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Journal de radiologie
Vol 79, N° 2  - mars 1998
p. 127
Doi : JRE-03-1998-79-2-0221-0363-101019-ART95
 

J Radiol 1998;79:127-132 (in French)

© Editions françaises de radiologie, Paris, 1998

ORIGINAL ARTICLE

Puerperal ovarian vein thrombophlebitis extending to the inferior venacava: US, CT, and MRI appearance.

Y Ranchoup (1), F Thony (1), S Dal Soglio (1), I Farah (2), JL Bosson (2),C Villar (3), M Coulomb (1) et G Ferretti (1)

(1) Service Central de Radiologie et Imagerie Médicale CHU Grenoble - BP 217 38043 Grenoble Cedex O9 (2) Service de Chirurgie Vasculaire (3) Service de Gynécologie Obstétrique Correspondance : Y Ranchoup

Abstract

Purpose: To evaluate the US, CT, and MR findings in women with post partumthrombophlebitis of the ovarian vein (TOV) extending to the IVC.

Materials and Methods: The Doppler US (n=9), CT (n=5), and MR (n=5)examinations of 9 patients with TOV (8 right-sided, 1 left-sided) and IVC extension wereretrospectively reviewed.

Results: US allowed correct diagnosis of TOV in all patients andvisualization of the distal ovarian vein, renal vein, and suprarenal IVC. CT and MR bothshowed the thrombosed ovarian vein but overlooked a free-floating IVC thrombus in 1patient.

Conclusion: US is easy to perform, allows accurate diagnosis of TOV,detection of potential IVC extension of thrombus, and identification of the cranial extentof IVC thrombus. In cases where US is suboptimal, CT and especially MR allow diagnosis ofTOV and potential IVC extension.

Keywords: Vein, ovarian. Vein, MRI. Vein, US. Vein, CT. Inferior venacava, thrombosis.

US = ultrasonography

CT = computed-tomography

MR = magnetic resonance

TOV = thrombophlebitis of the ovarian vein

IVC = inferior vena cava

ROV = right ovarian vein

LOV = left ovarian vein

SE = spin echo

Introduction

Thrombophlebitis of the ovarian vein (TOV) is a rare but potentially fatalentity that most commonly occurs during the postpartum period. Extension to the inferiorvena cava (IVC) occurs commonly but pulmonary embolism is extremely rare. Cross-sectionalimaging including US, CT an MR is used for diagnosis. We have retrospectively reviewed 9cases of TOV to evaluate the role of each imaging modality in diagnosing TOV and detectingIVC extension.

Materials and Methods

Between October 1988 and November 1996, 9 patients with puerperal TOV wereevaluated. The patients were aged 28 to 34 years old. Diagnosis was made by imaging(Doppler US, CT, MR) and confirmed by favorable clinical outcome following medical therapyin 6 cases and surgery in 3 cases. All patients presented with acute lower abdominal painand fever 3 to 9 days following delivery (8 C-section, 1 vaginal delivery). Seven patientshad clinical symptoms of endometritis. One patient presented with clinical symptoms ofright ureteral obstruction and fever.

US was performed in all patients and included pulsed Doppler (n=3)(Hitachi EUB 450) or pulsed and color Doppler (n=6) (Acuson XP 128). For all patients, USwas the first imaging test requested and performed 1 to 3 days following the onset ofsymptoms. CT of the abdomen and pelvis was performed in 5 patients (GE-CGR CE 12000) andincluded 10mm thick axial sections at 15mm intervals prior to and following intravenousadministration of iodinated contrast material. MRI was obtained in 5 patients (Magne-scanGE 0.5T) and included spin echo T1W sequences (TR 560 ms, TE 25 ms) in the axial plane(10mm thick at 16mm intervals) from the pelvis to the right atrium, and in a rightparasagittal plane centered over the IVC (7mm thick at 9mm intervals). Seven of 9 patientswere imaged with more than one modality over a time period not exceeding 3 days (3patients had US, CT, and MR; 2 patients had US and CT; 2 patients had US and MR). Allpatients underwent a ventilation/perfusion lung scan within 8 days following the onset ofsymptoms.

The usefulness of each individual imaging modality (US, CT, and MR) wasevaluated both for diagnosis of TOV and detection of IVC extension.

Results

All patients had ovarian vein thrombophlebitis (8 right, 1 left) extendingto the IVC.

