Pelvic Venous Disease: Evaluation and Management

2. Athanasios Katsargyris, MD PHDDepartment of Vascular & Endovascular SurgeryParacelsus Medical University, Klinikum Nuremberg201 Breslauer Str.90471 Nuremberg, Germany Clinical Case Report Pelvic venous disease Antonios P GasparisProfessor of Surgery Division of Vascular SurgeryDirector, Vein Center in collaboration with Stony Brook Medicine New York Venous Symposium Expert Vein Management CursoInterativo Vascular International Meeting on Aortic Diseases EVM IMAD Stony Brook University Medical Center New York www.venous-symposium.com

3. History of presentation A 43 year old female with history of progressive leftcalf swellingfor the past 2 years. Over the past year, she has developed left leg and thigh pain. Symptoms Dull ache and tightness in left leg and thigh that becomes worse with prolonged standing or ambulation Unable to run without severe pain Symptoms do not resolve with rest until after approximately 20 minutes

4. History Medical history: HTN, hypothyroid, obesity, depression Social history: non-smoker Family history: HTN Allergies: none Medications: HCTZ, Synthroid, Lexapro

5. Non-pitting edema left leg

6. What imaging should be obtained? ABI Arterial Duplex Venous Duplex

7. What imaging should be obtained? ABI Arterial Duplex Venous Duplex

8. Lower limb venous DU • Left GSV diameter was 6mm and • had reflux from SFJ to the distal thigh

9. Lower limb venous DU • No deep vein thrombosis • No deep venous reflux

10. Left limb venous duplex ultrasound • No deep vein thrombosis  • No deep venous reflux  • GSV diameter was 6mm and had reflux from SFJ to the distal thigh  • Varicose veins in the mid-thigh, distal thigh and mid-posterior calf  • No SSV reflux 

11. What is the next step? • ECS • CT scan • L GSV ablation

12. What is the next step? • ECS • CT scan • L GSV ablation

13. CT Venogram No evidence of abdominal or pelvic mass Left renal vein was normal Left Renal Vein

14. CT Venogram Right Common Iliac Artery Left Common Iliac Vein Left Common Iliac Artery Right Common Iliac Vein

15. CT Venogram Mild left CIV compression but not likely to suspect significant obstruction. However, the extent of her swelling could not be explained by the GSV reflux alone. Should further evaluation of the iliac veins be performed?

16. Venogram performed IVC IVC Left Common Iliac Vein Left Common Iliac Vein AP view LAO 45 No significant obstruction on venogram

17. Further evaluation for iliac obstruction is warranted due to high clinical suspicion with the clinical presentation of the patient.

18. Right common iliac artery Left common iliac vein Left common iliac vein distal to compression 73% area reduction of LCIV from the RCIA

19. What is the next step? GSV ablation Stenting of the left common iliac vein Both procedures

20. In some patients with swelling or lower limb aching,venous reflux alone cannot account for CVD severity. In such cases imaging of the iliac veins is often done to detect obstruction. Correcting obstruction and saphenous vein reflux has shown to improve clinical outcomes despite the deep vein incompetence. This was demonstrated by Neglen P, et al who did combined interventions in 99 limbs of 96 patientswith up to 5.5 years of follow-up. Neglen P, et al. Combined saphenous ablation and iliac stent placement for complex severe chronic venous disease. J VascSurg 2006;44:828-33

21. Antonios P GasparisProfessor of Surgery Division of Vascular SurgeryDirector, Vein Center Program Director, Phlebology DirectorVenous Symposium, NY DirectorExpert Venous Management Director HOT Hands on Training Education: Obtained an undergraduate degree at New York University in 1992 with a B.A. in Classical Civilization of Greece and Rome. Competed Medical School at SUNY HSC at Syracuse in 1996 and stayed at SUNY Syracuse for residency in General Surgery which was completed in 2000. Subsequently did a Vascular Surgery fellowship for 2 years at SUNY Stony Brook from 2001-2003 followed by an Endovascular fellowship in 2003 at Texas Tech. Professional Career: Following training, stayed on staff as an Attending Vascular Surgeon from 2003-present at Stony Brook University Medical Center. He won the Traveling Fellowship of the American Venous Forum. He founded the Stony Brook Vein Center in 2003 which is a leading venous center providing complete venous care. Dr. Gasparis is actively involved with both the AVF and ACP. He is on the AVF and ABVLM boards. His interests and research are in deep venous disease including diagnosis and treatment of deep venous thrombosis, chronic venous obstruction and pelvic vein disease. He has published over 30 papers, presented over 20 original abstracts and given over 100 lectures both nationally and internationally. Commentary Dr. Nicos Labropoulos, Director of ScIENCE Dr. Gasparis has great experience in management of venous disease from spider veins to complex deep vein cases . He has significant background on administration and in reducing costs. He has been teaching trainees and colleagues nationally and around the world. He helped developed our Vein Center that has also an OBL and other satellite centers. In the middle of his carrier he has already a significant impact on the venous world.