JBR–BTR, 2004, 87: 1-8. THE PELVIC CONGESTION SYNDROME: ROLE OF THE “NUTCRACKER PHENOMENON” AND RESULTS OF ENDOVASCULAR TREATMENT O. d’Archambeau, M. Maes, A.M. De Schepper1 Purpose: Pelvic Congestion Syndrome (PCS) is a less known pathologic condition in multiparous women. The major symptoms are: low abdominal pain, dyspareunia or postcoïtal ache, gluteal or thigh varices, and emotional disturbances. The purpose of this retrospective study is to evaluate the pathogenesis, diagnosis and immediate, and longterm clinical results of the endovascular treatment of PCS. Methods and Materials: From February 1992 until January 2000, 67 diagnostic ovarian vein phlebographies followed by transcatheter embolization were performed in 66 patients with pelvic varicosities. These patients were traced back and submitted to a standardized questionnaire. The data of 48 patients was obtained this way. Results: In 83%, extrinsic compression of the left renal vein between the aorta and the superior mesenteric artery known as the “nutcracker phenomenon”- was observed together with congestion of the left ovarian vein and pelvic varicosities. The technical success rate of endovascular embolization was 96%. The initial clinical success rate was 86%, with a long-term benefit for 75% of the patients. After embolization there was a reduction in pain intensity, pain attacks, and emotional disturbances. Globally there was a mean reduction of complaints of 73% (Visual Analog Scale). Conclusion: The “nutcracker phenomenon” was detected in most of the treated patients and could explain the congestion of the left ovarian vein. Transcatheter embolotherapy is an effective way of treating pelvic varicosities, resulting in a great improvement of the quality of life for most of the patients. In experienced hands the procedure is relatively simple, and it is well tolerated. Moreover it can be performed in one step with the diagnostic phlebographic procedure. Keywords: Veins, ovarian – Varices – Veins, therapeutic blockade. Pelvic varicosities are a poorly understood pathologic condition in multiparous women that may cause a variety of symptoms. With few exceptions the affected women are multigravid, and most frequently they complain of chronic abdominal pain, with or without dyspareunia and/or postcoital ache. Other symptoms, as menstrual disorders, urinary complaints, gluteal or thigh varices, and emotional instability can supplement the clinical picture. In the literature this clinical entity is known as “Pelvic congestion syndrome” (PCS) ((1-4() More seldom a patient with pelvic varicosities may present with renal colics, due to ureteral compression by a dilated ovarian vein. This is known as “Ovarian vein syndrome” ((5-10). It was Richet who first described pelvic varicosities in 1854 (11). Freund postulated a vascular origin in 1885 (12) and Cotte in 1928 believed that the etiology was vascular insufficiency due to postpartum thrombophlebitis (13). PCS as such was first described by Taylor in 1949 confirming vascular insufficiency as a major etiologic factor (14-16). In case of clinical suspicion of pelvic varicosities, the diagnosis can be confirmed by means of ultrasound, abdominal CT-scan, pelvic MRI or ovarian vein phlebography (17-22). Phlebography is still considered the “gold standard” for diagnosis. Once the diagnosis is confirmed, patients may be treated surgically (3, 23-27) or, as it is the case in our institution, by transcatheter embolization of the dilated ovarian vein. Although the first paper describing a case of successful transcatheter ovarian vein embolization was published by Edwards in 1993, transcatheter ovarian vein embolization procedures are performed in our department since the early 1980’s. This retrospective study was undertaken to evaluate the technical and clinical results of embolization procedures performed between 1992 and 2000 and the phlebographies were reviewed to evaluate the possible mechanical factors contributing to the pathogenesis. Methods and materials From February 1992 until January 2000, 67 transcatheter embolization procedures were performed in 66 patients presenting with a clinical picture of PCS and sonographic, CTscan or MRI evidence of pelvic varicosities. The patients were contacted for an interview on the basis of a From: Department of Radiology, University Hospital