Abstract
Compression and superficial varicosities outperform gonadal vein diameter in differentiating symptomatic from asymptomatic pelvic venous disorders: A case-control study
Gonzales E, Nguyen V, Risner V, du Pisanie L, Keefe N, Mody P, Kohi MP, Salazar G. Cardiovasc Intervent Radiol. 2026 Jun 7. Online ahead of print. doi: 10.1007/s00270-026-04493-5.
In this study, the authors evaluated whether gonadal vein (GV) diameter associates with pelvic venous disorder (PeVD)-consistent symptoms in women with pelvic varices, compared with proximal venous outflow obstruction (VOO; iliac/left renal vein stenosis/obstruction) and superficial varicosities. This retrospective case-control study included patients with abdominopelvic imaging performed between 2013 and 2024 showing parauterine or pelvic varices larger than 5 mm and with available clinical documentation for symptom assessment. GV diameter was measured using venous-phase computed tomography or magnetic resonance imaging by two readers, or by ultrasound when cross-sectional imaging was unavailable. Proximal VOO was assessed using the highest-confidence available diagnostic examination. A total of 200 patients with a mean age of 52.4 ± 17.0 years were included, of whom 84 (42.0%) were symptomatic, and 116 (58.0%) were asymptomatic. Mean GV diameter did not differ by symptom status (8.89 ± 2.29 vs 9.43 ± 2.50 mm; p = .121) and was not associated with symptoms in crude (odds ratio [OR], 0.91 per mm; 95% confidence interval [CI], 0.80-1.03) or adjusted analysis (adjusted OR [aOR], 0.97 per-mm; 95% CI, 0.81–1.14). Proximal VOO was assessable in 189 patients and more common in symptomatic versus asymptomatic patients (32.9% vs 2.6%; P < .001), as were lower-extremity (LE) varices (44.0% vs 12.9%; P < .001) and superficial pelvic varicosities (28.6% vs 1.7%; all P < .001). In the adjusted model, younger age (aOR, 0.50 per 10 years; 95% CI, 0.39–0.65), LE varices (aOR, 9.80; 95% CI, 3.76–25.50), and any proximal VOO (aOR, 10.89; 95% CI, 2.66–44.55) were independently associated with symptomatic status. Discrimination was acceptable (c-statistic, 0.82; 95% CI, 0.76–0.89) and unchanged by GV diameter.
The authors concluded that GV diameter was not associated with symptoms consistent with Pe||VD and provided no additional predictive value beyond age, lower-extremity varicose veins, and proximal VOO. Coexisting superficial venous disease and VOO may therefore be more useful than gonadal vein diameter thresholds for identifying clinically significant PeVD.
Direct transvaginal ultrasound-guided sclerotherapy for pelvic venous disease
Hipola JM, Alonso-Burgos A, Cárdenas R, Pillado E, Leal Lorenzo JI. J Vasc Surg Venous Lymphat Disord. 2026 May 25:102539. Online ahead of print. doi: 10.1016/j.jvsv.2026.102539.
In this study, the authors reported the feasibility, safety, and clinical outcomes of direct transvaginal ultrasound (TVUS)-guided foam sclerotherapy for isolated periuterine/pericervical varices or residual venous reservoirs after prior embolization. This prospective, single-center observational cohort included consecutive women treated between January 2023 and October 2025 who met predefined inclusion and exclusion criteria. Procedures were performed under general anesthesia using ultrasound-guided transvaginal venous puncture with fluoroscopic confirmation. Low-nitrogen 3% polidocanol foam was injected directly into the targeted periuterine and pericervical venous plexuses until the treated reservoirs were completely filled. The primary endpoints were technical success and changes in the Pelvic Venous Clinical Severity Score (PVCSS) and Pelvic Varicose Vein Questionnaire (PVVQ) score at 1 month and 1 year. A total of 23 patients with a mean age of 40.5 years underwent treatment. Of these, 74% had undergone prior gonadal vein embolization and presented with persistent symptoms, whereas 26% had no prior embolization and presented with isolated periuterine or pericervical varices without axial reflux. Technical success was 100%. The mean procedural time was 36.0 ± 12.5 min, the mean fluoroscopy time was approximately 1 min, and the mean sclerosant volume was 18.5 ± 5.3 mL. Radiation exposure remained low, with a mean dose-area product of 1.945 ± 0.347 Gy cm2 and a mean absorbed dose of 72.0 ± 3.1 mGy. All patients were discharged on the same day and resumed normal activities the following day. Minor vaginal bleeding occurred in 82% of patients on the day after treatment, but no menstrual disturbances were reported. TVUS follow-up demonstrated complete closure of the treated periuterine and pericervical venous plexuses, with no evidence of recanalization in any patient. The PVCSS improved from 12.91 at baseline to 7.87 at 1 month and 7.96 at 1 year. The PVVQ score improved from 75.97 at baseline to 46.12 at 1 month and 50.32 at 1 year. Overall improvement was significant (P < .001). Tukey’s honestly significant difference test confirmed significant decreases from baseline to both 1 month and 1 year for the PVCSS (P < .001) and PVVQ (P < .003). Differences between the 1-month and 1-year results were not significant for either the PVCSS (P = .987) or PVVQ (P = .094).
