Safety and efficacy of endovenous ablation in patients with a history of deep vein thrombosis

Abstract

Objective: Endovenous ablation is the standard of care for patients with symptomatic superficial venous insufficiency. For patients with a history of deep vein thrombosis (DVT), concern exists for an increased risk of postprocedural complications, particularly venous thromboembolism. The objective of this study was to evaluate the safety and efficacy of endovenous thermal ablation in patients with a history of DVT.

Methods: The national Vascular Quality Initiative Varicose Vein Registry was queried for superficial venous procedures performed from January 2014 to July 2021. Limbs treated with radiofrequency or laser ablation were compared between patients with and without a DVT history. The primary safety end point was incident DVT or endothermal heat-induced thrombosis (EHIT) II-IV in the treated limb at <3 months of follow-up. The secondary safety end points included any proximal thrombus extension (ie, EHIT I-IV), major bleeding, hematoma, pulmonary embolism, and death due to the procedure. The primary efficacy end point was technical failure (ie, recanalization at <1 week of follow-up). Secondary efficacy end points included the risk of recanalization over time and the postprocedural change in quality-of-life measures. Outcomes stratified by preoperative use of anticoagulation (AC) were also compared among those with prior DVT.

Results: Among 33,892 endovenous thermal ablations performed on 23,572 individual patients aged 13 to 90 years, 1698 patients (7.2%) had a history of DVT. Patients with prior DVT were older (P < .001), had a higher body mass index (P < .001), were more likely to be male at birth (P < .001) and Black/African American (P < .001), and had greater CEAP classifications (P < .001). A history of DVT conferred a higher risk of new DVT (1.4% vs 0.8%; P = .03), proximal thrombus extension (2.3% vs 1.6%; P = .045), and bleeding (0.2% vs 0.04%; P = .03). EHIT II-IV, pulmonary embolism, and hematoma risk did not differ by DVT history (P = NS). No deaths from treatment occurred in either group. Continuing preoperative AC in patients with prior DVT did not change the risk of any complications after endovenous ablation (P = NS) but did confer an increased hematoma risk among all endovenous thermal ablations and surgeries (P = .001). Technical failure was similar between groups (2.0% vs 1.2%; P = .07), although a history of DVT conferred an increased recanalization risk over time (hazard ratio, 1.90; 95% confidence interval, 1.46, 2.46; P < .001). The groups had comparable improvements in postprocedural venous clinical severity scores and Heaviness, Aching, Swelling, Throbbing, and Itching scores (P = NS).

Conclusions: Endovenous thermal ablation for patients with a history of DVT was effective. However, appropriate patient counseling regarding a heightened DVT risk, albeit still low, is critical. The decision to continue or withhold AC preoperatively should be tailored on a case-by-case basis.

Keywords: Deep vein thrombosis; Endovenous ablation; Superficial venous insufficiency; Vascular Quality Initiative; Venous thromboembolism.

Fig 1

Kaplan-Meier curve summarizing recanalization of ablated veins stratified by a history of deep vein thrombosis (DVT). Tick marks indicate censored events. P value computed using log-rank test.

Fig 2

Kaplan-Meier curve summarizing recanalization of ablated veins in patients with a history of deep vein thrombosis (DVT) stratified by preoperative anticoagulation (AC) status. Tick marks indicate censored events. P value computed using log-rank test.

Fig 3

Box-and-whisker (Tukey) plot of quality-of-life scales for all limbs undergoing endovenous thermal ablation stratified by a history of deep vein thrombosis (DVT). A, Venous clinical severity score (VCSS). B, Heaviness, Aching, Swelling, Throbbing, and Itching (HASTI) score. n.s., P value not significant; Pre, preprocedural; Post, postprocedural at latest follow-up. ∗∗∗P < .001.

Supplementary Fig (online only)

Box-and-whisker (Tukey) plot of quality-of-life end points for all treated limbs stratified by a history of deep vein thrombosis (DVT). A, Venous clinical severity score (VCSS). B, Heaviness, Aching, Swelling, Throbbing, and Itching (HASTI) score. n.s., P value not significant; Pre, preprocedural; Post, postprocedural at latest follow-up. ∗∗P < .01; ∗∗∗P < .001.