Comparison of ultrasound-guided endovenous laser ablation and radiofrequency for the varicose veins treatment: An updated meta-analysis

Radiofrequency ablation for the treatment of great saphenous venous insufficiency using a newly developed VENISTAR catheter: A preliminary study

OBJECTIVES

This study was aimed to assess the preliminary outcomes of radiofrequency ablation (RFA) using a newly developed catheter (VENISTAR) for the treatment of incompetent great saphenous veins (GSVs).

METHODS

In this prospective observational study, endovenous RFA using a VENISTAR catheter was performed on 16 saphenous veins in 12 patients between August and November 2019. Patients' pre- and post-procedural data were recorded. Doppler ultrasound imaging and clinical evaluation were performed at 1 week and 1, 3, and 6 months to determine the efficacy and safety of the treatment.

RESULTS

Technical success and complete closure of the targeted GSVs immediately after the procedure were observed in all 16 limbs (100%). However, one patient (one limb) was found to have partial occlusion without significant reflux after 1 week of follow-up. Kaplan-Meier analysis yielded a complete occlusion rate of 93% at 6 months of follow-up. The Venous Clinical Severity Scores at the time of all follow-up were significantly lower than those at baseline (3.3 ± 1.1 at baseline to 0.6 ± 0.6, 0.3 ± 0.6, 0.1 ± 0.4, and 0.2 ± 0.4 at 1 week and 1, 3, and 6 months, respectively) (p < .001). Mild post-procedural pain was noted in 7 and 4 limbs at 1 week and 1 month, respectively. Grade 1 ecchymosis over the ablated segment was noted in 5 (35.7%) of 14 limbs at 1-week follow-up.

CONCLUSIONS

Endovenous treatment of GSV insufficiency using a new VENISTAR radiofrequency catheter has been shown to be feasible, effective, and safe throughout the 6-month follow-up.

Endovenous radiofrequency ablation vs laser ablation in patients with lower extremity varicose veins: A meta-analysis

BACKGROUND

Endovenous radiofrequency ablation (RFA) and laser ablation (LA) have been commonly used for treating lower extremity varicose veins (LEVVs). Their therapeutic effects have been widely recognized compared with conventional surgery. However, there have been some controversies regarding the choice between RFA and LA. The objective of our study was to conduct a systematic review and meta-analysis comparing the early and long-term outcomes of RFA and LA.

METHODS

A comprehensive search was performed in the PubMed, Embase, and Cochrane databases to identify relevant literature on endovenous thermal ablation for primary LEVV up until June 2023. Randomized controlled trials, cohort studies, and case-control studies involving RFA and LA for LEVV treatment were included. The primary endpoints were the occlusion rate of the great saphenous vein (GSV) and occurrence of venous thrombotic events. Secondary outcomes included nerve injury, hyperpigmentation, burns, recurrence of VVs, postoperative pain, and phlebitis. Data were analyzed using Review Manager 5.3 software.

RESULTS

A total of 29 studies met the inclusion criteria, consisting of 16 randomized controlled trials and 13 cohort studies. At 1 month, the occlusion rates of GSV were 98.35% for RFA and 98.04% for LA, whereas at 1 year, the rates were 93.13% for RFA and 94.18% for LA. Subgroup analyses revealed that RFA had higher GSV occlusion rates at 1 year since 2016 (93.27% vs 91.24%; odds ratio [OR], 1.35; 95% confidence interval [CI], 1.0-1.83; P = .05). The incidence of postoperative venous thrombotic events was 0.78% for RFA and 0.87% for LA at 1 month (OR, 1.46; 95% CI, 0.77-2.74; P = .24). RFA showed a reduced risk of burns and ecchymosis (OR, 0.65; 95% CI, 0.48-0.87; P = .005), postprocedural pain (mean difference, -0.85; 95% CI, -1.06 to -0.64; P < .001), recurrence of VVs (OR, 0.58; 95% CI, 0.36-0.92; P = .02), and paresthesia since 2016 (OR, 0.42; 95% CI, 0.19-0.91; P = .03), but an increased risk of skin pigmentation (OR, 1.75; 95% CI, 1.06-2.9; P = .03) compared with LA therapy. The rate of phlebitis was similar between RFA and LA (OR, 0.87; 95% CI, 0.33-2.27; P = .78).

