Vein Specialists’ providers consider venous disease as consisting of 3 separate but related categories: venous insufficiency (VI), venous thromboembolic disease (VTE) and iliac venous compression syndrome (IVCS). The veins below the groin are referred to as the inflow veins delivering blood from the legs back to the pelvis. The outflow veins are the external iliac veins, internal iliac veins, common iliac veins and the inferior vena cava, all of which receive the blood from the legs (inflow veins) and direct the blood back to the heart. Venous thromboembolic (VTE) disease consists of deep vein thrombosis (DVT) and pulmonary embolism (PE). A pulmonary embolism results from a piece of a DVT breaking loose and traveling to the lungs. This can be fatal when it occurs. Risk factors for VTE are many but venous insufficiency and iliac vein compression syndrome are two important ones on that list. Thus, when considering the evaluation, diagnosis and treatment of patients with venous insufficiency and iliac vein compression/obstruction, it is important the weigh the risk each poses in terms of increasing the risk of VTE if left untreated.
Anatomically, the deep system of veins is located in the muscular compartments of the legs and communicates with the superficial system of veins (saphenous veins) which are located under the skin within the fatty tissue. There is a network of communicating or perforating veins which act as bridges between the two systems. The normal direction of blood flow is from superficial to the deep system, from the feet upwards toward the abdomen and heart. When the one way gates (or valves) fail to close tightly, pressure increases in the veins of the legs resulting in many of the signs and symptoms of venous insufficiency. Although spider and varicose veins are the most common presenting signs of venous disease, there are a myriad of other signs and symptoms of venous disease which justify a thorough venous evaluation. Most patients who present with anything more than small spider veins in the thighs will undergo ultrasound evaluation of their lower extremity venous system as part of their comprehensive venous workup. A conservative trial of therapy is part of every patient’s journey, although the level of compression in commercially available stockings is not sufficient enough to halt the progression of venous insufficiency. Thus, although compression therapy is required prior to definitive therapy, it is not a realistic long term treatment strategy for patients with symptomatic significant venous insufficiency or iliac vein compression/obstructive disease.