Pelvic Venous Disorders: Male PVD, Stenting and Evidence

Session 7: Special Topics and Cases

The closing session ranged from an under-recognized patient group to the vocabulary the field uses.

Male Pelvic Venous Disease

A ten year protocol covering 146 patients found that disease in men reaches well beyond varicocele. Obstruction and reflux frequently coexist, multi-territorial involvement was common once intravascular ultrasound was used to look for it, and targeted treatment improved pain and quality of life with low complication rates.

Arguments Worth Having

• Drop the nutcracker label. On rotational venography and ultrasound, at least half of left renal vein compressions are stretching over the aorta rather than compression by the superior mesenteric artery. That matters, since transposition stretches an already stretched vein.
• Treat the iliac lesion first. In one patient with both renal and iliac stenosis, stenting the iliac vein alone took the pelvic venous severity score from 12 to zero within nine months.
• Position changes the picture. A patient with no stenosis upright showed severe compression when supine, so cross-sectional imaging alone cannot establish a lesion.
• Selection beats anatomy. Leg symptoms, not percentage stenosis, predicted who benefited, and a sham controlled trial is testing embolization against placebo.