Elsevier

Annals of Vascular Surgery

Volume 52, October 2018, Pages 158-162
Annals of Vascular Surgery

Clinical Research
Recanalization After Endovenous Thermal Ablation

Presented at the 2016 Annual Meeting of the Eastern Vascular Society, Philadelphia, PA, September 15–17, 2016.
https://doi.org/10.1016/j.avsg.2018.03.017Get rights and content

Background

Endovenous thermal ablation in the form of radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) has quickly ascended to a prime position in the treatment of venous insufficiency. Although there are good data examining the rates of thrombotic complications, there is a relative paucity of data examining the recanalization rates after endovenous thermal ablation (ETA).

Methods

Data analysis was performed for 1475 thermal ablations in 485 patients from 2012 to 2015 as a retrospective chart review. RFA was performed in 1027 patients and EVLA in 448 patients. The target veins included the great saphenous vein (GSV) (778), short saphenous vein (SSV) (401), accessory saphenous vein (ASV) (140), and perforator veins (PV) (156). Data were collected from follow-up visit within 1 week of procedure, every 3 months for the first year, and every 6 months thereafter. Recurrence was defined as >500 ms for the GSV, SSV, and ASV and as >350 ms for the PV. Data for recanalization were also correlated with age, gender, laterality, presenting symptoms, and treated targeted vein.

Results

The average age of the study population was 64.7 years (SD ± 15.6) with 66% women and 326 bilateral veins. At 1-week follow-up, women (2.6%) had higher recanalization rate (P = 0.018). Failure rate of obliteration for GSV and SSV were 0.8% and 0.8%, respectively (P = 0.98). PV had the highest failure rate (16.6%), followed by ASV (2.9%) (P < 0.001). At mean follow-up after 13.5 ± 12 months, PV (41.2%) and ASV (14.85) had higher recanalization rate than GSV (7.7%) and SSV (8.5%) (P < 0.001). Excluding PVs, no difference with recurrence rates between RFA (10%) and EVLA (8.8%) was observed at 1-week and 1-year follow-ups (P = 0.54). Also, 56% of patients with recanalization were symptomatic. Among these 1475 procedures, redo for recurrent symptoms were performed in 76. At 1 week, there was no difference between nonrepeated (92.7%) and repeated procedures (89.5%) (P = 0.41). However, 1 year later, there was significant difference between obliteration rate in nonrepeated (86.9%) and repeated (76.3%) procedures (P = 0.014).

Conclusions

These data do suggest low overall rates of recanalization after thermal ablation of the GSV and SSV. However, at 1-year follow-up, accessory veins had almost twice the recurrence rate as compared with GSV and SSV, and PV had almost 5 times the recurrence rate. There was no significant difference between RFA and EVLA in recanalization rates. Redo procedures in recanalized veins after venous ablation are effective with a success rate at 76.5%.

Introduction

Endovenous thermal ablation (ETA) has now become the treatment modality of choice for chronic venous insufficiency. ETA has increased in volume by 450-fold to 300,000 procedures during the last decade.1 The therapeutic goal of ETA is to obliterate the targeted vein segment by thermal injury to the venous wall. This procedure can be performed using endovenous laser ablation (EVLA) technique or the radiofrequency ablation (RFA). It has been shown that EVLA and RFA are both highly effective and safe from both anatomic and clinical standpoints, and neither modality has achieved superiority over the other.2, 3 In comparison to older techniques involving vein stripping and ligation, these minimally invasive techniques have greater patient satisfaction rates early on and higher quality of life scores.4

Previous literature has mostly focused on the morbidity involving thrombotic complications in the form of endothermal heat–induced thrombosis and deep vein thrombosis. Durability is another important long-term characteristic of this vascular procedure, so recurrence of symptoms is a key outcome measure for ETA to treat venous insufficiency.3 Recurrence of varicose veins (VVs) with ligation and stripping of the great saphenous vein (GSV) has been well described, ranging from 20% to 80%. Its incidence increases with the length of time after the procedure.5, 6, 7 Recanalization is also a common complication with ETA and has been reported in up to 10% of the patients after 1 year.5, 8, 9 In these patients, recanalization may be the result of the technique used (e.g., laser or RFA), device settings (e.g., energy delivered and number of RF cycles), and/or experience of the physician.6, 7, 10 Other factors may also play a role, such as patient characteristics and clinical and duplex ultrasound (DUS) findings.11, 12

