Regarding “Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques”

Abstract

Although the extension of saphenous thrombus into the femoral vein is a potential complication of new endovenous ablation techniques (J Vasc Surg 2005;41:130-5), it is very rare. Most published data on endovenous laser ablation have supported performing the technique in the absence of general or spinal anesthesia.1Min R.J. Khilnani N. Zimmet S.E. Endovenous laser treatment of saphenous vein long term results.J Vasc Interv Radiol. 2003; 14: 991-996Abstract Full Text Full Text PDF PubMed Scopus (514) Google Scholar, 2Perkowski P. Ravi R. Gowda R.C. Olsen D. Ramaiah V. Rodriguez-Lopez J.A. et al.Endovenous laser ablation of saphenous vein for the treatment of venous insufficiency and varicose vein early results from a large single center experience.J Endovasc Ther. 2004; 11: 132-138Crossref PubMed Scopus (92) Google Scholar However, it is of great importance to perform the procedure under adequate tumescent anesthesia, which allows the operator to obtain feedback from the patient and avoid overtreatment of the vein. Complete collapse of the vein also minimizes thrombotic occlusion. Insertion of the catheter, whether radiofrequency or laser, into the common femoral vein (CFV) must be avoided at all costs to reduce damage to the CFV or the great saphenous vein (GSV) proximal to the epigastric vein. In our own experience at the Arizona Heart Institute with >1,000 cases, we have seen only one pulmonary embolus in a patient with leg ulcer who weighed >350 pounds. Her ultrasound scan on the fifth day did not show any thrombus extending into the CFV. She was not as ambulatory as most of our other patients, who return to normal activity in 2 days. The original instructions for radiofrequency ablation (VNUS closure system, San Jose, Calif) called for placement of the catheter in the CFV with pullback into the GSV. After Dr Hingorani’s presentation at the American Venous Forum meeting in February 2004,3Hingorani A.P. Ascher E. Markevich N. Schutzer R.W. Kallakuri S. Hou A. et al.Deep venous thrombosis after radiofrequency ablation of greater saphenous vein a word of caution.J Vasc Surg. 2004; 40: 500-504Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar we cautioned the company that this practice could lead to intimal damage, especially in smaller veins. Maintaining physiologic drainage at the saphenofemoral junction is the most important aspect in the endovenous closure technique, which has been well illustrated in our observations and by Pichot et al.4Pichot O. Kabnick L.S. Creton D. Merchant R.F. Schuller-Petroviae S. Chandler J.G. Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration.J Vasc Surg. 2004; 39: 189-195Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar We strongly believe that the procedure should be done under complete tumescent anesthesia, without any intravenous sedation. Furthermore, only minimal manipulation should be done at the saphenofemoral junction. Extension of saphenous thrombus into the femoral vein: A potential complication of new endovenous ablation techniquesJournal of Vascular SurgeryVol. 41Issue 1PreviewEndovenous techniques such as radiofrequency ablation (RFA) and endovenous laser therapy (ELT) have emerged as percutaneous minimally invasive procedures for ablation of incompetent great saphenous veins in patients with varicosity and venous insufficiency. Early reports showed safety and efficacy of both techniques, with excellent technical success rates and few major complications, such as deep vein thrombosis or pulmonary embolism. During our initial experience with ELT in 56 limbs of 41 patients, 39 underwent postoperative duplex scanning. Full-Text PDF Open ArchiveReplyJournal of Vascular SurgeryVol. 42Issue 1PreviewWe greatly appreciate the comments of Dr Ravi and his colleagues from the Arizona Heart Institute. With an experience of >1,000 endovenous cases, it is commendable that they observed only one pulmonary embolism. We wonder if all of their patients (beyond their published early experience) had early postoperative duplex scanning and what was the rate of extension of thrombus from the saphenous vein toward the common femoral vein (CFV)? Full-Text PDF Open Archive