Dr. Michael Lichtenberg, MD, Dipl. Health Economist is a recognized specialist in the field of angiology and serves as Chief Physician of the Department of Angiology at the Klinikum Hochsauerland, where he heads the Center for Pelvic Vein Obstructions in Arnsberg. This center is one of the largest specialized departments in Germany for treating pelvic vein disorders.
With his many years of experience in treating venous and arterial vascular diseases, Dr. Lichtenberg has earned an excellent national and international reputation. His particular focus is on diagnosing and treating complex pelvic vein disorders, with his team performing several hundred minimally invasive procedures annually. Advanced imaging techniques and catheter-based methods are used to treat patients with symptoms such as swelling, chronic pain, or open leg ulcers in a targeted and gentle manner.
Another key focus of Dr. Lichtenberg’s work is treating critical circulatory disorders in the limbs, particularly in the context of peripheral arterial disease (PAD). To support this, a dedicated research center has been established at the site, where novel endovascular techniques are tested and scientifically monitored. Long-term patient care by a specialized team ensures particularly high quality of care. Dr. Lichtenberg also actively contributes to the advancement of his specialty: as Managing Director and future President of the German Society for Angiology, he advocates for new guidelines and the promotion of young medical professionals. His work stands for modern, evidence-based vascular medicine at a high clinical and scientific level.
The editorial team of the Leading Medicine Guide spoke with Dr. Lichtenberg about pelvic vein syndrome and learned more about its difficult diagnosis and effective treatment.
Pelvic vein syndrome is a frequently underestimated cause of chronic discomfort in the pelvic and leg regions, primarily affecting women—but it can also occur in men. This venous condition is characterized by impaired blood outflow from the pelvic veins due to compressions, narrowings, or post-thrombotic changes. The result is venous congestion, which can lead to symptoms such as chronic pelvic pain, swelling, varicose veins, or a feeling of heaviness in the legs. Due to the nonspecific nature of the symptoms, pelvic vein syndrome often remains undiagnosed for a long time. However, modern imaging techniques and minimally invasive treatment options now make targeted diagnosis and effective therapy possible—significantly improving patients' quality of life. Pelvic vein syndrome causes chronic blood pooling, which may result in swelling, pain, varicose veins, or even leg ulcers (ulcera). Common causes include congenital narrowings, scarring after thrombosis, or external compressions—for example, by neighboring vessels or structures such as the artery (as in May-Thurner syndrome).
May-Thurner syndrome—also known as Cockett syndrome—is a venous outflow disorder caused by compression of the left common iliac vein (Vena iliaca communis sinistra) by the overlying right common iliac artery (Arteria iliaca communis dextra). This anatomical narrowing can lead to chronic obstruction of venous return from the left leg and result in various symptoms. The left iliac vein passes beneath the right iliac artery—an anatomical configuration found in all humans. In May-Thurner syndrome, however, the angle is particularly unfavorable or the surrounding tissue is so tight that the vein becomes chronically compressed. Over time, the arterial pulsation can lead to thickening and damage of the venous wall.
Because the symptoms are often nonspecific, pelvic vein syndrome is frequently diagnosed late. Modern imaging techniques such as ultrasound, CT, or MRI, as well as venous pressure measurements, help confirm the diagnosis. Treatment is usually minimally invasive, involving the placement of a stent to permanently improve venous outflow.
“Pelvic vein syndrome is a condition that primarily affects women—roughly 70% women to 30% men. Patients often report intense lower abdominal pain that radiates into the groin and legs. A particularly striking feature is the worsening of symptoms around menstruation. In addition, severe pain during intercourse is common, often leading to relationship strain. Many patients also report discomfort when urinating—so-called dysuria—or pain during urination. The underlying cause is typically a narrowing of the pelvic vein, usually on the left side. Anatomically, the left iliac vein runs underneath the right iliac artery—exactly where both vessels cross in front of the fifth lumbar vertebra. If this space is too narrow, it creates a kind of 'competition': the stronger-pulsing artery compresses the vein beneath it. This impedes blood flow, causing venous congestion. It's like squeezing a garden hose—when pressure builds up, the water backs up. In women, nothing bursts, but the resulting venous pressure leads to intense lower abdominal pain. That is what we call pelvic vein syndrome,” explains Dr. Lichtenberg at the beginning of our conversation, and continues:
“One may wonder whether this also causes leg swelling—such as difficulty standing. That can occur, but not always. If it does, it's typically on the left side, often starting at the ankle. Patients notice significant pain when standing or walking, especially under load. It's like inflating a balloon: blood flows into the leg via the artery, but the vein's return is blocked. Rising venous pressure compresses everything—tendons, nerves, muscles—and causes often unbearable pain. How long it takes for symptoms to appear varies. In some, it develops slowly over years; others notice earlier that 'something is wrong.' So there’s no general rule for when the discomfort becomes so severe that medical evaluation is necessary—but that is precisely when action is needed.”
