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Patient coordinatorPelvic venous insufficiency in women
Introduction
Pelvic venous insufficiency (English. Pelvic Venous Insufficiency, PVI) is a condition that most commonly affects women of childbearing age, but not exclusively. Studies and our own - already more than 15 years - observations indicate that PVI affects approximately 12-15% womenand in the female population with chronic pelvic pain (English. Chronic Pelvic Pain, CPP), this percentage rises up to 30-40%. Niewydolność żylna miednicy charakteryzuje się nadmiernym poszerzeniem pni i gałęzi żylnych w obszarze drenażu żylnego miednicy i/lub jamy brzusznej, co prowadzi do wstecznego przepływu krwi, jej nadmiernego gromadzenia się w rezerwuarowych naczyniach żylnych narządowych lub okołonarządowych (np. splotach żylnych przymacicz) oraz patologicznego zastoju. Ta kaskada niekorzystnych zjawisk doprowadza do powstawania szeregu różnych symptomsof which the most common are: lower abdominal pain, painful, prolonged and heavy periods, heaviness of the legs during menstruation or pain during intercourse.
Pelvic venous insufficiency is often unrecognised (especially during routine gynaecological visits) or confused with other pathologies, such as endometriosis external- and intrauterine (so-called adenomyosis). This delays the implementation of appropriate treatment (sometimes by 10-15 years!), leads to incorrect treatment decisions venous disease of the lower limbs, znacznie pogarsza jakość życia kobiet, a w konsekwencji zmniejsza szansę na posiadanie potomstwa.
In the context of misdiagnosis of pelvic venous insufficiency, it is worth noting its similarities with endometriosis. Obie choroby mogą mieć podobne objawy, co utrudnia diagnozę. Badania wskazują, że endometriosis dotyka około 10% kobiet w wieku rozrodczym. Jednak w przypadku kobiet z przewlekłym bólem podbrzusza częstość występowania endometriozy może być znacznie wyższa. Biorąc pod uwagę, że niewydolność żylna miednicy występuje aż u ponad 30% kobiet z przewlekłym bólem miednicy, należy wziąć pod uwagę możliwość współwystępowania obu schorzeń. Z naszej codziennej praktyki wynika, iż te choroby dość często się nakładają, a objawy bólowe przez nie wywoływane mają wyjątkowo dokuczliwą specyfikę i nazywane są endo-żylnymi. Niewydolność żylna miednicy uwarunkowana nieprawidłową anatomią układu żylnego daje zwykle objawy kilka lat wcześniej niż endometrioza (wykrywana jest u dziewczynek i młodych kobiet w wieku 12-19 lat). Poza tym spektrum objawów związanych z niewydolnością żylną miednicy jest much wider than in the case of typical endometriosis.
Failure, venous disease
or passive pelvic congestion syndrome?
We phlebology there are several related terms, the meaning of which can be somewhat confusing for both Patients and medical staff. Below we explain the key differences and interrelationships between these terms, the understanding of which is quite important in terms of the diagnosis and treatment of Patients presenting with suspected pelvic venous insufficiency.
Pelvic venous insufficiency (English. PVI) is a term used to describe the phenomenon of abnormal functioning of the veins in the pelvic region. It is unfortunately an oversimplification of the reality, as a significant proportion of cases of pelvic venous insufficiency originate in the epigastrium, within the drainage of the left ovarian vein To left renal vein.
Pelvic venous disease (Pelvic Venous Disease, PeVD) - is a broader term referring to the entire spectrum of pelvic venous disorders with concomitant symptoms for this disease. The clinical symptoms of PeVD result from venous reflux or obstruction within the interconnected veins of the abdomen, pelvis and lower limbs.
About the passive pelvic congestion syndrome (Pelvic Congestion Syndrome, PCS) we refer to when a patient has specific symptoms resulting from a diagnosis of pelvic venous insufficiency. By definition, PCS is characterised by:
- Chronic Pelvic Pain, CPP) lasting more than six months;
- an increase in discomfort when standing, sitting or during exertion or lifting;
- dyskomfortem lub bólem w czasie współżycia (tzw. dyspareunia);
- bólem podbrzusza w czasie miesiączki lub tuż przed;
- coexistence of varicose veins in the pelvis.
