PeVD: past, present, and what the future holds
Neil Khilnani, MD
Drs. Chadalavada and Khilnani discuss pelvic venous disorders. They talk about the dangers of physicians who overlook or are skeptical about PeVD, which can result in a lack of diagnosis and verifiable treatment.
Episode Transcript
Hi, everyone. Good morning. My name is Ram Chadalavada. I’m here with Dr. Neil Khilnani. We are here live at Cook’s medical soundproof booth at SIR 2023. We’re going to be discussing a very relevant, and prevalent, topic of PEVD. Dr. Khilnani, please tell us a little bit about yourself.
Hey, thanks, Ram. I’m Neil Khilnani from Weill Cornell, New York Presbyterian Hospital in New York. And, first off, I just wanted to kick off by thanking Cook to give us the opportunity to shine a light on a topic that I’m very passionate about, pelvic venous disorders, and also to give us the full latitude of being able to talk about anything and anything we want, you know, in the– in this context. So, very appreciated. And it’s a pleasure to be here with you Ram. Maybe I’ll just give a little background on my practice and myself. I’m an interventional radiologist, but, in–I guess practicing for little over 30 years now in New York at the same place at Cornell. The first 10 years or so I did a little bit of everything, but I definitely had a good component of my practice was a deep vein practice. And then over the last 20 or so years, I’ve really pivoted more toward venous only practice, which is really where I’ve been for the last 10, 12 years. You know, initially involved in everything, but primarily superficial venous disease, lower extremity veins, and we see a lot of pelvic venous disorder patients come in because of pelvic origin, lower extremity, varicose veins. And so that’s sort of my history in the area.
That’s great.
Yeah.
I think we could learn a lot about that and I would love to hear how your career evolved related to that. A little bit about myself: I’m at University of Cincinnati. I’m an associate professor there in radiology and surgery. I started my career in 2015, so actually it was my first job right out of practice. It was a unique opportunity in that we were kind of the new wave of folks who were establishing a clinic practice as well, and getting involved in procedures. And you know, my involvement with pelvic disorders was interrelated with filters, IVC filters, and then just helping manage with women’s health. I’ve developed a good relationship with a lot of the OB and that’s kind of helped me get into the pelvic, venous disorder space.
Yeah, there’s a lot of cynicism in the obstetrics and gynecology world about venous disease. You know, we were talking in the past about this. My wife is a gynecologist, and it’s really eye-opening to me to see how little interest they have in this, and how much skepticism they have about the association of abnormal veins in the pelvis and pelvic pain or even pelvic varicosities. You know, for them, the–you know, the visualization of pelvic varices is such a common thing that they’ve just learned to overlook it. So this is a barrier that we need to recognize, and it’s an opportunity for us to recognize that there’s really an educational gap for them. So–
Yeah. No, that’s interesting that it’s part of your household discussion,
Yeah, absolutely. You know, I think, for me, the focus in pelvic venous disorders has become more of a, not just a clinical thing, but an academic thing. Certainly, you know, the observations that I’ve made clinically in terms of how prevalent the problem is and how often we see it in lower extremity venous disorders is a common thing. The gap that I described with the obstetrician gynecologists who I talk to all–you know–all the time about this, who–you know–very freely, you know–express their skepticism. But also there’s such a tremendous amount of heterogeneity in terms of how these patients are cared for by vascular specialists in all different disciplines. And I think to some extent, it had to do a little bit with the fact that the entity has never really been properly, until recently, defined. And I think we’ve learned a lot in the last few years.
You’re absolutely right. I think one of the most interesting things I read–you know, there’s several articles in EVT and others that come out–the cost of this disease and not knowing–the lack of diagnosis, the lack of clearly identifiable treatment, just because of that classification and understanding, is almost three–I think I wrote it down–almost 2.8 billion dollars is directed towards this. So, clearly it’s an important topic and I think you–we were talking about how you were going to lead us off in this discussion about classification on–so–
Well, we definitely, you know, have learned a lot about the interrelationship between venous and abdominal venous anatomy and pathophysiology, and how important it is in the last few years. But I think we’ve also recognized how interrelated a lot of these things that we used to silo into separate categories are. And so–
Absolutely.
A few years ago, the term pelvic venous disorders was proposed by a research consensus panel funded by the Society of Interventional Radiology Foundation. And I–and I think–first off, I’m very happy to see how well that nomenclature has caught on worldwide. It really–
Absolutely.
It’s pretty much the standard. Very, very infrequently do you hear any of those old eponyms being used anymore. I think–
The fact that it was multi-societal and multidisciplinary was a huge part of that.
