Jan Sloves: Addressing Diagnostic and Treatment Variability in Pelvic-Origin Varicose Veins
Jan Sloves, CEO and Founder at Ultrasound Unlocked LLC, shared a post on LinkedIn about a recent article by Peyton Cramer and co-authors, published in Journal of Vascular Surgery: Venous and Lymphatic Disorders, adding:
”A 194-physician survey just put a number on something many of us have sensed in practice: when it comes to pelvic-origin varicose veins, there is no consensus.
Peyton Cramer, Kimberly Scherer, Ronald Winokur and Neil Khilnani at Weill Cornell deserve real credit for quantifying it. Their international survey of vascular surgeons and interventional radiologists across the US, Europe, and Asia examined how we evaluate and manage V3a (vulvar) and V3b (pelvic-origin lower extremity) varicose veins in women without pelvic pain.
- Only 46 percent document the SVP classification before treatment – most of these women are triaged without a shared clinical framework
- Duplex is still our anchor: 81 percent use lower-extremity duplex for V3b, 62 percent for V3a. But dedicated vulvar/escape-point duplex, arguably the study most likely to localize the source, is ordered in just 36-42 percent of cases.
- Treatment sequencing is nearly an even split: 42-47 percent start ‘top-down’ with pelvic embolization first; the rest go ‘bottom-up,’ treating the visible varices directly. As the authors note, this likely reflects two reasonable philosophies rather than one being wrong, the comparative data to guide selection simply isn’t there yet
- When iliac compression and pelvic reflux coexist, there is no dominant strategy: 37 percent treat compression first, 24 percent treat reflux first, 9 percent treat both together, 30 percent decide case by case.
- A quarter of respondents use no formal outcome tool after treatment, making it hard for any of us to know, with confidence, which approach is truly working.
- At six months, persistent symptoms are managed just as variably, shaped as much by specialty and geography as by anatomy.
The authors aren’t asking anyone to pick a side. They’re asking for standardized diagnostic pathways, consistent use of a classification system and a core outcome set so future studies can be compared. For those of us performing the duplex studies these decisions are built on, that starts with making vulvar and escape-point imaging routine rather than optional.
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Title: Vulvar and Pelvic Origin Lower Extremity Varicose Veins: A Survey of Current Evaluation and Management
Authors: P. Cramer, K. Scherer, R.S. Winokur, N. Khilnani
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