Należy pamiętać, że PCS nie rozpoznaje się na USG ani na obrazach radiologicznych (TK czy MR). Rozpoznanie zespołu jest zawsze diagnozą kliniczną, opartą na obecności charakterystycznych objawów i potwierdzoną badaniami obrazowymi w USG Doppler żył miednicy i jamy brzusznej oraz w badaniach wenograficznych typu MR czy TK. Zdarza się, że Pacjentki z ultrasonograficzne i obrazowym rozpoznaniem pelvic venous insufficiency, have venous insufficiency of the lower limbs secondary to PVI with typical limb symptoms, but no lower abdominal pain symptoms. In such a patient, then, full-blown PCS should not be diagnosed, but only chronic venous disease of lower limbs. W takich sytuacjach objawy występują w zakresie kończyn dolnych, a nie w rzucie miednicy.
To sum up:
PeVD (Pelvic venous disease) - is the broadest term, encompassing all pelvic conditions with a venous background;
PVI (Pelvic venous insufficiency) - is a haemodynamic disorder that can lead to venous stasis in the pelvis and produce (but not necessarily) the typical symptoms of PCS;
PCS (Passive pelvic congestion syndrome) - is a set of symptoms that follow PVI;
Pelvic varices - are the anatomical manifestation of the PVI (the most common of which are varicose veins of the parametria).
Factors that increase the risk
the occurrence of pelvic venous insufficiency
- unfavourable anatomical conditions in the structure of the venous system
- postural defects (e.g. scoliosis)
- strength training in interview
- chronic constipation
- prolonged sitting or standing
- number of pregnancies and deliveries
- family and genetic background
- hormonal imbalances (especially oestrogen)
- history of gynaecological and pelvic surgery
- high rise
Mechanism of pelvic venous insufficiency
Pelvic venous insufficiency is a complex disorder of the venous system that particularly affects the female sex. In the case of pre-pregnancy pelvic venous insufficiency The following factors play a key role in its formation:
- anatomical abnormalities of the venous system (e.g. hypoplasia of the left renal vein);
- genetic (family) predisposition;
- overuse of forceful physical exercise (heavy weight training).
Najczęstszą postacią niewydolności żylnej miednicy jest jej postać wtórna do przebytych ciąż i porodów. Mid-pregnancy hormone surge (estrogen levels in a single pregnancy can increase by up to 50-100 times), an increase in circulating blood volume (increases by approximately 30-50%) and pressure on the pelvic veins, renal veins or inferior vena cava, are factors that directly affect the condition of the main venous axes and reservoir veins located around the reproductive organs.
Is did you know that?
In the initial diagnosis of pelvic venous insufficiency, expert Doppler ultrasound examination of the abdominal, small pelvis and lower limb veins performed standing and lying down is crucial.
dr n. med. Cezary Szary
About the passive pelvic congestion syndrome (Pelvic Congestion Syndrome, PCS) we refer to when a patient has specific symptoms resulting from a diagnosis of pelvic venous insufficiency. By definition, PCS is characterised by:
Powysiłkowa niewydolność żylna miednicy
Powysiłkowa niewydolność żylna miednicy (ang. Exercise-Induced Pelvic Venous Insufficiency) to termin medyczny wprowadzony do użycia przez doctors of the Department of Phlebology już kilkanaście lat temu. Po wielu latach kompleksowej oceny diagnostycznej naszych Pacjentów, analizowaniu ich nawyków życiowych, a także gwałtownej zmianie trendów w aktywności fizycznej (moda na siłownie), zauważyliśmy, że trafia do nas co raz więcej młodych kobiet z niewydolnością żylną miednicy związaną z nadmierną aktywnością siłową. Są to Panie w wieku 18-25 lat (nierodzące), które w badaniu USG Doppler żył na stojąco i leżąco prezentują całościowe poszerzenie łożyska żylnego w jamie brzusznej i miednicy. U tych osób wyjątkowo szybko dochodzi do rozwoju niewydolności żylnej na nogach.
Już 6-12 miesięczne, ale intensywne wykonywanie takich ćwiczeń jak: podnoszenie sztangi w przysiadzie, dźwiganie sztangi z rwaniem or intensywne martwe ciągi, którym towarzyszy nieprawidłowe oddychanie i zbyt duże obciążenie, prowadzi do powysiłkowej niewydolności żylnej miednicy.
