Outcomes of Symptom-Driven Top-Down versus Bottom-Up Strategies for Pelvic-Origin Extra-Pelvic Varicose Veins

Pelvic-origin extra-pelvic varicose veins are increasingly recognized as a distinct phenotype of chronic venous disease. The optimal treatment sequence remains uncertain and is often selected according to the dominant clinical presentation. This study evaluated outcomes after symptom-driven top-down or bottom-up strategies in women with pelvic-origin extra-pelvic varicose veins.

We reviewed consecutive women with pelvic-origin extra-pelvic varicose veins treated between 2018 and 2024. Diagnosis was based on clinical examination, duplex ultrasound, and pelvic venous imaging. Patients with clinically relevant pelvic symptoms were generally treated with a top-down strategy, whereas patients with predominantly extra-pelvic manifestations and no significant pelvic symptoms were treated with a bottom-up strategy. Extra-pelvic outcomes were assessed using the revised Venous Clinical Severity Score (rVCSS), the Chronic Venous Insufficiency Questionnaire-20 (CIVIQ-20), technical success, escape point occlusion, and recurrence-free survival. Pelvic pain response in the top-down group was assessed using the visual analog scale (VAS) and parauterine vein diameter.

Seventy-five patients were included: 32 in the top-down group and 43 in the bottom-up group. The groups had similar baseline characteristics, except for age (bottom-up group was older). At 3 months, no statistically significant differences were observed in rVCSS and CIVIQ-20 scores between the selected treatment groups (P = 0.71 and P = 0.86, respectively). Escape point occlusion rates were 93.8% and 97.7% (P = 0.58), lower limb symptom resolution rates were 100% and 95.3% (P = 0.24), and vulvar varices resolution rates were 87.5% and 93.0% (P = 0.47), respectively. At 3-year follow-up, the recurrence rate was 6.25% in the top-down group and 11.6% in the bottom-up group. Recurrence-free survival rates at 5 years were not statistically different between the groups (log-rank P = 0.33). Cox regression analysis identified BMI as a significant predictor of recurrence (HR = 2.654, P = 0.015).

In this retrospective cohort of clinically selected patients, symptom-driven top-down and bottom-up strategies were both associated with favorable short-term outcomes and mid-term durability. Because the two groups represented different clinical phenotypes rather than randomized comparable populations, these findings should not be interpreted as proof of equivalent effectiveness. Treatment selection should be individualized based on pelvic symptoms, pelvic hemodynamics, and extra-pelvic anatomical patterns.