Antwerp, Antwerp, Belgium. Address for correspondence: O. d’Archambeau, MD, Department of Interventional Radiology, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium. standardized questionnaire. The questionnaire contained a list of symptoms and localizations of which the presence or absence before and immediately after treatment as well as at the time of the study was noted. The overall results of the treatment were rated using a visual analogous scale (28) indicating the severity of complaints (from none to unbearable). The questionnaire was completed by 48 patients and the collected data were sufficient for statistical analysis. The mean age of the 48 patients was 37.2 years (20-73) and the mean gravidity at the time of treatment was 2.7 (0-7.3 nulliparous patients). The patient’s history included 14 laparascopies (29%), pelvic inflammatory disease in eight (17%), six appendectomies (12.5%) and two cases of endometriosis (4%). Before treatment most patients complained of pain in the lower abdominal region (80%), the lower back (35%), the right side (35%) or the left side (21%). Other locations noted were the groins and even the upper leg. Frequently the ache was localized in more than one of the above mentioned regions. The pain often occurred after a long maintained erect position (60%), during or immediately after sexual intercourse (44%), or during the premenstrual period (28%). Fifteen patients (31%) experienced a continuous gnawing feeling superimposed by pain attacks. All the patients were selected for 2 JBR–BTR, 2004, 87 (1) Table I. — Grading of pelvic varicosities according to De Schepper. Grade I Grade II Grade III dilated left ovarian vein/plexus + dilated left uterovaginal vein plexus + dilated right uterovaginal plexus and right ovarian vein Table II. — Original grading of extrinsic left renal vein compression at the aortomesenteric fork. The “nutcracker phenomenon” according to d’Archambeau and De Schepper. Grade I Grade II Grade III Extrinsic impression with retrograde filling of paralumbar veins and/or ovarian vein Extrinsic compression with retrograde filling of side branches including the ovarian vein and reflux towards the renal hilum Total “cut-off” of the renal vein Fig. 1. — Diagnostic phlebography (left) with a 4F cobra catheter. Grade 3 pelvic varicosities with contralateral filling of the right ovarian vein (arrow). “One-step” embolization of the left ovarian vein (right) using Gianturco coils at the level of the sacro-iliac joint (arrow). ovarian phlebography when the initial abdominal ultrasound, CT-scan or MRI performed for clinical symptoms of PCS revealed pelvic varicosities without other pathology. In 35 out of the 48 patients more than one non-invasive radiological examination was performed prior to the phlebography. The patients underwent ovarian vein phlebography that confirmed the suspected diagnosis of pelvic varicosities by demonstrating a dilated left and/or right ovarian vein in all. The procedures were performed from a femoral approach using a 0.038” hydrophilic guide-wire (Terumo Europe, Herent, Belgium) and a 4 or 5F Cobra-shaped catheter (Terumo Europe, Herent, Belgium) for the left side or a Simmons 1 or 2-shaped catheter (Terumo Europe, Herent, Belgium) for the right side. The left ovarian vein was usually catheterized first. Low-osmolar contrast (Hexabrix 320, Laboratoire Guerbet, Aulnay-Sous-Bois, France) was injected manually with the patient in a semi-upright position allowing good opacification of the enlarged ovarian vein, collaterals and varices. Pelvic varicosities were graded according to De Schepper (18, 29) (Table I). Consequently, the enlarged ovarian vein was embolized in one step with the diagnostic phlebographic procedure (Fig. 1). A total of 55 embolization procedures were performed, 42 left and 6 bilateral with one patient needing a right ovarian vein embolization 3 months after the left ovarian vein was embolized due to incomplete disappearance of symptoms. Embolization was achieved using MReye 0.038” Gianturco Coils (William Cook Europe, Bjaeverskov, Denmark) in 45 patients. The coils were pushed through the catheter with the guide-wire and usually placed at the level of the sacroiliac joint. An average of 4-5 coils were necessary for complete occlusion sizing from 3-20 mm in width and 40-200 mm in total length. Collaterals were identified in 21 