CONCLUSIONS

RFA and LA demonstrated similar efficacy in terms of early and long-term occlusion rates of GSV and the incidence of thrombotic and phlebitis complications. However, since 2016, RFA has shown higher GSV occlusion rates compared with LA. Furthermore, RFA was associated with fewer complications such as paresthesia, burns and ecchymosis, and recurrence of VVs when compared with LA.

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Strategies and challenges in treatment of varicose veins and venous insufficiency

Patients with varicose veins can be treated with conservative or surgical approaches based on the clinical conditions and patient preferences. In the recent decade, the recommendations for managing symptomatic varicose veins have changed dramatically due to the rise of minimally invasive endovascular techniques. The literature was systematically searched on Medline without language restrictions. All papers on the treatment of varicose veins and venous insufficiency with different procedures were included and reviewed. Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) both are same safe and effective in terms of occlusion rate, and time to return to normal activity. In comparison with RFA or EVLT, Cure conservatrice et Hemodynamique de l'Insufficience Veineuse en Ambulatoire (CHIVA) may cause more bruising and make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury, or hematoma. In terms of recurrence of varicose veins, there is little or no difference between CHIVA and stripping, RFA, or EVLT. Great saphenous vein recanalization is highest in the ultrasound-guided foam sclerotherapy (FS) group (51%) during 1 year of follow-up. The 2013 National Institute for Health and Care Excellence clinical guidelines recommend surgery as a third-line therapeutic option after EVLA or RFA and sclerotherapy. Although the mechanochemical endovenous ablation (MOCA) is a non-thermal, non-tumescent option and appears to be of similar efficacy to stab avulsion with no potential risk of nerve damage, the overall success rate of MOCA is lower than those of other procedures such as EVLA, RFA, or high ligation and stripping. EVLA is the most cost-effective therapeutic option, with RFA being a close second for the treatment of patients with varicose veins. Endovenous thermal ablation (EVLA or RFA) is recommended as a first-line treatment for varicose veins and has substituted the high ligation of saphenofemoral junctional reflux and stripping of varicose veins. Ultrasound-guided FS is associated with a high recurrence rate and can be used in conjunction with other procedures. MOCA and cyanoacrylate embolization appear promising, but evidence of their effectiveness is required.

Comparing the Success Rate and Side Effects of Endovenous Laser Ablation and Radiofrequency Ablation to Treat Varicose Veins in the Lower Limbs: A Randomized Clinical Trial

Introduction: Varicosis is a condition affecting the superficial venous system of the lower limbs. Endovenous laser ablation (EVLA) is a minimally invasive method that uses different frequencies of laser for treatment. Radiofrequency (RF) has also been effectively used for vein ablation through thermal mechanisms. This study compares the success rate and side effects of EVLA and RF to treat varicose veins in the lower limbs within 12 months. Methods: In this two-arm, parallel-group, randomized controlled, single-blind study, 1090 patients with lower limb varicosis proven by Doppler ultrasonography (DUS) were randomly placed into one of the two groups: EVLA and RF ablation. In the EVLA group, we used a 980-nm diode laser in a pulse mode and in the RF group, a 7-cm ClosureFast (Covidien, USA) catheter with an RF generator. We assessed pain during the operation and 8 and 24 hours after the surgery by the numerical rating scale (NRS). The patients were followed up on day 7, then 3, 6, and 12 months postoperatively. The presence or absence of pain and then the severity of pain (according to NRS), the recurrence rate, complications, and the length of the procedure were compared. Results: There was no significant difference between the two groups in the patients' characteristics, major adverse events and pain severity during the procedure and 8 and 24 hours after the surgery. According to NRS, the mean chronic pain severity in the EVLA group was 3.99± 0.754 versus 4.50± 0.657 in the RF group, and the difference was not significant. The length of operation and the recurrence rate 12 months after the procedure were not significantly different. Conclusion: The results of our study further establish the efficacy of EVLT and RF ablation for lower limb varicosis treatment without any significant difference in the clinical outcomes and complications during a 12-months follow-up.

Anterior accessory saphenous vein confluence anatomy at the sapheno-femoral junction as risk factor for varicose veins recurrence after great saphenous vein radiofrequency thermal ablation

BACKGROUND

Varicose veins recurrence rate remained almost unchanged despite the constant technological advancement in its treatment. The aim of this study is to evaluate the variable accessory saphenous vein (ASV) anatomy at the sapheno-femoral junction (SFJ) as a possible risk factor for recurrent varicose vein (RVV) after great saphenous vein (GSV) radiofrequency thermal ablation (RTA).

