Endovenous Heat-induced Thrombosis Research Articles

Flush endovenous laser ablation (fEVLA) in the treatment of lower limb venous insufficiency a systematic review and meta-analysis.

To assess the safety and efficacy of flush endovenous laser ablation (fEVLA) in the treatment of chronic venous insufficiency. Following the PRISMA 2020 guidelines, a systematic review aiming to identify studies published from inception to March 2024 was conducted. The investigation covered single-arm studies and studies comparing fEVLA to standard EVLA (sEVLA). The primary endpoint was endovenous heat-induced thrombosis (EHIT) class ≥II. Eleven studies encompassing 2738 patients and 3147 truncal veins were included. The pooled EHIT ≥II was 1.37% (95%CI:0.57-3.28). Meta-regression identified an association between linear endovenous energy density (LEED) applied at the saphenofemoral junction and EHIT ≥II outcomes (β=0.011,p<0.01). The pooled medium-term GSV occlusion was 97.59% (95% CI:94.89-98.88). The pooled and crude deep vein thrombosis and pulmonary embolism estimates were 0.97% (95%CI:0.64-1.47) and 0.04%. The comparative analysis regarding GSV occlusion, odds ratio (OR) 3.26 (95%CI:0.76-13.97) and refluxing anterior accessory saphenous vein (AASV), RR 0.45 (95%CI:0.11-1.77) suggested a non-statistically significant trend favoring fEVLA. Non-statistically significant differences were identified in terms of EHIT ≥II between the techniques, risk ratio (RR) 1.00(95%CI:0.18-5.53). Statistically-significant differences favoring fEVLA were identified in terms of proximal groin recurrence RR 0.35 (95%CI:0.16-0.80) and stump length (mean difference) MD -7.23 (95% CI:-11.59to-2.88). This review has demonstrated the safety of fEVLA while also suggesting a potentially improved efficacy of fEVLA over sEVLA in terms of proximal groin recurrence. Moreover, the trend indicating fEVLA's superiority in terms of GSV occlusion and the occurrence of new-onset AASV reflux merits further research.

Can internal cooling radiofrequency catheters with local hypothermia eliminate the need for tumescent anesthesia? A single-center, retrospective, observational study.

Background: Tumescent anesthesia not only prolongs the operation time but also induces postoperative pain, bruising, and swelling. This study investigated the effectiveness and safety of tumescentless RFA using an internal cooling system with a VENISTAR catheter and local hypothermia. Methods: We retrospectively analyzed patients who had undergone RFA for above-knee (AK) great saphenous vein (GSV) between March 2023 and November 2023. We compared the efficacy and safety of tumescentless RFA between group T (conventional tumescent group, n = 50) and group N (non-tumescent group, n = 59). Results: The operative time was shorter in group N than in group T (group N: 31.37min, group T: 42.31min, p < .01), with no severe adverse events occurred in either group, such as endovenous heat-induced thrombosis or deep vein thrombosis. Postoperative pain (Group N, 0.53% vs Group T, 0.52%; p = .86), postoperative complications such as bruising (Group N, 6.78% vs Group T, 4%; N= .34) and paresthesia (Group N, 1.7% vs Group T, 6%; p = .27) showed no significant difference between the two groups on postoperative day 10. Conclusion: Tumescentless RFA with internal cooling and local hypothermia shows promising results with minimal complications. This novel approach represents a recent advancement in endovenous RFA that omits additional tumescent anesthesia.

Prospects of Endovenous Laser Ablation (EVLA) Standardization-Mid-Term Results of a Four-Zone Dosimetry Guiding Tool for 1940 nm Laser.