patients and embolized with small coils (3 or 5 mm in diameter and 40 or 50 mm in length). In 3, included from another hospital, a mixture of lipiodol (Laboratoire Guerbet, Aulnay-Sous-Bois, France) and glue (Histocryl Transparant, B. Braun, Melsungen, Germany) was used and delivered using a coaxial 5F-3F catheter system. A manual control injection was performed in the ovarian vein and left renal vein to assess the result of the embolization. In 40 out of the 48 patients (83%) an extrinsic compression of the left renal vein at the crossing site with the aorta was observed. This was most obvious after embolization when opacification of the reno-azygolumbar plexus and sometimes contrast reflux in the renal vein towards the renal pelvis was observed. We graded extrinsic compression of the left renal vein at the crossing site with the aorta as follows (Table II): extrinsic impression with filling of paralumbar veins and/or ovarian vein: Grade 1 (Fig. 2A); extrinsic compression with filling of various side branches including the ovarian vein and THE PELVIC CONGESTION SYNDROME — D’ARCHAMBEAU et al. A 3 B Fig. 2. — The “nutcracker phenomenon”. Grade 1 (A): extrinsic impression of the left renal vein at the aortomesenteric fork with filling of the ovarian vein (long arrow). Grade 2 (B): extrinsic compression with ovarian and paralumbar venous reflux (short arrows). Grade 3 (C): total “cut-off” of the left renal vein and paralumbar collateral filling of the inferior caval vein (long arrow). ranging from no complaint to unbearable pain representing the severity of symptoms before and after treatment. For each patient the denoted grade of symptoms was converted to a numerical score (VA score, 0-10), that could be statistically analysed. General improvement of the symptoms was noted as the difference between the VA score before and after treatment (Table III) and symptomatic improvement in term of percentage was calculated using the following formula : %improvement = 100 / VA score pre x (VA score pre - post). This was done for all 48 patients. The mean follow-up was 43,4 months (2.084.3). C reflux towards the renal hilum: Grade 2 (Fig. 2B); total “cut-off” of the left renal vein: Grade 3 (Fig. 2C). Pressure measurements were not Results performed because of lack of value in the absence of a control group. We assessed the clinical success rate using a visual analogous scale, Complete occlusion was achieved in 46 patients (53 embolizations: 40 left-sided, 1 right-sided and 6 bilateral), partial occlusion in 2 patients 4 JBR–BTR, 2004, 87 (1) Table III. — Visual-analogous score for all 48 patients, before and after treatment. N = 48 MEAN RANGE SD VA score before treatment VA score after treatment Improvement Improvement (%) 7.88 2.15 5.74 73.31 5.0-10.0 0.0-10.0 -1.0-10.0 -12.5-100 1.67 3.25 3.44 37.6 % improvement = 100 VA score pre (2 left-sided embolizations), as observed by phlebography at completion of the embolizations, resulting in a technical success rate of 96,4%. There were no major complications. In one patient, proximal coil misplacement resulted in migration to the left inferior pulmonary lobe artery needing a snare loop for coil retrieval. The clinical success rate was evaluated using a visual analogous scale. We found an overall statistically significant reduction of the VA score from 7.88 before treatment to 2.15 after transcatheter embolotherapy (p < 0.001; Wilcoxon Signed Ranks Test), corresponding to a mean proportional improvement of complaints of 73,3% (Table III). Although symptoms did not disappear completely for all patients, most of them experienced an improvement in their “quality of life” that remained constant over the years of follow-up. A total of seven patients (14.5%) did not respond favourably to the embolization. Six patients (12.5%) had unchanged symptoms, one patient (2%) experienced a slight worsening of her complaints. It should be noted that from those seven patients, three were younger than 30 years and nulliparous and three were older than 50 year, what could suggest another origin of their complaints. In the follow-up (2-84.3 months, mean 43.4 months), five patients (10%) experienced a relapse of symptoms after a period of 232 months (mean 14.3 months), meaning a long-term clinical success rate of 75%. A control phlebography was performed in 3 patients with recurrent