British Journal of Radiology (2006) 79, e152-e155
© 2006 British Institute of Radiology
doi: 10.1259/bjr/24717606
Double retroaortic left renal veins as a possible cause of pelvic congestion syndrome: imaging findings in two patients
Z Koc, MD
S Ulusan, MD
N Tokmak, MD
L Oguzkurt, MD
and
T Yildirim, MD
Ba
kent University Adana Teaching and Medical Research Centre, Department of Radiology, Adana, Turkey
Correspondence: Zafer Koc, Bakent University Adana Teaching and Medical Research Centre, Dadalo
lu Mah. Serin Evler 39. Sok. No: 6 Yüreir, Adana/Turkey. E-mail: koczafer{at}gmail.com; zaferkoc{at}superonline.com.
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Abstract
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Pelvic congestion syndrome is characterized by chronic pelvic pain and varicose veins around the uterus and ovaries. We report two cases of double retroaortic left renal vein, associated with left-sided pelvic congestion syndrome, diagnosed by CT and confirmed by clinical findings and colour Doppler ultrasound. Double retroaortic left renal veins may be a contributing factor for the development of left pelvic congestion syndrome. This is the first report of double retroaortic left renal vein and associated pelvic congestion syndrome.
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Introduction
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Chronic pelvic pain (CPP) is a common gynaecological problem. Pelvic congestion syndrome (PCS), one of the causes of CPP, is characterized by persisting dull pelvic pain that worsens pre-menstrually [1]. It is characterized by dilatation of the ovarian vein and pelvic venous plexus typically in multiparous women of childbearing age [2].
Retroaortic left renal vein (RLRV) is an infrequent congenital venous variation, but double RLRVs is a rare entity (Figure 1
). RLRV causing PCS has been reported [3]. We present two patients with double RLRVs, diagnosed by multidetector row CT as the possible cause of PCS. To the best of our knowledge, this is the first report of an association between PCS and double RLVRs.
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Figure 1. (a) Coronal diagram shows embryological development of the renal veins and inferior vena cava. Three paired embryonic vessels and their anastomoses contribute the inferior vena cava and renal veins. Dashed lines represent trace of the left renal vein variants; normal left renal vein, type 1 retroaortic left renal vein and type 2 retroaortic left renal vein. (b) Coronal diagram shows upper (Type 1) and lower (Type 2) double retroaortic left renal veins (RLRV) identified in our patients. LOV: left ovarian vein, IVC: inferior vena cava, LRV: left renal vein, card: cardinal, post: posterior.
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Case 1
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A 55-year-old woman was brought to our emergency department after falling 3.5 m from the roof of a house to the ground. She complained of pelvic pain. The only physical finding was tenderness in the left lower abdomen around the left ovarian area. Her past medical history was significant for having had dull pelvic pain for 17 years that was exacerbated by prolonged standing. She had given birth to six children.
Results of laboratory analyses revealed mild anaemia. An initial abdominal and pelvic ultrasound was performed. No intra-abdominal or pelvic fluid, mass or bowel abnormality was observed. CT (Sensation 4; Siemens, Erlangen, Germany) was performed for further evaluation and to find out a probable cause for the CPP. CT scan showed double RLRVs and varicose veins around the uterus, and tortuous and dilated left ovarian veins seen from the level of the ovaries up to the L4 level, where the left ovarian vein joins the inferior RLRV. There was also a second superior RLRV. Both RLRVs drained separately into the inferior vena cava (Figure 2). Mild dilatation of arcuate uterine veins and right ovarian varicose veins also was identified. Continuous retrograde flow was identified by colour Doppler ultrasound (CDUS) in the left ovarian vein during Valsalva manoeuvre as well as during normal breathing in the supine position.
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Figure 2. 55-year-old woman with pelvic congestion syndrome. (a,b) Axial and (c) coronal thin-slab maximum intensity projection multidetector row CT images show upper (arrows) and lower (arrowheads) retroaortic left renal veins and left pelvic varices (double arrows in (c)) that drain into the lower retroaortic left renal vein. AO: aort, IVC: inferior vena cava, RLRV: retroaortic left renal vein, ROV: right ovarian vein, LOV: left ovarian vein, U: uterus.
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Common causes of chronic pelvic pain which include endometriosis, irritable bowel syndrome and pelvic inflammatory disease were excluded based on the physical findings, normal biochemical tests results, absence of pelvic mass, fluid or intestinal abnormality on ultrasound and CT examinations. Typical history, clinical and radiological findings were diagnostic for PCS.
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Case 2
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A 48-year-old woman presented with pelvic and upper abdominal pain, sweating and fatigue. Her physical examination revealed tenderness over the entire abdomen and varicose veins in the subcutaneous tissue of the lower abdomen and both thighs. Her past medical history was significant for moderate lower abdominal pain of 12 years. Urgency and post-coital pain were associated with these symptoms. She had been pregnant seven times, with two abortions and five live children.
Laboratory findings revealed mild anaemia. Thrombocyte count was low at 68 900 (normal range 130–400x103 mm–3). Results of blood chemistry including hepatic and renal functions, antithrombin III and glucose-6-phosphate dehydrogenase levels, activated partial thromboplastin and prothrombin times, results of the sickling test, and factor V level were all normal. Real-time B-mode and CDUS demonstrated portal vein thromboses, splenomegaly and splenic infarcts. Abdominal CT scan showed portal vein and superior mesenteric vein thromboses, splenorenal collateral veins, double RLRVs, dilated left pelvic-ovarian veins and arcuate veins of the uterus. Variceal lower abdominal and pubic-vulvar veins also were observed. Intra-abdominal fluid, mass or intestinal abnormality were not identified on CT scan. Transabdominal, pelvic and transvaginal CDUS revealed a dilated left ovarian vein and parauterine varices. Continuous reversed caudal flow was identified by CDUS in the left ovarian vein during Valsalva manoeuvre and during normal breathing in the supine position. The uterus and ovaries were normal. Results of a bone marrow and liver biopsies were normal. History and clinical findings were suggestive for PCS; CT and ultrasound findings with biochemical test results were diagnostic for PCS.