Heterogeneity regarding dosimetry and reporting of endovenous laser ablation (EVLA) mandates the development of a standardized protocol. This study presents the mid-term results of EVLA with 1940 nm-laser and radial-fibre, supported by a four-zone dosimetry tool. Four anatomical dosimetry zones for great saphenous veins (GSV) and two for small saphenous veins (SSV) were defined with set power levels. Zone-1G (4 W) extended from the inguinal ligament to the apex of femoral triangle, Zone-2G (4 W) from the apex of femoral triangle to the upper border of patella. Zone-3G (3 W) from the patella to the tibial tuberosity. Zone-4G (2 W) extended from the tibial tuberosity to the ankle. Zone-1S from the sapheno-popliteal junction to the tibial tuberosity. Zone-2S from the tibial tuberosity to the ankle. Power was increased by 1 W for veins >10 mm and decreased by 1 W when fibre sticking was encountered. Pullback-velocity was max. 1 mm/s. A total of 152 consecutive patients (185 procedures) were recruited. Mean follow-up time was 11.9 months. Mean linear endovenous energy density for GSV was Zone-1G:42 J/cm, Zone-2G:33 J/cm, Zone-3G:27 J/cm, Zone-4G:22 J/cm, Zone-1S:34 J/cm, Zone-2S:27 J/cm. Occlusion rates were 98.9% (1-month) and 93.7% (12-months). Complications at 1 M were low, namely laser-induced paraesthesia (LIP) 2.2% and endovenous heat-induced thrombosis (EHIT) 1.6%. Persistent LIP (12 M) was observed in 0.5%. The proposed four-zone guiding tool is a step towards standardizing dosimetry and documentation for EVLA with 1940 nm. This strategy shows good mid-term results with minimal complications. Long-term follow-up and application in further centres are necessary to prove its reproducibility. Such a guiding tool could improve the ability to analyse, compare and review different EVLA wavelengths and fibre types.

TCTAP C-149 A Case Report of Class II Endovenous Heat-Induced Thrombosis Post Endovenous Laser Ablation: Prompt Treatment or Watchful Waiting?

TCTAP C-149 A Case Report of Class II Endovenous Heat-Induced Thrombosis Post Endovenous Laser Ablation: Prompt Treatment or Watchful Waiting?

Outcomes of a single-center experience in eliminating routine postoperative duplex ultrasound screening after endovenous ablation

ObjectivesThe current guidelines recommend routine postoperative duplex ultrasound (DUS) screening after endovenous ablation (EVA). This is a grade 2C recommendation, and several contemporary reports have called for revision of this recommendation as there is insufficient evidence to support universal DUS screening after EVA. There are currently no studies that evaluate outcomes among EVA patients who did not have DUS screening. The aim of our study is to present outcomes from our single-center experience among patients who did not have DUS routinely performed after EVA. MethodsWe performed a single-center, prospective cohort study that included consecutive patients who underwent EVA of the great saphenous vein at our institution between September 30, 2021, and March 15, 2022. At 30 days after the procedure, electronic medical records were queried to identify patients who may have presented for the evaluation of venous thromboembolism (VTE) symptoms. ResultsOver the study period, a total of 80 lower extremity EVA procedures (71 endovenous laser ablation and 9 radiofrequency ablation) were performed among 76 patients. Postoperative DUS was performed on 24 patients, of whom none were identified as having endovenous heat-induced thrombosis. Of the 54 patients who did not have DUS, a 30-day postprocedure chart review revealed that none of these patients were seen for symptoms of VTE. We estimate total cost savings of $14,289 by eliminating routine DUS without impact to clinical outcomes after EVA. ConclusionsPostoperative DUS assessment after EVA comes with associated health care cost and has low yield given that the incidence of clinically significant endovenous heat-induced thrombosis (3 and 4) is rare. In our experience, eliminating routine DUS had no impact on clinical outcomes, improved vascular lab access, and had a positive financial impact in our organization. Limiting DUS screening to EVA patients who exhibit symptoms of VTE can be a cost-effective approach that limits unnecessary imaging, time, and resources with no potential change in clinical outcomes based on our data. Further research is required, and a randomized controlled trial would be ideal to answer this question.

Incidence and Significance of Deep Venous Reflux in Patients Treated with Saphenous Vein Ablation

