Advanced Pelvic Venous Duplex: Utility of Vascular Ultrasound

We begin by discussing Dr. Gibson's career. She was the first woman to complete a vascular surgery fellowship, which was in 2001. Her training, like most, was very arterial focused at the time. She then moved into the private practice space while still completing clinical research. She began to realize that more of her patients had venous disease than arterial. For example, she saw many more patients with varicose veins than abdominal aortic aneurysms. Pelvic venous disorders (PeVD) in particular, remain poorly studied and understood. She became interested in this patient population because she saw many women present with pelvic pain and varicose veins after multiple targeted saphenous vein treatments. She realized this was because the source of the problem, the pelvic veins, were being left untreated.

Dr. Gibson developed a varicose vein classification that is being disseminated around the world, and has been translated into multiple languages. It is called the SVP Classifier (Symptoms-Varices-Pathophysiology). It was developed to be used in conjunction with CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification for venous disease. There is an app available, as well as a workbook that can be used to claim CME. It is a tool that can aid providers and vascular technologists alike when working up PeVD.

Lastly, Dr. Gibson reviews her workup of a patient with pelvic pain. Before undergoing ultrasound and vascular workup, it is important to think of other causes of pelvic pain in women of certain ages. In young women, she always ensures patients have seen a gynecologist, as endometriosis is the most common cause of pelvic pain in this group. If they are post-menopausal and present with new onset pain, she also has the patient see a gynecologist to rule out malignancy. Finally, if the patient is postpartum, she loops in a pelvic floor physical therapist because myofascial pain from pregnancy can mimic pain from PeVD. For the vascular workup, she begins with an ultrasound performed by a vascular technologist. She meets with the patient to discuss symptomatology and impacts on quality of life. If PeVD is found on US but the patient has minimal pelvic symptoms, she does not pursue treatment. She treats the patient, not the imaging. If symptoms are bad enough, she will move forward with stenting (for obstruction) or embolization (for varicosities). For embolization patients, there is no routine follow up unless there is a complaint. For stenting in NIVL (non-thrombotic iliac vein lesion) patients, she follows patients with annual US for a couple years. For post-thrombotic stenting she sees patients for US every 6 months, and then annually, as re-thrombosis is always a concern in these patients.