Incidence and Significance of Deep Venous Reflux in Patients Treated with Saphenous Vein Ablation

BACKGROUND

Venous ablation (VA) of the saphenous vein is the most common procedure performed for venous insufficiency. The incidence of concomitant deep venous reflux (DVR) in patients undergoing VA is unknown. Our hypothesis is that patients undergoing saphenous VA with concomitant DVR exhibit a higher clinical, etiology, anatomy, and pathophysiology (CEAP) stage and less relief after VA compared to patients without DVR.

METHODS

Electronic medical records of patients treated with saphenous VA at a tertiary care center from March 2012 to June 2016 were reviewed. Patients were divided into 2 groups based on presence or absence of DVR on initial ultrasound (US) before saphenous VA. Patient characteristics and outcomes were compared. A telephone survey was conducted to assess long-term symptomatic relief, compliance with compression, and pain medication use. Subgroup analysis of patients with post-thrombotic versus primary DVR was performed.

RESULTS

362 patients underwent 497 ablations, and the incidence of DVR (>1 sec) was 20% (N = 71). Patients with DVR were significantly more likely to be male (46.4% vs. 32.1%, P = 0.021) and of Black race (21.2% vs. 5.5%, P = 0.0001) compared to patients without DVR. Patients with DVR were more likely to have a history of deep vein thrombosis (DVT) (15.1% vs. 7.9%, P = 0.045), but there was no difference in other comorbidities. There was no significant difference in presenting symptoms, CEAP stage, or symptom severity based on numeric rating scale (NRS) (0-10) for pain and swelling. Clinical success of saphenous VA was comparable between the 2 groups, but patients with DVR were more likely to develop endovenous heat-induced thrombosis (EHIT) II-IV (6% vs. 1%, P = 0.002). After a mean follow-up of 26 months, there was still no difference in pain or swelling scores, but patients with DVR were more likely to use compression stockings and used them more frequently. Only 11 of 71 patients with DVR had a history of DVT. Patients with post-thrombotic DVR were significantly older than patients with primary DVR (67.3 vs. 57.2, P = 0.038) and exhibited a trend toward more advanced venous disease (C4-C6: 45.4% vs. 33.3%, P = 0.439).

CONCLUSIONS

In this study, 20% of patients undergoing saphenous VA demonstrated DVR, which was more common in Black men. Presence of DVR is associated with increased risk of EHIT after saphenous VA but does not seem to impact disease severity or clinical relief after ablation. Larger studies are needed to understand outcome differences between post-thrombotic and primary DVR.

Human trial using the novel bioprosthetic VenoValve in patients with chronic venous insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) is a disease characterized by failure of the venous valves that allow blood from the lower limbs to return to the heart. The more severe types of CVI (C4b-C6 disease) significantly influence patients' quality of life (QOL). The treatment options for CVI of the deep system are limited. The present study is the first-in-human study using a prosthetic venous valve, VenoValve, to initially evaluate patient outcomes. We evaluated the feasibility, initial safety, and performance outcomes of the VenoValve.

METHODS

Ten patients with C5-C6 CVI of the deep venous system secondary to postthrombotic syndrome had had a VenoValve surgically implanted into the femoral vein in Bogota, Colombia, under approval of the local ethics committee and Colombian National Food and Drug Surveillance Institute, national health care regulatory body, or the Colombian National Food and Drug Surveillance Agency. Follow-up examinations were conducted postoperatively at 2 and 14 days and then every 30 days for 6 months. The results of the assessments for adverse events, reflux time, disease severity (venous clinical severity scores), pain scores (visual analog scale), and QOL (VEINES-QOL/Sym [venous insufficiency epidemiological and economic study-QOL/symptoms] questionnaire) were documented.

RESULTS

Ten patients underwent successful implantation of the VenoValve into the femoral vein as outpatients (100% technical success rate). Of the 10 patients, 9 had undergone VenoValve placement under regional anesthesia and 1 under local anesthesia. Six patients had required bovine patch angioplasty of the vein. Four adverse events occurred, including one case of hematoma at the incision site that was aspirated, 2 cases of superficial wound infection in C6 patients treated with antibiotics, and 1 case of a bleeding complication due to warfarin anticoagulation. One patient's VenoValve had thrombosed at 5 months due to nontherapeutic anticoagulation. Improvements in all 5 patients who had reached the 6-month follow-up mark with the VenoValve were demonstrated during the study period by decreases in the venous clinical severity scores (61% decrease from baseline), visual analog scale for pain scores (57% decrease), and reflux time (40% decrease) and a statistically significant improvement in the VEINES-QOL/Sym questionnaire. The patient with the occluded VenoValve had experienced improvements in all areas except for the reflux time. The latter patient had shown improvement because her ulcer had nearly healed before the occurrence of the thrombosis.

CONCLUSIONS

The early results of the first-in-human trial using the VenoValve appear promising, with improvements in clinical outcomes and QOL. The VenoValve is the first prosthetic valve that has shown success at 6 months of follow-up. These findings offer insight for creating better outcomes for these highly disabled patients.