Endovenous Heat-induced Thrombosis Research Articles

Incidence, progression, and risk factors for endovenous heat-induced thrombosis after radiofrequency ablation.

Endovenous radiofrequency ablation has become an accepted mode of treatment for superficial venous reflux. In this study, we evaluated the incidence of endovenous heat-induced thrombosis (EHIT), its progression, and risk factors that may contribute to its formation. This was a prospective study of all patients who underwent radiofrequency ablation of the great saphenous vein (GSV), accessory GSV, and small saphenous vein (SSV) from March 1, 2010, to September 30, 2011, from 12 of our affiliated vein centers in a primary vein practice. Demographic data, CEAP classification, previous history of deep venous thrombosis (DVT), body mass index, vein diameter, reflux time, catheter tip position, EHIT progression, number of stab phlebectomies, and Venous Clinical Severity Score of patients with EHIT were analyzed. Of the 6707 treated limbs, 4906 (73%) had GSV, 145 (2%) had accessory GSV, and 1656 (25%) had SSV ablation. EHIT developed in 201 limbs of 194 patients for an overall incidence of 3%. A nonfatal pulmonary embolism occurred in two patients (0.03%). Patients who developed EHIT were slightly older than those without EHIT (median age, 59 vs 56 years). In patients with EHIT, 34.8% were men, but only 25% were men among those who had no EHIT (P= .002). GSV, accessory GSV, and SSV diameters were larger in EHIT patients (P< .001 for all). Reflux time and catheter tip distance from the saphenous junctions were similar in those with and without EHIT. EHIT resolution occurred in 2 to 4 weeks in most patients, but EHIT worsening occurred in nine (4.5%) that all resolved ≤4 weeks. In the EHIT patients, 68% had multiple concomitant phlebectomies compared with 39.4% of those without EHIT (P< .0001). DVT history made no difference for EHIT development (P= .065). All but two class 1 and one class 2 EHIT patients were managed with observation and aspirin due to DVT history and physician concern. The Venous Clinical Severity Score was obtained only in the last 70 EHIT cases. The mean score was 5.92 preoperatively and improved to 2.08 at the 1-month follow-up. Large vein diameter, male sex, and multiple phlebectomies are risk factors for development of EHIT. We recommend that EHIT class 1 and 2 patients be managed with observation or antiplatelets, or both, but class 3 and 4 patients should be anticoagulated.

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

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.

Less Invasive Ultrasonography-Guided High Ligation of Great Saphenous Vein in Endovenous Laser Ablation

endovenous heat-induced thrombosis (EHIT) and great saphenous vein (GSV) recanalization. To eliminate these complications, we developed ultrasonographyguided high ligation (UGHL) using a puncture-sized incision as an adjunct treatment to EVLA. UGHL combined with EVLA was used in 20 patients. The GSV was encircled with 2-0 silk thread at 2 cm distal to the saphenofemoral junction through two incisions of 2-3 mm by using a Deschamps aneurysm needle under ultrasonographic guidance. UGHL was technically feasible in all cases, and no case presented with complications. UGHL may be used in addition to EVLA.

Vein Mapping Prior to Endovenous Catheter Ablation of the Great Saphenous Vein Predicts Risk of Endovenous Heat-Induced Thrombosis

We investigate the value of vein mapping for predicting the risk of endovenous heat-induced thrombosis (EHIT) after endovenous laser treatment (EVLT) and radiofrequency ablation (RFA) of the great saphenous vein (GSV). In all, 355 consecutive vein mappings were retrospectively analyzed. A generalized estimating equations approach to linear logistic regression was used to evaluate the variables. Among the 312 vein ablation of the GSV, 10 (3.2%) developed EHIT. When comparing the group of patients who developed EHIT versus no EHIT, the mean GSV diameter was 13.05 ± 5.59 mm versus 8.39 ± 3.38 mm (odds ratio [OR]: 1.25, P = .001), the presence of valvular incompetence at the saphenofemoral junction (SFJ) was 10.71% versus 0.44% (OR: 27.75, P =.001), and 3.09% in RFA versus 3.33% in EVLT (OR: 1.09, P = .89). Patients with valvular insufficiency of the SFJ and a large proximal GSV diameter had a significantly higher risk of developing heat-induced thrombosis after endovenous catheter ablation.

Great saphenous vein patency and endovenous heat-induced thrombosis after endovenous thermal ablation with modified catheter tip positioning

Thrombus extension into a deep vein after superficial venous thermoablation remains a unique complication in the treatment of superficial reflux disease of the great saphenous vein (GSV). In this study, we evaluate if catheter tip positioning or vein diameter correlate with the length of proximal patent segment of GSV after ablation and more caudal catheter positioning decreases the incidence of proximal thrombus extension into the femoral vein. This was a prospective study conducted from January 2008 to November 2009 of 73 patients undergoing radiofrequency ablation (RFA). Preoperative, intraoperative, and postoperative duplex ultrasound scans were obtained using standard protocols to establish reflux and target vein diameter. Intraoperative measurements were performed from the catheter tip to the femoral vein margin. Duplex ultrasound studies were obtained between 5 and 7 days after the procedure, with 1-month follow-up. The relationship between catheter tip positioning and vein diameter with the length of the proximal patent GSV segment after ablation and the incidence of proximal thrombus extension were analyzed. RFA was performed in 73 patients. Intraoperatively, the mean catheter tip positioning distance was 2.75 cm (range, 2.4-3.0 cm) from the saphenofemoral junction (SFJ), with 93% of the catheters placed within 2.6 to 2.9 cm of the femoral vein. The GSV mean diameter at the SFJ was 0.90 cm (range, 0.37-1.88 cm). After RFA, all GSVs were occluded, with a mean residual patent proximal GSV length of 1.17 cm (range, 0.3-10 cm). Two patients demonstrated thrombus extension from the SFJ into the femoral vein for a 2.7% incidence of endovenous heat-induced thrombosis. In patients undergoing RFA for saphenous reflux, neither catheter tip positioning nor vein diameter correlates with the length of the proximal patent segment of GSV after ablation. In addition, catheter positioning does not decrease the incidence of proximal thrombus extension into the femoral vein.

Deep Vein Thrombosis (DVT) after Venous Thermoablation Techniques: Rates of Endovenous Heat-induced Thrombosis (EHIT) and Classical DVT after Radiofrequency and Endovenous Laser Ablation in a Single Centre

Introduction Deep vein thrombosis (DVT) after varicose vein surgery is well recognised. Less well documented is endovenous heat-induced thrombosis (EHIT), thrombus extension into a deep vein after superficial venous thermoablation. We examined the rates of DVT in our unit after radiofrequency (RFA) and endovenous laser ablation (EVLA) with specific attention to thrombus type. Method Retrospective analysis of all cases of RFA under general anaesthesia and EVLA under local anaesthesia was performed. Cases of DVT were identified from the unit database and analysed for procedural details. Results In total, 2470 cases of RFA and 350 of EVLA were performed. Post-RFA, DVT was identified in 17 limbs (0.7%); 4 were EHIT (0.2%). Concomitant small saphenous vein (SSV) ligation and stripping was a risk factor for calf-DVT (OR 3.4, 95%CI 1.2–9.7, P = 0.036), possibly due to an older patient group with more severe disease. Post-EVLA, 4 DVTs were identified (1%), of which 3 were EHIT (0.9%). Conclusion The DVT rate including EHIT was similar in patients treated with RFA and EVLA and was low. Routine post-operative duplex ultrasound scanning is recommended until the significance of EHIT is better understood, in accordance with consensus guidelines. DVT rates for both techniques compare favourably with those published for saphenous vein stripping.