complaints, but only in 1 patient there was evidence of residual varicosities, due to a collateral circulation through the renal pelvic venous plexus, not observed during the initial procedure. In the x (VA score pre - post) other 2, even iliac catheterization could not demonstrate the pelvic varicosities shown on sonography. The effect of embolotherapy on pain was also studied. After embolization there was a decreased frequency of pain attacks and less areas were involved. This reduction was significant (Wilcoxon Signed Rank Test, p < 0.05) for several of the inquired parameters (Table IV). Other physical complaints such as menstrual disorders, urinary complaints and external varices were less frequently mentioned after treatment. Emotional disturbances (depression, anxiety, stress,...) were mentioned by 25 of the 48 women (52%) and 21 women (44%) complained of dyspareunia before treatment. After treatment this number decreased to 10 (21%) and 8 women (17%) respectively. This reduction in emotional complaints and dyspareunia was statistically significant (Wilcoxon Signed Rank Test, p < 0.001). The phlebographies of all patients were reviewed and the grade of pelvic varicosities was noted according to De Schepper (Table I). We noted a grade 1 in 10 patients (21%), a grade 2 in 22 patients (46%) and a grade 3 in 16 patients (33%). In 40 patients (83%) extrinsic compression of the left renal vein at the level of the aortomesenteric fork was found to be the major contributing factor to the pathogenesis and graded according our original grading system (Table II). We found a grade 1 in 12 patients (25%), grade 2 in 16 patients (33%) and a grade 3 in the other 12 patients (25%). No extrinsic impression or compression was detected in the remaining 8 patients (17%), due to insufficient imaging of the left renal vein in 5 patients. Absent or incompetent valves could possibly be the cause of reflux in the remaining 3 patients. By comparing the patient’s VA scores and phlebographies, we noted that the patients with a more pronounced extrinsic compression of the left renal vein (grade 2 and 3 in Table II) had the largest ovarian veins and varices (grade 2 and 3 in Table I) and a higher VA score before embolization, although this finding was not statistically analyzed. Discussion Pelvic varicosities are associated with a marked increase in diameter and tortuosity of visceral pelvic veins. The diameter of the ovarian Table IV. — Pain localization percentage before and after treatment Before N = 48 % After N = 48 % 38 10 17 17 35 80 21 35 35 73 19 4 10 6 17 40 8 21 13 36 < 0.001 0.014 0.008 0.001 < 0.001 Long standing Sexual intercourse Continuous Premenstrual During menstruation Fatigue Others 29 21 15 13 10 12 17 60 44 31 27 21 25 35 13 8 0 2 8 4 12 27 17 0 4 17 8 25 < 0.001 < 0.001 < 0.001 0.001 0.157 (NS) 0.005 0.025 Wilcoxon Signed Ranks Test n = number of patients NS = not significant (p > 0.05) Pain Significance Localization Lower abdomen Left side Right side Back Others Time of occurrence THE PELVIC CONGESTION SYNDROME — D’ARCHAMBEAU et al. 5 A Fig. 3. — The “nutcracker phenomenon”. CT-scan (A) and venous phase of aortography (B) show a distinct compression of the left renal vein in the aortomesenteric fork (long arrow) and retrograde filling of an enlarged left ovarian vein (short arrow). vein and ovarian vein plexuses is larger than 6 mm. The connecting veins are usually larger than 4 mm. When symptomatic, this condition is known as the “Pelvic congestion syndrome” (PCS) (1, 2, 3, 4). PCS is a vascular syndrome most frequently found in multigravid females in their 3rd-4th decade of life (30). The exact prevalence is unknown, but pelvic varicosities are probably present in up to 30% of females with unexplained chronic pelvic pain (31-33). Symptoms appear shortly after pregnancy and include lower abdominal or back pain, dyspareunia, external varicosities, urinary and menstrual problems as well as emotional disturbances (2, 3). Patient’s history and clinical examination are important diagnostic tools. Diagnosis is made using various imaging modalities. Intravenous urography shows only indirect signs of pelvic varicosities which are more obvious in erect position. Pelvic color Doppler ultrasound is a good screening method, but with a large number of false negative results due to slow blood flow in pelvic