Segmental Thermal Ablation of the Small Saphenous Vein Using an Endovenous Heat-Induced Thrombus Classification System and Treatment Algorithm

Abstract

We evaluated our experience with segmental radiofrequency ablation (RFA) of the small saphenous vein (SSV), a less common procedure than great saphenous ablation, and developed a endovenous heat-induced thrombus (EHIT) classification system and algorithm, based on modifications of our prior algorithm of EHIT after great saphenous ablation. Endovenous ablation was performed on symptomatic patients with incompetent SSVs after a minimum of 3 months of compression therapy. Demographic data, risk factors, CEAP classification, procedure details, and follow-up data were recorded. A four-tier classification system and treatment algorithm was developed, based on EHIT proximity to the popliteal vein. Between October 2008 and March 2012, 62 consecutive patients (23 men and 39 women; CEAP C3, 38 limbs; C4, two limbs; C5, three limbs, and C6, 26 limbs) underwent 69 RFA of the SSV. All patients underwent duplex ultrasound imaging between 24 and 72 hours after the procedure. Ablation was successful in 100% (69 of 69) of procedures. Fifty patients (81%) had level A closures, and 10 patients (16%) had level B closures and were observed. Two patients (3%) had EHIT extending into the popliteal vein (level C) and were treated with outpatient low-molecular-weight heparin anticoagulation. Thrombus retracted to the level of the saphenopopliteal junction in both patients at a mean of 12 days. No patient developed a deep vein thrombosis (DVT; level D). Mean follow-up time was 7 months; no patient had SSV recanalization or DVT. LMWH, low-molecular-weight heparin; SPJ, saphenofemoral junction. RFA of the SSV in symptomatic venous patients has a high success rate with a low risk of DVT. A classification system based on the level of EHIT in relationship to the saphenopopliteal junction is useful in managing patients. The approach to patients with thrombus flush with the popliteal vein or bulging has not been previously defined; our outcomes were excellent, using our treatment algorithm.