Pelvic vein syndrome most commonly affects women in middle age, particularly after pregnancy. In many cases, the syndrome is caused by a congenital or acquired compression or narrowing of the pelvic veins.
The diagnosis of pelvic vein syndrome involves several steps, usually beginning with a thorough medical history and physical examination. Patients often report nonspecific symptoms such as swelling, a feeling of pressure, or pain in the pelvic or leg area, especially when sitting or standing.
“A woman experiencing chronic lower abdominal pain typically sees a gynecologist first. They routinely examine the ovaries, uterus, and vagina, and perform an ultrasound—but rarely focus on the pelvic veins. Many gynecologists are also unfamiliar with the appearance of varicose veins in the pelvis, which usually develop due to elevated venous pressure. These veins dilate, much like varicose veins in the legs, because blood can’t drain properly. And that often goes unnoticed for years. As a result, many patients are misdiagnosed at first. A classic misdiagnosis is endometriosis. Some are even advised to have their uterus removed, thinking it might relieve symptoms. Yet the diagnostics are extremely challenging—symptoms can resemble several conditions, including adenomyosis, or nerve involvement like pudendal neuralgia. Cysts, bleeding, or other gynecological changes can also cause similar pain. This often leads to multiple surgeries or evaluations—like laparoscopy—without finding the cause. Even modern imaging like MRI often fails because the pelvic veins are overlooked. The radiologist must specifically look for this narrowing—otherwise, the issue remains invisible,” explains Dr. Lichtenberg.
MRI or CT can generally visualize the condition. The key is the clinical question—what exactly you're looking for.
Dr. Lichtenberg comments: “Specialists often focus narrowly on their own field—I self-critically call this 'tunnel vision diagnostics.' The broader interdisciplinary perspective is often missing. Yet this kind of collaboration is crucial: among gynecology, radiology, gastroenterology, general surgery. After all, 'diffuse abdominal pain' can have many causes—and only broad thinking leads to the right diagnosis. To visualize the narrowing, gadolinium is used as a contrast agent in MRI, iodine-based contrast in CT. The affected vein still functions—but is narrowed in one location. Imagine a dog bone: the vein is wide before the narrowing, squeezed in the middle, and expands again afterward. That’s where the blood backs up—causing the typical symptoms. Actual treatment begins only after diagnosis is confirmed. Symptoms must be clear: if a patient reports severe, quality-of-life-limiting pain—affecting parenting, relationships, or work—treatment is indicated. The next step is usually a special MRI with venous imaging. Patients bring the scans, and if symptoms match the images, targeted treatment—such as catheter intervention—can be initiated.”
Treatment of pelvic vein syndrome primarily involves minimally invasive procedures aimed at restoring unimpeded blood flow through the pelvic veins.
