The Rationale for Ablation of Incompetent Perforating Veins Is Not Substantiated by Current Clinical Evidence

Abstract

Radiofrequency ablation (RFA) is increasingly being employed for treatment of perforator vein insufficiency and venous ulcer healing. Previous studies have shown a closure rate of 60% to 80% in incompetent perforator veins (IPVs) with RFA. The purpose of the study was to determine the utility of a redo RFA for symptomatic recanalized perforators and to predict factors associated with recanalization.A retrospective analysis of 642 procedures in 256 patients with venous insufficiency due to IPVs from 2009 to 2015 was conducted. All 642 procedures were performed using RFA in patients who failed to respond to initial conservative management. Postoperative duplex ultrasound scans were performed within 3 to 7 days. Successful obliteration was defined as lack of color flow on postoperative scan. Recanalization was defined as presence of reflux on duplex ultrasound in symptomatic patients in the targeted vessel at follow-up. Follow-ups were conducted every 3 months in the first year and every 6 months thereafter.Among the 642 procedures, redo ablation was performed in 52 IPVs (29 patients, 37 extremities) including 14 women, with mean age of 65 years (standard deviation [SD], ±15 years). The Clinical, Etiology, Anatomy, and Pathophysiology class of the patients was as follows: C1, 0; C2, 0; C3, 3; C4a, 11; C4b, 7; C5, 0; and C6, 16. The distribution of the targeted IPVs included the calf (40) and ankle (12). The mean maximum diameter of the targeted veins was 4.6 mm (SD, ±1.1 mm). The initial technical success rate was 64.9%. Redo procedures had an early closure rate of 67.3%. At follow-up after a mean duration of 24 months (SD, ±16.8 months), the closure rate was 65.38%. No clinical correlation was found between successful obliteration in the redo procedure and age (P = .54), sex (P = .14), clinical class (P = .82), laterality (P = .84), or location of the vein (P = .54). When data were compared to predict factors associated with a redo procedure, IPVs located in mid and distal calf areas tended to recanalize more compared with the ankle (P = .04). Temperature of the radiofrequency stylet also showed a linear association, with patients treated at 85°C having higher probability of recanalization compared with patients treated at 90°C and 95°C (P = .01).The rates of successful closure for IPVs on initial and redo procedures are comparable. The data validate the utility of performing redo perforator ablations and suggest that temperature of the radiofrequency stylet and location of the IPVs may be predictive of a successful outcome or recanalization.