The authors concluded that direct TVUS-guided 3% polidocanol foam sclerotherapy achieved high technical success and significant, durable symptom improvement at 1 year in this small, highly selected cohort, with no major complications or recanalization. The technique may offer a minimally invasive, targeted treatment option for periuterine and pericervical venous reservoirs, particularly in cases not amenable to conventional endovascular access.
Adjunctive procedure utilization and cost comparison of cyanoacrylate versus endothermal ablation for saphenous vein reflux
Gibson K, Glorieux K, Minjarez R, Foster E, Neradilek M, Polissar N. Vasc Med. 2026 Jun;31(3):360–368. doi: 10.1177/1358863X261434818. Epub 2026 Jun 10.
In this study, the authors compared the utilization of adjunctive procedures in limbs with saphenous reflux treated with endothermal ablation (ETA) or cyanoacrylate closure (CAC). Secondary outcomes included adverse events (AEs), unscheduled care, and treatment costs. The authors retrospectively reviewed 654 limbs, including 327 treated with CAC and 327 treated with ETA. Demographic data, Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification, revised Venous Clinical Severity Score (rVCSS), adjunctive procedures, and AEs occurring within 6 months were recorded. Costs included the index and adjunctive procedures, unscheduled visits, and imaging, and were reported in US dollars. Concurrent adjunctive procedures were more frequent in the ETA group than in the CAC group, including phlebectomy (48% vs 6%, p < .001) and sclerotherapy (40% vs 7%, p < .001). The need for staged procedures did not differ between the groups, and improvement in rVCSS was comparable (ETA, 5.0 ± 2.2 vs CAC, 4.8 ± 2.3; p = .4). Patients treated with ETA had more unscheduled visits (9% vs 3%, p = .006) and ultrasound examinations (7% vs 2%, p = .007). Initial treatment costs were higher for CAC than for ETA ($2479 ± 617 vs $2332 ± 449, p = .001). Overall costs were also higher for CAC, with a difference of $210 (95% CI, $104–317; p < .001). In the ETA group, AEs were associated with increased costs ($2520 vs $2354, p = .008), whereas AE-related costs in the CAC group were not significantly different ($2571 vs $2496, p = .298).
The authors concluded that ETA was associated with greater use of adjunctive procedures and more unscheduled care. CAC achieved similar clinical improvement with fewer concurrent procedures and less unplanned follow-up. Although total expenditures converged, CAC had higher upfront charges, whereas ETA accrued more downstream costs related to adjunctive treatment and AEs (ClinicalTrials.gov Identifier: NCT04006184).
A duplex ultrasound observational study establishing the impact of position on left iliac vein compression
Labropoulos N, Raiker A, Raiker A, Souza A, Gasparis A. Eur J Vasc Endovasc Surg. 2026 May 8(26)00460-0. doi: 10.1016/j.ejvs.2026.04.044. Online ahead of print.
In this study, the authors evaluated the impact of body position on left iliac vein stenosis. The haemodynamics of non-thrombotic iliac vein lesions are not well understood, and although stenosis may change with position, diagnostic testing is commonly performed in the supine position. This observational cross-sectional study included 100 women aged ≥16 years presenting with symptoms and signs of pelvic venous disease. Patients were selected based on the presence of >50% left common iliac vein diameter stenosis while supine. Demographic data, Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classes, and body mass index (BMI) were recorded. Duplex ultrasound was performed in both the supine and standing positions. Stenosis of >50% diameter reduction was determined by a peak vein velocity ratio >2.5, reverse flow in the ipsilateral internal iliac vein (IIV), the presence of collaterals, or planimetric measurements. The 100 women were young, with a mean age of 38 ± 12.4 years, and lean, with a mean BMI of 23.8 ± 5.2 kg/m2. By selection, all patients had >50% iliac vein diameter stenosis while supine; however, only 32 patients had >50% stenosis while standing. Reverse flow in the ipsilateral IIV was observed in 83 patients while supine but in only 32 patients while standing. There were no differences in signs or symptoms between patients with fixed and positional stenoses.