Nie podlega dyskusji, iż rozsądnie, regularnie i prawidłowo wykonywana aktywność fizyczna, jak: pływanie, joga, pilates, stretching, nordic walking czy ćwiczenia z taśmami oporowymi są korzystne dla układu żylnego. Trzeba jednak pamiętać, że nie ze wszystkimi aktywnościami jest tak samo. Dlaczego tak się dzieje? O tym przeczytacie Państwo poniżej.
Mechanizm powstawania powysiłkowej niewydolności żylnej miednicy
Trzeba pamiętać, że niektóre aktywności sportowe, szczególnie te siłowe, mogą prowadzić do znacznego wzrostu ciśnienia śródbrzusznego (ang. Intra-Abdominal Pressure, IAP). Wpływa to zawsze negatywnie na nasz układ żylny, który jest układem zupełnie innym niż układ tętniczy.
Układ żylny człowieka cechuje niskociśnieniowość, bardzo duża rozciągliwość i duża podatność na zgniatanie.
W warunkach spoczynkowych ciśnienie śródbrzuszne u zdrowych osób waha się w granicach od 0 do 5-8 mmHg. Podczas aktywności fizycznej dochodzi do jego wzrostu, który w zależności od rodzaju wysiłku może osiągać różne wartości:
- bieganie: 10-20 mmHg
- tenis: 15-25 mmHg (serwowanie 50-100 mmHg)
- jazda na rowerze: 15-30 mmHg
- ćwiczenia siłowe:
- martwy ciąg: 50-170 mmHg
- rwanie ze sztangą: do 160-180 mmHg
- przysiady ze sztangą: 100-200 mmHg
Długotrwałe, gwałtowne i powtarzalne okresy podwyższonego ciśnienia śródbrzusznego mogą prowadzić do rozwoju symptomatic pelvic venous insufficiency i wtórnej do niej venous insufficiency of the lower limbs. U tych osób typowo występująca ciężkość czy ból w podbrzuszu, dnie miednicy czy w nogach nasilają się po wysiłku. Z czasem dochodzi do przeciążenia żył układu głębokiego w nogach i powstawania żylaków w układzie żył powierzchownych. Widoczne są one na udach lub podudziach. Powysiłkowa niewydolność żylna jest trudna do leczenia z uwagi na długoletnie i całościowe poszerzenie łożyska żylnego. Widujemy ją często u sztangistów, amatorów siłowni, sportowców o wysokim wzroście ćwiczących z dużymi obciążeniami (np. u siatkarzy, koszykarzy), wioślarzy czy u bokserów.
Symptoms of pelvic venous insufficiency
SUBJECTIVE SYMPTOMS
- colicky pains on the left side of the body in the kidney projection (e.g. after running)
- a feeling of fullness and distension in the abdomen, frequent abdominal bloating
- chronic lower abdominal pain, worsening on standing and after exertion
- lower abdominal and/or back pain during the first days of menstruation
- painful, prolonged (>7 days) and heavy periods
- pain or discomfort during intercourse (dyspareunia)
- bladder hypersensitivity
- symptoms of venous vulvodynia (spontaneous burning of the vulva, vestibular area as a result of venous stasis)
- heaviness of the legs during the first days of menstruation
- feeling of heavy legs after exertion
- perimenopausal leg swelling (sometimes painful)
- paroxysmal pain in the casts of the adnexa, reproductive organs (effect of thrombophlebitis of the venous plexuses of the parametria).
ADDITIONAL SYMPTOMS
- vulvar and perineal varicose veins discernible by the patient
- niewydolność żylna kończyn dolnych (w tym żylaki) udzielone z miednicy, wtórne do przecieków żylnych z miednicy
- poszerzenia w obrębie tylnych spływów kończynowych (telangiektazje, żylaki siatkowate) schodzące na okolice dołów podkolanowych
- Anaemia (anaemia) in blood tests.