No, yeah, that was–and yeah–and as a result of that, we’ve, you know, from that RCP, we developed a work group that’s been moving a research agenda through. And so maybe just to step back and sort of draw a circle around what pelvic venous disorders are, you know, you can look at it from a pathophysiologic point of view. You know, it includes reflux in the ovarian veins, the internal iliac veins. It includes obstruction in the iliac vein and in the left renal vein. But clinically, which is another way to look at them, it focuses in on the four different clinical presentations. And so, you know, I think a lot of times we focus only on the issue of chronic pain in women. And so chronic pain of venous origin would certainly be a pelvic venous disorder clinical presentation, but so would other–some of these other presentations. So flank pain and hematuria is part of a venous disorder discussion. And lower extremity swelling and pain, and, what we’ll call extra pelvic lower extremity or vulvar, varicose veins. And it’s, you know, what makes this area so confusing for people is that the same clinical presentation can result from a variety of different pathophysiologic mechanisms. And it all depends on, you know, how the high pressure in the veins is managed in terms of collateral pathways. What efficiency exists will determine what kind of symptoms the patients present with. And so tying it all together with this overarching pelvic venous disorders term, I think is really going to help us present this to our–to ourselves and our own societies, but also to other societies of physicians, and then, you know, other interested stakeholders, including patients.
Yeah, well, Neil, I think you said it really well, framed that well. We’re essentially describing CPP, which is chronic pelvic pain. And, you know, I’ll just name some of the conditions that were typically classified into this grouping. You know, we have anywhere from May-Thurner, we have Nutcracker, the whole PCS or pelvic congestion, which was more broadly applied, but, you know, now subclassified and better organized, as well as pelvic dumping. I know you have some background–and actually I would love to pick your brain–about pelvic dumping and sharing some context about that.
Yeah, no, it’s a very important topic. And in fact, in the final session of SIR this year, the Superficial Veins, we’ll have a talk that I’m going to give in that session, dealing with patients who have varicose veins of their lower extremity of pelvic origin and vulvar varicose veins as well. And, you know, the question is always, do you need to treat the pelvic source or can you treat just the lower extremity problem? And the sort of take home message, the final slide to get there, to give you the answer right from the get-go, is if you have another reason to treat the pelvis, you know, if the patient has significant pelvic pain that’s probably a ven–that you think is of venous origin, then it’s probably reasonable to start there and then treat the legs.
But pretty much all other circumstances–maybe the other exception would be a patient who clearly has a post-thrombotic iliac problem.
Sure.
There you’d need to go to the iliac, sort of the pelvic system, and deal with that. But pretty much everything else can be managed very well. Symptomatic vulvar varicose veins and symptomatic lower extremity varicose veins can be managed very well from what we’d consider a bottom-up approach. In other words, treating the veins beginning at the pelvic floor, at the pelvic escape points, and then managing the varicose veins in traditional ways lower down. So it’s a very important, controversial topic. The evidence is a little weak in that area, and we need to improve that.
Absolutely. And we’ll talk more about how we improve this particular area. But I think this is maybe a good time to talk about the SVP classification. I was wondering if you could kind of shed some light–and I–this is something I actually always pull up in my clinic, and actually to help patients, but also to articulate my communication, but also to my referring physicians. So would you like to share a little bit about the SVP?
Yeah, absolutely. And it was another byproduct of the research consensus panel. One of the things that was highly cited as a major gap in what we have right now is a way to classify patients, and even to take the sort of classification that we talked about before with pelvic venous disorders to another level, so that you can be very precise about what patient you’re talking about. This is going to be crucial when research is done. So, much like the CEAP classification or all the other classifications in interventional oncology, you really need to know what your patient population is when you’re talking about data, you know, and outcomes, and so this tool will allow us to categorize patients into certain bins, so to speak, so that we can talk about things a little bit more clearly.
So rather than talking about pelvic congestion syndrome, which could be caused by reflux or obstruction, or both, we’ll talk about it in a, you know, sort of– in a very simple way. We wanted to make it a clinically relevant tool and so, unlike things like CEAP, that really just deal with, you know, things that aren’t really patient-centered sometimes–
Absolutely.
Symptoms come first. And so that first–the “S” is–it’s Symptoms, Varices, and Pathophysiology is what the acronym SVP stands for.
Mm-hmm.
One of the members of the team that helped us put this together is French, and so he goes, “Of course, it’s ‘s’il vous plaît.’ Please answer this question to give us the precise definition of your patients.”
