliographic review was motivated by the case of a 27-year-old female patient who had never been pregnant and sought care complaining of burning pain, heaviness, and tiredness in lower limbs symptoms that were exacerbated during her menstrual period. Reported therapeutic success rates of embolization to treat PVC range from 70 to 85%, with no negative impacts on the menstrual cycle, fertility, or ovarian hormone levels, with rates of complications estimated at 3.4 to 9%.
5 The minimally invasive character of endovascular procedures enables treatment of these patients in the office or day-hospital, reducing both the discomfort and the costs of a conventional surgical procedure. 3Īlthough the studies available are of low quality, in terms of inappropriate study designs for assessing the efficacy of endovascular treatment with occlusion of varicose veins using coils and/or injection of sclerosant substances, 4 the endovascular approach, with embolization of pelvic varicose veins and points of reflux, does appear to be the best method of treatment for PVC currently available. Notwithstanding, knowledge of anatomic variants of the IVC is of vital importance, especially during retroperitoneal surgery and endovascular interventions. 3 Since then, its incidence has been estimated in the range of 0.3 to 3% in several reports, with the great majority of cases being asymptomatic, with incidental diagnosis. 2 The first report of duplication of the inferior vena cava (IVC) was published in 1916 in London (A case of double inferior vena cava. This set of symptoms associated with findings on physical examination of varicose veins involving vulva, perineum, and the posterior aspect of the tops of the lower limbs and buttocks is highly indicative of PVC and investigation should proceed to diagnostic confirmation with adequate imaging methods. Pain is characterized as heaviness, with associated symptoms, such as headaches, bloating, nausea, lower limb heaviness, lumbar pain, rectal discomfort, urinary urgency, lethargy, and depression. Pelvic venous congestion is most often diagnosed in multiparous women, with clinical status typically characterized by non-cyclical lower abdominal or pelvic pains that are exacerbated by standing for long periods and by sexual intercourse, during the menstrual period and in pregnancy.
1 Pelvic venous congestion (PVC), which can cause CPP, occurs when varicose veins develop around the many pelvic organs. The most common etiologies of CPP include endometriosis, adenomyosis, pelvic inflammatory disease, and leiomyomas.
It affects around 1/3 of all women and this symptom is responsible for up to 20% of all gynecological consultations. Chronic pelvic pain (CPP) is defined as non-cyclical pain in the pelvic area lasting 3 months or more.
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