Value and limitations of postoperative duplex scans after

endovenous thermal ablation

Pavel Kibrik, DO, Ali Basil Ali, MD, Jesse Chait, DO, Michael Arustamyan, DO, Hason Khan, BS,
Sarah Mazurovsky, MS, Ahmad Alsheekh, MD, Natalie Marks, MD, Anil Hingorani, MD, and
Enrico Ascher, MD, Brooklyn, NY

ABSTRACT
Background: Endovenous thermal ablation (EVTA) of the lower extremity veins has risen to become the main treatment
modality for symptomatic venous reflux disease. One of the main reported side effects of EVTA is recanalization. As of
today, there is no clear protocol as to when follow-up duplex ultrasound scans should be performed. However, the
standard for postoperative duplex after truncal ablation is within 1 week of the procedure. Our aim is to try to find
whether there is a particular time period when postoperative duplex ultrasound scans should be performed to allow us
to best diagnose recanalization.
Methods: We retrospectively analyzed 9799 procedures in 3237 patients with chronic venous insufficiency owing
to great, small, and anterior accessory saphenous vein insufficiency from 2012 to 2018. We excluded 466
perforator veins. All 9799 procedures were performed using EVTA in patients who failed to respond to conser-
vative management initially. Postoperative duplex ultrasound scans were performed within 1 week (3-7 days
postoperatively). We defined a successful obliteration as lack of color flow on postoperative scan. We defined
symptomatic recanalization as presence of reflux on duplex ultrasound examination in the targeted vessel at
follow-up with symptom recurrence. Follow-ups were performed every 3 months in the first year and every
6 months thereafter.
Results: Patient ages ranged from 15 to 99 years. The median patient age at the time of the procedures was 63 years
(interquartile range [IQR], 51-73 years). The median overall follow-up was 25 months (IQR, 4-56 months). The Clinical,
Etiology, Anatomy, and Pathophysiology (CEAP) class of all the procedures were: C1, 21; C2, 208; C3, 3585; C4, 4680; C5, 188;
and C6, 1117. There were 145 redo procedures performed after symptomatic recanalization was diagnosed in patients.
CEAP class of the redo patients were: C1, 0; C2, 2; C3, 49; C4, 70; C5, 5; and C6, 19.
Conclusions: Most patients underwent a redo procedure performed within the first year after the initial procedure.
Conversely, there was great variability as to when redo procedures were performed. Because there is no defined pattern
as to when these symptomatic occurrences arise, it may not be required to perform postoperative duplex ultrasound
scans after EVTA routinely, but instead when a patient comes back with symptoms such as swelling. (J Vasc Surg Venous
Lymphat Disord 2024;12:101672.)
keywords: Duplex ultrasound; Endothermal ablation; EVLA; RFA

Endovenous thermal ablation(EVTA) of the lower ex- and effectiveness of EVTA, it carries well-known risks of
tremity veins has emerged as the primary treatment mo- side effects, recanalization, and can pose a significant
dality for treating chronic venous insufficiency (CVI).1 problem for patients’ health outcomes.2 Recanalization
Radiofrequency ablation (RFA) and endovenous laser with EVTA and has been reported in #10% of the pa-
ablation (EVLA) have increased in usage volume by tients after 1 year.4-6 In these patients, recanalization
450-fold within the last decade.2,3 Despite the safety may be the result of the technique used (eg, EVLA or
RFA), device settings (eg, number of RF cycles, energy
delivered), and/or physician experience.7-9 Other factors
From the Vascular Institute of New York. may also play a role, such as clinical and duplex ultra-
Presented at the Thirty-second American Venous Forum Annual Meeting, Ame-
sound (DUS) findings and patient characteristics.2,10,11
lia Islands, Florida, March 3-6, 2020.
However, the effectiveness of an EVLA cannot be
Correspondence: Pavel Kibrik, DO, 960 50th St, Brooklyn, NY 11219 (e-mail:
pkibrik@gmail.com). measured based on the energy outcomes or wave-
The editors and reviewers of this article have no relevant financial relationships to lengths.12 The characteristics of a patient, including their
disclose per the Journal policy that requires reviewers to decline review of any ultrasound findings, may be mentioned as the cause of
manuscript for which they may have a conflict of interest.
recanalization.13
2213-333X
Kemalog  lu14 found that recanalization of the great
Copyright Ó 2023 The Author(s). Published by Elsevier Inc. on behalf of the So-
ciety for Vascular Surgery. This is an open access article under the CC BY-NC- saphenous vein (GSV) is the primary reason for the pres-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ence of recurrent postprocedural varicose veins. The
https://doi.org/10.1016/j.jvsv.2023.06.016 leading cause of recanalization, according to Kemalog  lu,

