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

Abstract

Dear Editor,

We read the comment of Whiteley et al.¹ on our review with great interest. It should be mentioned that our paper was part of a controversial discussion whether or not embolization is essential in the treatment of leg varices due to pelvic venous insufficiency.² Although the paper by Hartung supported this proposal,³ we consider this an extreme viewpoint. Nevertheless, we agree completely with this paper and others in that embolization is the method of choice but only if pelvic venous reflux is associated with disabling symptoms of pelvic congestion syndrome (PCS). This was stated in our paper.²

Whiteley et al.⁴ quoted their paper on the frequent pelvic origin of recurrent varicose veins in women and their good long-term results of coil embolisation.⁴ However, these excellent results fall short in answering the question whether embolization is mandatory in the treatment of varicose veins of pelvic origin.

In many women vulvar, pudendal and perineal varicose veins are not associated with PCS. In these cases, the question arises whether the refluxing ovarian veins or internal iliac tributaries must be occluded. To date no prospective randomised or comparative studies have investigated this point.

In our experience treatment of varicose veins should be symptom driven. In patients with varicose veins of pelvic origin, but without the symptoms of PCS, the treatment of the visible refluxing veins by phlebectomy or sclerotherapy is justified, and good results have been published.^5,6 In patients with recurrent varicose veins where the origin of the reflux is located in the ovarian or internal iliac veins, embolization may be a good option,⁴ but there is no evidence supporting a mandatory requirement from randomised controlled trials.

There are many good indications for embolization of pelvic venous reflux including PCS, but the treatment should always consider the pelvic symptoms of the patient, the possible side-effects of the treatment, the pelvic reflux volume and the expected results. Therefore, embolization may not be mandatory in every case of pelvic venous reflux associated with varicose veins.

References

Whiteley M. Letter regarding embolization is not essential in the treatment of leg varices due to pelvic venous insufficiency. Phlebology 2016; 31: 588.

Rabe

Pannier

. Embolization is not essential in the treatment of leg varices due to pelvic venous insufficiency. Phlebology 2015; 30(1 Suppl): 86–88.

Hartung

. Embolization is essential in the treatment of leg varices due to pelvic venous insufficiency. Phlebology 2015; 30(1 Suppl): 81–85.

Whiteley

Taylor

Dos Santos

. Pelvic venous reflux is a major contributory cause of recurrent varicose veins in more than a quarter of women. J Vasc Surg Venous Lymphat Disord 2014; 2: 411–415.

Dos Santos SJ, Holdstock JM, Harrison CC, et al. Long-term results of transjugular coil embolisation for pelvic vein reflux – results of the abolition of venous reflux at 6–8 years. Phlebology 2016; 31: 456–462.

Sukovatykh

Rodinov

Sukovatykh

. Diagnosis and treatment of atypical forms of varicose disease of pelvic veins. Vestn Khir Im I I Grek 2006; 167: 43–45.