METHODS

Two-hundred consecutive patients affected by chronic venous disease (mean age 52.4±10.3 years; 187 women; CEAP C2-C6; 25.2±1.4), underwent to RTA from 2014 to 2016, at our Institute. Preoperatively all patients underwent duplex-ultrasound scanning, reporting the anatomical site, extension of reflux and the ASV anatomy at the SFJ. Duplex ultrasound and physical examination was performed postoperatively at 1, 6 and 12 months, and yearly thereafter.

RESULTS

Patients were divided in two groups based on the anatomical site of reflux: group A (N.=187) including GSV and SFJ, group B (N.=82) including SFJ reflux. There was no preoperative statistical difference between the two groups. At a mean follow-up of 29.7±2.4 months, a freedom from recurrent varicose vein and GSV recanalization was: 100% and 100% at 1 month, 95.9% and 99.1% at 1 year, 93.7% and 96.7% at 3 years, respectively. A higher rate of RVV was documented for patients in group A at 3-year of follow-up (P=0.042). Cox regression analysis found, among five potential predictors of outcome, that direct confluence of ASV in SFJ (HR=1.561; 95% CI: 1.0-7.04; P=0.032) was a negative predictors of 1-year RVV.

CONCLUSIONS

Sapheno-femoral junction morphology may affect recurrent varicose veins formation. In particular, a concomitant incompetence of the accessory saphenous vein or its directly confluence into the SFJ could represent an indication to simultaneous treatment by non-surgical techniques (RTA or laser) and avoid surgical ligation.

Efficacy of Endovenous Laser Treatment Combined with Sclerosing Foam in Treating Varicose Veins of the Lower Extremities

INTRODUCTION

This study aims to investigate the efficacy of incision-free endovenous laser treatment (EVLT) combined with sclerosing foam in treating varicose veins of the lower extremities.

METHODS

A total of 140 patients (186 limbs) who underwent laser closure of the great saphenous vein + injection sclerotherapy were included in the present study. Preoperative information, intraoperative conditions, duration of the operation, and length of hospital stay were recorded in detail. During the 6-month follow-up, the closure of the trunk and branches of the great saphenous vein, postoperative pain, the recovery of ulcer and dermatitis, and postoperative complications were traced.

RESULTS

All patients were treated with laser closure of the great saphenous vein and lauromacrogol injection. Twenty-six stage C6 limbs (lower extremity with ulcer) healed within 6 months, and the postoperative subjective pain disappeared after 1 month. In six patients, pigmentation in the surgical site did not completely disappear at 6 months after the operation. Saphenous nerve injury was found in five patients within 3 months after the operation, and all healed at 6 months after the operation.

CONCLUSION

EVLT combined with sclerosing foam is effective for treating varicose great saphenous veins.

TRIAL REGISTRATION

This study was registered at http://www.chictr.org.cn (registration number: ChiCTR1900021409).

European College of Phlebology guideline for truncal ablation

Background

The purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence.

Method

A systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded.

Results

For the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results.

Conclusion

For the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.

Therapies of varicose veins: Protocol for the reporting and methodological quality of pairwise meta-analyses

BACKGROUND

Many pairwise meta-analyses (MAs) related to therapies of varicose veins have been published, but their reporting and methodological quality remain unclear. The present study was designed to assess the overall quality of pairwise MAs related to therapies of varicose veins.

METHODS

We will systematically search 4 electronic databases, including PubMed, EMBASE, Cochrane Library, Chinese Biomedical Database, to identify pairwise MAs related to therapies of varicose veins. The search time-span was set from inception to March 2019. The pairwise MAs related to therapies of varicose veins will be included in our overview. The reporting and methodological quality of included MAs will be assessed using preferred reporting items for systematic review and meta-analysis and a measurement tool to assess systematic reviews 2, respectively. Meanwhile, we will extract some general characteristics of included MAs, including first author; published year, journal, sample size, number of studies, number of randomized controlled trials and intervention details, and so on. All literatures screening, quality assessment, and data extraction will be independently completed by 2 of all reviewers, and any disagreement will be resolved by discussion. Besides, an increasingly popular method - evidence mapping, will be used to present the whole evidence landscape related to therapies of varicose veins. The assessment results will be presented as percentage and event/total. The Excel 2016 will be used to manage and analyze data.

RESULTS

The results of the overview will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This overview will summarize the overall reporting and methodological quality related to therapies of varicose veins.

PROSPERO REGISTRATION NUMBER

CRD42019126722.