The authors concluded that position-dependent iliac vein stenosis was present in approximately two thirds of patients. Given that diagnostic testing is routinely performed in the supine position, whereas patients generally experience symptoms during activity, these findings warrant modification of current testing protocols. The results may help guide decisions regarding stent treatment and reduce overtreatment.
The American Venous Forum clinical practice guideline on the care of patients with upper extremity deep venous thrombosis
Malgor RD, Etkin Y, Mouawad NJ, Le L, Sullivan L, Xenos E, Rodriguez L, Vemuri C, Fukaya E, Lal BK, Furtado Neves PJ, Aziz F, Sadek M, Tomita N, Puggioni A. J Vasc Surg Venous Lymphat Disord. 2026 Mar 2;14(4):102461. doi: 10.1016/j.jvsv.2026.102461. Online ahead of print. PMID: 41780672.
The authors present a new clinical practice guideline for patients presenting with upper extremity deep venous thrombosis (UEDVT). This is a prevalent issue accounting for 5-10% of all DVTs, and without clear strategies for patient management. This is also a heterogenous population, and the initial strategy employed in the guidelines is to first categorize patients based on etiology (rather than anatomy) into those with venous thoracic outlet syndrome (vTOS), cancer-related and noncancer upper extremity DVT. Amongst the noncancer patients, an additional distinction is made between catheter-associated and noncatheter-associated DVT. There is a lot of latitude in the recommendations. In addition to medical management and therapeutic anticoagulation there are recommendations for procedural intervention. Early thrombus removal may be considered for acute UEDVT (<21 days), assuming of life expectancy of greater than 1 year. For vTOS, first rib resection is part of initial management. Some guidance is provided for superior vena cava filters. One of the only 1A recommendations is to recommend against routine anticoagulant prophylaxis in patients with long-term central venous catheters.
The authors conclude that significant additional data are required to further inform management of UEDVT, but this represents a significant advancement in the treatment of UEDVT.
2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation and management of acute pulmonary embolism in adults: A report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines
Creager MA, Barnes GD, Giri J, Mukherjee D, Jones WS, Burnett AE, Carman T, Casanegra AI, Castellucci LA, Clark SM, Cushman M, de Wit K, Eaves JM, Fang MC, Goldberg JB, Henkin S, Johnston-Cox H, Kadavath S, Kadian-Dodov D, Keeling WB, Klein AJP, Li J, McDaniel MC, Moores LK, Piazza G, Prenger KS, Pugliese SC, Ranade M, Rosovsky RP, Russo F, Secemsky EA, Sista AK, Tefera L, Weinberg I, Westafer LM, Young MN. J Am Coll Cardiol. 2026 Apr 7;87(13):1626-1710. doi: 10.1016/j.jacc.2025.11.005. Epub 2026 Feb 19. PMID: 41712898.
The authors present a new clinical practice guidelines document for the management of acute pulmonary embolism (PE) in adults. The document covers evaluation and diagnosis, acute management, monitoring and follow-up, complications and sequelae, evidence gaps and future directions. The document is notable for new Acute Pulmonary Embolism Clinical Categories. The categories are meant to be dynamic and reassessed over time. Validated clinical severity scores such as the pulmonary embolism severity index PESI, and so on may be used.
A: Subclinical - incidental and asymptomatic.
B: Symptomatic - low clinical severity score, and subcategorized: B1-subsegmental, B2-non-subsegmental.
C: Symptomatic - high clinical severity score, and subcategorized by right ventricle (RV) status +/− biomarker: C1 - normal RV + normal biomarker; C2 - abnormal RV OR abnormal bio; C3 - abnormal RV + abnormal biomarker.
D: Incipient cardiopulmonary failure, D1 - Transient hypotension; D2- Normotensive shock (i.e. end organ compromise).
E: Cardiopulmonary failure: E1 - Cardiogenic shock; E2 - Refractory cardiogenic shock or cardiac arrest.
There are also respiratory modifiers for categories C-E.
Some of the key takeaways from the guidelines:
A: Can be safely discharged home from the emergency room.
B: Early hospital discharge is recommended.
C: Categories C, D, and E should be hospitalized to further optimize care.