TOV was always seen, irrespective of the imaging modality. On US, itpresented as a retroperitoneal hypoechoic tubular structure, 15 to 28mm wide, lateral tothe infrarenal IVC for right-sided TOV (Fig. 1) or lateral to the aorta for left-sidedTOV. The pelvic portion of the involved ovarian vein was poorly seen in 4 patients due tothe presence of overlying bowel gas, but the distal 5cm were visualized in all patientsallowing diagnosis. On CT (n=5), the typical appearance of TOV included: enlarged andhypodense vein with peripheral rim-enhancement, retroperitoneal, lateral to the IVC (n=4)or aorta (n=1), lateral to the ureter (Fig. 2). On MR (n=5), thrombosed ovarian veinsappeared enlarged and contained heterogeneous but hyperintense thrombus, more so at theperiphery, and a peripheral rim of low signal (Fig. 2).

In 7 cases of right-sided TOV, extension of the thrombus in the IVC to thelevel of the renal veins was well shown on US (Fig. 3). In the last case of right-sidedTOV, the confluence of the ROV was high, thrombus in the IVC extended to the level of therenal veins, and there was incomplete thrombosis of the right renal vein. In all cases ofright-sided TOV with IVC extension, the thrombus in the IVC was non-mobile and partiallyobstructive. For the single patient with left-sided TOV, the IVC thrombus was thin, verymobile, and extended superiorly to the level of the hepatic veins; this patient also hadpartial thrombosis of the left renal vein which was not seen on US. The IVC below theconfluence of the ovarian vein was seen on US in 5 of 9 patients. In patients withright-sided TOV, both CT (n=4) and MR (n=4) showed the IVC thrombus (Fig. 2). The superiorextent of the IVC thrombus was poorly visualized on CT, but it was very well demonstratedon sagittal MR images (Fig. 3). Right renal vein thrombus was well seen on axial MR images(not included on CT examinations). For the single case of left-sided TOV, a long and thinIVC thrombus was not visible on CT and MR. However, the partial thrombosis of the leftrenal vein, not seen on US, was seen with both CT and MR. Evaluation of the IVC below theconfluence of the ovarian vein was always possible on CT and especially MR, and thisportion of the IVC was patent in all patients (Fig. 2).

In 8 patients with right-sided TOV, the collecting system of the rightkidney was dilated. The patient that presented with symptoms of right ureteral obstructionhad findings suggestive of obstruction on contrast-enhanced CT with delayed excretion ofcontrast material. On all imaging studies, the uterus was enlarged but without discretefluid collection. All lung scans were normal.

Discussion

Thrombophlebitis of the ovarian vein may occur in the setting of pelvicinflammatory disease, malignancy or following gynecological surgery (1, 2).

Nonetheless, TOV most commonly occurs during the post-partum period. Theincidence of TOV is low, ranging from 0.05 to 0.18% (3, 4). Three risk factors have beenreported (5): stasis, infection, and hypercoagulable state. It corresponds to uterinethrombophlebitis and seems to occur more commonly following cesarean section (8 of 9cases). Predilection for the right ovarian vein (80% ROV, 14% bilateral, 6% LOV) could besecondary to compression of the ROV against the sacral promontory by an enlargeddextroverted uterus and presence of retrograde flow in the left ovarian vein. Clinicalfindings are non-specific. Symptoms usually appear during the first week followingdelivery and typically include pain in the iliac fossa or lumbar region, fever, andsometimes a palpable mass. Symptoms of ureteral obstruction may predominate (6). Clinicalsymptoms may simulate acute appendicitis or a pelvic infection (torsion of an ovariancyst, tubo-ovarian abscess, hematoma of the broad ligament) (1-3). On intravenous urogram,dilatation of the ipsilateral upper tract is seen due to compression of the ureter by thethrombosed ovarian vein (6, 7). IVC venography may suggest the correct diagnosis byshowing a filling defect at the ovarian vein confluence or thrombus in the IVC (7, 8).Prior to the advent of cross-sectional imaging, the diagnosis of TOV often was surgical[54/64 cases in a series by Erny (9)].

