Throughout each examination, the sonographer should:

• Observe sonographic characteristics of normal and abnormal tissues, structures, and blood flow, allowing necessary adjustments to optimize exam quality.
• Assess and monitor the patient’s physical and mental status, allowing modifications to the procedure plan according to the patient’s clinical status.
• Analyze sonographic findings to ensure that sufficient data is provided to the physician to direct patient management and render a final diagnosis.

Follow a standard imaging protocol per department specific/facility specific anatomic algorithm. A complete transabdominal pelvic venous evaluation incorporates B-mode, spectral Doppler with color and/or power Doppler imaging and include the following:

• B-Mode imaging is used to depict presence or absence of venous dilatation, optimize vessel wall and abnormalities i.e. thrombus or intraluminal echoes.
  • Proper vein diameter measurements are acquired anterior wall to posterior wall.
  • Calculate diameter ratio as required by facility-specific protocol.
• Color Doppler is used to depict areas of abnormal flow or significant stenosis. Power Doppler is useful to confirm areas of possible vessel occlusion or low flow states.
• Spectral Doppler is used to evaluate flow characteristics and velocity. To obtain peak velocity, utilize color Doppler to note areas of concern and “walk” the spectral Doppler cursor throughout these areas. Post-stenotic turbulence is documented when present. Calculate velocity ratio as required by facility-specific protocol. To achieve accurate velocity ratio results, consider the following:
  • Obtain velocity measurements in longitudinal plane.
  • Maintain a Doppler angle between 45° and 60° parallel to the direction of the blood flow/vessel walls. Doppler angles less than 45° may be necessary due to patient anatomy. The same angle of insonation is maintained throughout the examination.
• Utilization of varying maneuvers to elicit reflux: Patient positioning, Valsalva maneuvers, distal augmentation and/or proximal compression.

Interrogation and documentation of the following veins is the minimum requirement:

• Inferior vena cava (IVC)
• Left renal vein (LRV)
• Bilateral iliac veins (common, external and internal)
• Bilateral ovarian veins
• Trans-uterine and peri-uterine veins

The following veins are included if indicated or required by the facility specific-protocol:

• Common Femoral Vein
• Pelvic leak points: obturator veins, superior and inferior gluteal veins, perineal vein, labial vein, clitoral vein and round ligament vein.

Evaluation of the Uterus and Uterine/Parauterine Veins

It is best to begin with the evaluation of the fundus of the uterus and uterine/parauterine veins. The patient should have a full bladder to optimize visualization of the veins. Utilize B-Mode, Color Doppler and/or Spectral Doppler images to evaluate for the presence or absence of varicosities.

For patient comfort, the patient may relieve their bladder after completing this evaluation. Further evaluation of the transabdominal pelvic veins is continued according to facility-specific protocol.

Evaluation of the IVC

Interrogation and documentation of vein diameter measurements and spectral Doppler waveforms are obtained at the following sites:

• The entire length of the IVC between the xiphoid process and umbilicus.
• Anatomic anomalies require additional images i.e., hypoplasia, aplasia and duplication.
• Abnormalities require additional images i.e., presence of collateral veins, obstruction and compression.

Evaluation for Left Renal Vein Compression

Interrogation and documentation of vein diameter measurements and spectral Doppler waveforms are obtained in longitudinal plane at the following sites:

• Left renal vein
  • Cava side (before it crosses the SMA and AO)
  • At the level of the SMA and Aorta
  • Kidney side (peripheral to the SMA and Aorta)
  • Any areas of luminal reduction
• Anatomic anomalies require additional images, i.e., retro-aortic renal vein.
• Abnormalities require additional images i.e., in the presence of collateral veins and flow diversion from the LRV to the left ovarian vein (LOV).
• If required according to facility-specific protocol, calculate velocity ratio.

Evaluation for Iliac Vein Compression or Obstruction

Interrogation and documentation of vein diameter measurements and spectral Doppler waveforms are obtained at the following sites:

• Left Common Iliac Vein
  • Proximal, at and distal to the right common iliac artery
  • Any areas of luminal reduction (Proximal, at and distal to the narrowed segment)
• Right Common Iliac Vein
• Bilateral External Iliac veins
• Abnormalities require additional images, i.e., in the presence of collateral veins, asymmetrical flow and any areas of luminal reduction.
  • Note: While less common, compression of all of the iliac vein segments is possible. When fully evaluating for pelvic venous disease compression of all of the iliac vein segments should be considered and documented appropriately.
• If required according to facility-specific protocol, calculate velocity ratio.

Evaluation of the Internal Iliac Veins

Evaluation of the internal iliac veins for assessment of flow characteristics may include different patient positioning and/or maneuvers to elicit reflux, according to facility-specific protocol. The following should be considered when assessing for reflux:

• To elicit reflux, the following maneuver(s) can be performed: Valsalva maneuver, distal augmentation or proximal compression.
• In the absences of spontaneous reflux with the patient in reversed Trendelenburg position, pelvic leak points can be evaluated according to facility-specific protocol.

Interrogation and documentation of vein diameter measurements and spectral Doppler waveforms are obtained at the following sites:

• Bilateral Internal Iliac veins
  • at the confluence of the external and common iliac veins
• Document reflux time measured in milliseconds, according to facility-specific protocol.
• Abnormalities require additional images when present.
• Anatomic anomalies require additional images, according to facility-specific protocol.
• External pelvic source veins on the lower extremity or pelvic leak points (obturator veins, superior and inferior gluteal veins, perineal vein, labial vein, clitoral vein and round ligament vein).
  • While not required, evaluation of pelvic leak points can indirectly show evidence of incompetence of deep pelvic vein branches some of which are directly related to the internal iliac veins.

Evaluation of the Ovarian Veins (Female) or Gonadal Veins (Male)

Evaluation of the ovarian veins or gonadal veins for assessment of flow characteristics may include utilization of different patient positioning and/or maneuvers to elicit reflux, according to facility-specific protocol. The following should be considered:

• To elicit reflux, the following maneuvers are performed: Valsalva maneuver, distal manual augmentation or proximal compression.
• In the absences of spontaneous reflux with the patient in reversed Trendelenburg, position the patient in upright (sitting or standing) position. Repeat interrogation and documentation of the ovarian/gonadal veins.

Interrogation and documentation of vein diameter measurements and Color/Spectral Doppler waveforms are obtained at the following sites:

• Bilateral ovarian veins (female):
  • Proximal, mid and distal
• Bilateral gonadal veins (male):
  • Proximal, mid and distal
• Document reflux time measured in milliseconds, according to facility-specific protocol.
• Abnormalities require additional images when present.
• Anatomic anomalies require additional images, according to facility-specific protocol.