Vulvar and Pelvic Origin Lower Extremity Varicose Veins: A Survey of Current Evaluation and Management

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

An electronic survey was internationally distributed to vascular specialists to assess the current state of pelvic venous disorder (PeVD) care. The 51-question survey utilized the Qualtrics platform and was distributed through medical society forums, international vascular meeting mailing lists, and direct distributions. The survey was open from June 2024 to July 2024, requiring approximately 10-15 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 5 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.

The majority of survey respondents were vascular surgeons (47%) and interventional radiologists (38%) from the US (43%), Asia (17%), and Europe (16%). 194 respondents reported treating women with extra-pelvic varices of pelvic origin and completed this portion of the survey. For V3a and V3b women, 46% utilized the SVP classification tool as a part of the clinical assessment prior to treatment. The preferred imaging modality prior to 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 utilized 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% utilizing a clinical outcome tool post-procedurally. Management of persistent or recurrent symptoms after treatment is variable, ranging from conservative care (8%), re-treating with the same approach (10-29%), or utilizing a different approach (if "top down" initially, then "bottom up" or if "bottom up" initially, then "top down") (22-27%).

This 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.