A 36-year-old female with an 8-year history of symptomatic right lower limb varicose veins that presents with pain, heaviness and fatigue of the right leg with prolonged standing. The patient notes that she has also experienced symptoms of pelvic pain and fullness associated with dyspareunia and increased urinary frequency that is worsened at the end of the day and during menstruation. Past medical history includes hypothyroidism, uterine ablation and is G4, P3. There is a family history of varicose veins. On examination, both lower limbs are warm and well perfused with distal pulses palpable (2+ bilaterally). There is no swelling, skin changes or ulcerations. Prominent varicosities (CEAP C2) are located in the right posterior thigh and proximal posterior calf. Venous duplex of the lower limbs demonstrated right great saphenous vein measuring 6 mm with 0.4 sec reflux and extensive posterior thigh varicose veins with >5 sec reflux which originate from gluteal area. Pelvic venous duplex demonstrated left ovarian vein reflux 8 mm with extensive periuterine veins.
What is the best course of management for this patient?
The correct answer is: C. Left ovarian vein embolization and phlebectomy.
Pelvic pain is common in women and the differential is quite extensive, including pelvic venous disease. Patients with pelvic venous disease can have a diverse clinical presentation including varicose veins in the legs, pelvic pain, dyspareunia, back pain and GI/GU symptoms. Other common gynecological causes should be excluded. Symptoms tend to be worse with prolonged standing and are typically present throughout the menstrual cycle, worse during menstruation. Women usually have a low BMI and multiple (≥2) pregnancies. Underlying pathology is usually ovarian vein reflux with extensive periuterine veins. In some patients, iliac vein compression or renal vein compression is the underlying pathology. Treatment in patient with ovarian reflux includes elimination of reflux with embolization of the pelvic and ovarian vein. Patients that have lower extremity non-saphenous veins which communicate with the pelvis, require treatment of the leg veins as well.
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