PROCEDURE: 

  1. Selective right internal iliac venogram.
  2. Sclerotherapy/embolization of right pelvic varices.
  3. Selective left internal iliac venogram.
  4. Sclerotherapy/embolization of left pelvic varices.

 

DATE: 

CLINICAL INDICATION: Pelvic venous insufficiency . The patient is status post embolotherapy of both ovarian veins. 

OPERATING PHYSICIANS: 

MEDICATIONS: 150 mcg IV fentanyl, 3 mg IV Versed, 50 mg IV Benadryl, and 1 g IV Ancef. 

ACCESS: Right internal jugular vein.

CONTRAST: 150 mL nonionic. mL non-ionic

FLUOROSCOPY TIME: 19.1 minutes

COMPLICATIONS: None immediate.

 

PROCEDURE: 

The risks, benefits and alternatives of the procedure and moderate sedation were discussed in detail with the patient. The specific risks of DVT and pulmonary embolism were discussed and accepted.  Written informed consent was obtained.

The patient was brought to the angiography suite and laid supine. The right neck was prepped and draped in sterile fashion. Under ultrasound guidance, a 21-gauge micropuncture needle was advanced into the internal jugular vein. A 0.018 inch Nitinol wire was placed through the needle. Over the needle, a 5 French transitional dilator was placed. This was used to exchange the 0.018 inch wire for a 0.035 inch Bentson wire. The Bentson wire was advanced into the inferior vena cava. A long 7 French vascular sheath was placed over the Bentson wire.

Through the sheath, a 5 French MPA catheter and Glidewire were used to select the right internal iliac vein. Right  internal iliac venography was performed. This catheter was used to exchange for a 0.035 inch Amplatz wire. The catheter was removed and a Fogarty catheter balloon was placed into the proximal/central right internal iliac vein and the balloon inflated under fluoroscopic guidance. Digital subtraction right internal iliac venography was performed. Care was taken to ensure no reflux into the external or common iliac veins was present. A mixture of sodium tetradecyl sulfate, Gelfoam pledgets, and air was used to create a  foam. Under fluoroscopic guidance, with the Fogerty balloon inflated, the sclerosant was injected, displacing static contrast within right pelvic varicosities. Approximately     mL of the sclerosing agent was used on the right. The sclerosant was allowed to dwell with the Fogarty balloon inflated for 15 minutes. The Fogarty balloon was then deflated and removed.

Over the Glidewire, the MPA catheter was again advanced and was used to select the left internal iliac vein. Left internal iliac venography was performed through the catheter to confirm position. An Amplatz wire was advanced through the catheter and the catheter was removed. The Fogarty catheter balloon was again placed over the wire. The Fogarty catheter balloon was inflated within the proximal/central left internal iliac vein and digital subtraction venography was performed. No appreciable reflux into the external or common iliac veins was identified. Similar to the contralateral side, foam sclerosant was injected, with the Fogarty catheter balloon inflated, displacing static contrast within left pelvic varicosities. Approximately 3 mL of the sclerosing agent was used on the right and was allowed to dwell with the Fogarty balloon inflated for     minutes. The Fogarty catheter balloon was then deflated and the catheter and sheath were removed. 

Hemostasis at the right neck was obtained with direct pressure. A sterile dressing was applied. The patient tolerated the procedure well and was transferred to the postprocedural care unit in stable condition.

 

FINDINGS: 

  1. Extensive right pelvic varicosities arising from right internal iliac vein branches that demonstrate cross-filling into the left sided pelvic varicosities.
  2. Static contrast within the right pelvic varicosities are displaced by foam sclerosant.
  3. Left pelvic varicosities arising from the left internal iliac vein are present, but less conspicuous than that seen on the right, likely related to right-sided  

 

IMPRESSION:  

Successful sclerotherapy/embolization of bilateral pelvic varicosities arising from the internal iliac veins.