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Pelvic venous insufficiency and POTS

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    By Katherine Kozlowski, Medical Author and Contributor to Ven News and www.VeinsVeinsVeins.com

    Imaging findings of pelvic venous insufficiency in patients with postural orthostatic tachycardia syndrome

    What is POTS ? 
    Postural orthostatic tachycardia syndrome (POTS) is a condition in which the heart rate increases significantly (tachycardia) due to a change in posture (orthostatic), from lying or sitting down to standing upright. This is due to dysfunction of the autonomic nervous system (dysautonomia).

    What is the autonomic nervous system? 
    The autonomic nervous system is a component of the non-central nervous system which regulates involuntary physiologic processes including heart rate regulation, blood pressure regulation via vasodilation and vasoconstriction, respiration, and digestion among others.

    What is the incidence of POTS? 
    According to Dysautonomia International, POTS is estimated to affect 1 out of 100 teenagers and, including adult patients, a total of 1 million to 3 million Americans. It is most frequently seen in young women, often less than 35 years of age.

    What are the diagnostic criteria for POTS? 
    The current diagnostic criteria for POTS is the presence of orthostatic intolerance associated with a sustained heart rate increase of 30 beats per minute (bpm) or absolute rate exceeding 120 bpm within the first 10 minutes of standing or upright tilt in the absence of other chronic debilitating disorders

    What is the natural history of POTS? 
    AK Agarwal and colleagues state that  ">90% respond to a combination of physical methods as well as pharmacotherapy. In the hyperadrenergic state, patients will require lifelong treatment. In the secondary form, the causative disorder has to be treated in order for patients to become symptom-free".

    In the study we are reviewing in this article, researchers at the Mayo Clinic Arizona tried to determine the relationship of POTS with pelvic venous insufficiency. 

    What is pelvic venous insufficiency and how is it diagnosed? 
    According to Mark Meissner and colleagues, multiple diagnostic modalities including pelvic duplex ultrasonography, transvaginal ultrasonography, computed tomography, and magnetic resonance were studied. In the current literature, selective ovarian venography, an invasive imaging approach, is believed to be the gold standard for diagnosing pelvic congestion syndrome and pelvic venous insufficiency.

    Pelvic venous insufficiency (PVI) is the standardized definition that specifically refers to the pathophysiology of retrograde flow through incompetent ovarian and pelvic varices.

    What is the background to this study? 
    Some patients with POTS show improved dysautonomic symptoms after treatment for pelvic venous insufficiency. 

    What was the hypothesis of this study? 
    The authors sought to determine if POTS and venous compression are independent of one another. Knuttinen et al (2020) did a retrospective study to examine the prevalence of left common iliac vein compression (LCIV) in patients with POTS. LCIV compression by the common iliac artery contributes to pelvic venous insufficiency.

    How was the study done (methods)? 
    CT images of pelvic veins for 216 women were reviewed.

    What were the results of this study?
    131 of 191 females (69%) with POTS had significant (greater than 50%) LCIV compression. 

    40% of controls had significant LCIV compression.

    The results of the study suggest that POTS and venous compression are related (p = .005).

    What are the conclusions of this study? 
    Knuttinen et al. concluded that “the incidence of iliac venous obstruction [in female POTS patients] may be higher than the general population”. Thus, they suggest that patients diagnosed with postural orthostatic tachycardia syndrome that have symptoms of pelvic venous insufficiency could benefit from venous outflow obstruction assessment.


    Knuttinen, M., Zurcher, K., Khurana, N. et al., Imaging findings of pelvic venous insufficiency in patients with postural orthostatic tachycardia syndrome. Phlebology 2020: 36(1) 32-37.

    Labrpopoulos NL, Jasinski PT, Adrahtas D, Gasparis AP, Meissner MH. A standardized ultrasound approach to pelvic congestion syndrome.  Phlebology 2017; 32(9): 608-619. 

    Agarwal AK, Garg R, Ritch A and Sankar P.  Postural orthostatic tachycardia syndrome.  Postgrad Med J 2007; 83: 478-480.