I did not know that.
So, symptoms can be defined. Varices would be defined, again, by where they are and so we divided the abdominal and pelvic venous system, so to speak, into three zones. One zone is the zone near the kidneys. So essentially we’re looking for renal vein and perihilar veins in Zone One. Zone Two is broadly the pelvis. And Zone Three are extra pelvic areas where vulvar varicose veins would be. So that would be Zone Three A, and extra pelvic varicose veins would be in the lower extremities, that would be Zone Three B. And so we would use symptoms, we would define where the symptoms are, we would define where the varices are with the S and the V component. So in a patient with venous origin, chronic pelvic pain, they have their symptoms in Zone Two, S2, and they have presumably varices in the pelvis, and so we’ll label that as a V2. And then the P is pathophysiology, which deals with what anatomy is involved, what hemodynamics are involved, and what etiology is involved. It sounds very daunting as many of these tools go, but it’s actually quite easy because it uses very simple abbreviations for things. And so, rather than getting into the details, the American Vein and Lymphatic Society was a partner with us in putting all this together, and in fact they spearheaded the SVP initiative, and the American Vein and Lymphatic Society on their website, and in both the Android world and in the Apple world, host a calculator that you can use to score a patient and come up with the exact SVP classification for them. As it turns out, if you look at it a few times, you can do it without the com–without the help of the app, but the app is really helpful.
That’s awesome to know. I mean, as you probably know, and–I tend to deal with oncology and several other disease areas, and those calculators are very helpful. Oftentimes they’re on MDCalc–they’ve kind of summarized them there–but having that referenced, really helps me organize my thought. But also the preparation, presentation of your note, that would need to be submitted. And for your colleagues and referring providers to also see. I think you’re so right in that this was a multidisciplinary, much-needed classification. It really helps us organize things in a logical manner when you actually, like you said–I also was–felt daunting, but if you actually look through the sub classification, it’s very nicely organized, and I encourage everyone to take a look at this classification and incorporate this into your daily practice.
Yeah, you can find the SVP classification–it was published in two journals. It was published in the Journal of Vascular Surgery, but it was also published in the journal Phlebology, and so you’d be able to find it. And it’s being used internationally, and it’s very exciting to go to meetings and now see people not say, “Here’s our series of patients that we treated with pelvic congestion syndrome,” but rather “Here’s our patients with S2V2, and then you know, P ovarian–right ovarian vein reflux,” kind of thing.
Yeah. Neil, can I ask, how much of the bridging work are you doing? For example, because a lot of the patients, when they Google and they come to see me, that’s the older terminology that they may be most familiar with, you know. So I’m spending a lot of time explaining this part, like you eloquently described, at a professional level. How do you explain this transition to patients?
Yeah, I think the transition in the categorization may not be as relevant to them as the change in the nomenclature for how we describe things. And I think we–you know, the pelvic congestion syndrome term carries so much baggage that doesn’t help our cause, particularly in the gynecologic world, that we really just need to get rid of it. And I think, as much as possible, you know, when we consider what pelvic congestion syndrome meant to people before, venous-origin chronic pelvic pain is probably the term we should be using. And so when we speak with our colleagues and when we tell–when we talk to patients, we can say, “Your chronic pelvic pain seems to be of venous origin.” And that is the best way to describe it. And then that leaves the opportunity to then just, you know, at some point if you–if it’s necessary, get into the pathophysiology.
Yeah. I think you put it really well, because I think part of our communicators back is actually our patients. You know, “I got to meet Dr. Khilnani, I got to meet Dr. Chadalavada, this is how they explained it to me.” And I think in some ways, our patients are also advocates for this transition, or this communication pathway, because oftentimes it’s our patients who help us re-refer. They’re kind of the recurring currency back with our providers as well.
Yeah, no, I think the anchoring part that you brought up earlier is a great idea. It hadn’t occurred to me before, and we probably should now actually consider the patient-facing aspect of this nomenclature change. And maybe it would be an–you know, an opportunity for us at SIR to create a patient information site or a patient information handout that we would share with our members to educate patients on why we’ve changed the way we consider this and how that might benefit you.
Yeah, no, I think that’s great, because currently I notice a lot of patients bring in references, and then I have to associate a timeline. “Yes, that’s correct. Actually, if you saw me five years ago or six years ago, this is the way it used to be presented, but we’ve modified and improved.” And, so I do think there’s some work there. So hopefully, this is some of the things that we can talk about.
Action item number one from the podcast.
