Tailoring superficial venous interventions to gender

The purpose of this editorial is to underscore the paucity of research investigating gender-specific outcomes in superficial venous reflux (SVR) interventions. By addressing disparities in procedural success, recurrence rates, and patient-reported outcomes (PROs), this work seeks to advocate for more personalised, gender-informed treatment strategies to refine clinical guidelines for the management of chronic venous disease (CVD) and enhance patient quality of life (QoL).

Previous research has consistently suggested gender differences in SVR prevalence and presentation. ¹ This may be a result of selection bias due to females being more predisposed to seek treatment at earlier stages when symptoms are primarily cosmetic. Nevertheless, intervention outcomes by gender in other vascular pathologies, such as peripheral arterial disease (PAD) are also vastly more researched with differences shown. ² Data has shown that gender has numerous significant impacts on outcomes, such as bypass failure, stent thrombosis, long-term post-intervention patency, amputation-free survival and procedural complications. ² Despite this, there has been minimal investigation into the effect of gender on intervention outcomes for SVR.

Existing evidence suggests notable gender differences in outcomes following SVR interventions. For instance, men may experience higher rates of complications such as endovenous heat-induced thrombosis (EHIT), while women may report greater symptom improvement yet exhibit higher recurrence rates. These findings, however, are inconsistent and studies were limited by retrospective designs or were not primarily focused on investigating gender-specific outcomes.

A retrospective cohort study evaluated ablation in truncal veins for patients accrued from the Vascular Quality Initiative Varicose Vein Registry. ³ This observed significantly greater overall physician-reported improvement for men, measured by the Venous Clinical Severity Score (VCSS). However, three cohorts of female patients had improved VCSS when compared to males: those with BMI >40, deep reflux and C2 classification. Perioperative change of VCSS scores regarding ulceration (number, size, duration) were similar between genders. In PROs, women recorded a greater improvement in total symptom score.

There was also a lower total complication rate in these female patients, specifically in terms of endovenous heat-induced thrombosis (EHIT) and infection. This reinforces the results from a 2013 paper, which also observed a higher EHIT rate among men. ⁴ Unfortunately, the use of a retrospective registry excludes other objective measures of procedural failure and recurrence, such as post-operative ultrasound findings.

Conversely, a 2016 retrospective study demonstrated that men were significantly more satisfied post-operatively, although all varicose venous procedures were included in their study design. ⁵ Men felt more positive about procedural success with significance in rating ‘much better’ compared to ‘much worse’ via the EuroQol-5-domain (EQ-5D) questionnaire. Interestingly, individuals with high levels of anxiety and depression were more likely to respond with dissatisfaction. Women have a greater prevalence of depression and anxiety, which may provide an explanation to their findings. ⁶ Numerous studies have found female gender to be associated with worse PRO including anxiety and mood. ⁷

The 2014 REVATA trial investigated recurrent disease after thermal ablation in 164 patients. ⁸ In their population, 83% of those with recurrence were noted to be female, suggesting a gender discrepancy. However, it has been noted that women are more likely to present with SVR symptoms and to have a history of varicose vein treatment. ³ Moreover, a 2021 retrospective review identified male gender as a significant predictor of long-term failure of superficial vein occlusion after ablation. ⁹ The authors hypothesised that the reason behind this was larger vein diameters seen in males, but this was disproven. Unexpectedly, great saphenous veins larger than 7 mm in females were significantly associated with a higher incidence of long-term recanalisation. Future studies geared towards assessing vein diameter in the context of failure rates and patient gender are required to draw meaningful conclusions.

Given the high rates of recurrence and subsequent reintervention, researchers retrospectively looked at the predictive factors for successful redo-ablation in the small saphenous vein. ¹⁰ Patient gender was not significant at an average follow-up duration of 2 years. Redo procedures in other venous locations are yet to be studied according to gender.

In conclusion, the limited literature has highlighted key gender-specific differences in SVR intervention outcomes. Women generally reported better symptom improvement although were less satisfied post-operatively. They were also associated with lower complication rates. Discrepancies in recurrence rates of vein diameters between genders underscore the need for further studies to clarify predictive factors of long-term success and refine patient selection criteria. Personalised, gender-specific treatment approaches are essential to optimise QOL improvements. This requires clarification of gender differences in PRO disagreements, subgroup outcomes, failure and recurrence for all interventions. These conclusions may then have a greater bearing on clinician judgement. Communicating gender specific expectations of procedural results and complications to patients is essential. Future studies on SVR interventions should therefore report gender stratified data for subgroup analyses to support this approach.

There is also a notable lack of research primarily geared to detecting gender outcomes in SVR interventions. Addressing this would enhance understanding of observed differences, resulting in greater guideline granularity and potentially gender specific treatment options to improve patient outcomes.