1
2 Kibrik et al Journal of Vascular Surgery: Venous and Lymphatic Disorders
January 2024

is the diameter of the GSV.14 The author explains that

GSVs >10 mm during both EVLA and RFA lead to recan- ARTICLE HIGHLIGHTS
alization and increases the risk of early recanalization.14 d
Type of Research: Single-center retrospective study
There is significant evidence in the literature regarding d
Key Findings: Ages ranged from 15 to 103 years. The
the causes of recanalization after an EVLA.13-16 However, mean patient age was 62.5 6 15.6 years. The mean
there is a lack of research on the use of follow-up DUS overall follow-up was 25.8 6 12.9 months. There
scans for early identification of recanalization. Therefore, were 143 redo procedures performed after diag-
the present study investigated the best period for per- nosing patients with symptomatic recanalization. A
forming postoperative DUS scans to enable early recana- significant finding was the lack of clustering on
lization diagnosis. It is hypothesized that, if the best when recanalization symptoms arise.
period for performing postoperative DUS scans is identi- d
Take Home Message: Most patients underwent a
fied, DUS examinations can be better targeted. redo procedure performed within the first year after
the initial procedure. Conversely, there was great
METHODS variability as to when redo procedures were per-
Approach. This retrospective study was conducted by
formed. Because there is no defined pattern as to
surveying data from an existing electronic database at
when these symptomatic occurrences arise, it may
a single-center outpatient clinic. The data were ob-
not be required to perform postoperative duplex ul-
tained from January 2012 to December 2018. A total of
trasound scans after endovenous thermal ablation
9799 procedures were undertaken during the time
routinely, but instead when a patient comes back
period and analyzed among 3237 patients who had been
with symptoms such as swelling.
diagnosed with CVI. The protocol for the collection and
interpretation of data conformed to the principles set by
the Declaration of Helsinki. The protocol was approved wavelength catheter (VenaCure EVLT NeverTouch Direct,
by the Institutional Review Board of Vascular Institute of Angiodynamics, Inc., Queensbury, NY) or the 7-cm Clo-
New York, and because the data are retrospective, low sureFast RFA catheter (Covidien, San Jose, CA) was
risk, and deidentified for analysis, informed consent was advanced to be certain the device will transverse the
waived. JMP, Version 14 (SAS Institute Inc., Cary, NC). was vein. For GSV and AASV, 6 watts of energy were used,
used for all statistical analyses. whereas 5 watts of energy was used for the SSV. The de-
INCLUSION AND EXCLUSION CRITERIA vice was then advanced further to a position 2.5 to 3.0 cm
The inclusion criteria used were that the patient should caudad to the origin of the vein for ablation of the AASV,
have been diagnosed with the CVI and that the proced- GSV, or SSV. Tumescent anesthesia was then injected cir-
ures were performed between January 2012 and cumferentially around the course of the vein, using ultra-
December 2018. All the assessed procedures included sound guidance. After initiation of the energy source, the
needed to have been performed using endovenous abla- tip was withdrawn at the recommended rate set by the
tion. The patients had to have failed $3 months of con- manufacturer. No adjunctive procedures (ie, ligation of
servative management, and the initial postoperative the saphenofemoral junction or phlebectomies) were
DUS scans were performed within 3 to 7 days. Patients performed in this study. For RFA procedures, the ceph-
continued to be followed throughout their outpatient alad segment of the vein was treated twice to ensure
care period. The exclusion criteria entailed patients diag- closure.
nosed with any other condition other than CVI, those
diagnosed with CVI in the perforator veins, and those POSTOPERATIVE FOLLOW-UP
diagnosed outside January 2012 to December 2018. Patients underwent postoperative DUS within 3 to 7
Also excluded were CVI diagnoses that were not treated days postoperatively, followed by every 3 months during
using endovenous ablation. the first year postoperatively and every 6 months after
that. The lack of color flow during the DUS indicated a
PROCEDURE successful EVTA, and recanalization was noted by the
EVTA of the anterior accessory saphenous vein (AASV), presence of reflux in the targeted vessel during the
GSV, and small saphenous vein (SSV) was performed us- scan. Reflux in the tributaries or perforator veins were
ing either EVLA or RFA. The steps to perform venous not considered as recanalization after the procedure.
ablation using either EVLA or RFA were similar. At the
beginning of the procedure, the extremity was draped RESULTS
in sterile fashion, with the leg positioned to allow target A total of 9799 procedures were included in the study.
vein access. Under direct vision using ultrasound guid- The number of patients that were assessed who had
ance with local anesthesia, the vein was punctured, been diagnosed with CVI was 3237. Patient-related base-
and the 0.021-inch micropuncture wire was advanced. line characteristics for the procedures can be seen in
Either the 600-micron fiber with a 1470-nanometer Table I. The patients included in the study were between
Journal of Vascular Surgery: Venous and Lymphatic Disorders Kibrik et al 3
Volume 12, Number 1