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Discussion
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PCS is a frequently overlooked gynaecological complaint characterized by CPP. The pain is exacerbated by movements that cause an increase in intra-abdominal pressure such as lifting, walking, or prolonged standing [4]. Dysmenorrhoea, post-coital pain, bladder irritability, vulval and lower extremity varicosities may be associated findings [1]. Clinical examination is characterized by ovarian point tenderness on abdominal palpation [4]. It is believed that mechanical and hormonal factors are responsible in the aetiology of PCS. It has been suggested that the dilatation of the ovarian veins during pregnancy is a likely cause of subsequent venous incompetence. Reflux in the ovarian veins may lead to dilatation of ovarian veins and parauterine varices, which is the most likely aetiology of PCS [5].
The ultrasound findings of ovarian and pelvic varicoceles are tortuous and dilated pelvic venous plexuses around the ovary and uterus with a reversed caudal flow of the ovarian vein [2]. CT findings of the PCS consist of retrograde filling of incompetent dilated ovarian veins from the left renal vein (LRV) in the arterial-phase [6] and varicose veins around the uterus and ovaries [5]. The presence of dilated pelvic veins greater than 5 mm in diameter is indicative of pelvic varices, and greater than 8 mm in diameter is indicative of PCS [2]. Passive reflux from the LRV to the left ovarian veins and pelvic varices has been reported in asymptomatic women; therefore, diagnosis of PCS depends heavily on appropriate clinical history [5]. Embryologically, the LRV develops from a circumaortic venous ring (Figure 1a
). In the normal form, the LRV forms ventral to the aorta through regression of the retroaortic component. Retroaortic LRV variant, seen in 1.7–3.4% of population [7], arises from persistence of the retroaortic component and regression of the anterior limb. Two types of RLRV have been noted. Type 1 develops from persistence of the left subsupracardinal anastomosis, the intersupracardinal anastomosis and the dorsal LRV. Type 2 is formed by persistence of the left subsupracardinal anastomosis and left supracardinal vein. Type 2 RLRV is low in position (at the level of the L4–L5) compared with type 1 RLRV [8].
Double RLRV is very rare and has not been reported as a cause of PCS. In both of our cases, type 1 and type 2 RLRV observed together formed a double RLRV (Figure 1b). We clearly visualized dilated and varicose left ovarian vein draining into the inferior left renal vein by CT and CDUS in both patients. Continuous retrograde flow in the incompetent left ovarian vein was demonstrated by CDUS. Both patients had the clinical findings of PCS and all of these findings were diagnostic for PCS. The left ovarian vein was draining into the inferior RLRV.
Desimpelaere and colleagues [6] have reported that CT is an effective method for diagnosing PCS by demonstrating retrograde filling of the incompetent and dilated left ovarian vein from the RV in arterial-phase by using helical CT. In their report, they did not mention the presence of the RLRV, which we suggest might be a possible cause of retrograde filling of the left ovarian vein. Today, arterial-phase is not required with MDCT for demonstration of the ovarian vein reflux because the uterus is in its parenchymal phase and uterine and parauterine veins are not yet opacified during the portal venous phase. Opacification of the left ovarian, parauterine and uterine veins in the portal phase indicate retrograde flow from the left renal vein [5].
Varied venous abnormalities or variants causing PCS have been reported. These include anterior and posterior Nutcracker syndromes and RLRV without Nutcracker syndrome [3]. The Nutcracker or LRV compression phenomenon is defined as LRV compression between the aorta and the superior mesenteric artery (anterior Nutcracker phenomenon), or between the aorta and vertebral column (posterior Nutcracker phenomenon) [3]. If the compression causes renal venous hypertension, it is then called Nutcracker syndrome; which can result in left flank pain, unilateral haematuria, varicocele and pelvic varices [3]. CT criterion for the syndrome has been defined as a diameter ratio of the left renal vein at the draining level of the left ovarian vein and at the compression (aortomesenteric) level of 5 or more. The findings in our patients did not meet the criterion for Nutcracker syndrome although we considered that compression of the double RLRVs between the aorta and the vertebral column might have caused incompetence and retrograde flow in the left ovarian vein. Drainage of the left ovarian vein into a variant lower retroaortic renal vein might be the cause of incompetence of the left ovarian vein. There is a possible direct relationship between RLRV and left PCS, which requires further research. This phenomenon has not been reported previously. In our second case, we assessed CT demonstration of the enlarged left gonadal vein as a drainer of portal-systemic shunt. Because of the collateral splenorenal veins and retrograde flow in the left ovarian vein, the dilated left ovarian vein also drained some renal and portal venous blood return. This might be a contributing factor for PCS.
In conclusion, double retroaortic left renal veins may be a contributing factor for the development of left pelvic congestion syndrome. Variant venous anatomy should be searched in symptomatic patients with pelvic varices. This may provide an opportunity for treatment, such as coil embolisation of the left ovarian vein.
Received for publication July 27, 2005.
Revision received January 6, 2006.
Accepted for publication January 9, 2006.
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References
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Abstract
Introduction
