Embolization is not essential in the treatment of leg varices due to pelvic venous insufficiency

Introduction

Atypical varicose veins (VVs) without sapheno-femoral or sapheno-popliteal reflux may develop in the vulvar or pudendal area in women. Reflux in these varices may be connected with insufficient pelvic veins.^1–3 In most of the cases, the left ovarian vein or the hypogastric veins are involved. ² Venous obstruction or local pathology are other but rare reasons for pelvic venous insufficiency (PVI). ³ Pudendal or vulvar VVs may be a reason for recurrent VVs after surgery ³ or thermal ablation but in many cases these veins are located only in the genital, pudendal or proximal thigh area. ² Many of the affected women are multipara and the VVs develop during pregnancy. ² Geier et al. ² could demonstrate that in the majority of cases combined reflux in more than one pelvic vein could be demonstrated.

In a part of the patients with PVI, a pelvic congestive syndrome (PCS) may develop. ⁴ PCS patients present with chronic pelvic pain that has been present for greater than six months and is otherwise unexplained. ⁴ The syndrome is associated with PVI and frequently with vulvar or pudendal varices.

Methods

We reviewed the current literature concerning treatment options of leg VVs associated with PVI.

Results

Only a few case reports and case control series have been published concerning the treatment of vulvar or pudendal VV, and no prospective randomized study comparing different treatment options is available. Some authors suggest that embolization of pelvic reflux is essential in the treatment concept.^5,6 Others treat isolated vulvar and pudendal VV by phlebectomy^7,8 or sclerotherapy.^9–11

Aslam et al. ⁵ published a case of vulvar VV in a 44-year-old woman arising from an incompetent external pudendal vein. A combined treatment of sclerotherapy and embolization with coils led to freedom of symptoms at two months follow-up. ⁵ Creton et al. ⁶ published the results of embolization in 24 women with non-saphenous VV of pelvic origin. At a follow-up of three years, only 10 of 24 women had no recurrent VVs. Symptoms were improved in the majority of their patients. ⁶

Paraskevas ¹¹ published a case of successful treatment of vulval and leg varicosities of pelvic origin by ultrasound-guided foam sclerotherapy alone. The VVs were completely resolved at six months follow-up and in addition symptoms from a previously diagnosed PCS had improved. ¹¹ Sukovatykh et al. ¹⁰ published the results of sclerotherapy in 59 patients with atypical VV of pelvic origin. Excellent results were obtained in 32.6%, good in 46.1%, satisfactory in 19.1% and unsatisfactory in 2.2%. ¹⁰

Marsh et al. ¹² could demonstrate that in women presenting with VV, ovarian vein reflux may be present in about one of six patients. Although the exact prevalence of PCS is unknown, it is far less frequent than ovarian reflux. If PCS is involved, embolization has been shown to be as efficient as hysterectomy ¹³ and shows good long-term results.^14,15 In the guidelines of the American Venous Forum on the care of patients with VVs, the treatment of pelvic congestion syndrome by ovarian and pelvic vein embolization is recommended on a Grade 2B level. ¹⁶

The benefit of embolization of pelvic veins in patients without PCS was not demonstrated in studies comparing the results with VV treatment alone by phlebectomy or sclerotherapy. ¹⁷ Embolization is not free of risks like embolization of coils. ¹⁸ Therefore, embolization should only be used in well-established indications. ¹⁶

Discussion

PVI, vulvar and pudendal VVs as well as PCS are underdiagnosed entities. ¹ Embolization of ovarian and pelvic veins is well established in PCS. ¹⁶ In VV of pelvic origin but without PCS, comparative studies comparing the outcome of embolization or treatment of VVs by sclerotherapy or phlebectomy alone are missing. ¹⁷

Keeping in mind that PVI may also occur in pelvic compression syndromes, ¹⁹ embolization should be recommended in PCS due to ovarian or pelvic vein reflux with or without vulvar, pudendal or leg VVs.^13–16 In asymptomatic patients with PVI but without PCS or VV, embolization is not indicated. Foam sclerotherapy or phlebectomy shows good results in patients with VV of pelvic origin.^10,11 Embolization should be considered in symptomatic cases with recurrent VVs after treatment even if no PCS is present. Randomized comparative studies comparing embolization of incompetent pelvic veins and sclerotherapy of VV with pelvic origin should be performed.

Conclusion

Embolization is not essential in the treatment of leg varices of pelvic origin without PCS. Foam sclerotherapy or phlebectomy shows good results in patients with vulvar or pudendal VV.