Diagnosis and recognition of female pelvic venous insufficiency
Diagnostyka niewydolności żylnej miednicy opiera się na kompleksowej ocenie klinicznej oraz zastosowaniu ultrasonografii dopplerowskiej i zaawansowanych badań obrazowych. W części klinicznej skupiamy się na zebraniu wywiadu medycznego dotyczącego wszystkich istotnych objawów, w tym „żylnych”, Ważna jest ocena widocznych oznak niewydolności żylnej, takich jak: varicose veins of the intimate area (usually located in the perineum, vulva or inguinal canals) or atypical varicose veins of lower limbs. Badania obrazowe, takie jak: ekspercka ultrasonografia dopplerowska, wenografia rezonansu magnetycznego (MRV) czy wenografia tomografii komputerowej (CTV), pozwalają na uwidocznienie struktury anatomicznej i zaburzeń funkcji w układzie żylnym jamy brzusznej, miednicy i kończyn dolnych.
Doppler ultrasonography
Doppler ultrasound of the veins is a non-invasive examination, widely available and, compared to MR venography, relatively inexpensive. Its role is to assess the anatomy and morphology of vessels and organ structures. The key feature of Doppler ultrasound, however, is the possibility to examine the flows intravitally and thus assess the capacity of the venous vessels in different breathing situations, as well as in different positions of the patient's body. As is well known in the study of the venous system, these are key issues.
Problems with ultrasound of the venous system arise when it needs to be assessed holistically. Such an examination covers the venous system from the feet up to the right atrium of the heart. Unfortunately, in Poland, most often only the veins of the lower limbs are examined, "forgetting" that the venous system begins, among other things, in the legs and ends in the heart. There are still too few specialists who have the necessary experience in this type of examination. It should be remembered that the specialists who perform this type of examination should also be able to assess other pathologies (e.g. endometrial lesions), which are quite common in women with suspected pelvic venous insufficiency.
The secrets of pelvic and abdominal vein Doppler ultrasound examination
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There is often a misconception that testing Transvaginal ultrasound is able to replace expert Doppler ultrasound examination of the veins with their assessment through the sheaths. Transvaginal examination (TV ultrasound) performed by gynaecologists is only a screening examination, allowing the pelvic venous vessels to be assessed in a way that is quite significantly different from reality. This is due to the limitations and distortions of the imaged area, the way the examination is performed and the very design of the ultrasound probe used for transvaginal examination. It is important to remember that most venous problems originate in the epigastrium (the pelvic veins are usually the recipient of the problem, and this is due to gravitational influences), and any insufficiency should be confirmed by a standing examination. For this reason, it is crucial to perform a trans-shell Doppler ultrasound of the veins with a full assessment of the pelvic floor, the most common sites of venous leakage and, most importantly, a full assessment of the abdominal and pelvic veins. The Doppler ultrasound examination should also exclude other causes (so-called secondary causes), which often lead to flow disturbances or redistribution.
Magnetic resonance venography (MRV)
MR venography is a minimally invasive examination, usually performed with intravenous administration of gadolinium (Gd) contrast agent, using a magnetic field and radio waves to create a comprehensive map of veins and organ structures. MR venography can assess contrast dynamics, demonstrate stasis or flow in the veins (assessed by analysing the movement of excited hydrogen atoms), and perfectly visualise thrombotic changes, both in the acute phase of thrombosis and retrograde changes in the so-called post-thrombotic syndrome.
MR venography study Among other things, it enables an accurate assessment of the anatomy of the venous system, allows the detection of various vascular malformations, perfectly illustrates the collateral circulation, allows the degree of venous dilatation to be assessed and, importantly, perfectly illustrates extrauterine and intrauterine endometrial lesions (adenomyosis) and adhesions, which are often formed after caesarean sections or laparoscopies performed in the abdominal or pelvic area. Further advantages are the high resolution of imaging and the absence of ionising radiation. The latter feature is crucial for women of reproductive age.
Among the undoubted disadvantages of venography performed using the MRI technique include its prolonged duration (it can even reach 1h), its rather high cost, its limited availability (venous MRI examinations should be performed on 3-tesla systems and assessed by experienced staff) and the usual contraindications to MR imaging and those arising from allergy to the gadolinium contrast agent.
Computed tomography venography (CTV)
Computed tomography venography (CTV) is an imaging study that uses X-rays to create images of organs and veins. The patient receives intravenous contrast, which increases the absorption of X-rays from the vessels being contrasted, thus allowing them to be better visualised. CT venography with intravenously administered iodine contrast allows: a detailed evaluation of the vascular anatomy, including the possibility of performing 3D reconstruction and curved vessel analysis, detection of anatomical anomalies, visualisation of possible causes of external compression, and an excellent assessment of organ pathology. The undoubted advantages of CT venography are the short examination time (the entire examination takes up to 3 minutes) and the very good spatial resolution of the imaged structures. The disadvantages are certainly the exposure to ionising radiation, the need to administer iodine contrast (allergies to it occur) and the low sensitivity in detecting endometrial lesions.
