Abdominal & Pelvic Venous Disorders A New Paradigm
Mark H. Meissner, MD Peter Gloviczki Professor of Venous & Lymphatic Disease University of Washington School of Medicine Seattle, WA Disclosures
Mark H. Meissner, MD
I Have No Disclosures Relevant To This Presentation The Nonsense of the Nomenclature The “Pelvic Congestion Syndrome” Independently describedREALLY?? in 1949 by W. Lo and H.C. Taylor
Would we be taken seriously if we talked about “Leg Congestion Syndrome (LGS)” Br Med J 1949 Primary Pelvic Venous Disorders
Pelvic Varices • Gluteal • Perineal Leg Chronic Pelvic • Vulvar Symptoms Pain • Pain • “PelvicPain Chronic •PelvicSwelling • Dysparunia FourReflux ClinicalObstruction Congestion• Dysuria Venous TwoPresentations Patterns≠ of Reflux Syndrome” Disorders
Renal Symptoms • Flank Pain • Hematuria Internal Iliac Ovarian Vein Iliac Vein Nutcracker Syndrome Reflux Obstruction Reflux The Female Pelvic Circulation Four Interconnected Venous Systems
SEV Deep External Pudendal
Superfical External Pudendal
Great Saphenous Internal Iliac Vein Anatomy The Gateway to the Leg
Buttock / Vulva Posterior Thigh
Internal iliac tributaries
The “gateway” to the leg Exactly analogous to perforatingPerineum / veins, connecting The deep veins ofMedial the pelvis Thigh
The superficial veins of the leg Pelvic Escape Points Kachlik D, Phlebology2010 Ovarian L IIV Coils L OvarianL Ovarian Occlusion CoilsCoils Balloon
Occlusion “P” Point Balloon “O” Point “G” Point
R Inferior R Obturator Gluteal Vein Sclerosant L ObturatorGSV Reflux SciaticVein Varices The Venous “Reservoirs” of the Abdomen & Pelvis
Hilar Hilar Varices Varices
Symptoms presumably related to reservoir distension
All reflux and obstruction occurs in 2 patterns
Uncompensated – No outflow from distal reservoir TheThe Pelvic Renal Venous Hilar Plexus Plexus The Lower Compensated – CollateralDrained outflow by from distal reservoirExtremity The LeftOvarian Renal Veins Vein Pattern determines symptomsThe Internal Iliac Veins Uncompensated Obstruction L Renal Vein L Renal Vein L Common Iliac Vein Renal Reservoir Compensated Obstruction L Renal Vein L Common Iliac Vein L Ovarian Vein Uncompensated Reflux L Ovarian Vein L Internal L Internal Iliac Vein Iliac Vein
Compensated Reflux Pelvic L Ovarian Vein Reservoir L Internal Iliac Vein Pelvic Floor Pelvic Escape Leg Points Reservoir The Current Status of Pelvic Venous Disease The Alphabet Soup of “Syndromes”
Inaccurate diagnosis
Poor treatment outcomes
Denied reimbursement The AVLS International Pelvic Venous Workgroup
Organized by the American Vein & Lymphatic Society
Organizing meeting July 27, 2018 (Chicago, IL)
16 delegates representingOUR GOAL 9 international societies A Valid & Reliable Classification System that American Vein & LymphaticPlaces Patients Society into BinsInternational with Similar Pelvic Pain Society American Venous Forum• Clinical FeaturesInternational Union of Phlebology American College of Obstetrics• Natural& HistoriesKorean Society of Interventional Gynecology • Responses to Treatment Radiology Cardiovascular & Interventional Society of Interventional Radiology Radiological Society of Europe European Venous Forum The SVP Classification
3 Domains
Symptoms – “S”
Involved Variceal Reservoirs “V” (signs)
Pathology – “P” (3 subdomains) • Anatomy “A” • Hemodynamic abnormalities “H” • Etiology “E” Conclusions
• 4 interconnected systems • L renal vein• 2 abdominal-pelvic reservoirs • Ovarian veins • The renal hilum • Internal iliac veins• The pelvis • Symptoms related• toGreat reservoir saphenous distension vein SEV • Different patterns of reflux / obstruction produce identicalDeep External reservoir distension & symptoms Pudendal • Uncompensated reflux / obstruction – Pressure transmitted Superfical to distal reservoir External • Compensated reflux / obstruction – Pressure decompressedPudendal via collaterals • Syndromic classification MUST be abandoned Great Saphenous • Clear need for a new discriminative instrument – SVP