Pelvic escape points: Bottom- up is the way to go!

Abstract

Varicose veins (VVs) of pelvic origin are one of the clinical presentations of pelvic venous disorders (PeVD) and are increasingly being diagnosed in patients in phlebological offices these days. To investigate VVs potentially resulting from pelvic vein incompetence (PVI), a usual full duplex ultrasonography (DUS) of lower extremity veins in the upright position is recommended as well as DUS for evaluation of pelvic escape points (PELVs). Seven PELVs have been described, connecting the pelvic veins to the veins of the genital region and/or legs. There are two possible treatment options for pelvic origin VVs, top-down treatment such as pelvic vein embolization or treatment of iliac/renal vein compression if it is the cause of PVI and bottom-up treatment of PELVs and related VVs. The idea of the latter approach is to treat the causes of the external pelvic VVs in the genital region and VVs in the legs without having to treat asymptomatic pelvic veins within the pelvis. The most common methods of bottom- up treatment are sclerotherapy, surgical ligation and miniphlebectomy. The efficacy of such treatment approach for VVs of pelvic origin has been reported in the literature, whereas studies have failed to demonstrate good results of top- down treatment in the context of eliminating VVs of pelvic origin as well as minimizing the risk of VVs recurrence. Bottom-up treatment is a useful option to avoid unnecessary and more expensive pelvic vein embolization and should be considered as an initial therapeutic approach. Only if bottom-up treatment fails, if the VVs recur rapidly, or if the patient develops pelvic symptoms due to PVI, pelvic veins embolization can be considered.