Yeah, there’s definitely a few components to this process of, you know, changing their perception of how veins and clinical clinical scenarios relate. And there’s definitely an education role. And in many ways, as part of our research efforts, we’ve been trying to cross-pollinate as much as possible. We’ve had people from their community speak in our group, and we’ve had people in their communities speak here as well. But it really is going to come down to the research. You know, I think we need to show evidence. So there’s a dean of a medical school who is part of our work group, who was the ACOG (American College of Obstetrics and Gynecology)-appointed person to our work group, which came from the RCP, so he was part of the RCP. And he wrote the 2020–the most recent–practice bulletin, is what they call it in ACOG–on chronic pelvic pain.
And he contacted me when it was coming out, and he said, “I’m sorry you’re going to be disappointed, but this is what I wrote for the paragraph that had–and it was a very short paragraph–that had anything to do with venous disease. And basically there are those who believe there’s an association between abnormal veins and pain. However, at this point, the evidence is inadequate to both prove causality and to prove that treatment makes a meaningful difference in patient outcomes.” And I don’t think that’s the exact quote, but that’s basically what he wrote. But he said, “I’m–” you know, to me, and also on some talks that we’ve been on, he’s very eager to help support the evidence. And he’s connected me with a lot of really important leaders in both ACOG, but also the International Pelvic Pain Society, a group of mostly gynecologists, but also a smattering of other physicians, mostly in urology, and then a lot of physiotherapists for pelvic floor treatments. And he’s connected me with a lot of experts in that area. And that is an additional partnership that we’ve leveraged, in terms of how we think about what we’re doing and how we’ll move forward with the research. And so, you know, I think we’ve got some eager gyne–clinic–really good scientist gynecologists who want to work with us. Some are sold already, some are very skeptical, and they–others are just like, “I know it’s there, but I just don’t know how to pick the right patients.”
Absolutely. Yeah.
So, and I think that’s really–that’s one of the things we’ve been talking about, is how do you define a patient with venous-origin chronic pelvic pain?
Well, actually, Neil, you know, just hearing about all of the work that you’ve done, honestly, we–I want to thank you for all the things that you’ve contributed within this space and all the meaningful work and connections you’ve made with the different societies and, you know, on behalf of SIR and actually all our providers that are interventional radiologists and who deal with vascular. So thank you for all the headway you’ve made in this.
Yeah, no, no, and it’s–it’s a lift, it’s not–this is a community. It’s not just a single person. But, I’ve been fortunate to be able to connect with people on many different levels in different areas who, you know, we–who work with us together on this initiative. So, absolutely. I’m pleased.
Yeah. I’ll tell you a little bit about what I’ve–rather than on the, almost on the front end, I’ve also–I’ve utilized the patience that I’ve taken care of to help me actually communicate back to the gynecologist. So we’ve had some great success stories. I’ll have to thank Cook Medical for this; last year at SIR in Boston, for the Synergy where we have the residents and fellows, we featured–we had a discussion about, you know, pelvic venous disorders. And we interviewed one of my patients that we treated successfully. And so it was a beautiful story. It’s about Ashley and her pelvic, symptoms had been going on for a number of years, you know, kind of went through ER visits, number of different visits, and some of it was mislabeled, and we–we took care of her, after having a clinical evaluation. And she’s been one of my most and biggest patient advocates. And there’ve been other patients that have come along, particularly in our particular practice, I’ve taken care of some of our University of Cincinnati employees who’ve had successful treatment, and they’ve been my advocates back to the gynecologist. And actually even also educating our family practitioners and some of the internal medicine primary care physicians as well. So, that’s been huge for me.
Some of–and these–there’ve been some very compelling cases in our clinical practice too, in terms of patients, how they respond and the–you know, the thankfulness they have at the end of what sometimes, as you mentioned, is an extremely long saga. And then there are other patients that are a little bit even more complicated than that. Some have that saga, we treat them, and yet they still remain uncomfortable. And I think that’s an important thing to talk about too, Ram, which is many of these patients end up with what seemingly are pain generators in multiple different locations. And so they’ll have what we might define as features of chronic pelvic pain, of venous origin, but yet they’ll have other features too. Their pelvic floor may be unhappy, they may have some bladder issues and bowel issues. And that was always very confusing for me.
