Does ablation of non-incompetent veins in the leg reduce recurrence?

Treatment of the below knee GSV

Below-knee reflux post initial treatment is a recognised cause of recurrence of symptoms, even in patients who initially present with a normal below-knee GSV. ³

Several studies have shown the technical feasibility of below-knee treatment in patients with reflux in the below-knee GSV, ⁵ and current practice is to treat this entire refluxing segment of the GSV, which may extend to mid-calf.

The REVATA study followed 2380 patients following thermal ablation and assessed patients for recurrence. ¹ New insufficiency in unablated portions of the GSV accounted for 14% of all recurrences, leading the authors to suggest all thermal ablations should begin at the midcalf. Considering the technical feasibility and safety of below-knee treatment, the possible benefits of treating the below-knee GSV warrant further investigation, as this may reduce symptom recurrence and reintervention rates.

However, a potential twist in the argument ‘for’ is work by Gifford et al who estimated 91% of below knee GSV incompetence at their centre was in fact asymptomatic.

Treatment of the anterior saphenous vein (ASV)

After reflux in the GSV and small saphenous vein, the next most common source of reflux is the Anterior Saphenous Vein (ASV). Reflux in the ASV also accounts for a third of patients presenting with recurrent varices after surgery, ² raising the possibility that prophylactic treatment of the ASV may reduce reintervention rates. This is also queried by most recent AVLS guidance, which emphasises the need for further research in the area. ⁴

Muller et al performed prophylactic treatment of the ASV and other ascending tributaries of the GSV on 213 patients, showing the feasibility of the procedure: the primary outcome, rate of technical success was 99.6%. ⁶

Flush ligation

A number of studies have tried to prevent subsequent reflux in the ASV by flush occlusion of the GSV at the saphenofemoral junction (fEVLA).^6–8 This has coincided with the widespread adoption of radial endovenous laser fibres, which were used by all papers referenced in this article. Radial fibres allow occlusion of the GSV much closer to the saphenofemoral junction (SFJ) than bare tip fibres, without causing intimal damage to the SFJ itself, allowing fEVLA to be performed safely. Spinedi et al performed a single centre retrospective analysis of 135 fEVLA procedures. ⁷ The procedure was technically feasible in the vast majority of cases. Similarly, a prospective randomised study by Rits et al showed fEVLA was superior in reducing incidence of reflux in the GSV stump, and patients who underwent fEVLA had a lower incidence of recurrence of varicosities. ⁸ A recent systematic review and meta-analysis has also found fEVLA superior in reducing groin recurrence, and a trend favouring fEVLA in reducing the rate of ASV reflux post treatment. ⁹

Interestingly, although fEVLA is shown to be technically feasible, only Rits et al measured Venous Clinical Severity Score or quality of life, both of which showed no significant difference between patients who had fEVLA and those who did not at 900 days. ⁸

The SYNCHRONOUS study is an ongoing prospective multicentre study of 1150 patients assessing the impact of concurrent prophylactic treatment of the ASV alongside the refluxing GSV, and whether this reduces recurrence. One-year and three-year interim results have shown concomitant prophylactic treatment of the ASV is superior in reducing recurrence rates. ¹⁰ It is yet to be seen whether these results continue in the long term, and their effect on patient symptoms.

Treatment of a normal vein is not without risk. However, concurrent treatment of initially normal veins which carry the propensity to reflux and cause recurrence of symptoms in future may subject the patient to increase risk of complications. While treatment of normal segments of the below knee GSV and ASV may reduce recurrence, more evidence is required before widespread adoption of this as standard practice.