Venous ablation (VA) of the saphenous vein is the most common procedure performed for venous insufficiency. The incidence of concomitant deep venous reflux (DVR) in patients undergoing VA is unknown. Our hypothesis is that patients undergoing saphenous VA with concomitant DVR exhibit a higher CEAP stage and less relief after VA compared to patients without DVR. Electronic medical records of patients treated with saphenous VA at a tertiary care center from March 2012 to June 2016 were reviewed. Patients were divided into two groups based on presence or absence of DVR on initial ultrasound before saphenous VA. Patient characteristics and outcomes were compared. A telephone survey was conducted to assess long-term symptomatic relief, compliance with compression, and pain medication use. Subgroup analysis of patients with post-thrombotic versus primary DVR was performed. 362 patients underwent 497 ablations, and the incidence of DVR (>1 second) was 20% (N=71). Patients with DVR were significantly more likely to be male (46.4% vs 32.1%, p = 0.021) and of black race (21.2% vs 5.5%, p = 0.0001) compared to patients without DVR. Patients with DVR were more likely to have a history of deep vein thrombosis (DVT) (15.1% vs 7.9%, p = 0.045), but there was no difference in other comorbidities. There was no significant difference in presenting symptoms, CEAP stage, or symptom severity based on numeric rating scale (0-10) for pain and swelling. Clinical success of saphenous VA was comparable between the two groups, but patients with DVR were more likely to develop endovenous heat induced thrombosis (EHIT) II-IV (6% vs 1%, p = 0.002). After a mean follow up of 26 months, there was still no difference in pain or swelling scores, but patients with DVR were more likely to use compression stockings and used them more frequently. Only 11 of 71 patients with DVR had history of DVT. Patients with post-thrombotic DVR were significantly older than patients with primary DVR (67.3 vs 57.2, p = 0.038) and exhibited a trend towards more advanced venous disease (C4-C6: 45.4% vs 33.3%, p = 0.439). In this study, 20% of patients undergoing saphenous VA demonstrated DVR, which was more common in black men. Presence of DVR is associated with increased risk of EHIT after saphenous VA but does not seem to impact disease severity or clinical relief after ablation. Larger studies are needed to understand outcome differences between post-thrombotic and primary DVR.

Safety and effectiveness of indirect radiofrequency ablation (closure FAST) of incompetent great saphenous veins with Type I aneurysms: Long-term results radiofrequency ablation for saphenous aneurysms.

Assess the safety and effectiveness of indirect radiofrequency ablation (RFA, Closure FAST) for the treatment of incompetent great saphenous veins (GSVs) with type 1 aneurysms. This was a retrospective analysis performed in three centers (2007-2021). All patients presenting with saphenous aneurysms close to the junction (within 2cm) were included. They were treated with RFA. Phlebectomies and/or sclerotherapy were performed during the same treatment session. Duplex ultrasound (DUS) was performed early after the procedure and then, more than a year later. Eight patients (11 limbs) were included between June 2007 and May 2021 with a median diameter of the GSV aneurysm 21mm (IQR 17.2-23.4). No severe adverse events occurred apart from one endovenous heat-induced thrombosis (EHIT) class III (9.1%). After more than a year (mean 7.2 ± 4.2, median 8years), none of the aneurysms was present on DUS and the truncal obliteration rate was 100%. RFA appears to be a safe and effective treatment for patients presenting with incompetent saphenous veins with the type 1 aneurysm.

Midterm results of radiofrequency ablation with multiple heat cycles for incompetent saphenous veins

ObjectiveRecent reports suggest that the number of radiofrequency ablation (RFA) cycles impacts the depth of vein wall damage. This study evaluates the midterm occlusion rate after delivering increased energy during RFA of incompetent saphenous veins. MethodsBetween 2016 and 2019, consecutive patients who underwent RFA with multiple heat cycles were enrolled in the study. The exclusion criterion was previous treatment history for chronic venous disease. Duplex ultrasound data and medical records were reviewed retrospectively. ResultsThis study enrolled 217 patients (345 veins). Follow-up examinations were performed for 65% of treated veins after 6 months, 31% after 12 months, and 26% after more than 24 months with a mean follow-up period of 23 ± 18.9 months. The numbers of great saphenous and small saphenous veins were 178 and 62, respectively. According to the Kaplan-Meier method, the occlusion rate of saphenous veins was 100% at 3 years and 95.4% at 5 years. Except for one case (0.3%) of endovenous heat-induced thrombosis class 2, no significant side effects were noted. ConclusionsRoutine use of RFA with multiple heat cycles for incompetent saphenous veins exhibits good clinical outcomes considering midterm occlusion rate without an increase in side effects.