Patients would come in–it was like the proverbial coming in with like the hand truck of charts, you know, and they just dump it in front of you and, you know, you’re expected to like do a consult in 40 minutes on somebody like that. And you know, what we’ve learned is–and I’ve learned this really from the physicians, from the IPPS, as much as any, is that chronic pain patients, regardless of where the chronic pain is, are very different than patients with other issues. And, you know–so normal pain is, nociceptor is stimulated. and so that sends a signal up to the spinal cord, which then stimulates a neuron that runs up the spinal thalamic tract. And, you know, in the thalmus, it’s then cortically perceived and we react to it, and there’s inhibitory pathways that can reduce it, and that’s kind of normal pain.
But in patients with chronic pelvic pain, things change. And also they change differently in different patients, which probably lets us know that some people are just neuro wired differently biologically than others. Some patients develop what we could call crosstalk, and so they end up having pain where there isn’t really a nociceptor that’s really firing. So this called–so-called nociplastic pain, and so–and probably there are a number of mechanisms to explain that, but many patients with a single organ that’s abnormal in the pelvis particularly, will perceive symptoms in multiple other organs. One of the most plausible explanations that I’ve seen is the central sensitization argument. And probably it has to do with changing depolarization thresholds in the spinal cord in neurons that are adjacent to each other, that all map to the organs and the pelvis.
So those nociceptors that have their cells that go up to the spinal cord are in the same location as the ones of the bladder, the pelvic floor, and the uterus. And so all those crosstalk, the brain can’t perceive where the pain’s coming from. It seems like it’s coming from all of those places. And then in some patients, the inhibitory pathways are very different too. It’s fascinating, the brain–you know, there’s a lot of good studies in the endometriosis world looking at functional MRI showing that patients with the same lesions who have no pain have a very different functional MRI appearance than patients who have perceptions of debilitating pain. So there’s a lot there. So it’s important to recognize that even though we might be treating these patients effectively, some of them are not going to get better, and it’s going to require working with other consultants, including consultants who deal with mental health. We don’t want to, sort of, say that you have a psychological problem. You have a neurobiological problem that got stimulated by the fact that you were in pain with an unrecognized primary pain generator for the last three years. And it just needs to get reset. And patients are very, very open to those conversations.
Yeah. No, Neil, I think you hit, you know, a really important point of setting the expectations, and I think that’s part of our responsibility, as clinicians to–you know, we rather under-promise and over-deliver, typically, but I think this is definitely a disease base and patient conditions that I’m very frank and share with them that this is–you know, potential etiologies and we’re going to work through this and we have to know that there’s going to be other folks involved as part of this care dynamic.
Absolutely. You know, I think, one of the other players that we underappreciate who have potential access to these patients are the physiotherapists who do pelvic floor therapy. Oh, in fact, as part of one of the things that we’re doing–again, a spinoff of the research consensus panel–was trying to identify what the clinical criteria for venous origin chronic pelvic pain is. That was called out in systematic reviews going back to 2016 as a real gap in our literature. You know, the definitions for different people, for different publications, were so vastly heterogeneous. And so working with the work group that came out of the Pelvic Pain RCP, with the experts from ACOG and IPPS as well as other vascular interventionalists, but particularly Richard Marvel, who’s a inter–who’s a gynecologist, chronic pelvic pain, past president of the IPPS,
we came up with a framework with how we might sort of look for these patients, and that’s what we’re going to use to identify patients to develop a disease-specific patient reported outcome measure for this entity. You know, I think, just to sort of make an aside here, it’s–you know, I think we underappreciate the impact that the UFS QOL–quality of life–tool for fibroid symptoms played both in the promotion of fibroid embolization as a viable alternative to the other gynecologic approaches for taking chronic pelvic pain, but to just fibroid research in general, it, as you know–
Absolutely.
Jim Sprees talked about this last night at the foundation dinner, that that tool is now used by pharma companies to prove drug–you know, in drug efficacy studies, it’s used for myomectomy, it’s used for hysterectomy.
Yeah.
And this gap that we have in our area, we don’t have a tool for certainly venous origin, chronic pelvic pain. So it turns out there isn’t a tool, really a good tool, for chronic pelvic pain. So we wanted to define what venous origin chronic pelvic pain was so that we can do the psychometric interviews of patients and then develop, you know, patient-reported outcome measure before we do any, you know, formal RCT type studies. And so we’re in progress with that.
That’s great.
