Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications

Alessandra Puggioni, Manju Kalra, Michele Carmo, Geza Mozes, Peter Gloviczki
Journal of Vascular Surgery 2005, 42 (3): 488-93

BACKGROUND: Endovenous laser therapy (EVLT) and radiofrequency ablation (RFA) are new, minimally invasive percutaneous endovenous techniques for ablation of the incompetent great saphenous vein (GSV). We have performed both procedures at the Mayo Clinic during two different consecutive periods. At the time of this report, no single-institution report has compared RFA with EVLT in the management of saphenous reflux. To evaluate early results, we reviewed saphenous closure rates and complications of both procedures.

METHODS: Between June 1, 2001, and June 25, 2004, endovenous GSV ablation was performed on 130 limbs in 92 patients. RFA was the procedure of choice in 53 limbs over the first 24-month period of the study. This technique was subsequently replaced by EVLT, which was performed on the successive 77 limbs. The institutional review board approved the retrospective chart review of patients who underwent saphenous ablation. According to the CEAP classification, 124 limbs were C2-C4, and six were C5-C6. Concomitant procedures included avulsion phlebectomy in 126 limbs, subfascial endoscopic perforator surgery in 10, and small saphenous vein ablation in 4 (EVLT in 1, ligation in 1, stripping in 2). Routine postoperative duplex scanning was initiated at our institution only after recent publications reported thrombotic complications following RFA. This was obtained in 65 limbs (50%) (54/77 [70%] of the EVLT group and 11/53 [20.8%] of the RFA group) between 1 and 23 days (median, 7 days).

RESULTS: Occlusion of the GSV was confirmed in 93.9% of limbs studied (94.4% in the EVLT [51/54] and 90.9% in the RFA group [10/11]). The distance between the GSV thrombus and the common femoral vein (CFV) ranged from -20 mm (protrusion in the CFV) to +50 mm (median, 9.5 mm) and was similar between the two groups (median, 9.5 mm vs 10 mm). Thrombus protruded into the lumen of the CFV in three limbs (2.3%) after EVLT. All three patients were treated with anticoagulation. One received a temporary inferior vena cava filter because of a floating thrombus in the CFV. Duplex follow-up scans of these three patients performed at 12, 14, and 95 days, respectively, showed that the thrombus previously identified at duplex scan was no longer protruding into the CFV. No cases of pulmonary embolism occurred. The distance between GSV thrombus and the saphenofemoral junction after EVLT was shorter in older patients (P = .006, r(2) = 0.13). The overall complication rate was 15.4% (20.8% in the EVLT and 7.6% in the RFA group, P =.049) and included superficial thrombophlebitis in 4, excessive pain in 6 (3 in the RFA group), hematoma in 1, edema in 3 (1 in the RFA group), and cellulitis in 2. Except for two of the three patients with thrombus extension into the CFV, none of these adverse effects required hospitalization.

CONCLUSION: GSV occlusion was achieved in >90% of cases after both EVLT and RFA at 1 month. We observed three cases of thrombus protrusion into the CFV after EVLT and recommend early duplex scanning in all patients after endovenous saphenous ablations. DVT prophylaxis may be considered in patients >50 years old. Long-term follow-up and comparison with standard GSV stripping are required to confirm the durability of these endovenous procedures.

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