Incidence and distribution of lower extremity reflux

Introduction: Women with pelvic venous insufficiency (PVI) often present with lower extremity symptoms and manifestations of chronic venous disorders (CVD). The purpose of this investigation was to determine the incidence of lower extremity CVD and the types and distribution of lower extremity veins involved in patients with a known diagnosis of PVI.

Methods: Between January 2012 and December 2015 we retrospectively reviewed the charts of 227 women with PVI as well as their lower extremity (LE) venous duplex investigations. Presenting symptoms, CEAP class, initial rVCSS and the types of LE veins with reflux and their locations were noted. Patients were also subcategorized according to their primary pelvic disorder as follows: Entire cohort (PVI), Ovarian vein reflux (OVR), iliac vein stenosis (IVS) or both (OVR+IVS).

Results: The study group consisted of 227 women (454 limbs) with documented PVI. The average age was 44.71 ± 10.2. In decreasing order, patients presented with the following lower extremity symptoms: pain (66%), swelling (32%), heaviness (26%), limb fatigue (13%), itching (13%), leg cramps (10%), skin changes or SVT (2%) and ulceration or bleeding (0.004%). Table 1 outlines the CEAP class for 215 of the 227 patients. For the entire cohort 48% of right and 50% of left limbs demonstrated C0 or C1 disease. The incidence and type of symptomatic lower extremity veins were as follows: Any axial vein: 32%, Great Saphenous (GSV): 21%, Small Saphenous (SSV): 11%, GSV and SSV: 5%, Non-saphenous tributaries: 15%, Saphenous tributaries: 12%, Posterior or postero-lateral thigh distribution: 5%, vulvar distribution: 4%, perforators: 4%, deep veins: 2%, and Anterior Accessory Saphenous Veins: 1%. For the GSV and SSV, the following patterns of reflux were observed: Entire GSV: 4%, entire above knee GSV: 2%, entire below knee GSV: 2%, above knee segmental GSV: 20%, below knee segmental GSV: 21%, above and below knee GSV segmental disease 1%, Entire SSV: 4%, SSV segmental disease: 12%. The incidence of reflux in any axial vein, the GSV and AAGSV was greater in the OVR group compared to IVS or OVR+IVS (p ≤ 0.03). Sixty-four of 227 (28%) patients had a history of prior lower extremity venous ablations: OVR (10/39, 26%), IVS (15/50, 30%) and OVR+IVS (39/127, 9%). The number of ablations per patient was the following: OVR 1.48 ± 0.5, IVS 1.7 ± 0.7 and OVR+IVS was 1.65 ± 0.7.

Conclusion: At least 50% of patients with PVI present with lower extremity venous disease. The incidence of reflux in any axial vein is greatest in the OVR group suggesting a correlation with hormonal fluctuations and pregnancy. The majority of symptomatic patients present with segmental axial GSV or SSV disease. Although vulvar and gluteal escape veins are highly associated with PVI, they are infrequently observed. In patients who experience residual or persistent symptoms after treatment for CVD, a pelvic venous ultrasound should be performed to assess for the presence of PVI.