varicosities. Computed tomography or MRI has the capability to exclude other pelvic pathologies. Vulvar varicography and transuterine venography are obsolete and today widely abandoned. Laparoscopy yields a high number of false negative results due to emptying of the vessels in the recumbent position. The “gold standard” for the diagnosis of pelvic varicosities remains the phlebography which enables us to look for abnormalities of the ovarian and B iliac veins as well as to treat the pathology. Etiopathogenesis of PCS is multifactorial. The symptoms are worse in the premenstrual phase suggesting a hormonal etiology (2, 3). Progesterone induces a venodilatation and its blood level increases from ovulation until shortly before menstruation. There is also a tenfold increase in progesterone blood level during pregnancy, what could be an explanation for the development of varices. The role of psychological factors is not well defined as many patients describe a long history of emotional stress, which could be a cause as well as a consequence of longstanding PCS. Mechanical factors are undoubtedly the most contributing factors in pelvic varicosities. Pelvic varicosities develop due to venous reflux and flow reversal in the left ovarian vein. Varices can extend to the plexus uterovaginalis, vulvaris, vesicalis, rectalis, and finally the right ovarian vein. De Schepper explained this phenomenon by the so-called “left-to-right” theory of PCS (29). Causes for reflux in the left ovarian vein are multiple. First of all congenital absence of valves in the ovarian veins (29, 34-38). Ahlberg found a congenital absence of valves in 15% of the females on the left side and in 6% on the right side [38]. Secondly many patients have incompetent valves. This could be the case for 43% on the left side and 35-41% on the right side (38). The causes of valvular incompetence are multifactorial (35). It could be congenital or due to previous thrombophlebitis of the ovarian vein, but most frequently it is due to an extreme dilation of the ovarian vein during pregnancy. Reflux in the left ovarian vein may be caused by a pressure increase in the left renal vein secondary to thrombosis, tumoral compression or invasion of the left renal vein, inferior vena cava anomalies and even portal hypertension (35, 39, 40), but as demonstated in more than 80% of our patients is most frequently caused by extrinsic compres- sion at the aortic crossing. In rare instances, this can be attributed to a retroaortic or circumaortic course of the left renal vein, but CT, MRI or ultrasound performed in all patients during investigation of chronic pelvic pain did not reveal this finding. Instead, crushing of the left renal vein at the aortomesenteric fork, the so-called “nutcracker phenomenon” (29, 34, 35, 37, 40, 41) was demonstrated (Fig. 3). It causes an increase in venous pressure in the left renal vein with reflux in the left ovarian vein and reno-azygo-lumbar plexus as a consequence. The flow reversal in the ovarian vein is more pronounced with absent or incompetent valves and in an upright position (29, 34, 35, 37, 41). This is also the reason why PCS is more frequently found in multigravid women. During pregnancy, the ovarian veins enlarge due to increase in uterus size and blood volume. This enlargement induces valvular incompetence which may be transient but some- 6 JBR–BTR, 2004, 87 (1) Fig. 4. — Pelvic congestion syndrome”. Enlarged left ovarian vein with high flow through multiple connecting veins to the left external iliac vein (short arrow). times permanent, favouring reflux and varices. The “nutcracker phenomenon” can easily be demonstrated on venography as an extrinsic compression or even total “cut-off” of the left renal vein at the aortomesenteric fork with reflux in the left ovarian vein and/or azygolumbar veins. An argument in favour of the “Nutcracker phenomenon” is that the patients with grade 2 and 3 extrinsic renal vein compression had the largest ovarian veins and frequently experienced discomfort in the left kidney region after embolization, which could be explained by a sudden pressure raise in the left renal vein due to blocking of a large collateral channel. The discomfort was transient and lasted from a few hours to a few days. Another argument in favour of the “nutcracker phenomenon” and the concomitant “left-to-right” pressure