Factors Associated with Ablation Related Thrombus Extension (ARTE) Following Microfoam Versus Radiofrequency Saphenous Vein Closure.

OBJECTIVES: Polidocanol endovenous microfoam (MFA) is approved by the US Food and Drug Administration for great saphenous vein (GSV) closure, yet there is little published data on the subsequent risk of ablation related thrombus extension (ARTE). Recent societal practice guidelines recommend against routine post-procedure duplex ultrasound (DU) following thermal ablation of the GSV in asymptomatic patients. At present, limited data does not allow this recommendation to extend to MFA. Our aim is to identify characteristics and outcomes associated with ARTE following MFA versus radiofrequency ablation (RFA).

METHODS: A retrospective review of a prospectively maintained database was conducted of patients who underwent MFA and RFA closure of incompetent above-knee GSV's. Patients who were treated for isolated tributary vein treatment or did not have a post-procedure DU within 48-72 hours were not included. Patients were classified into two groups: ARTE and No ARTE. Demographic data, CEAP class, venous clinical severity score (VCSS), operative details, post-procedure (48-72 hours) DU findings and adverse events were analyzed. Variables which were significant on univariate analysis were evaluated using multivariate logistic regression with the primary outcome being development of ARTE.

RESULTS: Between June 2018 and February 2023, 800 limbs were treated with either MFA (n=224) or RFA (n=576). Ninety-six GSV's treated with MFA met study criteria. One hundred fifty successive GSV's treated with RFA during the same period were included as a comparison group. There was no statistically significant difference in baseline demographics between the two groups. Six patients (2.4%) demonstrated ARTE on postoperative DU at 48-72 hours (MFA: n=5 (5.2%), RFA: n=1 (0.7%); p=0.02). Saphenous vein ablation with MFA (p=0.045) and vein diameter > 10 mm (p=0.017) were associated with ARTE on both univariable and multivariable analysis. All patients who developed ARTE were treated with oral anticoagulants (Mean = 15.6 days). Body mass index, CEAP class, VCSS, microfoam volume, operative time, and prior DVT were not predictive of ARTE.

CONCLUSIONS: Ablation related thrombus extension following above-knee GSV closure occurred more frequently following MFA. Our results suggest that a saphenous vein diameter greater than 10 mm may be associated with ARTE. Despite this finding, all patients with ARTE were treated with short-term anticoagulation with no related complications. Until larger studies with high-risk subgroups have been studied following MFA, DU should be performed routinely post-procedure and ARTE patients anticoagulated until the thrombus retracts caudal to the saphenofemoral junction or is no longer present on duplex. Current societal guidelines recommending against routine post-thermal ablation DU should not be applied to similar patients following saphenous non-thermal MFA ablation.