CLINICAL INDICATION: Painful expanding left vulvovaginal varix.
PROCEDURE, DESCRIPTION AND FINDINGS: With the patient supine on the
examining table, the skin over the right groin was prepped and draped
in standard fashion and locally anesthetized with 1% Lidocaine. The
skin over the vulval varix was also locally anesthetized. The right
common femoral vein was punctured with a single wall needle, allowing
the insertion of a 0.035 inch guidewire and #7 French RVC guide.
Through this, selective catheterization of both the left and right
ovarian veins was performed using a coaxially introduced Cobra glide
catheter. However, contrast injection for bilateral ovarian
venography showed retrograde flow in the ovarian veins down to the
level of the round ligaments and pelvic vault without retrograde
filling into the known left vulval varix. Direct puncture of the
varix was then performed with a #21 gauge needle and contrast
injection was performed demonstrating drainage by what appeared to a
deep pelvic vein on the right side. Therefore, the catheters were
advanced initially for selective left hypogastric venography and
subsequently selective right hypogastric venography. While these did
not initially show retrograde flow into the varix, there was
enlargement of the lower pelvic venous plexus. From the right side,
using a coaxially introduced Renegade microcatheter, it was possible
to eventually catheterize the incompetent deep pelvic vein supplying
the left vulval varix. During the course of this, multiple other
retrograde contributing incompetent veins in the left-sided deep
pelvic vein were identified. Therefore, selective catheterization of
three incompetent left pelvic veins was performed and these were
selectively embolized with microcoils until there was occlusion. The
catheter was then advanced into the nidus of the left vulval varix.
Through the catheter, sclerosis was performed with a total of 20 cc
of 3% Sotradecol foam. The dominant incompetent feeding vein was
then embolized from the inguinal ring retrograde to the origin of the
deep pelvic plexus using multiple additional microcoils. Completion
venography demonstrates stasis of contrast within the vulval varix
without any persistent retrograde venous filling.
The vulval needle and the right femoral sheath and catheter were
removed and hemostasis achieved on both sides by manual compression.
There were no immediate complications. Fentanyl and Versed were
given for intravenous analgesia under Radiology Nursing supervision
with pulse oximetry. Less than 150 cc of contrast were used.
IMPRESSION:
Successful selective catheterization, sclerosis and embolization of
multiple deep pelvic incompetent veins supplying a left vulval varix.
Pls suggest the codes.
PROCEDURE, DESCRIPTION AND FINDINGS: With the patient supine on the
examining table, the skin over the right groin was prepped and draped
in standard fashion and locally anesthetized with 1% Lidocaine. The
skin over the vulval varix was also locally anesthetized. The right
common femoral vein was punctured with a single wall needle, allowing
the insertion of a 0.035 inch guidewire and #7 French RVC guide.
Through this, selective catheterization of both the left and right
ovarian veins was performed using a coaxially introduced Cobra glide
catheter. However, contrast injection for bilateral ovarian
venography showed retrograde flow in the ovarian veins down to the
level of the round ligaments and pelvic vault without retrograde
filling into the known left vulval varix. Direct puncture of the
varix was then performed with a #21 gauge needle and contrast
injection was performed demonstrating drainage by what appeared to a
deep pelvic vein on the right side. Therefore, the catheters were
advanced initially for selective left hypogastric venography and
subsequently selective right hypogastric venography. While these did
not initially show retrograde flow into the varix, there was
enlargement of the lower pelvic venous plexus. From the right side,
using a coaxially introduced Renegade microcatheter, it was possible
to eventually catheterize the incompetent deep pelvic vein supplying
the left vulval varix. During the course of this, multiple other
retrograde contributing incompetent veins in the left-sided deep
pelvic vein were identified. Therefore, selective catheterization of
three incompetent left pelvic veins was performed and these were
selectively embolized with microcoils until there was occlusion. The
catheter was then advanced into the nidus of the left vulval varix.
Through the catheter, sclerosis was performed with a total of 20 cc
of 3% Sotradecol foam. The dominant incompetent feeding vein was
then embolized from the inguinal ring retrograde to the origin of the
deep pelvic plexus using multiple additional microcoils. Completion
venography demonstrates stasis of contrast within the vulval varix
without any persistent retrograde venous filling.
The vulval needle and the right femoral sheath and catheter were
removed and hemostasis achieved on both sides by manual compression.
There were no immediate complications. Fentanyl and Versed were
given for intravenous analgesia under Radiology Nursing supervision
with pulse oximetry. Less than 150 cc of contrast were used.
IMPRESSION:
Successful selective catheterization, sclerosis and embolization of
multiple deep pelvic incompetent veins supplying a left vulval varix.
Pls suggest the codes.