AVF Summit: Top-Down and Bottom-Up Pelvic Vein Treatment

Workup Pearls for Zone Two and Three Disease

IVUS is essential for planning, gonadal vein issues are treated first with reassessment before adding a stent, and clinicians must watch for nickel allergy risk with nitinol stents and rare but serious stent migration requiring snare retrieval.

Choosing Top-Down Versus Bottom-Up Treatment

Uncompensated reflux or obstruction driving pelvic or leg symptoms favors top-down stenting or coil embolization first, while compensated disease escaping into extra-pelvic veins often responds to bottom-up sclerotherapy alone, sparing patients an unneeded lifelong stent.

Ultrasound Diagnosis of Pelvic Escape Points

Six escape points, clitoral, labial, perineal, inguinal, gluteal, and obturator, drain into extra-pelvic varices through tributaries of the internal pudendal vein, and duplex ultrasound in standing and gynecologic positions reliably identifies which ones require treatment.

Sclerotherapy Technique and Long-Term Outcomes

Direct ultrasound-guided foam sclerotherapy of escape points, without embolization, achieved 90 percent occlusion at three years with minimal complications, while incomplete treatment or embolization alone left roughly half of patients with recurrent varices.