Reflux in the Below-knee Great Saphenous Vein Can Be Safely Treated with Endovenous Ablation.

Abstract

Intervention on the great saphenous vein (GSV) has traditionally been limited to the above-knee (AK-GSV) segment for fear of saphenous neuralgia, in spite of incompetence demonstrated in the below-knee (BK-GSV) segment. Ignoring the refluxing BK-GSV is reported to result in residual symptoms and need for re-intervention in nearly half the patients. Experience with endovenous ablation of the BK-GSV at the time of AK-GSV treatment is sparsely reported in the literature. The aim of this study is to evaluate the safety of endovenous ablation of the refluxing BK-GSV. Data from consecutive patients treated with superficial venous ablation over a 30-month period from January 2010 until August 2012 were retrospectively reviewed. Demographic and procedure-related outcome and complication data were analyzed specifically for patients undergoing BK-GSV interventions. A total 387 patients were treated with superficial venous ablation during the study period. Of those, 38 (47 limbs) underwent BK- GSV ablation for reflux at this site. There were 22 females and 16 males (mean age, 51 years). Median CEAP score was 3; 27 limbs were treated for symptomatic varicose veins (C 1-3) and 20 for advanced venous insufficiency (C 4-6). Five (10.6%) limbs were treated following prior failed intervention with AK-GSV ablation, sclerotherapy, or stripping. Comorbidities included obesity (41.7%) with mean body mass index of 31.4 (range, 19 to 52), obstructive sleep apnea (13.2%), pulmonary hypertension (2.6%), and congestive heart failure (2.6%). Ablation was performed in 45 limbs (97%), utilizing the VenaCure EVLT laser vein treatment (AngioDynamics, Queensbury, NY) and two limbs using RFA (radiofrequency ablation) with ClosureFAST system (VNUS Medical Technologies, San Jose, CA) . Mean GSV length ablated was 51.6 cm (range, 26 to 65 cm). Endovenous ablation was performed concomitantly on 18 accessory GSVs (38.3%) and 4 incompetent perforators (8.5%). Ambulatory stab phlebectomy of branch varicosities was performed simultaneously in 37 (79%) limbs. All veins treated were evaluated with ultrasound on post procedure day 1, and no evidence of endovenous heat induced thrombosis (EHIT) was detected. Seven patients (14.9%) went on to have preplanned sclerotherapy treatment for small branch varicosities. Postoperative hyperesthesia occurred in one patient (2.1%) and resolved within 2 weeks. No patient required repeat endovenous ablation during this period. Wound infection in two (4.3%) stab phlebectomy wounds resolved with oral antibiotic therapy. Endovenous ablation of the refluxing BK-GSV segment can be performed safely with minimal complications. Consideration should be given to concomitant ablation of the BK-GSV when treating patients with varicose veins with reflux extending below the knee to improve long-term outcomes.