The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

Abstract

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domainsdSymptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVP A,H,E . For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Venous thromboembolism in a patient with an uncommon etiology of May-Thurner syndrome

“…We hope that our etiological conceptualization can complement the SVP system in the classification of MTS. 8 Park and colleagues recently studied MTS variants, including what we refer to as secondary MTS as well as right common iliac vein compression. They noted that these MTS variants occurred in roughly 6% of patients with symptomatic MTS and that these patients are commonly elderly, which they attributed to the aging process's effects on the vasculature and nearby structures.…”

Poorly Understood Pelvic Venous Disorders Require a Multidisciplinary Approach

“…In another study, in accordance with results of pelvic venography, clinical signs with the highest sensitivity for diagnosis of PCS are vulvar varicose veins (100 %), sensitivity of the ovarian region upon palpation (87 %), dysmenorrhea (84 %) and postcoital pain (79 %) [10]. It should be kept in mind that if patient also has a history of deep vein thrombosis in lower extremity, symptoms of PeVD may occur because of post-thrombotic syndrome caused by iliac vein obstruction [11].…”

“…Pathophysiology(P) domain encompasses pelvic and abdominal vein anatomy (A), symptomrelated hemodynamic abnormalities (H) and underlying etiology (E). According to this classification, the pelvic disease score of an individual is shown as SVP A, H, E [11].…”

“…It is known that venous occlusive diseases such as Nutcracker syndrome and May-Turner syndrome cause PCS.It has been observed that symptoms of pelvic venous insufficiency improved after stenting of occluded vein. However, randomized controlled studies evaluating the efficacy of stenting are needed [11].…”

“…Therefore, it has been claimed that considering the diameter as a sign of ovarian venous reflux would not be an appropriate approach. In recently published SVP (Symptom-Varices-Pathophysiology) classification, it has been stated that incidence of venous disease increases with increase in diameter of vein, but the classification remained cautious about presenting a clarification regarding this situation [11].…”