Table I. Baseline characteristics: presented according to procedures performed

Characteristics <80 Years old 80-89 Years old 90-99 Years old
Variablesa
1.Male 2885 376 51
2.Female 5636 732 119
3.Right leg 4157 550 83
4.Left leg 4364 558 87
Vein treated
5. GSV 5904 743 125
6. SSV 2241 313 39
7. ASV 376 52 6
CEAP classificationb
8. CEAP-1 21 0 0
9. CEAP-2 200 4 4
10. CEAP-3 3273 279 33
11. CEAP-4 4045 561 74
12. CEAP-5 141 35 12
13. CEAP-6 841 229 47
Total No. of veins treated 8521 1108 170
Median follow-up in months (IQR) 27(5-57) 15 (3- 42) 9 (1.25-25.8)
Recanalization (No. of veins) 115 25 5
ASV, Accessory saphenous vein; CEAP, Clinical, Etiology, Anatomy, and Pathophysiology; GSV, great saphenous vein; SSV, small saphenous vein; IQR,
interquartile range.
a
All numbers for 1-7 refer to number of procedures.
b
All numbers for 8-13 refer to number of procedures.

3500

3000

2500

2000 Vein
ASV
GSV

1500 SSV

1000

500

Left Right
Laterality
Fig 1. Laterality with vein. ASV, accessory saphenous vein; GSV, great saphenous vein; SSV, small saphenous vein.
4 Kibrik et al Journal of Vascular Surgery: Venous and Lymphatic Disorders
January 2024

100%

75%

Laterliaty
50% L
R

25%

0%

No Yes
Recanalization
Fig 2. Laterality by recanalization.

the ages of 15 and 99 years. The median patient age at DISCUSSION

the time of the procedures was 63 years (interquartile EVTA has been established as a safe and effective pro-
range [IQR], 51-73 years). The Clinical, Etiology, Anatomy, cedure for the treatment of CVI. The main advantages
and Pathophysiology (CEAP) class of all the procedures include fewer complications, quicker recovery, and
were counted individually and were: C1, 21; C2, 208; C3, improvement in the quality of life compared with con-
3585; C4, 4680; C5, 188; and C6, 1117. In our cohort, the ventional surgery.7 Nonetheless, it is not yet clear what
veins that were operated on were 434 AASVs, 6772 the defined prognostic factors for EVTA success in a pa-
GSVs, and 2593 SSVs. The left leg was operated on in tient and when alternate procedures such stripping/
5009 procedures and the right leg in 4790 procedures. ultrasound-guided foam sclerotherapy and high ligation
Fig 1 depicts the distribution of veins according to lateral- are to be considered the treatment of choice.
ity in the whole cohort. With the increased use of EVTA, the risk of recanaliza-
Symptomatic recanalization was diagnosed and tion has risen.2,13 Van der Velden et al13 mentioned that
treated in 145 veins as a redo procedure. CEAP class of recanalization in the GSV had been reported to occur
the redo veins were: C1, 0; C2, 2; C3, 49; C4, 70; C5, 5; in 10% of patients. In the present study, a total of 145
and C6, 19. Of the 145 redo procedures, 68 were per- redo procedures owing to recanalization were observed.
formed on the left leg, and 77 were performed on the The present study’s findings indicate a high success rate
right leg. Fig 2 shows the laterality distribution by recan- of identifying recanalization using postoperative DUS ex-
alization. Redo procedure were done on 8 AASVs, 101 aminations. Our results are similar to previous data.17 The
GSVs, and 36 SSVs. Fig 3 depicts the distribution of veins authors mentioned that DUS examinations can be used
in the recanalized and nonrecanalized groups. The time- to diagnose venous disease during the postoperative
line from the initial procedure to the redo procedure is follow-up period accurately.17 The study’s findings,
presented in Table II. however, differed from the findings from Karam et al.15
Journal of Vascular Surgery: Venous and Lymphatic Disorders Kibrik et al 5
Volume 12, Number 1

