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Recurrence of Varicose Veins after Endovenous Ablation

Venous Insufficiency is the most common cardiovascular disorder in the human species. It also is unique to human beings as animals do not get varicose veins.  Why? Because it is directly related to the erect posture of humans and is a direct influence of gravity.  This is why veins below the heart build up pressure and eventually get dilated and start refluxing.

Incidence of some variation of varicose veins is around 20% in the general population but the incidence of venous insufficiency is 40%.  For example, 50% of venous insufficiencies are hidden until you check for this with ultrasound.  Over time, varicose veins get bigger with increased pressure and damage to venous valves and this blood starts pooling into the lower extremities causing swelling, discomfort, edema, restless leg syndrome, and chronic skin changes.  If untreated up to this stage, it can lead to venous ulcers and infection.

Several years ago, varicose vein treatment was a nightmare.  For example, vein stripping was more of a brutal procedure with a high recurrence rate.  Then came endovascular techniques using laser and radiofrequency ablation.  Since then routine varicose vein surgery has proliferated and changed the venous disease dynamics.

Even with new endovascular techniques recurrence of varicose veins is still a significant problem in 15-18% within a year and especially in women.

The most common reason for recurrence is treating the wrong vein or treating only one source of the reflux.  It is common to have more than one area of venous reflux and identification of those areas is a pre-requisite to good success.

The most commonly ignored area is the pelvic veins. This is poorly understood and a difficult territory to visualize.  Some physicians take the easy way with the large saphenous vein and assumes everything will be okay.  But the source of the reflux is up higher in the pelvis and recurrence is common.  It is especially common in females.  Females with multiple births see 20% of the source of their reflux coming from pelvic veins.  There are two types of veins responsible for pelvic reflux.  Ovarian vein 7% and internal iliac vein 93%.

Significant reflux leads to lower abdominal pain, excessive menstrual bleeding, pain during intercourse, bladder and lower GI irritability, and lower extremity edema.  This is called Pelvic Congestion Syndrome.

Conventional superficial ultrasound does not identify pelvic congestion syndrome.  Some selected centers to have CT Venography or MRA to rule out venous reflux but it is not common practice and you can still miss the diagnosis.

Most useful diagnostic test in transvaginal ultrasound to identify dilated and refluxing pelvic veins. But most of the vein centers do not have this option available. That is why you see frustrated women having recurrences of varicosities after successful operations.

The clue to pelvic reflux is one of the symptoms discussed above and the examination where you can visualize vulvular varicosities and the thigh vein extending into medial aspect and going to the pelvis or entering posteriorly via buttock area.  That gives you a good clue to assess pelvic veins before fixing greater saphenous vein.  So we see at least 20% of women with surgery come back with some problem since new physicians do not recognize it and do not have the means to diagnose it.  Make sure you tell them any pelvic symptoms you have and ask them if they are capable of doing a transvaginal venous ultrasound.  Good Luck!

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