The Role of CT Venography in the Diagnosis of Pelvic Venous Pathology in Women

Background: Pelvic venous disorders (PVDs) represent a common yet underdiagnosed cause of chronic pelvic pain in women of reproductive age. Diagnostic challenges are due to nonspecific symptoms and the necessity to exclude alternative disorders. Given the limitations of conventional catheter-based venography, there is increasing interest in noninvasive imaging techniques, particularly computed tomography venography (CT venography), as a potentially effective diagnostic modality.

Objective: To analyze current data on the capabilities of CT venography in the diagnosis of PVDs, including its effectiveness, advantages, and limitations compared with other imaging modalities.

Materials and methods: A systematic literature search was conducted using the PubMed and eLibrary databases, primarily covering publications from the last 10 years. Clinical studies, reviews, and consensus guidelines addressing the role of CT venography in PVDs were included.

Results: Recent studies demonstrate high sensitivity of CT venography in detecting varicose changes, venous reflux, and obstructive forms of PVD. The method enables detailed visualization of vascular anatomy, assessment of degree of compression, and identification of collateral circulation. CT venography is particularly valuable in suspected May–Thurner syndrome, nutcracker syndrome, and ovarian vein thrombosis. CT venography offers several diagnostic advantages including high spatial resolution, objectivity, and the ability to evaluate both anatomical features and etiopathogenesis, which is important for surgical treatment planning and for assessing treatment efficacy. However, its use is limited by radiation exposure and the requirement for intravenous contrast enhancement, necessitating a balanced approach when examining women of reproductive age.

Conclusions: CT venography represents a promising diagnostic modality for PVDs. When appropriately applied, it complements – and in some cases may surpass – other imaging techniques, improving diagnostic accuracy, and facilitating the selection of optimal treatment strategies. Further standardization of the technique and accumulation of clinical data are required to ensure its reliable integration into diagnostic algorithms for PVD. 

1. Marcelin C, Le Bras Y, Molina Andreo I, Jambon E, Grenier N. Diagnosis and Management of Pelvic Venous Disorders in Females. Diagnostics (Basel). 2022;12(10):2337. PMID: 36292025 PMCID: PMC9600975. https://doi.org/10.3390/diagnostics12102337

2. Fomina EE, Yakhin AM, Shavalieva AR. Rol’ KT-flebografii v diagnostike varikoznoi bolezni taza u zhenshchin. Acta Medica Eurasica. 2024; (2): 42–49 (in Russ)

3. Khilnani NM, Xia JJ, Winokur RS, Meissner MH. Diagnosis and Management of Pelvic Venous Disorders in Women. Cardiovasc Intervent Radiol. 2024;47(12):1650-1668. PMID: 39009841. https://doi.org/10.1007/s00270-024-03782-1

4. Meissner MH, Khilnani NM, Labropoulos N, et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disord. 2021;9(3):568-584. PMID: 33529720. https://doi.org/10.1016/j.jvsv.2020.12.084

5. Clark MR, Taylor AC. Pelvic Venous Disorders: An Update in Terminology, Diagnosis, and Treatment. Semin Intervent Radiol. 2023;40(4):362-371. PMID: 37575340. PMCID: PMC10415053. https://doi.org/10.1055/s-0043-1771041

6. Kashef E, Evans E, Patel N, Agrawal D, Hemingway AP. Pelvic venous congestion syndrome: female venous congestive syndromes and endovascular treatment options. CVIR Endovasc. 2023;6(1):25. PMID: 37076700. PMCID: PMC10115924. https://doi.org/10.1186/s42155-023-00365-y

7. Awad AS, Taha MM, Manaf MHA, Gad MMM, Mashhour SN. Role of multi-detector CT venography in evaluation of pelvic congestion syndrome. Egyptian journal of radiology and nuclear medicine. 2020; 51(1): 159. https://doi.org/10.1186/s43055-02000280-5

8. Knuttinen MG, Xie K, Jani A, Palumbo A, Carrillo T, Mar W. Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues. AJR Am J Roentgenol. 2015;204(2):448-458. PMID: 25615769. https://doi.org/10.2214/ajr.14.12709

9. Fomina EE, Yakhin AM, Shavalieva AR. The Role of CT Phlebography in the Diagnosis of Pelvic Varicose Disease in Women. Acta medica Eurasica. 2024;(2):42–49. (In Russ). https://doi.org/10.47026/2413-4864-2024-2-42-49

10. Knuttinen MG, Machan L, Khilnani NM, et al. Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review. AJR Am J Roentgenol. 2023;221(5):565-574. PMID: 37095667. https://doi.org/10.2214/ajr.22.28796

11. Hanna J, Bruinsma J, Barns M, Hanna M, Boulos B, Ponosh S. Pelvic congestion syndrome: Not all pelvic pain is gyn-aecological. Aust J Gen Pract. 2024;53(12 Suppl):S41-S44. PMID:

12. https://doi.org/10.31128/ajgp-07-23-6889

13. Kovaleva DD, Kutsenko VP, Postanogov RA, et al. Clinical and Diagnostic Aspects of the Nutcracker Phenomenon and Syndrome using Biomedical Visualization Methods. Bulletin of the Medical Institute of Continuing Education. 2025;5(3):48–58. (In Russ). https://doi.org/10.36107/2782-1714_2025-5-3-48-58

14. Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ, Nieboer TE. Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review. Acta Obstet Gynecol Scand. 2018;97(7):776-786. PMID: 29381188. PMCID: PMC6033028. https://doi.org/10.1111/aogs.13311

15. Gavrilov SG, Moskalenko YeP, Kulikov VM, et al. Protocol of ultrasound examination of pelvic veins in women. Angiology and Vascular Surgery. 2024;30(3):34–46. (In Russ). https://doi.org/10.33029/1027-6661-2024-30-3-34-46

16. Szkodziak F, Wozniak S, Szkodziak PR, Pyra K, Paszkowski T. Noninvasive diagnostic imaging of pelvic venous disorders. Nicht invasive diagnostische Bildgebung von Beckenvenen-Erkrankungen. Ultraschall Med. 2024;45(6):597-603. PMID: 38325406. PMCID: PMC11634453. https://doi.org/10.1055/a-2263-7193

17. Sevostyanova KS, Tulupov AA, Shevela AI. Dynamic monitoring in patients with venous thrombosis using non-contrast magnetic resonance venography. Flebologiya. 2022;16(2-2):24. (In Russ.)

18. Alsannan B, Alzeeny A, Etrusco A, Laganà AS, D’Amato A, Tulandi T. Diagnosis and Management of Pelvic Congestion Syndrome: Comprehensive Review. Gynecol Obstet Invest. 2024;89(6):437-444. PMID: 38981444. https://doi.org/10.1159/000539931

19. Rezaei-Kalantari K, Fahrni G, Rotzinger DC, Qanadli SD. Insights into pelvic venous disorders. Front Cardiovasc Med. 2023;10:1102063. PMID: 36742076. PMCID: PMC9892065. https://doi.org/10.3389/fcvm.2023.1102063

20. Yang W, Sun L, Shi Y, Ye T, Li Q. Radiological evaluation of pelvic venous Disorders: A comprehensive review. Eur J Radiol. 2025;183:111940. PMID: 39862625. https://doi.org/10.1016/j.ejrad.2025.111940

21. Chubchenko SV, Alenichev AV, Gavrilov SG. Sovremennaya diagnostika tazovykh venoznykh zabolevanii (obzor literatury). Izvestiya vys-shikh uchebnykh zavedenii. povolzhskii region. meditsinskie nauki. 2025; (1 (73)): 41–65. doi:10.21685/2072-30322025-1-4 (in Russ)

22. Brinegar KN, Sheth RA, Khademhosseini A, Bautista J, Oklu R. Iliac vein compression syndrome: Clinical, imaging and pathologic findings. World J Radiol. 2015;7(11):375-381. PMID: 26644823. PMCID: PMC4663376. https://doi.org/10.4329/wjr. v7.i11.375

23. Sheikh AB, Fudim M, Garg I, et al. The Clinical Problem of Pelvic Venous Disorders. Interv Cardiol Clin. 2022;11(3):307324. PMID: 35710285. https://doi.org/10.1016/j.iccl.2022.03.003

24. Ruel J. May-Thurner Syndrome: An often-missed cause of chronic pelvic pain. J Am Assoc Nurse Pract. 2019;31(7):388-390. PMID: 30908405. https://doi.org/10.1097/jxx.0000000000000205

25. Chait J, Sen I, Kalra M. Nutcracker Syndrome: How to Diagnose It and When/How Should It Be Treated in the Pelvic Venous Disease Population. Tech Vasc Interv Radiol. 2021;24(1):100734. PMID: 34147193. https://doi.org/10.1016/j.tvir.2021.100734

26. Oguzkurt L, Tercan F, Pourbagher MA, Kizilkilic O, Turkoz R, Boyvat F. Computed tomography findings in 10 cases of iliac vein compression (May-Thurner) syndrome. Eur J Radiol. 2005;55(3):421-425. PMID: 16129251. https://doi.org/10.1016/j.ejrad.2004.11.002

27. Liu P, Peng J, Zheng L, et al. Application of computed tomography venography in the diagnosis and severity assessment of iliac vein compression syndrome: A retrospective study. Medicine (Baltimore). 2018;97(34):e12002. PMID: 30142841. PMCID: PMC6113001. https://doi.org/10.1097/md.0000000000012002

28. El-Diasty MT, Noorelahi Y. Imaging Findings of Ovarian Vein Thrombosis. Cureus. 2023;15(11):e48672. PMID: 3802403.5 PMCID: PMC10640670. https://doi.org/10.7759/cureus.48672

29. Yassa NA, Ryst E. Ovarian vein thrombosis: a common incidental finding in patients who have undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy with retroperitoneal lymph node dissection. AJR Am J Roentgenol. 1999;172(1):45-47. PMID: 9888736. https://doi.org/10.2214/ajr.172.1.9888736

30. Cao W, Ni X, Wang Q, et al. Early diagnosis and precision treatment of right ovarian vein and inferior vena cava thrombosis following caesarean section: A case report. Exp Ther Med. 2020;19(4):2923-2926. PMID: 32256777. PMCID: PMC7086212. https://doi.org/10.3892/etm.2020.8548

31. Gloviczki P, Lawrence PF, Wasan SM, et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord. 2023;11(2):231-261.e6. PMID: 36326210. https://doi.org/10.1016/j.jvsv.2022.09.004