gradient in the ovarian-uterine venous system is found in our own series in which we have never seen filling of the left ovarian vein during phlebography of the right ovarian vein. Retrograde filling of the right ovarian vein during phlebographies of the inferior vena cava is never seen, moreover, preferential filling of right venous structures during transuterine phlebography in patients with PCS is in our opinion a consequence of the same “left-toright” pressure gradient phenomenon (42). De Schepper graded Fig. 5. — Diagnostic phlebography of the right ovarian vein using a 4F Simmons catheter after coil embolization of the left ovarian vein. Filling of the superior mesenteric vein (long arrow) through connecting veins (short arrow). pelvic varicosities according to this theory (18, 29) (Table I). He performed pressure measurements in the left renal vein and inferior caval vein in a total of 29 patients (21 with normal phlebographic findings and 8 with PCS and “nutcracker phenomenon”). As a result, he found a mean pressure gradient of 2mmHg in the normal group (mean caval pressure: 9mmHg, mean left renal vein pressure: 11 mmHg) and 5mmHg in the pathologic group (mean caval pressure: 10mmHg, mean left renal vein pressure: 15mmHg) (29). In our study, no pressure measurements were performed because no control group was available. Therefore, a comparative study was not possible. Treatment of PCS may be medical, surgical or endovascular. Medical treatment with medroxyprogesterone acetate (Provera, Upjohn) which suppresses ovarian function is not always effective. Dihydroergotamine is a venoconstrictor only effective during the acute phase of PCS and only for a few days. The efficacy of NSAID in the treatment of PCS is not proven. Surgical ligation of the ovarian vein whether transabdominal, translumbar or laparascopic is effective but invasive (22-24). Hospitalization is mandatory and complications are not rare. Total hysterectomy is also effective but radical (25, 26). Although transcatheter embolization is the treatment of choice in our department for more than 15 years, not many reports were published in the literature (43-49). The embolization procedure is performed in one step with the diagnostic phlebography and on an outpatient basis. Different embolic materials may be used, including detachable balloons, coils, sclerosing agents and glue. We do not recommend the use of sclerosing agents and glue in the ovarian vein for different reasons. First, the ovarian vein, unlike the testicular vein has only few collaterals and usually with a more distal origin. Secondly, the ovarian vein in PCS is frequently larger than 1 cm with a high retrograde blood flow rate. Therefore it is more difficult to control the polymerisation of glue and embolization of the plexus pampiniformis ovarica or passage of glue into the iliac vein is possible (Fig. 4). Reflux in the renal vein with pulmonary migration is also a concern as is embolization of mesenteric veins through connecting channels (Fig. 5). In our department, Gianturco Coils (Cook) are used and placed at the level of the sacroiliac joint. If necessary, small collaterals are selectively catheterized and embolized. Since we strongly believe in the “left-right” theory, we tried to avoid embolization of enlarged right ovarian veins. Embolization is only performed in cases of massive retrograde flow with filling of the peri- THE PELVIC CONGESTION SYNDROME — D’ARCHAMBEAU et al. ovarian venous plexus in a semiupright position. This was the case in 7 patients (15%) although right ovarian vein dilatation was found in 19 patiens (40%). A control phlebography of the ovarian and renal vein is performed after embolization, confirming the occlusion and the non-filling of renal pelvic collaterals. One complication occurred. In this case, the last coil was released too proximally in the ovarian vein, with the catheter in an unstable position resulting in misplacement and migration into a left lower pulmonary lobe artery. The coil was successfully retrieved using a snare-loop. The clinical results were evaluated using a visual analogous scale. The use of a VA scale in a retrospective study could be questioned, but the symptoms before treatment were usually severe and long-standing and the included patients had no trouble in remembering the immediate effect of the procedure on their