We were generously funded by the SIR Foundation and the industries and the independent physicians who’ve been donating to the foundation, I’d like to thank them for supporting us on this research. And we’re at the point where we’re getting IRB approval at all those different sites. But we came up with a really nice way of looking at how patients are defined, and we not only included history and imaging, but we also included the value of physical exam. So it turns out the biggest overlap in the clinical presentation of patients with venous origin chronic pelvic are the patients with pelvic floor myofascial pain. And we will be talking about that tomorrow in the morning session on pelvic venous disorder, so I encourage those of you who are lucky enough to be here with us here in Phoenix to join us in that session. But I think working with the physiotherapists and talking to them and saying, “Do you have some patients that you’re struggling with?” Or, “Do they have some other features? Do you see vulva varicose veins? Do you see leg varicose veins? You know, maybe those are patients we might want to image to see if they have a pelvic venous disorder physiology, and maybe we can help you with those patients in partnership.”
Absolutely. I think that was a great tidbit that you’ve shared and something that I actually have not thought of myself. The other thing I want to give a shout out to is actually the SIR foundation and the story from Dr. Spies last night. I actually didn’t realize that part as well, and how he said the monies and the commitment actually has paid for itself, given the commitment that has and the continuation. So I think there’s something else in order here along that same spectrum. So, again, thank you for that work, and yeah–
Another thing that I heard that, you know, his research was done with a fraction of the amount of money it now takes to develop patient-reported outcome.
Absolutely.
I think we’re 30 times more than what he did, so yeah, it was eye-opening to hear that figure that he used.
Absolutely. Actually, you know, we’ve been talking about this particular patient population. How about–can we talk about maybe, some of the varicose veins and lower extremity? I know you have upcoming talks, but maybe we can have you shed some light. So how do you treat the women with lower extremity or vulva varicose veins of the pelvic origin? Are you in the embo first or treat the varicose leg and vulva veins? Could you kind of just guide me through that process?
Yeah, no, there’s, this is another evidence void.
Absolutely.
There are a few papers that give us some guidance, but there’s still–the quality of that evidence is still at the sort of large case report sort of approach. There are two studies that with the intent of trying to prove that embolization would help demonstrated that it didn’t help. One of the studies suggested that it did help with vulva varicose veins, those shrunk, but both of the studies were very disappointed with how well or how much improvement both symptomatically and with–and both visually that patients varicose veins and their lower extremities got better when they had pelvic origin varicose veins. There’s one study that it wasn’t the intent–there’s one study that Dr. Gibson, who’s a vascular surgeon in Washington, did to look at what the sort of quality of life conversations were for patients with what she called perineal varicose veins, but essentially varicose veins of the–extra pelvic varicose veins.
And essentially they were very, very similar to the same kind of symptoms you hear from patients with lower extremity varicosities: heaviness, aching swelling, throbbing, itching. But very interestingly, the women with those varicose veins, only 7% of them described chronic pelvic pain that was suggestive of a venous origin. So that helps us know that most of these patients don’t have pelvic pain, and therefore, experience has shown that since the embolization doesn’t help, we’re going to have to treat the varicose veins anyway. Just do what you need to do to treat the varicose veins, and that’s usually enough. I think the addition of treating–first, being aware that veins may be coming from the pelvis is important. So look at the upper thigh. I use transillumination a lot. Some people have ultrasound techs who go and search for varicose veins. You know, the– after they do the standard ultrasound, they then say, “Well, I haven’t explained these yet, where do they come from?” But I use transillumination a lot.
And you really do see, you know, the pudendal or inguinal escape point source varicose veins very, very frequently, much more than you would think if you don’t go looking for them actively. And I think treating near those escape points is part of, you know, a crucial part of being successful at managing what’s going on in the legs. So, treat near the escape points. Usually that’s some sort of chemical ablation, whether you’re doing ultrasound guided sclerotherapy with liquid or foam, or visual sclerotherapy. I use transilluminated and visual sclerotherapy a lot, but some people do it, and have argued that maybe doing it a little bit more thoroughly, is more effective. And so an interventional radiologist, Mel Rosenblatt (??) a few years ago was promoting doing it fluoroscopically like you would for a venous malformation.
Yeah.
Put a little needle in, and then don’t do a venogram, just go right to injecting a mixture of contrast and sclerosants and just watch where it goes.
And when it gets to the point that you feel like you’ve covered what you want, you do it. And there’s, you know–we’ve done that. He’s shown us lots of images on this, and when you inject enough, you’ll actually fill the periuterine, perivulvar, periovarian plexus. You can actually retrograde fill the ovarian vein too.
Wow.
So it’s very effective, you know. I think it doesn’t take much to get up there.
Yeah.
And I think some of the empiric approaches, that’s why it works. These veins just close, I think, pretty easily. And generally the recurrence rates of treating with the bottom up approach or the bottom first approach are very, very low.
Okay. That’s great.
That’s my approach. And I think in the absence of a lot of data that’s probably, you know, as good as we can get.