Superficial venous procedures can be performed safely and effectively in patients with deep venous reflux

BackgroundThe finding of concurrent deep venous reflux (DVR) when interrogating superficial venous reflux is common and might be a marker of more severe chronic venous insufficiency. However, the safety and clinical and patient-reported outcomes for patients undergoing superficial venous treatment in the presence of DVR remains underreported. Moreover, the factors associated with the persistence and disappearance of DVR after superficial vein treatment have not been evaluated. In the present study, we sought to address these questions. MethodsWe performed a review of the institutional vascular quality initiative database from June 2016 to June 2021. Consecutive patient limbs were identified that had undergone a superficial venous intervention and had duplex ultrasound evaluations available. These patients were divided into those with and without DVR. Those with DVR were further reviewed for anatomic details and the persistence or resolution of DVR after the procedure. The primary outcome was the venous clinical severity score (VCSS) at a follow-up >3 months. The secondary outcomes included the incidence of any postoperative deep vein thrombosis or endovenous heat-induced thrombosis, differences in patient-reported outcomes, rate of resolution of DVR, and factors associated with DVR persistence. Both univariate analysis and multivariate logistic regression were applied. ResultsOf the patients who had undergone superficial venous treatment, 644 patient limbs had had DVR and 7812 had not, for a prevalence of 7.6%. The DVR group was associated with a higher burden of chronic venous insufficiency. On univariate analysis, patient limbs, both with and without DVR, had improved significantly in the VCSS at <3 months of follow-up and were not significantly different. At >3 months of follow-up, the VCSS had again improved significantly compared with the VCSS at <3 months of follow-up. However, the difference between the two groups was statistically significant at the longer interval. The magnitude of improvement in the VCSS between the two groups at the longer follow-up were similar statistically (VCSS, 3.17 ± 3.11 vs 3.03 ± 2.93; P = .739). The HASTI (heaviness, achiness, swelling, throbbing, itching) score had similarly improved significantly in both groups but remained significantly higher in the DVR group during follow-up. On multivariate logistic regression, DVR was not associated with an increased VCSS at >3 months of follow-up. No intergroup difference was found in the incidence of postoperative deep vein thrombosis or endovenous heat-induced thrombosis. Of limbs with DVR, 40.8% no longer had evidence of detectable DVR at the latest follow-up venous duplex ultrasound, and DVR limited to a single segment was more likely than DVR in multiple segments to be no longer detectable. ConclusionsOur results have shown that superficial venous procedures are safe and effective in patients with DVR, leading to improvements in clinical and patient-reported outcomes similar to those for patients without DVR. In a large proportion of the treated limbs, especially those with DVR in a single segment, no evidence of DVR was found after superficial venous intervention. Although patients with DVR will have a higher burden of chronic venous insufficiency, they still appear to derive significant benefit from superficial venous treatment.

Preliminary experience with a 1470 nm diode ring laser with echosclerotherapy in lower limb varicose veins

Objective：To study the effect of endovenous laser ablation (EVLA) of lower limb varicose veins using a 1470 nm diode ring laser with ultrasound-guided foam sclerotherapy (UGFS), also known as echosclerotherapy. Methods：From January 2020 to December 2022, 236 patients with primary lower limb varicose veins were enrolled in the study. All patients were treated with 1470 nm diode ring laser with echosclerotherapy in our center. Under tumescent anesthesia, venipuncture of the great saphenous vein (GSV) trunk was performed, followed by 1470 nm laser therapy (80-100J/10W). Before the procedure, 1% polidocanol foam was injected into the insufficient collateral veins extending from the main trunk of the GSV. During the 3days after surgery, self-adhesive elastic bandage was used for compression therapy. After 3 days of surgery, grade II compression stockings was used for 1 month. All patients underwent a follow-up duplex Doppler ultrasound 1, 30 days after the procedure. Hospital stay time, postoperative pain, GSV occlusion rate, recurrence rateand complications, such as ecchymosis, edema, paresthesia and endovenous heat-induced thrombosis (EHIT). Results: Four patients were lost to follow up. The average hospitalization time was 2.8 days, the average admission time after operation was 1-2 days. The average operating time was 45.79 ± 8.57min. At the one month follow up all treated GSV remained occluded. There were 2 patients were treated with echosclerotherapy in outpatient because of new reflux in the treated collateral veins. Seventy-five percent of patients did not have any pain after the treatment and ninety-one point eight percent of ones did not take any analgesic tablets at any time after the procedure. No severe complications such as deep venous thrombosis could be detected. And there was no patient developed EHIT after treatment. Minor complications were ecchymosis at 15.1%, edema at 44.8%, and paresthesia around ankle at 0, respectively. All patients expressed satisfaction with the operative curative effects and cosmetic effects. Conclusion: EVLA with 1470-nm diode ring laser with echosclerotherapy in lower limb varicose veins is comfortable with less incision, hospitalization procedure and is a safe and efficient treatment option.