On cross-sectional imaging, the diagnosis often is suggested due to thetypical appearance of the thrombosed ovarian vein. On US, TOV presents as a largeretroperitoneal tubular and echogenic structure, lateral to the IVC or aorta, anterior tothe psoas muscle (10-12); the limitations of US are related to the operator dependentnature of the technique and the presence of excessive bowel gas. In our series, it wasalways possible to visualize at least the distal few centimeters of the thrombosed ovarianvein. On CT, an enlarged and hypodense ovarian vein with peripheral rim-enhancement isnoted (12-15). The thrombosed vein is closely related to the lateral wall of thecontrast-filled ureter on contrast-enhanced CT; presence of gas within the thrombussuggests the septic nature of the process (7). The variable appearance of the thrombus onspin echo MR sequences is related to the paramagnetic properties of blood degradationproducts. On SE T1W sequences, the clot is hyperintense to muscle; on SE T2W sequences,the thrombus is hypointense centrally (deoxyhemoglobin), has an intermediate rim of highsignal (methemoglobin) and a peripheral rim of low signal (hemosiderin) (16, 17).Stranding of the retroperitoneal fat adjacent to the TOV can be seen on both CT and MR(12, 16).

US combined with Doppler, CT and MR can all diagnose the presence of IVCextension, which was present in all of the patients included in our sample. Because CTdata is acquired in the axial plane, perpendicular to the axis of the IVC, it may bedifficult to accurately identify the cranial extent of the thrombus, especially itsrelationship to the renal veins. US (18) and MRI (12, 16, 17) both allow directacquisition of images in the sagittal plane therefore facilitating evaluation of the IVCthrombus and accurate localization of its most cranial extent; it seems likely thathelical CT acquisition with sagittal reformatting of the dataset would improvevisualization of the IVC thrombus in its entire length. In patients with freely mobile IVCthrombus, CT and MRI may overlook the presence of thrombus, which is easily seen on US.Evaluation of the IVC below the confluence of the ovarian vein may be limited on US due tooverlying bowel gas; MRI allows good evaluation of this portion of the IVC and may alsoallow detection of slow flow phenomenon. MRA can be performed to further evaluate the IVC,either using a 2D time-of-flight technique or a gadolinium-enhanced sequence. However,thrombus in the IVC below the confluence of the thrombosed ovarian vein was seen in noneof our patients.

US, CT, and MRI are all adequate imaging techniques to visualize thepresence of renal vein thrombosis, especially on the left. Because the right ovarian veintypically joins the IVC a few centimeters below the level of the right renal vein,involvement of the right renal vein is rare. However, in patients with a more cranialconfluence of the right ovarian vein, close to the confluence of the right renal vein withthe IVC, involvement of the right renal vein with thrombus can occur; this was seen in oneof our patients. As previously described in the literature (19), involvement of the leftrenal vein with thrombus, seen in 2 of our 9 patients, did not impair function of theipsilateral kidney; this is probably due to the non-obstructive nature of the thrombus inthese patients. Dilatation of the renal collecting system, usually right-sided, is nonspecific. Symptoms of acute ureteral obstruction in a febrile patient raise thepossibility of compression of the ureter by the thrombosed ovarian vein (6), especially ifthere are findings suggestive of renal obstruction on contrast-enhanced CT scan. Pulmonaryembolism is rare, even in patients with IVC thrombus (20). This is probably due to thefact that the septic thrombus usually is adherent to the wall of the IVC (3).

Due to the small size of our sample and the retrospective nature of thisstudy, it is not possible to assess sensitivity and specificity for each of thecross-sectional imaging modalities. Reports in the literature are mostly anecdotal orbased on small series (5 patients in the largest series (12)). In our series, US correctlyidentified the presence of TOV and IVC extension in all patients. In only one patient didCT and MR improve detection of thrombus in a left renal vein.

Treatment of TOV includes antibiotics and anti-coagulation. Involvement ofthe IVC does not require surgical intervention. Surgery should be considered in patientswith persistent symptoms or in patients with pulmonary embolus despite adequate medicaltreatment. Thrombolysis of the IVC thrombus has been suggested by some authors (2, 3). USwith Doppler can easily be used for follow-up during medical management of patients withTOV.

Conclusion

Thrombophlebitis of the ovarian vein is a rare but potentially fatalcomplication of post partum. Its clinical manifestations are non specific. Early diagnosisallows adequate medical management and can prevent unnecessary surgical exploration. Thepossibility of TOV should be raised in all post partum patients presenting with acuteabdominal pain and fever. US with Doppler is easy to perform and can accurately diagnoseTOV, detect potential IVC involvement, identify the cranial extent of IVC thrombus, and itcan also be used for follow-up of patients being managed by medical treatment. In patientwhere US is suboptimal, MRI should be preferred over CT because it does not requireintravenous administration of iodinated contrast material and allows optimal evaluation ofthe inferior vena cava.



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