Pelvic Venous Reflux: A Hidden Cause of Varicose Veins and How CHIVA Can Help

Iliac Vein Compression and Varicose Veins: A Comprehensive Approach to Diagnosis and Treatment

A female patient with lower limb varicose veins recently visited my clinic for a second opinion. Her CTV scan at a local hospital suggested iliac vein compression, and she was advised to undergo stent implantation before addressing her varicose veins. Concerned about the risks and benefits of stenting, she sought the expertise of the Zhang Qiang Doctor Group CHIVA Center in Beijing, known for its hemodynamic evaluations and vein-sparing CHIVA treatment.

Upon thorough hemodynamic assessment, it became evident that her varicose veins originated from N1-3 EP points in the popliteal area, with no typical signs of venous hypertension. To alleviate her anxiety and ensure accurate diagnosis, I recommended a semi-upright ultrasound evaluation, a specialized test performed by Dr. Liu Yong, an ultrasound expert trained in hemodynamics. The results confirmed no significant flow obstruction, ruling out the necessity for stent implantation. This case highlights the importance of critically evaluating the diagnosis and treatment of iliac vein compression.

Understanding Iliac Vein Compression and Varicose Veins

Pathophysiology of Varicose Veins

The core mechanism of varicose veins involves venous valve incompetence and structural changes in the vein wall, leading to increased venous pressure and blood reflux. Chronic venous insufficiency (CVI) may result in superficial vein dilatation, edema, pigmentation, and ulceration.

Functional Impacts of Iliac Vein Compression

Iliac vein compression often occurs due to anatomical pressure from the right common iliac artery on the left common iliac vein (May-Thurner syndrome), though right-sided compression is also documented. This can impair venous return, elevate distal venous pressure, and increase the risk of deep vein thrombosis (DVT) while exacerbating superficial venous conditions. The primary concern with iliac vein compression is acute thrombosis formation.

From Morphological to Functional Diagnosis

The Role of Hemodynamic Assessment

While advanced imaging techniques like CTV and MRV are widely available and enhance the morphological diagnosis of iliac vein compression, functional assessment remains critical for a comprehensive evaluation of the venous system.

1. Limitations of Morphological Imaging

   • CTV and MRV provide static anatomical information, often performed in the supine position, which may not accurately reflect venous drainage functionality. Evaluating collateral circulation can partially compensate for these limitations.

2. Dynamic Flow Evaluation

   • Traditional Doppler ultrasound assesses proximal and distal venous flow velocities and directions to evaluate functional impairment. However, operator expertise and interference from bowel gas can pose challenges.
   • Claude Franceschi, the founder of CHIVA and hemodynamic theories, advocated for semi-upright Doppler ultrasound to mitigate positional artifacts and identify pseudo-compression. Venography with intravascular pressure measurement is another option for dynamic assessment, offering insights into pressure gradients and flow patterns, though it is invasive.
     

Functional Diagnostic Standards

• A venous pressure gradient >2 mmHg (or >3 mmHg in some studies) or significantly reduced flow velocity indicates functional compression.
• Clinical manifestations such as unilateral edema, chronic fatigue, or recurrent DVT further support the diagnosis of functional impairment.

Treatment Strategies: A Functional Perspective

Clarifying Functional Impairment Before Intervention

Treatment decisions should prioritize interventions that address functional impairment impacting the patient’s quality of life. In cases without significant functional obstruction, addressing varicose veins first often yields a better risk-benefit balance. Minimally invasive methods, such as CHIVA, preserve vein function and minimize trauma.

Indications for Iliac Vein Stenting

• Functional compression with significant symptoms, such as unilateral edema or recurrent DVT, justifies stenting.
• Patients with anatomical compression but no functional impairment should avoid unnecessary interventions. Preventive measures, such as thrombosis management and regular monitoring, are recommended.

Comprehensive Management of Varicose Veins

• After resolving hemodynamic issues caused by iliac vein compression, individualized treatment for superficial vein reflux, such as CHIVA or other minimally invasive methods, can be implemented.
• Conservative approaches like compression stockings remain the first-line treatment for mild compression or asymptomatic cases.

Navigating the Gray Areas: Decision-Making in Complex Cases

The management of iliac vein compression remains a topic of debate, with diverging opinions on the necessity and timing of stenting. Key considerations include:

1. Balancing Morphological and Functional Findings

   • Morphological imaging often reveals compression without significant symptoms or hemodynamic abnormalities, questioning the need for intervention.

2. Risks of Stent Implantation

   • While stents effectively relieve anatomical compression, complications such as thrombosis, stent migration, or neointimal hyperplasia can occur. Long-term anticoagulation poses adherence challenges.

3. Framework for Decision-Making

   • Functional Assessment: Is the compression functionally significant?
   • Compression Severity: Does hemodynamic evaluation indicate substantial impairment?
   • Symptom Correlation: Are the symptoms attributable to iliac vein compression?
   • Patient Expectations: What are the patient’s goals and risk tolerance?
   • Risk-Benefit Analysis: Will iliac vein treatment provide greater benefits than addressing varicose veins alone?

Conclusion

The coexistence of iliac vein compression and varicose veins demands a meticulous approach to diagnosis and treatment. Clinicians should move beyond morphology, incorporating hemodynamic evaluations to determine functional impairment and guide personalized treatment strategies. Collaborative decision-making between physicians and patients is vital in navigating gray areas, ensuring optimal care and outcomes for patients with complex venous conditions.