Personal factors and postoperative changes in the revised Venous Clinical Severity Score of varicose veins

ObjectiveThe primary aim of this observational study was to measure the Revised Venous Clinical Severity Score (rVCSS) in patients treated for varicose veins (VVs) owing to saphenous vein reflux. Treatment was by endovenous thermal ablation (ETA) alone or by ETA and ambulatory phlebectomy (AP). A secondary aim was to determine whether participant characteristics and treatment methods affect rVCSS and how the score changes over time. MethodsWe enrolled 44 men with 55 treated legs and 79 women with 105 treated legs (bilateral cases, 23.1%). Patients were treated and evaluated from April 2016 to September 2020. All legs were treated by ETA, and participants were divided into three groups depending on AP treatment: E0 group (40 legs), no AP; EP1 group (101 legs), AP performed only at one site above or below the knee; and EP2 group (19 legs), AP performed both above and below the knee. The rVCSS was measured in the treated legs up to five times: preoperatively and on postoperative days (POD) 1, 7, 90, and 180. ResultsThe mean age was 67.5 ± 11.24 years (range, 32-87 years). No significant differences in medical history or demographics or lifestyle were found between the groups. The mean preoperative rVCSS also was not different between groups (E0, 4.4 ± 0.3 points; EP1, 4.6 ± 0.2 points; and EP2, 5.4 ± 0.4 points; P = .14). Factors associated with less improvement in the rVCSS were a high body mass index (P = .046) and the occurrence of endovenous heat-induced thrombosis (P = .001), and factors associated with more improvement in the rVCSS were hypertension (P = .026), hyperuricemia (P = .022), and wearing compression stockings (P = .013). The rVCSS decreased strongly at POD1 and then gradually decreased until POD180. It was not significantly different between EP1 and EP2, but it improved significantly earlier in these two groups than in the E0 group. The rVCSS at POD180 was as follows: E0, 1.633 ± 0.233 points; EP1, 1.003 ± 0.148 points; and EP2, 0.982 ± 0.322 points. ConclusionsFactors associated with less improvement in the rVCSS are a high body mass index and the occurrence of endovenous heat-induced thrombosis. Hypertension, hyperuricemia, and wearing compression stockings are associated with greater improvements in the rVCSS. Patients treated with ETA and AP tend to improve earlier than patients treated by ETA alone, but all patients improve to nearly the same level within 6 months.

Women benefit from endovenous ablation with fewer complications: Analysis of the Vascular Quality Initiative Varicose Vein Registry

ObjectiveTo evaluate the association between gender and long-term clinician-reported and patient-reported outcomes after endovenous ablation procedures. MethodsThis retrospective cohort study of prospectively collected data from the Vascular Quality Initiative’s Varicose Vein Registry included patients undergoing endovenous ablation procedures on truncal veins with or without treatment of perforating veins between 2015 and 2019. A univariate analysis included comparisons of preprocedural, postprocedural, and periprocedural change in Venous Clinical Severity Score (VCSS) and total symptom score by gender. Rates of complications including deep vein thrombosis, endovenous heat-induced thrombosis, leg pigmentation, blistering, paresthesia, incisional infection, and any postprocedural complications were reported by gender. Multivariable analysis leveraged linear regression to examine how gender affected the relationships between patient characteristics, complication rates, and periprocedural change in VCSS score and total symptom score. ResultsOf 9743 patients who met the inclusion criteria, 3090 (31.7%) were men and 6653 (68.2%) were women. The perioperative change in VCSS score was greater for men than women (average –4.46 for men vs –4.13 for women; P < .0001). Perioperative change in total symptom score was greater for women than for men (average –10.64 for women vs –9.64 for men; P < .0001). Women had lower incidence of any leg complication (6.1% vs 8.6%; P = .001) endovenous heat-induced thrombosis (1.1% vs 2.2%; P = .002), and infection (0.4% vs 0.7%; P = .001). In multivariable analysis, among patients with a body mass index of more than 40, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2, women had a greater periprocedural change in VCSS score than men. ConclusionsWomen benefited from endovenous ablation similarly as men, with a lower incidence of postprocedural complications. Gender may be useful for patient selection and counseling for endovenous ablation, with particular usefulness among patients with a high body mass index, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2.

