Bottom-up versus top-down treatment strategies for pelvic venous disorders: Comparative analysis of pain relief, recurrence, and procedural burden

Abstract

OBJECTIVE: To compare a peripheral "bottom-up" strategy using ultrasound-guided foam sclerotherapy with a conventional "top-down" embolization strategy in women with symptomatic pelvic venous disorders, with respect to pain relief, recurrence-free survival, and procedural burden. METHODS: This was a retrospective analysis of prospectively collected data from 40 women treated between January 2024 and December 2024, all classified as S3V3Pr according to the symptoms-varices-pathophysiology classification. Pain was categorized by anatomical location as pelvic pain above the pelvic floor, vulvar pain, perineal pain, or lower-limb pain related to varicose veins. Twenty patients underwent top-down treatment, and 20 underwent bottom-up treatment. The primary endpoint was change in the visual analog scale pain score. Secondary endpoints included recurrence-free survival, technical success, radiation exposure measured by dose-area product, procedure time, and direct procedural cost. RESULTS: Baseline pain severity was identical in the two groups (7.36 ± 1.34 vs 7.36 ± 1.07; P = 1.00). Both treatment strategies were associated with significant improvement in pain at follow-up (top-down, 7.36 ± 1.34 to 1.90 ± 1.07; bottom-up, 7.36 ± 1.07 to 2.49 ± 1.26; both P < .001), with no significant between-group difference in post-treatment pain (P = .12). Compared with top-down treatment, bottom-up treatment was associated with substantially lower dose-area product, shorter procedure time, and lower direct procedural cost (all P < .001). Technical success was achieved in all patients. Kaplan-Meier analysis showed lower recurrence-free survival in the top-down group, with an estimated 12-month recurrence-free survival of 70% vs 95% in the bottom-up group (log-rank P = .035). CONCLUSIONS: In women with S3V3Pr pelvic venous disorders, bottom-up foam sclerotherapy provided comparable pain relief to top-down embolization while reducing radiation exposure, procedure time, and direct procedural cost.