Missed pelvic varicose veins are a major cause of varicose veins coming back again after treatment
From the The Whiteley Clinica; and the Faculty of Health and Biomedical Sciences, University of Surrey.b
Author conflict of interest: none
Presented as an oral presentation at the American Venous Forum, Phoenix, USA, February 2013; 10th International Symposium on Endovascular Therapeutics, Barcelona, May 2013; 14th meeting of the European Venous Forum, Belgrade, June 2013; the Annual Spring Meeting of the Royal Society of Medicine Venous Forum, London, United Kingdom, April 2013 (Poster).
Mark S. Whiteley, MS, FRCS (Gen)
The Whiteley Clinic Stirling House, Stirling Road Guildford Surrey GU2 7RF, UK
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
Copyright© 2014 by the Society for Vascular Surgery. http://dx.doi. org/10.1016/j.jvsv.2014.05.003
Leg varicose veins are associated with pelvic venous reflux in approximately 20% of women who have had children. However, most venous units do not routinely look for pelvic venous reflux or treat it. We aimed to investigate what proportion of patients with recurrent varicose veins and a history of open surgery have pelvic venous reflux as a major contributing cause of their recurrence.
A retrospective study was performed of all patients referred in the previous year with recurrent varicose veins or venous reflux disease who had previously had open surgery performed elsewhere. All patients had routine lower limb venous duplex ultrasonography, and those found to have reflux of pelvic origin underwent transvaginal duplex ultrasonography. Each case was assessed by a consultant vascular surgeon, and the major cause (or causes, if more than one) of the recurrent varicose veins was noted.
A total of 109 patients with recurrent varicose veins in 172 legs were analyzed (mean age, 53.9 years; female-to-male ration, 97:12). Patients were divided into four groups: group 1, all patients; group 2, female patients; group 3, female patients with children; and group 4, female patients with children who had not had hysterectomy. Pelvic venous reflux was found to be a major contributing cause of recurrent varicose veins in 44 of 172 legs (25.6%). This rose to 43 of 154 legs (27.9%) in group 2, 40 of 131 legs (30.5%) in group 3, and 37 of 111 legs (33.3%) in group 4.
Pelvic venous reflux is a major contributing cause of recurrent varicose veins after open surgery that has rarely been reported previously. In view of this finding, we suggest that a duplex ultrasound protocol, incorporating a transvaginal duplex examination of the ovarian and internal iliac veins, be adopted for the investigation of pelvic venous reflux in female patients presenting with symptomatic leg varicose veins with duplex-observed reflux entering the leg vein pattern from the pelvis. In the event that it is found, we suggest that treatment and resolution of this source of venous reflux be considered before any intervention for the leg varicose veins, surgical or otherwise. (J Vasc Surg: Venous and Lum Dis 2014;2:411-5.)
Alice M Whiteley (The Whiteley Clinic Summer Research Fellow 2013 & BioMedical Student)
Daniel C Taylor (The Whiteley Clinic Summer Research Fellow 2013 & Medical Student)
Scott J Dos Santos (The Whiteley Clinic Research Co-ordinator & BioMedical Student)
Mark S Whiteley
All patients with varicose veins treated under The Whiteley Protocol® have a full duplex ultrasound performed on their leg veins by a specialist trained in identifying pelvic vein reflux.
Any women with venous reflux coming from the pelvis is offered a transvaginal duplex ultrasound scan – proven to be the gold standard test for this condition.
This scan shows which veins are causing the pelvic vein reflux so they can be treated.
This is one of the many reasons that the recurrence rate after varicose vein surgery at The Whiteley Clinic is so low.*
Journal of Vascular Surgery: Venous and Lymphatic Disorders 2014:Vol 2(4);411–415 http://www.jvsvenous.org/article/S2213-333X(14)00093-6/fulltext
American Venous Forum 2013 Annual Meeting, Phoenix, USA – February 2013
10th International Symposium on Endovascular Therapeutics – SITE 2013 – Barcelona, May 2013
14th Meeting of the European Venous Forum – Belgrade, June 2013
Annual Spring Meeting of the Venous Forum of The Royal Society of Medicine – London, April 2013 (Poster)
A retrospective review was performed of all of the patients referred to The Whiteley Clinic in a one year period, with recurrent varicose veins, having previously been treated elsewhere.
Over a quarter of women had pelvic venous reflux as the sole, or a major, cause of their recurrent leg varicose veins. This rose to one third of women who had previously had children and who had not had hysterectomy (and so their pelvic veins were not ligated or removed).
In these women, it was the second commonest cause of recurrent leg varicose veins. Only neovascularisation from previous stripping was more often the cause of the recurrent problem.
As the new endovenous techniques cause far less, if any, neovascularisation, it is likely that pelvic vein reflux will become the commonest cause of recurrent varicose veins in women who have had children if venous surgeons do not recognise and treat this condition as part of the treatment of leg varicose veins.
The failure of surgeons to identify and treat pelvic vein reflux feeding into leg varicose veins in women is a major cause of recurrent varicose veins.
All female patients with varicose veins should have a duplex ultrasound scan performed by a specialist who knows how to identify pelvic vein reflux.
All patients with leg varicose veins who are found to have evidence of venous reflux coming from the pelvis, should be offered the gold standard pelvic vein scan – a Transvaginal Duplex Ultrasound Scan.
Identifying and treating pelvic vein reflux as part of the varicose vein work-up should result in decreased recurrence of varicose veins after treatment.
Most doctors and nurses don’t even know that pelvic venous reflux (Pelvic varicose veins) can cause leg varicose veins – never mind look for them and treat them!
The failure of doctors to look for and treat pelvic vein reflux is a major reason that varicose veins recur after surgery in women. By treating these we can start combating the old idea that “varicose veins always come back”.