Thrombotic complications after radiofrequency and cyanoacrylate endovenous ablation: Outcomes of a multicenter real-world experience

ObjectiveChronic venous insufficiency (CVI) affects >40% of the U.S. population; thus, intervention for symptomatic venous disease comprises a large portion of many vascular practices. The treatment of superficial CVI has evolved from open surgical treatment to minimally invasive endovenous closure, including both thermal and nonthermal techniques. Thrombotic complications of thermal ablation have been well reported, with an overall complication rate of <2%. However, a paucity of high-powered, real-world data is available on the thrombotic outcomes of nonthermal techniques. In the present study, we compared the incidence of endovenous heat-induced thrombosis (EHIT) and endovenous glue-induced thrombosis (EGIT) in a large cohort of patients with CVI. MethodsA retrospective review was conducted at two tertiary-level institutions of patients who had undergone superficial endovenous ablation from 2018 to 2021. The patient demographics, comorbidities, and periprocedural outcomes were collected through medical record review. A Caprini risk assessment model score was assigned using the information available from the electronic medical records. The patients were categorized by procedure type (ClosureFast [Medtronic Inc, Minneapolis, MN] radiofrequency ablation [RFA] vs VenaSeal [Medtronic Inc] cyanoacrylate glue closure [CAG]). The primary end point was the incidence of EHIT or EGIT. The secondary end point was the incidence of deep vein thrombosis and/or pulmonary embolism. ResultsA total of 803 patients had undergone 1096 procedures during the study period. Their mean age was 62 ± 15 years, and 67% were women. Of the 1096 procedures, 700 were RFA and 396 were CAG procedures, with a combined closure rate of 98% by postprocedure duplex ultrasound at 7 days. The average Caprini score was 5.2 ± 1.8 (RFA, 5.0; vs CAG, 5.4; P < .001). The incidence of EHIT and EGIT was 1.9% and 1.3%, respectively (P = .57). The deep vein thrombosis rate was 0.1% in the RFA cohort and 0.3% in the CAG cohort (P = .81). A comparative analysis of thermal vs nonthermal techniques was performed. A univariate analysis of the risk factors for EHIT and EGIT revealed no significant factors predisposing to thrombotic events. ConclusionsThe results from the present study have demonstrated the safety of RFA and CAG closure techniques for CVI, with lower thrombotic rates than previously reported. Further work might help to identify how these results can be achieved across all venous ablative techniques for CVI, even for patient populations with advanced venous disease and possibly a greater than average risk of thrombotic events.

Periprocedural Thromboprophylaxis for Superficial Venous Interventions: A Literature Review

Foam sclerotherapy and endovenous thermal ablation (EVTA) with radiofrequency and laser are common treatments for superficial venous insufficiency. Despite the safety and effectiveness of EVTA, serious life-threatening thrombotic complications can occur. The overall incidence of endovenous heat-induced thrombosis, deep vein thrombosis, and pulmonary embolism after EVTA has been reported to be <1.5%. Several attempts to evaluate periprocedural thromboprophylaxis for superficial venous interventions have shown heterogeneous findings.

A-49 | Does Higher Energy Lead to Higher Endovenous Heat Induced Thrombosis Rates in Pathologic Perforator Veins Endovenous Laser Ablation Therapy?

Pathologic Perforator Vein (PPV) endovenous laser ablation therapy (EVLT) is known to be safe and effective. Published rates of procedure-related endovenous heat-induced thrombosis (EHIT) of the deep venous system are 1.20% at 1 month observed at an energy range of 50-70 Joules. We sought to examine if higher energy leads to an increase in EHIT rates.