Yeah, no, I absolutely agree. I think you hit it very comprehensively and beautifully, so, yeah. And I know there’s another area–and I’ll shed some light too–so there’s other spectrums. So there’s women who are convinced they have a venous origin for chronic pelvic pain. And what do you–what should we do in terms of treating first in a woman with concurrent reflux and obstruction?
Yeah, that’s a complicated question that I knew we would be getting to eventually.
Yeah, absolutely.
But I’d be curious to hear how you manage it. You know, I don’t think there’s really a lot of evidence. You know, certainly, I think, you know, for 20 years–maybe we’ll just cite out, you know, Tony Van Brooks (??), you know, in his first big paper, the light has been shined on reflux as the cause of venous origin chronic pelvic pain. But it’s definitely been, you know, apparent that there’s–obstruction is an issue. And obstruction, as we talked about, can come at the iliac vein level, but it can also come at the renal vein level. And, you know, these are challenging things. There’s the–you know, how do you define obstruction? We’re still struggling, you know, in a patient with a little bit of leg swelling, to define, is that enough?
Or, you know, you know, is it 50% anatomy, 50%, you know, cross-sectional areas. Is it, you know, 70–or 61% cross-sectional area, as one study would suggest. So there’s, there’s really not good evidence to suggest that. But there’s no doubt that some patients with severe compression of, let’s say the common iliac vein who have retrograde flow in the ipsilateral internal iliac vein, and you can see collaterals going across the pelvis, many of those patients probably have collaterals that were not opacifying that are going through the uterus and, you know, they’re coming from one side of the uterus across the archioid (??) veins to the other side of the uterus and probably causing pain. A lot of the collaterals we see, as you probably recognize, are presacral collaterals. I don’t know if those cause pain. It probably–it could, I guess, but I don’t know if that does.
So, how to judge what to treat first is always complicated. Certainly, you know, you can argue that treating reflux is probably a lower hanging fruit. The negatives of treating that is quite low. You know, the risks associated with some kind of sclerosant mechanical occlusion of the ovarian veins and the pelvic venous reservoir is important. You know, we could argue, and maybe at some point we can talk about this, do we really need to study all four veins, so to speak, the two ovarian veins and the two internal iliac veins? You know, I think ultimately we need to know what’s filling that reservoir and eliminate the reservoir in order to get durable outcome. But I think that’s a lower hanging fruit. And so if you have equapoise in terms of what you think, which is the more important one, I think that’s a reasonable one to start with. I think iliac stenting though in some patients is going to be required. And sometimes you’ll see trivial reflux, if any, and, you know, clear cut, you know, obstructive lesion with collaterals, and then it’s pretty easy. I think it’s important to recognize though, that a large ovarian vein doesn’t mean that it’s refluxing, because sometimes, you know, with an iliac vein obstruction, the ovarian vein on either side can be a collateral. So be careful to identify those and don’t, you know, don’t block a big collateral flow and potentially make the patient unhappy.
Absolutely, Neil. You know, you mentioned, the studying part. There have been some patients where we’re quite sure, you know, which one–sometimes the chicken or the egg kind of question in this situation as well, and we’ve actually done a diagnostic venogram, to kind of even check pressures across the gradient to help, kind of–just went into it with the diagnosis. Let’s, you know, collect the data and see what we can see if there’s a pressure grading, what the venous plexus looks like, and so on. So, you know, in some of those patients, like you said, I agree, the low hanging fruit is addressing the reflux and then addressing obstruction, especially if there’s hardware that’d be potentially impacting some of the critical veins, whether it’s the renal vein or the common iliac vein. So, makes a lot of sense because the age of the patient, the durability of the device that you may be using, all plays a role. I agree with you. So I guess some of the scenarios I–what I’m trying to say is we should advocate for actually evaluating–diagnostically evaluating invasively, if appropriate, with the patient.
Yeah, no, I totally agree. And I think sometimes it’s, you know–particularly in shared decision making scenarios–it’s reasonable to go ahead and do a diagnostic study, a diagnostic venogram and an IVUS if needed, and then stop and then talk to the patient and say, “This is what we thought. What do you think?” You know, one of the other tricky things is that we’re dealing primarily with anatomy. It’s very hard to tease out what the true physiology is. The pressure gradient thing is an interesting way to look at it. You know, one of the challenges though is when we have well-collateralized obstructions, the pressure gradient may not exist. And so the classic example is a left renal vein compression with a huge ovarian vein, and what’s interesting about that physiology, and you can see this–I remember seeing this on an MRI the first time I noticed it, is that in a patient with a true obstruction of the renal vein, the ovarian vein fills really fast.