complaints. The VA scale is a good method for evaluation of symptomatic relief, since we do not know if the symptoms can be attributed to the pelvic varicosities alone. Some symptoms may have another origin, and embolization, although technically successful will only result in a partial relief of symptoms. It is not always necessary to achieve total symptomatic relief in order to improve the “quality of life”. In our study there was an overall symptomatic relief of 73.3%. Bearing in mind that 7 patients did not respond to the treatment, we found a symptomatic improvement of 85.9% and a long-term clinical benefit in 75% of the patients. There was a 60% decrease in the number of patients with emotional problems (52% before, 20% after) and dyspareunia (44% before, 17% after). Our findings correlate well with those of other authors [43-49]. They indicate that transcatheter embolotherapy of ovarian veins is an effective treatment modality for female patients suffering from pelvic varicosities. The results are similar to those of surgical treatment, but embolotherapy is a less invasive technique. Moreover, it has the advantage to be performed on an outpatient base and in one step with the diagnostic phlebographic procedure. Finally, phlebographic review demonstrated the “nutcracker phenomenon” as the major contributing factor in the etiopathogenesis of “Pelvic Congestion Syndrome” although objective confirmation was not available as we did not perform pressure measurements. References 1. Railo J.E.: The pain syndrome in ovarian varicocele. Acta Chir Scand, 1968, 134: 157-159. 2. Hobbs J.T.: The pelvic congestion syndrome. Practitioner, 1976, 216: 529-540. 3. Hobbs JT.: The pelvic congestion syndrome. Brit J Hosp Med, 1990, 43: 200-206. 4. Beard R.W.: Clinical features of women with chronic lower abdominal pain and pelvic congestion. Brit J Obstet Gynaec, 1989, 96: 153-161. 5. Clark J.C.: The right ovarian vein syndrome. In: Emmett J.L., ed. Clin uro diagn, 1964 vol. 2: 1227-1236 W.B. Saunders, Philadelphia. 6. Melnick G.S., Bramwit D.N.: Bilateral ovarian vein syndrome. Am J Roentgenol Radium Therapy and Nuclear Medicine, 1971, 113: 509-517. 7. Dyckhuizen RF, Roberts JA. The ovarian vein syndrome. Surg Gynecol Obstet, 1970, 130: 443-452. 8. Reynolds S.R.M.: Right ovarian vein syndrome. Obstet Gynecol, 1971, 37: 308-313. 9. Ali Khan S., Jayachandran S., Desai P.G., Bonheim P.: Renal colic, a presenting symptom of pelviureteric varices. Int Urol Nephrol, 1985, 17: 11-14. 10. Montagnac R., Schillinger F., Schillinger D.: Le syndrome de la veine ovarienne. Rev Fr Gynecol Obstet, 1989, 84: 11-14. 11. Richet A.: Traité pratique d’anatomie médicochirurgicale 755 Lauwereyns, Paris, 1854. 12. Freund W.A.: Gynakol Klin 1885, I: 203-326. 13. Cotte G.: Les troubles fonctionnels de l’appareil génital de la femme. Masson & Cie, Paris,, 1928. 14. Taylor H.C.: Vascular congestion and hyperemia: their effect on function and structure in the female reproductive organs. Part I. Physiological basis and history of the concept. Am J Obstet Gynecol, 1949, 57: 211-230. 15. Taylor H.C.: Vascular congestion and hyperemia : their effect on function and structure in the female reproductive organs. Part II. Clinical concepts of the congestion-fibrosis syndrome. Am J Obstet Gynecol, 1949, 57: 637653. 16. Taylor H.C.: Vascular congestion and hyperemia : their effect on function and structure in the female reproductive organs. Part III. Etiology and therapy. Am J Obstet Gynecol, 1949, 57: 654-668. 17. Giacchetto C., Cotroneo G.B., Marincolo F., et al.: Ovarian varicocele : ultrasonic and phlebographic evaluation. J Clin Ultrasound, 1990, 18: 551-555. 7 18. De Schepper A., Van Rompaey W.: Computed tomographic diagnosis of dilated ovarian veins in a case of “ovarian vein syndrome”. Eur J Radiol, 1983, 3: 324-327. 19. Kennedy A., Hemingway A.: Radiology of ovarian varices. Brit J Hosp Med, 1990, 44: 38-43. 20. Radin D.R., Marilyn J.R., Harrison E., et al.: CT demonstration of ovarian varices. J Comput Assist Tomo, 1986, 10: 361-362. 21. Perlman S.J.: Varix of the left gonadal vein. J Ultras Med, 1993, 12: 483-485. 22. Hodgson T.J., Reed M.W.R., Peck R.J., et al.: Case report : the ultrasound and Doppler appearances of pelvic varices. Clin Radiol, 1991, 44: 208209. 23. Takeuchi K., Mochizuki M., Kitagaki S.: Laparoscopic varicocoele ligation for pelvic congestion syndrome. Int J Gynecol Obstet, 1996, 55: 177-178. 