100%

75%

Vein
ASV
50%
GSV
SSV

25%

0%

No Yes
Recanalization
Fig 3. Veins by recanalization. ASV, accessory saphenous vein; GSV, great saphenous vein; SSV, small saphenous
vein.

In their work, Karam et al found that using ultrasounds to bias may have been present, because patients chosen
diagnose recanalization could not yield significant find- for the procedures were treated at the discretion of the
ings.15 In their study, they noted that only 5% of recanali- interventionalists; the patients chosen had severe symp-
zation cases were noted using ultrasound examinations, toms and were high functioning. This study lacks the
whereas neovascularization was noted in 7.9% of the pa- numbers of asymptomatic recanalized patients and ul-
tients and reflux in the groin collateral were 23.5%.15 The trasound findings for those patients. However, the inci-
present study included 14 patients who underwent dence of asymptomatic patients from previous years
recanalization between 0 and 3 months postoperatively. was presented in our past work.18 Further studies are
Recurrences of recanalization were noted to have needed to address the outcome of the asymptomatic
occurred more during the first 25 weeks after an EVLA, patients in the long term.
at 19%, whereas 29% occurred past 25 weeks.16 Müller We do not have the Venous Clinical Severity Scores
and Alm16 reported a similar finding with the present retrospectively, although we are currently collecting
study; the present study indicated that 18.8% of recanali- them for all new patients. Further, this dataset did not
zation occurred within the first 6 months. Therefore, include patient-reported outcomes. Given that we do
further research is needed to identify how postoperative not perform weekly DUS examination and given our pa-
DUS scans may be used to identify recanalization earlier, tient population and that not all patients return for
more accurately, and more effectively. check-ups as scheduled, we may not have the granu-
Limitations of the study include those associated with a larity to identify most accurately when the recanalization
single-center retrospective analysis, performed by three first occurred. This factor may change the timeline from
interventionalists following a standardized preoperative, when the recanalization first occurred to when it
intraoperative, and postoperative protocol. Selection resolved, slightly.
6 Kibrik et al Journal of Vascular Surgery: Venous and Lymphatic Disorders
January 2024

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AUTHOR CONTRIBUTIONS recanalization after endothermal ablation of incompetent great
saphenous vein. Vascular 2019;27:1-5.
Conception and design: PK, NM, AH, EA 15. Karam B, Haddad F, Ataya K, Jaafar R, Nassar H. Long-term results of
Analysis and interpretation: PK, AAli, Aals Endovenous laser therapy (EVLT) of saphenous vein reflux: up to 9
Data collection: PK, AAli, JC, MA, HK, SM years follow-up. Eur J Vasc Endovasc Surg 2019;58:e766.
16. Müller L, Alm J. Feasibility and technique of endovenous laser abla-
Writing the article: PK, AAli tion (EVLA) of recurrent varicose veins deriving from the sapheno-
Critical revision of the article: PK, AAli, JC, MA, HK, SM, femoral junctionda case series of 35 consecutive procedures. PLoS
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Statistical analysis: PK, AAli, HK 18. Aurshina A, Ascher E, Mount L, Hingorani A, Marks N, Hingorani A.
Success rate and factors predictive of redo radiofrequency ablation
Obtained funding: Not applicable of perforator veins. J Vasc Surg: Venous and Lymphatic Disorders
Overall responsibility: PK 2018;6:621-5.
KK and AA contributed equally to this article and share
co-first authorship.
Submitted Mar 29, 2021; accepted Jun 29, 2023.

DISCLOSURES The CME exam for this article can be accessed at http://
None. www.jvsvenous.org/cme/home.