Anatomical patterns of pelvic venous reflux to the lower limbs

BACKGROUND: Pelvic venous insufficiency is an important but frequently overlooked cause of lower limb varicose veins and early recurrence after superficial venous interventions. Understanding the reflux patterns and distribution of lower limb varicose veins with pelvic origin is crucial for preventing recurrence and unsatisfactory outcomes, which may result from incomplete or inadequate investigation. METHODS: Data from 49 female patients (62 limbs) with pelvic reflux that connects to the lower limbs through pelvic escape points were analyzed. All patients were examined for reflux in the standing position using duplex ultrasound examination. Special attention was given to the reflux patterns, distribution, and connections to the saphenous veins, nerves, and lymph nodes. RESULTS: Most patients were classified as CEAP C2 (95%), and 70% reported leg pain. The most frequently observed patterns were varicose veins on the posterior surface of the thigh (19%), veins connected to the great saphenous vein (GSV) along the thigh and leg (29%), and veins running parallel to the GSV on the medial thigh (26%). Varicose veins confined exclusively to the perineal region were identified in 15% of patients. Less common patterns included varicose veins on the anterior thigh (8%), veins associated with the sciatic nerve (10%), and veins with lymph node connections (8%). Varicose veins connected to the small saphenous vein were the least frequent, accounting for 5% of cases. CONCLUSIONS: Although the GSV is often involved in patients with pelvic venous insufficiency and escape points, nonsaphenous varices appear to play a more prominent role in the reflux pattern. These findings support the concept that pelvic-origin reflux manifests as distinct patterns of lower limb varicose veins through defined pelvic escape points, underscoring the importance of thoroughly assessing the connection between pelvic and lower limb venous territories. A better understanding of the distribution of nonsaphenous reflux during venous mapping is essential for optimizing treatment strategies and reducing the risk of recurrence.