Survey demonstrates significant practice variability for the management of pelvic derived vulvar and lower extremity varices

Purpose: There is controversy regarding the optimal management of pelvic origin lower extremity and vulvar varicose veins (POLEVVV). A survey of vascular specialists was performed to assess current practice.

Materials and Methods: A survey was internationally distributed through IR and vascular societal contacts assessing current practice for managing women with POLEVVV. The survey was open from June to July 2024.

Results:

194 physicians who treat POLEVVV responded. Their primary disciplines included vascular surgery (47%) and interventional radiology (38%). 

Respondents frequently used pelvic imaging in women with POLEVVV without pelvic pain. Pre-treatment imaging for lower extremity varicose veins included ultrasound (TAUS 46%, TVUS 36% and escape point 36%), CT 34%, and MR 23%, and for vulvar varicose veins included ultrasound (TAUS 47%, vulvar 42%, and TVUS 39%), CT 33%, and MR 20%.

In women without pelvic pain, 42% and 47% treat women with lower extremity varicose veins of pelvic origin and vulvar varicose veins, respectively with a “top down” embolization as the first step, with only a small majority (70%) preferring a primary “bottom up” approach. During embolization for this indication, only 36% perform venography of both ovarian and internal iliac veins, with 29% stating that the pre-procedural imaging guides the choice of which vessels are examined. 71% do not routinely perform balloon occlusion venography. For the 30% that do, 15% perform it in the internal iliac vein, 6% in the ovarian vein, and 9% for all studied veins.

If both significant iliac vein compression and pelvic reflux are visualized, 37% treat compression first, 24% treat reflux first, 9% treat both, and 30% are situation dependent. Typical embolic agents used for pelvic venous embolization included foam sclerosant (69%) and coils (63%). Foam sclerosant was most commonly used to treat lower extremity or varicose veins when not performing pelvic vein embolization. Post-procedure follow up frequently included both imaging and clinical assessment of symptoms (65%). For persistent varicosities or extra-pelvic symptoms without pelvic pain 6 months after primary treatment, roughly half of the respondents would repeat the top down or bottom up approach they used initially, and the other half would switch to the other approach.

Conclusion: There is significant management heterogeneity of POLEVVV, including near equipoise on a top down or bottom up approach for treating these veins even in the absence of pelvic pain. This data demonstrates significant evidence gaps to inform optimal treatment approaches for these patients.