Treatment strategy for pelvic venous insufficiency
Appropriate treatment venous pelvic disease is usually the first stage sequential treatmentalso referred to as "descending treatment", i.e. from top to bottom. For decades, venous insufficiency has been treated symptomatically, often not in accordance with the logic and sequence of spoiling successive floors of the venous system.
Team Clinics of Phlebology has introduced a groundbreaking approach to treating venous disease by focusing on its root causes. The innovative approach relies on highly specialised ultrasound and imaging to identify the cause of venous insufficiency and eliminate the sources of abnormal blood flow (venous reflux), which are most often located in the abdomen and pelvis.
Our phlebotomists use proprietary methods to treat veins in the abdomen and pelvis (mainly minimally invasive). They perform such types of treatments as:
- venous embolisation - A procedure involving intravenous closure of malfunctioning veins;
- venoplasty - Modelling and dilatation of pathologically or developmentally narrowed venous vessels;
- venous stenting – wstawianie do światła zwężonego (lub prawie niedrożnego naczynia żylnego) specjalnych mini rusztowań, które trwale je poszerzają.
These treatments have significant therapeutic benefits:
- restore normal blood flow in the venous vessels, improving outflow from the lower limbs and reducing stasis;
- reduce the excessive load on the reservoir veins in the pelvis, both those in the pelvic walls and in the organs;
- reduce vascular volume overload in the leg venous system.
This novel treatment strategy significantly increases the effectiveness of venous disease treatment compared to the traditional approach focusing mainly on symptoms. Another advantage sequential causal treatment is the possibility of avoiding certain venous interventions in the legs. With more than 10-year follow-up by doctors at the Phlebology Clinic shows that in some patients, after pelvic venous embolisation and the healing of limbic venous leaks descending from the pelvis to the legs, there is spontaneous regression of symptoms and reduction of venous reflux in the main limbic axes. This saves, for example, the saphenous vein, which would have been unnecessarily and irrevocably closed in the opposite situation (haemodynamically incompatible treatment).
Treatment methods
Mostly
questions asked
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Untreated pelvic venous insufficiency can have a number of different effects. It can lead to:
- increasing psychological distress (depression or anxiety) as a result of chronic pain;
- chronic, worsening pain in the back, lower abdomen or perineum;
- development of varicose veins of the lower limbs and intimate areas;
- deep vein thrombosis;
- a significant deterioration in patients' quality of life;
- problems in intimate life
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From our daily practice, pelvic venous insufficiency and associated vulvar and perineal varicose veins are a common condition that is mainly diagnosed with in women who have previously given birth, usually after the second or third birth. This problem is encountered much more frequently after multiple pregnancies, including in women undergoing prolonged hormonal stimulation, e.g. at conception in vitro.
The typical age range for ladies presenting to the Phlebology Clinic with suspected pelvic venous insufficiency is increasingly changing. It currently stands at: 18-50 years. This is due to the fact that more and more gynaecologists have started to recognise the problem, more and more urogynaecological physiotherapists have started to recognise the problem, as well as the level of knowledge on the subject has greatly increased among patients.
During the so-called reproductive period, the symptoms of venous stasis in the pelvis and the cosmetic defect resulting from the presence of varicose veins of the intimate area are most pronounced. According to a study on large groups of women, approximately 20% women of reproductive age experience chronic pelvic pain, with pelvic venous insufficiency being the cause in approximately 30-40% of them. Varicose veins of the intimate area occur in approximately 10-15% women of reproductive age. These numbers increase significantly in multiparous women.
Our own experience shows that in more than 70% women giving birth suffering from venous insufficiency of the lower limbs, the problem initially starts in the venous system of the small pelvis and abdominal cavity. This regularity has even higher correlation rates in Patients who come to the Phlebology Clinic for an appointment with a venous problem already before their first pregnancy or after their first or second miscarriage pregnancy. These are patients who present with significant anatomical variations leading to impaired outflow in the venous system, secondary pelvic venous congestion and increased pressure in the venous system in the lower limbs.
