title: Pelvic venous reflux is a major contributory cause of recurrent varicose veins in more than a quarter of women.
abstract: BACKGROUND
  Leg varicose veins are associated with pelvic venous reflux in approximately 20% of women who have had children. However, most venous units do not routinely look for pelvic venous reflux or treat it. We aimed to investigate what proportion of patients with recurrent varicose veins and a history of open surgery have pelvic venous reflux as a major contributing cause of their recurrence.
  
  
  METHODS
  A retrospective study was performed of all patients referred in the previous year with recurrent varicose veins or venous reflux disease who had previously had open surgery performed elsewhere. All patients had routine lower limb venous duplex ultrasonography, and those found to have reflux of pelvic origin underwent transvaginal duplex ultrasonography. Each case was assessed by a consultant vascular surgeon, and the major cause (or causes, if more than one) of the recurrent varicose veins was noted.
  
  
  RESULTS
  A total of 109 patients with recurrent varicose veins in 172 legs were analyzed (mean age, 53.9 years; female-to-male ratio, 97:12). Patients were divided into four groups: group 1, all patients; group 2, female patients; group 3, female patients with children; and group 4, female patients with children who had not had hysterectomy. Pelvic venous reflux was found to be a major contributing cause of recurrent varicose veins in 44 of 172 legs (25.6%). This rose to 43 of 154 legs (27.9%) in group 2, 40 of 131 legs (30.5%) in group 3, and 37 of 111 legs (33.3%) in group 4.
  
  
  CONCLUSIONS
  Pelvic venous reflux is a major contributing cause of recurrent varicose veins after open surgery that has rarely been reported previously. In view of this finding, we suggest that a duplex ultrasound protocol, incorporating a transvaginal duplex examination of the ovarian and internal iliac veins, be adopted for the investigation of pelvic venous reflux in female patients presenting with symptomatic leg varicose veins with duplex-observed reflux entering the leg vein pattern from the pelvis. In the event that it is found, we suggest that treatment and resolution of this source of venous reflux be considered before any intervention for the leg varicose veins, surgical or otherwise.
authors.affiliation: Whiteley Clinic, Guildford, Guildford, Surrey, United Kingdom; University of Surrey, Faculty of Health and Medical Sciences, Guildford, Surrey, United Kingdom.
authors.forename: Alice M
authors.initials: AM
authors.lastname: Whiteley
authors.affiliation: Whiteley Clinic, Guildford, Guildford, Surrey, United Kingdom.
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Taylor
authors.affiliation: Whiteley Clinic, Guildford, Guildford, Surrey, United Kingdom; University of Surrey, Faculty of Health and Medical Sciences, Guildford, Surrey, United Kingdom.
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Dos Santos
authors.affiliation: Whiteley Clinic, Guildford, Guildford, Surrey, United Kingdom; University of Surrey, Faculty of Health and Medical Sciences, Guildford, Surrey, United Kingdom. Electronic address: mark@thewhiteleyclinic.co.uk.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Whiteley