Recurrent Vulvar and Thigh Varicosities After Two Ablations: Pelvic Source or Local Failure?
A 44-year-old woman, gravida 3 para 3, presents with recurrent varicosities of both labia and the left medial thigh that appeared in her third pregnancy and persist. She has had two endovenous ablations of the left great saphenous vein at another institution, with recurrence within a year each time. Symptoms worsen with standing, with menses, and at the end of the day; she reports a dull pelvic ache and dyspareunia. Body mass index is 31. Duplex of the legs shows a competent deep system, no reflux in the treated great saphenous segments, and 1.4 seconds of reflux in a large left anterior thigh tributary. She is not pregnant. The referring physician asks you to exclude a pelvic source before a planned third ablation, and your laboratory has a 2 to 5 MHz curvilinear probe and a transvaginal probe available.
1. Describe the pelvic venous scanning protocol you would use, including positioning, probes, and the vessels you must evaluate.
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Positioning and preparation. Scan supine in 15 to 30 degrees of reverse Trendelenburg so that the pelvic veins fill without valsalva-independent distension, and use Valsalva as the provocation. Have the patient fast where practical to reduce bowel gas; a full bladder is helpful for transabdominal windows but not required for the transvaginal approach. Ask her to describe the relationship of symptoms to menses and standing, and note parity.
Probes and approaches. Start transabdominal with the 2 to 5 MHz curvilinear probe for the renal veins, gonadal veins, and iliac veins. Use the transvaginal probe for the internal iliac tributaries, paravaginal and parauterine plexuses, and the vulvar drainage, which are poorly seen transabdominally.
Vessels to evaluate.
- Left renal vein, including the aortomesenteric angle, and the left ovarian vein from its origin to the pelvis.
- Right ovarian vein and its insertion into the vena cava.
- Internal iliac veins and their visceral and parietal tributaries bilaterally.
- Cross-pelvic communicating varices and the paravaginal plexus.
- Common iliac veins, looking for compression or intraluminal echoes, and common femoral vein phasicity as a downstream indicator.
Measurements. Ovarian vein diameter at its widest point, direction of flow, and duration of retrograde flow on Valsalva; the same for internal iliac tributaries, plus the largest pelvic varix diameter. Document augmentation maneuvers, since reflux is a dynamic diagnosis.
2. Which findings would confirm a pelvic source for the leg and vulvar varicosities, and what thresholds would you apply?
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Criteria for pelvic venous incompetence.
- Left ovarian vein diameter of 5 to 6 mm or more, with retrograde flow on Valsalva lasting more than 1 second; the left is most often affected because of its anatomy at the renal vein.
- Dilated, refluxing internal iliac tributaries feeding the vulvar and perineal varices, typically above 5 mm.
- Cross-pelvic varices and a distended paravaginal or parauterine plexus.
- Flow in the vulvar varices that reverses or increases with Valsalva, confirming a pelvic rather than saphenous origin.
Matching the findings to the limb. The 1.4-second reflux in the anterior thigh tributary must be traced proximally. If it fills from the pelvic collaterals and not from a saphenofemoral connection, then the leg disease is downstream of the pelvic disease, which explains two failed ablations that treated the saphenous vein twice for a problem that was never saphenous.
What to exclude as alternatives. Iliac vein compression, which can mimic pelvic reflux and also causes left leg swelling; right-sided ovarian vein reflux; and deep venous obstruction. A competent deep system on the leg study makes obstruction less likely but does not exclude an iliac lesion, so assessment of phasicity and compressibility at the groin should be part of the report. A negative study is also useful, provided the dynamic maneuvers were actually performed and documented.
3. The left ovarian vein measures 8 mm with 2 seconds of retrograde flow on Valsalva, and a 6 mm internal iliac tributary feeds the vulvar varices. How does this change the treatment plan?
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The diagnosis is pelvic venous incompetence, and it is the primary problem. An 8 mm ovarian vein with 2 seconds of retrograde flow on Valsalva, together with a 6 mm refluxing internal iliac tributary feeding the vulvar varices, meets the criteria. The thigh varicosity is a downstream manifestation. A third ablation of a saphenous or tributary vein alone would predictably fail again, for the same reason the first two did.
Sequence the treatment proximally to distally.
- Refer for pelvic venography, with a plan for embolization of the incompetent ovarian vein and, where indicated, the internal iliac tributaries.
- Evaluate the iliac veins before or during the same procedure, because compression or a web may need stenting and would otherwise undermine the result.
- Reassess the leg after pelvic treatment, typically at 6 to 12 weeks. Many thigh and vulvar varicosities shrink and symptoms improve; residual superficial reflux can then be treated selectively.
- Reserve leg ablation for disease demonstrated to persist after the pelvic source is controlled, and document that reasoning for the surgeon.
Counselling points. Explain the expected improvement in the pelvic ache and dyspareunia, and the possibility that symptoms will not fully resolve. Note that compression has limited value for vulvar varices and that pregnancy planning affects timing, since future pregnancies can cause recurrence. The report should state the diagnosis, the measurements, and an explicit recommendation that pelvic treatment precede further leg intervention.