Optimal duration of compression stocking therapy following endovenous thermal ablation for great saphenous vein insufficiency: A meta-analysis

BACKGROUND

The need for patients to wear compression stockings after varicose vein surgery and the duration of compressions tocking therapy has been debated. This study isa meta-analysis of randomized controlled trials (RCTs) to determine the optimal duration of compression stocking therapy after endovenous thermal ablation (ETA) of the great saphenous vein.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched before January 2019. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate the pooled effect size by using a random effects model. The primary outcome was the severity of pain in the postoperative period. Secondary outcomes were quality of life (QoL), leg volume, bruising scores, consumptionof analgesic agents, recovery time off work, satisfaction, and the incidence rates of postoperative complications including paresthesia and phlebitis.

RESULTS

Five RCTsinvolving775 patients were reviewed. The long-duration (1-2 weeks) group significantly reduced postoperative pain at 1 week (mean difference [MD] 1.19; 95% confidence interval [CI]: 0.58-1.80) and recovery time off work (MD: 1.01 day, 95% CI: 0.06-1.96)when compared with the short-duration (24-48 h) group. However, the mean pain scores at 2 (0.1; 95% CI: 0-0.2) and 6 weeks postoperatively (-0.3; 95% CI: -1.09-0.49) did not differ significantly between the two groups. Moreover, the incidence rates of complication, paresthesia, and phlebitis did not differ significantly between the short-duration and long-duration groups.

CONCLUSION

The use of compression therapy for a long time (1-2 weeks) is better than short-term (24-48 h) use in terms of postoperative pain at 1 week and recovery off work. Hence, we recommend the prescription of 1-week compression stocking therapy after ETA in routine clinical practice. However, the available evidence is of variable quality, further well-structured RCTs with improved standardization of compression treatment, types of stockings, and target populations are warranted.

Saphenous vein diameter is a single risk factor for early recanalization after endothermal ablation of incompetent great saphenous vein

Background and aim

The aim of this study was to compare endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) techniques for efficacy and side effects for great saphenous vein (GSV) ablation.

Materials and methods

Two hundred twenty-one patients and 287 extremities that underwent GSV ablation with EVLA and RFA methods were analysed retrospectively; 135 GSVs were treated with EVLA, 152 GSVs were treated with RFA. Physical examination and Ultrasound (US) records at the first week, first month and third month were evaluated. Recanalization, endothermal heat-induced thrombosis formation, presence of ecchymosis greater than 10 cm and GSV diameter parameters were statistically analyzed.

Results

In the RFA group, 96.7% of the GSVs that were ablated were occluded at the end of the third month. In the EVLA group, this rate was 92.6%. There was no statistically significant difference between success of ablation ( P = 0.118). In the RFA group, ecchymotic areas, that is larger than 10 cm diameter were observed in 16 extremities, whereas in the EVLA group, 66 of 135 (48.9%) limbs were found to have ecchymotic area larger than 10 cm ( P < 0.001). More recanalizations were observed in GSVs larger than 10 mm in diameter which was statistically significant ( P < 0.001).

Conclusion

Both EVLA and RFA methods are effective in treating GSV reflux. Compared to the EVLA, less ecchymosis occurs after RFA procedures. Regardless of the type of method used, the GSV diameter is a single predictor of recanalization.

Chronic venous insufficiency and varicose veins of the lower extremities

Chronic venous insufficiency (CVI) of the lower extremities manifests itself in various clinical spectrums, ranging from asymptomatic but cosmetic problems to severe symptoms, such as venous ulcer. CVI is a relatively common medical problem but is often overlooked by healthcare providers because of an underappreciation of the magnitude and impact of the problem, as well as incomplete recognition of the various presenting manifestations of primary and secondary venous disorders. The prevalence of CVI in South Korea is expected to increase, given the possible underdiagnoses of CVI, the increase in obesity and an aging population. This article reviews the pathophysiology of CVI of the lower extremities and highlights the role of duplex ultrasound in its diagnosis and radiofrequency ablation, and iliac vein stenting in its management.