“Pelvic vein syndrome is not a life-threatening condition: there’s no risk of amputation or severe complications like 'black leg.' However, if the diagnosis is clinically confirmed and supported by MRI, therapy typically involves placing a stent to open the narrowed vein. The procedure is minimally invasive via the groin vein. First, local anesthesia is applied at the puncture site, then a catheter is inserted and contrast is injected for precise angiographic visualization. An intraluminal ultrasound probe is advanced to measure the length and diameter of the stenosis to the millimeter, allowing for exact stent selection. The narrowed segment is carefully dilated with a balloon before the stent—a metal scaffold—is placed to keep the vessel permanently open and prevent collapse. Vein ligation would not be an option—unlike in ovarian vein insufficiency, where retrograde blood flow occurs. The pelvic vein is the main outflow from the leg—if ligated, severe thrombosis would be inevitable. The stent procedure is performed as an inpatient intervention in Germany. Patients are admitted on the day of the procedure, monitored overnight, and usually discharged the next morning. Post-procedure symptoms are typically mild, such as wound or back pain, and patients can return to normal daily life within a few days. Because the stent is a relatively large metal implant, there is a thrombosis risk; thus, consistent anticoagulation with a modern oral blood thinner is required for the first three months to safely prevent clot formation in the implant,” explains Dr. Lichtenberg.
The prospects for successful treatment of pelvic vein syndrome are generally very good—especially when diagnosed early and treated in a specialized center.
Minimally invasive procedures such as stent implantation result in lasting symptom relief in over 90% of cases. Many patients report noticeable improvement in typical symptoms like swelling, pressure, pain, or chronic leg fatigue shortly after the procedure. “The outcomes of stent implantation for pelvic vein stenosis are generally excellent, but expectations must be realistic. It’s not a one-step fix that instantly resolves all symptoms. Most patients have suffered from chronic outflow obstruction for many years. In that time, extensive venous collaterals and varicose veins in the pelvis have formed. Stenting sustainably reduces venous pressure, allowing these dilated vessels to regress over time. That gradually relieves symptoms. Patients should be informed that noticeable improvement may take weeks—sometimes two to three months. Symptoms typically decrease step by step. Complete resolution is possible, but not guaranteed, as individual responses vary. Regarding stent durability: although it is a robust, long-term implant, it remains a foreign object. As with other implants—such as pacemakers or coronary stents—a residual risk exists, e.g., for restenosis or occlusion. The stents used are relatively large (around 14 mm in diameter), and the five-year stent occlusion rate is currently under 5%. To detect potential complications early, at least one annual follow-up via ultrasound is recommended,” advises Dr. Lichtenberg.
Treatment aims not only to eliminate venous congestion but also to stabilize venous valve function and prevent complications like skin changes or ulcers. This typically results in significant improvements in quality of life: increased mobility, better performance, and the ability to manage daily activities without symptoms. Long-term, patients also benefit from reduced risk of recurrent thrombosis or progression of chronic venous disease. However, sustained treatment success requires careful follow-up, including regular clinical exams, ultrasound monitoring, and possibly adjustments in compression therapy.
Dr. Lichtenberg emphasizes: “Over the past few years, the Karolinen Hospital has become a leading center in Europe for diagnosing and treating pelvic vein syndrome. With over 400 documented and treated cases annually, the clinic has exceptional experience in this field. Patients come not only from across Germany but also from other European countries and increasingly from regions like the Middle East. In many of these countries—such as Saudi Arabia or the United Arab Emirates—this type of interventional therapy is rarely available, so targeted training and cooperation projects with local physicians are becoming increasingly important.”
When patients experience recurring or chronic lower abdominal pain, pelvic discomfort, or pain during intercourse without receiving a clear diagnosis over time, the resulting stress can be immense—often triggering a lengthy diagnostic journey.
“Online research may yield many personal accounts but cannot replace a structured medical evaluation. It’s absolutely right to first investigate obvious causes—such as gynecological conditions like endometriosis or cysts. Other specialties, including urology or gastroenterology, should also be considered, particularly when dealing with nonspecific pelvic or flank pain. However, if no definitive diagnosis is found despite thorough workup and symptoms persist—especially typical signs like cycle-dependent pain, discomfort during urination or intercourse, or leg swelling—an angiological exam should be seriously considered. Angiology specialists possess the expertise to identify and assess vascular causes like pelvic vein syndrome or May-Thurner syndrome. These conditions are not uncommon but often go undiagnosed because they fall between specialties and are frequently overlooked by gynecologists or radiologists. Although men are less frequently affected, they too may suffer similar symptoms due to significant venous outflow obstruction. Diagnostic and treatment approaches are not fundamentally different,” concludes Dr. Lichtenberg.
Thank you, Dr. Lichtenberg, for shedding light on this uncommon and often overlooked condition!
