755 - An Algorithm for Evaluation and Management of Patients with Pelvic Venous Disorders

Learning Objectives:

1. Review the pathophysiology of pelvic venous disorders (PeVD) and differential diagnoses in a patient with chronic pelvic pain


2. Discuss the pre-procedure clinical workup and anticipated imaging findings for a patient with suspected pelvic venous disorders, including review of the symptoms-varices-pathophysiology (SVP) classification


3. Present a diagnostic and therapeutic algorithm for the management of PeVD

Background: Chronic pelvic pain (CPP), defined as greater than 6 months of noncyclical pain, is a common and complex problem, which affects up to a third of women and accounts for up to 15% of outpatient gynecology visits {1}. A historically underdiagnosed but now more recognized cause of CPP are pelvic venous disorders, which encompasses pathophysiologic mechanisms for the previously named syndromes of May-Thurner, pelvic congestion and nutcracker. In addition, a new classification has been developed, named the Symptoms-Varices-Pathophysiology (SVP) classification, which allows for a more homogenous definition of the population, a more comprehensive workup of patients with suspected PeVD and the development of a treatment algorithm {2}.

Clinical Findings/Procedure Details: This image rich exhibit will demonstrate the full clinical evaluation and diagnostic evaluation and treatment algorithm utilized at a single institution. First, a review of PeVD, including relevant iliac and pelvic venous anatomy. Next, the suggested clinical evaluation of a patient with suspected PeVD will be discussed, with a focus on the SVP classification. Finally, an interventional diagnostic and treatment algorithm will be presented, which includes specifics of bilateral iliofemoral venography with intravascular ultrasound (IVUS), left renal venography (+/- IVUS and pressures), bilateral gonadal venography, and embolotherapy versus stenting depending on patient classification and imaging findings. Indicated surgical referral options for renal vein transposition or renal autotransplant will be discussed. Selected cases will highlight the algorithm focusing on patients with varying SVP classifications.

Conclusion and/or Teaching Points: Pelvic venous disorders are a complex group of disorders but one in which interventional radiologists play a critical role in providing significant relief for the appropriate patient. This exhibit presents a comprehensive review of PeVD and provides a detailed diagnostic and therapeutic approach to caring for a patient with suspected PeVD.