Vulvar and pelvic-origin lower-extremity varicose veins: A survey of current evaluation and management.

objectiveThe primary objective is to assess current practice for evaluating and managing vulvar (V3a) and pelvic (V3b) origin lower-extremity varicose veins to inform future research priorities and guideline development.

methodsAn electronic survey was internationally distributed to vascular specialists to assess the current state of pelvic venous disorder care. The 51-question survey was administered using the Qualtrics platform and distributed through medical society forums, mailing lists of the international vascular meeting, and direct distributions. The survey was open from June to July 2024, requiring approximately 10 to 15 minutes to complete. Background information included respondent age, gender, training experience, primary medical specialty, practice type, and practice location, with responses remaining anonymous. The survey included five sections, with evaluation and management of women with V3 disease being the focus of this paper. This study was reviewed by the Institutional Review Board and qualified for exemption.

resultsThe majority of survey respondents were vascular surgeons (47%) and interventional radiologists (38%) from the United States (43%), Asia (17%), and Europe (16%). A total of 194 respondents reported treating women with extrapelvic varices of pelvic origin and completed this portion of the survey. For women with V3a and V3b diseases, 46% used the Symptoms-Varices-Pathophysiology classification tool as a part of the clinical assessment before treatment. The preferred imaging modality before intervention is duplex ultrasound of the lower extremity (81%) and ultrasound of the vulvar region (62%). In women without pelvic pain, a "top-down" pelvic embolization first approach is used by 47% treating V3a and 42% treating V3b, and a "bottom-up" direct injection sclerosis was used by the remainder. The technical approach to pelvic embolization when choosing a "top-down" approach is variable, with the majority using foam sclerosant for pelvic venous embolization (69%), as well as for vulvar or lower-extremity varicose veins (84%). The majority prefer both imaging and clinical follow-up, with 75% using a clinical outcome tool postprocedurally. The management of persistent or recurrent symptoms after treatment is variable, ranging from conservative care (8%), retreating with the same approach (10%-29%), or using a different approach (if "top down" initially, then "bottom up" or if "bottom up" initially, then "top down"; 22%-27%).

conclusionsThis survey demonstrates the significant diagnostic and therapeutic heterogeneity of V3a and V3b in the absence of pelvic pain, including equipoise for top-down and bottom-up management. This heterogeneity demonstrates that significant evidence gaps exist, and highlights the need for comparative outcomes research to clarify them.