Pelvic venous disease and lymphatic dysfunction: evaluating the evidence for a proposed continuum

Pelvic venous disease (PeVD) and lymphedema are traditionally regarded as distinct clinical entities and are usually investigated and managed within separate clinical frameworks. However, both conditions may coexist in patients with chronic edema, raising the question of whether a venous-lymphatic interaction contributes to chronic edema and whether such a relationship is supported by current evidence.

A systematic-style review was performed of published literature on pelvic venous disorders, chronic venous disease, and lymphatic dysfunction. Evidence relating to pelvic venous reflux, central venous obstruction, lymphatic pathophysiology, imaging, and treatment outcomes was critically evaluated, with explicit distinction between established evidence, indirect associations, and hypotheses.

The evidence base consists predominantly of observational studies and systematic or narrative reviews. Across published cohorts and reviews, the predominant reported outcome measure for reflux-dominant pelvic venous disease is pelvic pain, with pain improvement reported in approximately 70-80% of patients following embolization. In contrast, the predominant reported outcome measure for obstruction-dominant pelvic venous disease is edema, with subjective improvement reported in approximately 60% of patients following iliocaval with or without caval venous stenting, although edema outcomes are rarely quantified and are not distinguished from lymphedema in the available literature. Objective lymphatic dysfunction is frequently reported in advanced chronic venous disease, but pelvic venous pathology has not been systematically evaluated in relation to lymphatic dysfunction or lymphatic assessment.

Current evidence does not establish a causal relationship between pelvic venous disease and lymphedema. While venous-lymphatic interaction is biologically plausible, the proposed surgical continuum should be regarded as hypothesis-driven rather than evidence-based. Routine pelvic venous intervention for lymphedema cannot be justified based on existing data, highlighting the need for integrated prospective studies combining venous and lymphatic assessment.