The peri–or the–if you will, the venous reservoir–fills really fast, and then the other ovarian vein fills really fast. So it really looks like a collateral pain. It doesn’t look like a congested situation. And so that should be a highlight first off. but in those situations, if you checked a pressure across the renal vein, it’s going to be normal. It’s the patients where the ovarian vein is not a good collateral or a collateral at all. It’s not refluxing. You have, you know, maybe a few hyler varices or maybe you–you know, sometimes you can’t tell, “Did I over inject or did my catheter flip in there?”
Absolutely. So many different factors, right?
Yeah. And so that’s where the gradient plays a big role. And so I want to shout out the Innovator of the Year award, Tom Sauce (??), my mentor at Cornell, who wrote a paper years ago defining what the normal pressure gradients are. He did this–they used to do a lot of renal vein renin measurements in the day when he was a hyper–renal vascular hypertension expert. And normal is about one, abnormal is clearly above three. So, one trick that is very interesting, I’m going to call out Kim Shearer )??), one of my colleagues who has been doing this, and I’ve heard now some other people are doing similar things, is to put a balloon in a patient who has a big ovarian vein and a questionable renal vein, and then measure the pressure gradient with the balloon inflated in the ovarian vein, across the renal vein. You’ll have a bunch of catheters across, or if you do it with a sheath, a single catheter, but it’ll give you a lot of insight. If the pressure gradient goes way up, when you inflate that balloon, then that’s a patient you need to be careful about and think about obstruction treatment first, whatever you think that is, whether you’re a stenter or a surgery type person.
Yep. So in the interest of time, I’m going to kind of look ahead and I also want to cover some of the SIR resources that we have for our providers and so on. So in 10 years, Neil, do you see the future, clinical data to help treat and add to education for referral physicians? So can you kind of give me an idea where you see this going in the next 10 years?
Yeah, I think it’s going to–it’s going to be–it’s going to hinge on our research and I hope in 10 years–
Absolutely.
You know, we’ll have completed in the next year or so, the patient reported outcome measure. One of my other colleagues at Cornell, Ron Winokur is putting together a sham-controlled, randomized trial of patients for embolization for venous origin chronic pelvic pain. We hope that study will be impactful in terms of a positive result and show the impact that we make there. And I’m sure–I’m hopeful other physicians are going to be doing similar kinds of studies so that we’ll have a much stronger base to go to patients, to go to the doctors who take care of them, the physiotherapists, and say, “Look, you know, this is what these patients look like. This is how we proved that they get better when we do these kinds of things in these sort of specific cases.” And hopefully we’ll have partnerships where gynecologists will be sending–and I’m seeing the beginning of this already–gynecologist sending us patients saying, “I think this patient has ave origin problem.” Or interventionalists recognizing the pelvic origin of the, you know, the varicose veins in the leg and managing them appropriately.
I completely echo what you said. You know, I want to give a shout out to Kush Desai, Ron Winokur, and others who are members of the Venous Council, who are also, you know, putting a lot of effort and sweat equity into this. So I do agree with you. I think it’s the research, to be able to give the foundation and–for all the work that we’re doing. One of the things that’s also been happening on the advocacy side and the economic group–I want to share this–is the SIR has a great patient center and patient appeals area. As you’re working through these conditions and trying to get patients treated, we’ve summarized a lot of the data that’s out there, and actually explanations to our insurance companies and different agents that are involved, about this disease, what evidence we have so far. And also, you know, share with them where we’re going, as well. And that this is a really important arena to treat and recognize for our patients. So I think all the work that you have contributed, plus the society, it’s going to be very meaningful in this way of being recognized, having perspective randomized data. And the sham control I think is going to be really important as well too.
Yeah. And I think that that carrier advocacy letter from the carrier advocacy work group is a great thing to call out. I appreciate your reminding everybody about that. It’s a great resource, and I’ve heard it has had a lot of traction, in reversing–you know, appealing– decisions where patients were not able to access care.
You know, one of the things I started doing was prospectively including that as part of my letter, and as part of my clinical evaluation. So. Well, I want to thank you, Neil. Thank you for being here today, and thank you to Cook for allowing us to have this podcast. And it’s been a pleasure.
Yeah, it’s been a pleasure for me too, and a little virtual fist bump there. And, yeah, we look forward to bumping into people here at the SIR meeting. And we’d love to talk pelvic venous disorders if you’re interested.
Thank you, everyone. Have a good day.