Recurrent varicose veins due to untreated pelvic veins

Recurrent varicose veins mean that varicose veins have been treated and come back again. It is commonly thought that varicose veins always come back again after treatment. However, this is incorrect. Varicose veins should not come back after treatment in the majority of people for many years, if the right veins have been treated by the right techniques.

Unfortunately, because the public expects varicose veins to come back again after treatment, they accept poor results without complaint.

Recurrent varicose veins of legs due to pelvic veins not being treated due to patient choice

Reasons that varicose veins come back again are usually one of the following:

• •  The wrong vein was treated because the duplex scan was inadequate. This usually occurs when doctors do their own ultrasound scan and do a quick scan lasting only 5 to 10 minutes. Sometimes it occurs when patients are scanned in an ultrasound department but by someone who is not expert in scanning veins. This is compounded by doctors and clinics that do not treat perforating veins or treat pelvic veins, both of which are common causes of leg varicose veins.
  • The right veins treated but using the wrong technique. It might be surprising to patients to think that in this day and age doctors might use the wrong technique but we see it all the time. We know that stripping causes veins to grow back again in the majority of patients, but many doctors still strip veins. Also, we know that many doctors use very low power when they use a laser, or they use radiofrequency in veins too large to get a good result. Some doctors even use foam sclerotherapy for major varicose veins, despite research showing that it only really works well in small veins.

However, this blog is about a patient who came to The Whiteley Clinic with leg varicose veins and decided against our recommended treatment.

The lady in question came to see us in 2006 with quite severe varicose veins in both legs. She underwent venous duplex ultrasound scan by a The Whiteley Clinic trained vascular technologist. This scan showed that the veins came from the pelvis. A further transvaginal duplex ultrasound scan showed that she had pelvic varicose veins. Both ovarian veins and both internal iliac veins in the pelvis were incompetent and she had considerable pelvic venous congestion.

This was explained to her and it was explained how the venous blood was coming from the pelvic veins into the leg varicose veins. She was recommended to have pelvic vein embolisation.

She decided that she did not like the sound of this and instead opted to have her leg veins treated alone. We agree to do this but on the understanding that if her veins came back again, it would almost certainly be due to having pelvic varicose veins.

In 2007 she went ahead with endovenous laser treatment of her leg veins. At that stage, all of her leg varicose veins had gone and she was very pleased with the result. Unfortunately, this is often the case where patients think they have had a good job in the short term because the veins look better initially, but because the underlying problem hasn’t been fully addressed they will only recur.

Recurrent varicose veins returned with a vengeance from untreated pelvic varicose veins

Over the next couple of years, her leg varicose veins returned massively. They clearly arise from the pelvis as can be seen from the photographs. The varicose veins on the inner aspect of the legs, next to the vulva, show that the varicose veins come from the pelvis.

Over the subsequent years, the varicose veins have got bigger in size and have now reached the stage that they are at risk of clotting. This would cause phlebitis. Even worse, she has started developing brown stains at the ankle. This is called CEAP C4 skin damage and is a clear sign she is heading towards leg ulcers.

She came back to see us recently, 10 years after her original surgery. Duplex ultrasound scan shows that the endovenous laser treatment of the leg veins had been successful. However, the very large pelvic varicose veins seen on transvaginal duplex ultrasound scan have caused more varicose veins to dilate in the leg and have caused all of the problems visible.

She will now need to have her pelvic vein embolisation that was originally suggested to treat the pelvic varicose veins. In addition, she will have to have her leg varicose veins treated all over again.

This is a good example of showing why it is important to follow the Whiteley protocol stopping the major source of venous reflux first and then working out to the more superficial cosmetic veins over three stages.

Please see our research:  Pelvic venous reflux is a major contributory cause of recurrent varicose veins in more than a quarter of women. Whiteley AM, Taylor DC, Dos Santos SJ, Whiteley MS. J Vasc Surg Venous Lymphat Disord. 2014 Oct;2(4):411-5. doi: 10.1016/j.jvsv.2014.05.005. Epub 2014 Jun 24.