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 .