Comparison of endovenous laser treatment and high ligation in treatment of limb varicosity: A meta-analysis

To assess the efficacy and safety of endovenous laser treatment (EVLT) and high ligation (HL) for limb varicosity using meta-analysis. Multiple databases including PubMed, Springer, Excerpta Medica Database, Ovid Technologies, and China Journal Full-text database were searched for relevant studies in English or Chinese, and full-text articles were used to compare EVLT and HL for limb varicosity. Review Manager 5.0 was used to estimate the effects of the results among eligible articles. Forest plots, sensitivity analysis, and bias analysis of the included articles were also conducted. Initial screening yielded 1031 studies, 11 randomised controlled trials involving 1145 limb varicosity patients met the inclusion criteria in this study. The results of the heterogeneity test suggested that intraoperative blood loss mean difference (MD) = -6.31[-9.03, -3.60], P < 0.00001), operative time (MD) = -39.76[-42.27, -37.24], P < 0.00001), rate of complications (odds ratio [OR] = 0.37[0.22, 0.61], P < 0.0001), and recurrence (OR = 0.28[0.16, 0.49], P < 0.0001) were significantly different. Although both EVLT and HL have their own merits and demerits, EVLT is a more effective and safe method to treat limb varicosity.

Evidence for varicose vein treatment: an overview of systematic reviews

BACKGROUND

Varicose veins affect nearly 30% of the world's population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs. Since there are cosmetic implications, treatments for which effectiveness remains unproven present risks to consumers and higher costs for stakeholders. These risks and costs justify conducting an overview of systematic reviews to summarize the evidence.

DESIGN AND SETTING

Overview of systematic reviews within the Discipline of Evidence-Based Health, at Universidade Federal de São Paulo (UNIFESP).

METHODS

Systematic reviews on clinical or surgical treatments for varicose veins were included, with no restrictions on language or publication date.

RESULTS

51 reviews fulfilled the inclusion criteria. Outcomes and comparators were described, and a narrative review was conducted. Overall, there was no evidence that compression stockings should be recommended for patients as the initial treatment or after surgical interventions. There was low to moderate evidence that minimally invasive therapies (endovenous laser therapy, radiofrequency ablation or foam sclerotherapy) are as safe and effective as conventional surgery (ligation and stripping). Among these systematic reviews, only 18 were judged to present high quality.

CONCLUSIONS

There was evidence of low to moderate quality that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency therapy are comparable to conventional surgery, regarding effectiveness and safety for treatment of varicose veins.

The effect of commercial insurance policies on outcomes of venous ablation

OBJECTIVE

The use of venous ablation (VA) for treatment of chronic venous insufficiency has exponentially increased. To limit cost and overuse, insurance companies have adopted aleatory policies. The goal of this study was to compare the policies of five major local insurance carriers and to determine whether treatment within the criteria of a certain policy is associated with improved patient outcomes.

METHODS

A retrospective single-center review of patients treated with VA was performed. Demographics, comorbidities, symptoms, and clinical class (Clinical, Etiology, Anatomy, and Pathophysiology classification) were recorded. Clinical success was defined on chart review by the patients' reporting of improvement or resolution of symptoms in the leg treated on follow-up, and technical success was defined by vein closure on ultrasound. Patients underwent a telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment of each leg as well as effects on quality of life (QOL). The policies of Aetna, Cigna, Anthem Blue Cross Blue Shield, UnitedHealthcare, and Connecticut Care were reviewed. The clinical and technical success rates were compared when veins were treated within the criteria of each policy. A subgroup analysis looking at patients who had clinical success only was performed to determine the potential rate of denial of coverage for each policy. A multivariable analysis was performed to determine independent predictors of clinical success.

RESULTS

There were 253 patients with 341 legs treated. The mean age was 58.5 ± 15.2 years (68% women). The most common symptom was pain (89.7%), with 47.8% of patients having C3 disease. The clinical success, technical success, and complication rates were 84.2%, 95.1%, and 5.6%, respectively. On survey, there was improvement of the numeric rating scale score in 84.3% of legs treated after the procedure, and 76.7% continued to experience improvement after a mean follow-up of 26.8 months. There was improvement of QOL in 76.5% of patients. There was no significant difference in procedural success, technical success, complication rate, or improvement in QOL when patients were treated within any of the five insurance policies. On multivariable analysis, there was no single policy significantly associated with clinical success. However, subgroup analysis of procedures with clinical success (n = 287) showed a significant difference between the five policies on analysis of the potential denial of coverage, ranging from 5.6% for Connecticut Care to 64.1% for UnitedHealthcare (P < .0001).

CONCLUSIONS

The different insurance policies have no correlation with outcomes of VA. Policies with more stringent criteria typically restrict treatment to larger veins and deny procedures to a significant number of patients with chronic venous insufficiency who can benefit from them.