Second-generation treatment of varicose veins: endovenous thermal ablation by laser or radiofrequency ablation

Background: Endovenous thermal ablation (EVTA) is the second-generation treatment of varicose veins in the lower extremities. It has overcome the shortcomings of the first-generation treatment of high ligation and stripping. Further, it is the basis for the development of the third-generation treatment with endovenous glue ablation. It is currently recommended as the first-line treatment for varicose veins accompanied by great saphenous vein incompetence.Current Concepts: EVTA involves obliterating the varicosed veins by applying thermal energy to blood or vein wall. It can be performed by laser or radiofrequency ablation methods, under local anesthesia. The treatment results are excellent and show lesser pain and faster recovery compared to the first-generation treatment. However, complications include endovenous heat-induced thrombosis, deep vein thrombosis, ecchymosis, and phlebitis.Discussion and Conclusion: To enhance the therapeutic effect and reduce the complications of EVTA, sufficient tumescent anesthesia, a controlled number of firing in radiofrequency ablation, and use of the novel highwavelength laser and a radial catheter tip in endovenous laser ablation are recommended. In addition, proficiency in other generations of varicose vein treatments could help in various situations.

Bilateral Endothermal Heat-induced Thrombosis

Endovenous ablation of the lower extremity veins has become the primary modality treatment for symptomatic venous reflux disease. Endovenous heat induced thrombosis (EHIT) has been reported as one of the main complications of these venous ablative procedures. We have previously described the incidence of this complication and the need for routine surveillance duplex post procedure. We have noted that a number of patients developed bilateral EHITs. Our aim was to determine what, if any, factors predispose patients to developing bilateral EHITs versus unilateral EHITs.

Systematic Review and Cost Analysis of Routine Deep Venous Thrombosis Ultrasound After Thermal or Nonthermal Endovenous Ablation

Duplex ultrasound (DUS) examination is performed following endovenous ablation of the saphenous vein to screen for thrombotic complications, this practice is endorsed by the Society for Vascular Surgery and the American Venous Forum. However, this blanket approach to screening may not be cost effective or clinically indicated, as the incidence of deep vein thrombosis (DVT) is low. The most common abnormal finding, endovenous heat-induced thrombosis (EHIT level I-II) represents extension of thrombus from the saphenous of <50% across the femoral or popliteal vein, which is thought to have a benign course regardless of intervention.

Systematic Review on the Incidence and Management of Endovenous Heat Induced Thrombosis (EHIT) Following Endovenous Thermal Ablation of the Great Saphenous Vein

Systematic Review on the Incidence and Management of Endovenous Heat Induced Thrombosis (EHIT) Following Endovenous Thermal Ablation of the Great Saphenous Vein

Thrombus extension after cyanoacrylate closure of incompetent saphenous veins.

Cyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins. This study aimed to investigate the incidence, the risk factors for, and the management of thrombus extension after cyanoacrylate closure (TEACAC) of incompetent saphenous veins in patients with chronic venous disease. This retrospective study included patients aged >18 years who were diagnosed with chronic venous disease with superficial venous reflux in the great saphenous vein, anterior accessory saphenous vein, or small saphenous vein, and who were treated with CAC at Siriraj Hospital (Bangkok, Thailand) during January 2017 to December 2018. A total of 126 saphenous veins of 101 patients were included. TEACAC occurred in 5 of 101 (4.9%) patients, and in 5 of 126 (3.9%) treated saphenous veins. The mean follow-up time was 285±12 days. Based on Kabnick classification of endovenous heat-induced thrombosis (EHIT), the following TEACAC grades were observed: grade I (N.=2), grade II (N.=1), grade III (N.=2), and grade IV (N.=0). No patient or procedural predictive factors for TEACAC were identified. In patients with TEACAC-1 or TEACAC-2, the thrombus spontaneously disappeared by the 2-week follow-up. Patients with TEACAC-3 received therapeutic rivaroxaban or dabigatran, which resolved the thrombus within 2-4 weeks. No deep vein thrombosis or symptomatic pulmonary embolism was found. TEACAC was found not to be a rare complication after CAC. All patients should be informed of the risk of TEACAC prior to treatment. Treatment of TEACAC class 1-3 following EHIT guideline seems to be both safe and effective.