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Vulvodynia is a fairly common disorder in women, involving constant discomfort, burning or pain that is localised to the intimate area, typically the vaginal vestibule, vulva or perineum. There are various forms of this affliction. Vulvodynia proper is characterised by chronic complaints of a fairly constant nature. The painful symptoms can vary in intensity and can occur in the labia majora, labia minora and also project to the vestibular area. Induced vulvodynia, otherwise known as provoked, is usually confined to the vaginal vestibule. It is an intense and burning pain typically triggered when touching or applying pressure to the vulvar area. Activities that trigger it are usually sexual intercourse and transvaginal gynaecological examination.
Pelvic venous insufficiency combined with congestion of the vaginal wall and not infrequently with varicose veins of the intimate area is one reason for this type of condition. Our observations show that this type of "venous" vulvodynia this is quite common in young patients with venous compression syndromessuch as nutcracker syndrome or May-Thurner syndrome.
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This is due to the fact that significant changes occur in the venous system during pregnancy. Among other things, this occurs:
- increased body weight, which puts additional strain on the venous system These changes can lead to permanent weakening of the vessel walls and impaired blood flow;
- increase in circulating blood volume by 30-50%;
- hormone-dependent relaxation and dilatation of venous vessel walls;
- a significant increase in the volume of the uterus, which over time puts pressure on the mother's venous vessels.
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Characteristics of pain resulting from pelvic venous insufficiency include:
- its intensity at the end of the day and after standing for a long time;
- reduction of discomfort after resting in a lying position;
- co-occurring with a feeling of heaviness in the legs and varicose veins on the legs;
- an increase in discomfort just before or during menstruation (first 2 days);
- co-occurrence with abdominal bloating.
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At Phlebology Clinic Diagnosis and treatment of pelvic venous insufficiency are provided by a team of specialists from the fields of: phlebology, diagnostic imaging and interventional radiology. In more difficult cases, we also collaborate with gynaecologists and vascular surgeons more familiar with the issue.
The therapeutic approach is determined by the cause of the disease. The biggest mistake in treating pelvic venous insufficiency and venous insufficiency of the lower limbs secondary to it is treating the Patient without a thorough imaging diagnosis and without excluding other concomitant diseases such as endometriosis or adenomyosis. In our practice, we quite often encounter cases where the Patient has undergone embolisation or surgical treatment without a properly performed qualification, only on the basis of the radiological description.
In the most difficult cases, when symptomatic pelvic venous insufficiency are accompanied by varicose veins of the intimate area and legs (full-blown form of the disease), we take a holistic approach. It involves eliminating the cause of venous stasis in the small pelvis (using venous embolisation, venous angioplasty, implantation of venous stents or use of chemical obliteration) and then treatment of varicose veins of the perineum, vulva and finally disfiguring venous widening in the legs (spider veins, dilated reticular veins and varicose veins).
In the Department of Phlebology, minimally invasive procedures carried out via percutaneous access and further via the endovascular route are by far the most common. Each procedure is carried out under the control of an ultrasound probe and digital angiography equipment (a so-called 'angiogram' is created). venogram, or vein map).
Procedure venous embolisation is carried out in a 4-6 hour admission to the hospital wardwithout the need for general anaesthesia. Treatments are carried out only in shallow sedation Under the guidance of the anaesthetic team. The patient is conscious and responds to the doctors' instructions given during the procedure. Recuperation from this type of procedure is usually quite short at 3-10 days.
Pelvic venous insufficiency - what should every woman know about its symptoms?
Przewlekłe, comiesięczne bóle podbrzusza, do tego bolesne miesiączki i uczucie pełności w kroczu? 😫 Czy to tylko zwykłe kobiece dolegliwości, czy może coś więcej? Zapoznaj się ze specyfiką objawów występujących u Pań z niewydolnością żylną miednicy – schorzenia, o którym mówi się zdecydowanie za mało! 🤫
Dr Venus: virtual patient advisor
Looking for answers to your vein question? Ask our Dr Venus!
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Can you help me with the problem of painful periods? My gynaecologist suspects a venous problem in me. -
Painful periods can be associated with a variety of problems, including pelvic venous insufficiency. If venous problems are suspected, consultation with a phlebology specialist is recommended.
Causal vein treatment
The phlebologists at the Department of Phlebology have pioneered the causal treatment of venous disease.