D: Advanced therapies may be used for E1 and may be considered for D1 and D2. for categories A-C1 there does not appear to be any benefit to advanced therapies. For C2 and C3, the evidence for advanced therapies remains unclear.
The authors concluded that treatment may need to be extended beyond the original 3–6 months phase in those with a persistent risk factor or for the first acute PE without a major reversible risk factor. Patients should continue to be screened up to 1 year for chronic thromboembolic pulmonary disease (CTEP).
Randomized controlled trial of mechanical thrombectomy with anticoagulation versus anticoagulation alone for acute intermediate-high risk pulmonary embolism: Primary outcomes from the STORM-PE trial
Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP, STORM-PE Trial Investigators. Circulation. 2026 Jan 6;153(1):21-34.
The authors’ aim was to test the efficacy and to evaluate the safety of mechanical thrombectomy utilizing computer-assisted vacuum thrombectomy (CAVT) with anticoagulation compared to anticoagulation alone. Methods: STORM-PE is an international randomized controlled trial with 1:1 randomization to CAVT with anticoagulation or anticoagulation alone. Eligible adults had acute-onset (symptoms ≤14 days), intermediate-high risk PE and were normotensive, with an RV/LV ratio ≥1.0 on computed tomographic pulmonary angiography and elevated cardiac biomarkers. The primary end-point analysis tested for a difference between groups for the change in RV/LV ratio at 48 h, assessed by a blinded independent imaging core laboratory. Secondary end points included major adverse events within 7 days (a composite of clinical deterioration necessitating rescue therapy, PE-related mortality, symptomatic recurrent PE, and major bleeding), adjudicated by an external clinical events committee. Other outcomes included change in vital signs and core laboratory-assessed pulmonary artery obstruction at 48 h. Results: 100 patients enrolled across 22 sites were randomized to CAVT (n = 47) or anticoagulation alone (n = 53). Baseline characteristics were comparable between arms. At 48 h, mean reduction in RV/LV ratio was greater for CAVT (0.52 ± 0.37) than anticoagulation (0.24 ± 0.40), a difference of 0.27 (95% CI, 0.12-0.43; P < .001). Refined modified and modified Miller scores exhibited greater changes for CAVT than anticoagulation alone at 48 h (P < .001). Early normalization of vital signs within 48 h was more frequent after CAVT. The major adverse event rate within 7 days was not different between groups (CAVT, 4.3% vs anticoagulation, 7.5%; P = .681). Two PE-related deaths occurred in the CAVT arm.
The authors concluded that CAVT was superior to anticoagulation alone in reducing RV/LV ratio within 48 h in patients with intermediate-high risk PE, accompanied by earlier normalization of vital signs and major adverse event rates comparable to those for anticoagulation.
Early outcomes of a randomised controlled trial comparing concomitant with staged tributary treatment as an adjunct to endovenous laser ablation of the saphenous trunk: The FinnTrunk study
Rahman T, Viljamaa J, Firoozi K, Laivuori M, Pihlaja T, Heinola I, Pokela M, Venermo M, Hakovirta H, Halmesmäki K. Eur J Vasc Endovasc Surg. 2026 Jun;71(6):1071-1079. doi: 10.1016/j.ejvs.2026.01.029. Epub 2026 Jan 22. PMID: 41580273.
The FinnTrunk Study is a multi-center randomized controlled trial comparing simultaneous endovenous laser ablation and tributary foam sclerotherapy versus staged treatments. This has been a long-standing debate (including prior debates with staged microphlebectomy), but uncertainty still exists. This is reflected in recent clinical practice guidelines, and in real world practice, there is often shared decision making between the clinical and the patient. This trial included endovenous laser ablation of the great, small or anterior saphenous veins in patients with C2, C3 or C4c disease. The primary outcome was the need for additional tributary intervention at 3 months, and this was patient determined. Other endpoints evaluated included time of treatment and venous clinical severity score (VCSS). 214 patients were randomized, (111 ablation alone vs 103 combined treatment). Relating to the primary outcome, 20.7% versus 0.0% pursued additional tributary treatments at the 3-months time point. Combined procedures were 9 min longer (46 min vs 55 min, P < .001). VCSS scores reduced by a greater amount in the combined treatment group (3.0 vs 4.0, P < .001). Patient reported quality of life outcomes were similar between the cohorts.
The authors concluded that early clinical benefits were noted, but both cohorts achieved the primary therapeutic objective with similar quality of life outcomes. Longer term data are warranted.