Introduction
The podcast features an in-depth conversation with Dr. Peter Pappas, a pioneering figure in the field of venous disease. As the current Program Director and Regional Medical Director for the Center for Vein Restoration and the Program Director for the Vein, Venous, and Lymphatic Medical Fellowship, Dr. Pappas brings extensive experience and insights. He is also the ex-president of the American Venous Forum and the Vascular Society of New Jersey. This detailed discussion explores his recent work on pelvic venous disorders, including the latest findings, treatment strategies, and future directions.
Exploring Pelvic Venous Disorders
Dr. Pappas explains that his work focuses on both superficial and deep venous diseases. The Center for Vein Restoration primarily deals with superficial venous disease, while its sister organization, the Center for Vascular Medicine, specializes in deep venous disease, particularly the pelvic veins. Many patients with pelvic disease are referred to them by primary care physicians, OBGYNs, and other specialists. The majority of these patients are women, who often experience a range of symptoms including pelvic pain, pain with deep penetration during intercourse, abdominal bloating, and urinary frequency.
Common Symptoms and Initial Findings
The most common symptoms among women with pelvic venous disorders include pelvic pain, dyspareunia (pain with deep penetration during intercourse), postcoital pain (pain after intercourse), abdominal bloating, and urinary frequency. Additionally, these patients often have lower extremity symptoms, such as varicose veins, which are related to their pelvic symptoms. Dr. Pappas highlights that a significant percentage of patients with pelvic venous disease also have varicose veins, indicating a strong correlation between the two conditions.
Research and Treatment Strategies
In their initial research, Dr. Pappas and his team analyzed different therapies for pelvic venous disorders. They discovered that a substantial number of patients had a combination of ovarian vein reflux and iliac vein stenosis. Their approach involved treating these conditions separately and then combined. They found that only a small percentage of patients with isolated ovarian vein reflux benefited from ovarian vein embolization. However, the majority of patients with combined disease experienced significant improvement after iliac outflow obstruction treatment.
Challenges and Criticisms
One of the criticisms of their study was the short interval between ovarian vein embolization and stenting, which was only two to four weeks. Some experts suggest waiting three to six months before stenting to ensure that the ovarian vein embolization alone is insufficient. Despite this, Dr. Pappas emphasizes that for non-thrombotic diseases, newer technologies can help salvage stents if they begin to fail, providing long-term benefits for patients.
Non-Thrombotic vs. Post-Thrombotic Patients
For non-thrombotic patients, the stents offer good long-term patency, but they may still fail early in some cases. Dr. Pappas points out that the latest technologies can address these failures, allowing for maintenance and improvement over time. On the other hand, post-thrombotic patients face more challenges, as their stents have a shorter lifespan. Recent studies, such as the one by Bill Marston, indicate that the type of anticoagulant used post-stenting significantly impacts the patency and failure rates.
Future Technologies and Clinical Trials
Dr. Pappas is optimistic about future technologies that could either prevent the development of debris in stents or remove it effectively. For instance, devices like the RevCore can core out intraluminal debris, while other technologies focus on drug-eluting stents. He emphasizes the importance of clinical trials to validate these technologies and overcome the current limitations posed by third-party payers.
Hypotheses and Practical Outcomes
Dr. Pappas explains that the common iliac vein lesion can lead to hypertension in the internal iliac vein, resulting in pelvic symptoms. His team’s studies support this hypothesis, showing that treating the iliac vein disease significantly alleviates pelvic symptoms. They presented their findings at the American Venous and Lymphatic Society (AVLS) meeting, showing promising results for stenting in women with combined ovarian vein reflux and iliac vein disease.
Diagnostic Approaches and Patient Selection
Dr. Pappas’s team relies on transabdominal ultrasonography to diagnose pelvic venous congestion syndrome. Although it is sensitive in detecting stenosis, its specificity is lower for identifying the degree of stenosis. The presence of a lesion does not necessarily indicate the need for a procedure unless the patient has significant symptoms affecting their quality of life.
New Developments in Deep Venous Disease
In addition to pelvic veins, there are exciting developments in treating deep venous disease in the lower extremities. Dr. Pappas mentions the SAVE trial involving a porcine-mounted valve surgically inserted into the femoral vein for post-thrombotic patients. Initial results are promising; further data is expected to support FDA approval. Additionally, percutaneous valves are being developed, which could revolutionize the treatment of lower extremity deep venous disease.
Conclusion
The conversation with Dr. Pappas highlights significant advancements in understanding and treating pelvic venous disorders. With ongoing research, new technologies, and the potential for clinical trials, the future looks promising for patients suffering from these conditions. Dr. Pappas’s insights underscore the importance of careful patient selection, long-term follow-up, and the need for further studies to validate emerging therapies. As the field evolves, these advancements will likely provide better quality of life for patients with venous disease.