24. Mathis B.V., Miller J.S., Lukens M.L., et al.: Pelvic congestion syndrome : a new approach to an unusual problem. Am Surgeon, 1995, 6: 10161018. 25. Grabham J.A., Barrie W.W.: Laparascopic approach to pelvic congestion syndrome. Brit J Surg, 1997, 84: 1264. 26. Beard R.W., Kennedy R.G., Gangar K.F., et al.: Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelvic congestion. Brit J Obstet Gynecol, 1991, 98: 988-992. 27. Emge L.A.: The surgical treatment of varicose veins of the female pelvis. J Am Med Ass, 1995, 85: 1690-1693. 28. Huskisson E.C.: Measurement of pain. Lancet, 1974, 2: 1127-1131. 29. De Schepper A.: Studie van het ovarieel syndroom door flebografie van de linker vena ovarica. Ph D thesis.University of Antwerp, 1976 . 30. Beard R.W.: Clinical features of women with chronic lower abdominal pain and pelvic congestion. Brit J Obstet Gynaecol, 1988, 95: 153-161. 31. Mathias S.D., Kupperman M., Lieberman R.F., et al.: Chronic Pelvic Pain : prevalence, health-related quality of life and economic correlates. Obstet Gynecol, 1996, 87: 321-327. 32. Priou G., Arvis P., Rind A., et al.: Etude de l’apport diagnostique de la coelioscopie dans le bilan des algies pelviennes chroniques. J Gynecol Obstet Biol Repr, 1984, 13: 395-402. 33. Beard R.W., Highman J.H., Pearce S., et al.: Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet, 1984, 2: 946-949. 34. Chait A.: Vascular impressions on the ureters. Am J Roentgenol Radium Therapy and Nuclear Medicine, 1971, 111: 729-749. 35. Melnick G.S., Bramwit D.N.: Bilateral ovarian vein syndrome. Am J Roentgenol Radium Therapy and Nuclear Medicine, 1971, 113: 509-517. 36. Chidekel N.: Female pelvic veins demonstrated by selective renal 8 37. 38. 39. 40. 41. 42. JBR–BTR, 2004, 87 (1) phlebography with particular reference to pelvic varicosities. Acta Radiol Diagn, 1968, 7: 193-211. Helander C.G., Lindbom A.: Varicocele of the broad ligament. Acta Radiol, 1960, 53: 97-104. Ahlberg N.: Circumference of the left gonadal vein. Acta Radiol, 1965, 3: 503-512. Coolsaet B.L.R.A.: Ureteric pathology in relation to right and left gonadal veins. Urology, 1978, 12: 40-49. Perlman S.J.: Varix of the left gonadal vein. J Ultrasound Med, 1993, 12: 483-485. Grant J.C.B.: Method of anatomy. Williams & Wilkins, Baltimore 158, 1937. Chidekel N., Edlundh K.O.: Transuterine phlebography with particular 43. 44. 45. 46. reference to pelvic varicosities. Acta Radiol Diagn, 1968, 7: 1-12. Edwards R.D., Robertson I.R., Maclean A.B., et al.: Case report : pelvic pain syndrome – succesful treatment of a case by ovarian vein embolization. Clin Radiol, 1993, 47: 429-431. Sichlau M.J., Yao J.S., Vogelzang R.L.: Transcatheter embolotherapy for the treatment of pelvic congestion syndrome. Obstet Gynecol, 1994, 83: 892-896 . Tarazov P.G., Prozorovskij K.V., Ryzhkov V.K.: Pelvic pain syndrome caused by ovarian varices. Treatment by transcatheter embolization. Acta Radiol, 1997, 38: 1023-1025. Capasso P., Simons C., Trotteur G., et al.: Treatment of symptomatic pelvic varices by ovarian vein embolisation. Cardiovasc Inter Rad, 1997, 20: 107111. 47. Cordts P.R., Eclavea A., Buckley P.J., et al.: Pelvic congestion syndrome : early clinical results after transcatheter ovarian vein embolization. J Vasc Surg, 1998, 28: 862-868. 48. Maleux G., Stockx L., Wilms G., et al.: Ovarian vein embolization for the treatment of pelvic congestion syndrome : long-term technical and clinical results. JVIR, 2000, 11: 859-864. 49. Venbrux A.C., Chang A.H., Kim H.S., et al.: Pelvic Congestion Syndrome (Pelvic Venous Incompetence): Impact of Ovarian and Internal Iliac Vein Embolotherapy on Menstrual Cycle and Chronic Pelvic Pain. J Vasc Interv Rad, 13: 171-178. CLASSIFIED SERVICES Le Centre Hospitalier Jolimont-Lobbes annonce l’ouverture d’un poste de radiologue, orientation échographie (HDI 5000, ANTARES), CT-Scanner (4 – 16 canaux) et RMN (1,5 Tesla) sur le site de Jolimont (650 lits). Toute personne intéressée par ce poste peut adresser des demandes de renseignements à l’adresse ci-dessous. De ziekenhuisinstelling Jolimont-Lobbes, site Jolimont (650 bedden), heeft een vacature voor een radioloog, oriëntatie echografie (HDI 5000, ANTARES), CT-scanner (4 – 16 kanalen) en NMR (1,5 Tesla). 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