IS case 542: Varix of the left gonadal vein, secondary to obliteration of the IVC

Jeremy Duda, MD

University of Rochester

Imaging Sciences URMC 2010
Publication Date: 2010-09-17

History

Patient is a 47-year-old male with past medical history of chronic venous insufficiency now presenting with nausea, vomiting and severe left flank pain.

Findings

Axial and reconstructed images from a CT venogram were obtained of the pelvis. Axial images showed a venous-enhancing, globular, undulating mass of uncertain origin in the left pelvis. Coronal images showed a communication to the left renal vein, as well as a tortuous ectatic course through the pelvis, and a distal communication with the left gonadal vein. Further review of the axial images demonstrated obliteration of the distal IVC. Axial CT images of the lower extremity demonstrated soft tissue changes consistent with chronic venous insufficiency.

Diagnosis

Varix of the left gonadal vein, secondary to obliteration of the IVC

Discussion

IVC obstruction may be secondary to extrinsic compression or thrombosis, the latter precipitated by trauma, tumor, instrumentation, or idiopathic causes.

Subsequently, central venous return from the lower extremities and pelvis must take an alternative pathway, depending on the caliber of vessel and the chronicity of the occlusion. Primary deep venous systems such as the azygous-hemiazygous and vertebral venous plexus freely communicate with the IVC. Secondary deep venous systems include the inferior mesenteric, renal, ureteral and gonadal veins.

The gonadal vein can be the largest single collateral vessel, especially in instances of chronic occlusion of the IVC. There are numerous venous connections with the pelvic venous plexus, particularly in females, which allows bidirectional flow to either vein. However, the left gonadal vein is more constant due to the higher frequency of right gonadal vein thrombosis.

In this case, the patient presented with obliteration of the IVC, a likely cause of the patient's chronic lower extremity venous insufficiency, and a large varix of the left gonadal vein secondary to the central obstruction.

References

  1. Golub R, Parsons R, Sigel B, Barnes AU. Review of venous collaterals in inferior vena cava obstruction. Clinical Anatomy 1992;5:441-451.
  2. Royal SA, Callen PW. CT evaluation of anomalies of the inferior vena cava and left renal vein. AJR Am J Roentgenol. 1979 May;132(5):759-63. PMID: 107741

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