We suggest that if patient characteristics and DUS findings are indeed associated with the risk of recanalization, physicians might be able to predict which patients are likely to develop recanalization before the treatment. Identification of these patient-specific predictors may result in a more personalized approach in practice and minimize health-care costs.13

The objective of this study was to compare the successful closure rates after RFA and EVLA in the treatment of venous insufficiency for the 4 commonly treated veins and to identify the recanalization rate in both the procedures at long-term follow-up. We specifically looked at the closure rate in the GSV, short saphenous vein (SSV), accessory saphenous vein (ASV), and perforator veins (PV) and correlated it with the patient characteristics, DUS findings, and choice of ETA used. Also, the closure rate after a redo procedure in recanalized vein to assess early successful closure was identified.

Section snippets

Materials and Methods

A retrospective chart review was performed on patients who were treated with ETA (RFA or EVLA) from 2012 to 2015. All procedures were performed in a single vascular surgery outpatient office by 3 practitioners, with assistance from registered vascular technicians. During the initial office visit, a clinical severity score of venous insufficiency was given to each patient as determined by the presenting symptoms based on clinical severity, etiology, anatomy, and pathophysiology (CEAP)

Results

A total of 1475 procedures were performed from January 2012 to August 2015 in 485 patients. The average age of the patients included in the study was 65.2 years (range, 21–94; SD, ±14.9). Our data included 1475 procedures in 539 males and 936 females. Among the 1475 procedures, 222 procedures were lost to follow-up after first postoperative duplex scan. The laterality, targeted veins included, presenting symptoms of CEAP, mean maximum vein diameter, and choice of procedure are noted in Table I.

Discussion

ETA has been recognized to be the safe and effective procedure for treatment of chronic venous insufficiency. Their main advantages include fewer complications, quicker recovery, and improvement in the quality of life compared with those of conventional surgery.4 However, it is still not clear yet what are the defined prognostic factors for the success of ETA in a patient and when an alternate procedure such as high ligation and stripping/ultrasound-guided foam sclerotherapy are to be

Conclusion

Our data suggest that there is a low overall recanalization rate after thermal ablation of the GSV and SSV. However, at 1 year, accessory veins demonstrated twice the recurrence rate compared with GSV and SSV, and the PV had almost 5 times the recurrence rate. If the PV were excluded, there was no significant difference between the recanalization rates by RFA or EVLA. Females have a higher failure rate of obliteration than males. Repeated procedures in recanalized veins tend to have lower rate

References (22)

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    Another second option could have been the use of newer nonthermal nontumescent procedures such as mechanochemical endovenous ablation and cyanoacrylate vein ablation, which promise to have high occlusion success rates compared with those reported for EVLA and RFA.29 Aurshina et al.19 described 76 SA procedures for clinical recurrence after ETA (RFA or EVLA), distributed in GSV, SSV, ASV, and PV. They compared occlusion rates between first and second ablation procedures showing no difference at 1-week follow-up, but a significant difference at 14-month follow-up: 86.9% occlusion in the first ablation group and 76.3% in the SA group.19

  • Radiofrequency Ablation Increases the Incidence of Endothermal Heat-Induced Thrombosis

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    All RFA procedures of the saphenous veins were performed using the ClosureFast catheter (Medtronic, Minneapolis, MN), whereas all RFA procedures of perforator veins were performed using the ClosureRFS stylet (Medtronic, Minneapolis, MN). The technique for endovenous saphenous ablation has been previously reported by our group.10 After the procedure, a compression bandage was applied to the region overlying the ablated vein and patients were instructed to leave it on for 48 hr and return to the office within 3–7 days for a follow-up DUS.

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Conflicts of interest: The authors declare no conflicts of interest to disclose.

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