History is Flawed. A New Paradigm for Abdominal & Pelvic Venous Disorders

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1 History is Flawed A New Paradigm for Abdominal & Pelvic Venous Disorders Mark H. Meissner, MD Peter Gloviczki Professor of Venous & Lymphatic Medicine University of Washington School of Medicine

2 Disclosures Mark H. Meissner, MD I Have No Disclosures Relevant To This Presentation

3 The Nonsense of the Nomenclature The Pelvic Congestion Syndrome REALLY?? Independently described in 1949 by W. Lo and H.C. Taylor The term Pelvic Congestion Syndrome is NONSENSE and needs to be abandoned in favor of Chronic Pelvic Venous Disorders Would we be taken seriously if we talked about Leg Congestion Syndrome (LGS) Br Med J 1949

4 The Current Status of Pelvic Venous Disease The Alphabet Soup of Syndromes Inaccurate diagnosis Poor treatment outcomes Denied reimbursement

5 Primary Pelvic Venous Disorders Chronic Pelvic Pain Pain Dysparunia Dysuria Pelvic Pelvic Varices Gluteal Perineal Vulvar Congestion Syndrome Four Reflux Clinical Presentations Obstruction Two Patterns of Reflux Leg Symptoms Pain Swelling Chronic Pelvic Venous Disorders Ovarian Vein Reflux Renal Symptoms Flank Pain Hematuria Iliac Vein Obstruction Internal Iliac Nutcracker Syndrome Reflux

6 The Female Pelvic Circulation Four Interconnected Venous Systems Internal iliac tributaries The gateway to the leg SEV Superfical External Pudendal Exactly analogous to perforating veins, connecting The deep veins of the pelvis The superficial veins of the leg Great Saphenous Deep External Pudendal

7 Pelvic Escape Points Kachlik D, Phlebology2010

8 The Venous Reservoirs of the Abdomen & Pelvis Hilar Varices Hilar Varices Symptoms presumably related to reservoir distension All reflux and obstruction occurs in 2 patterns Uncompensated No outflow from distal reservoir The Pelvic Renal Venous Hilar Plexus Drained by The Left Ovarian Renal Veins The Internal Iliac Veins The Lower Extremity Compensated Collateral outflow from distal reservoir Pattern determines symptoms

9 Uncompensated Obstruction L Renal Vein L Common Iliac Vein Compensated Obstruction L Renal Vein L Common Iliac Vein Uncompensated Reflux L Ovarian Vein L Internal Iliac Vein L Renal Vein L Ovarian Vein Renal Reservoir L Internal Iliac Vein Compensated Reflux L Ovarian Vein L Internal Iliac Vein Pelvic Escape Points Pelvic Reservoir Leg Reservoir Pelvic Floor

10 Pelvic Venous Disorders A New Paradigm For now, refer to the primary underlying pathophysiology 1º L renal vein obstruction 1º or 2º (post-thrombotic) Iliac vein obstruction 1º Ovarian vein reflux 1º Internal iliac vein reflux Clear need for a new classification instrument based on Clinical presentation Anatomy & physiology Natural history Treatment options

11 Pelvic Venous Classification Currently in developmental phase Funding by SIR / ACP Pelvic Clinical Category Description 0 No clinical manifestations of venous disease 1 Non-cyclic chronic pelvic pain of venous origin 2 Pelvic origin lower extremity varices 3 Lower extremity edema of pelvic venous origin 4 Venous claudication 5 Chronic left flank pain of venous origin with or without hematuria a Left flank pain b Hematuria Further designation of etiology, anatomy, & pathophysiology

12 Pelvic Classification Examples Post-thrombotic Venous Chronic Pelvic Pain Claudication L Renal Vein Pelvic Congestion Compression w Chronic Syndrome Pelvic Pain C1EPALOV,ROVPR Pelvic Congestion Syndrome C4ESALCIV.LEIVPO C1EPALRV(O),LOV (R)PR,O

13 Conclusions 4 interconnected systems L renal vein 2 abdominal-pelvic reservoirs Ovarian veins The renal hilum Internal iliac veins The pelvis Symptoms related to Great reservoir saphenous distension vein Syndrome terms are imprecise and misleading Precise patient definition is needed Clinic presentation Anatomy Natural history Treatment response Great Saphenous A discrimitive instrument, aligned with CEAP, is needed SEV Superfical External Pudendal Deep External Pudendal