Factors Associated with Clinical Failure of Vein Ablation in the VQI

Insurance companies have imposed inconsistent approval criteria for chronic venous insufficiency (CVI) treatment. While vein ablation (VA) is accepted as the standard of care for venous ulcers, the treatment criteria for patients with milder forms of CVI remains controversial. This study aims to identify factors associated with clinical failure in patients undergoing VA to improve patient selection for treatment.

Methods:

Retrospective analysis of patients undergoing VA for CEAP C2-C4 disease in the VQI varicose veins database from 2014-2023. The difference in VCSS score (∆) (VCSS score prior – VCSS score after the procedure) was used to categorize patients. Patients with VCSS ∆≤ 0 were defined as “clinical failure,” and patients with VCSS ∆≥ 1 as “clinical improvement.” Patients who required intervention in multiple veins, had prior interventions, or presented with CEAP C0-C1 or C5-C6 disease were excluded. The characteristics of both groups were compared.

Results:

A total of 4,348 patients underwent initial treatment of CVI with a single VA, and 32% (N=1408) had clinical failure. Patients with clinical failure were more likely to be white, less likely to have symptoms at baseline, and more likely to be CEAP C2 than patients with clinical improvement. Patients with clinical improvement were more likely to have reported using compression stockings before treatment. Vein diameters were not different between the two groups, but patients with clinical failure were more likely to have isolated GSV reflux in the thigh and deep venous reflux. (Table1) After treatment, the mean ∆VCSS was significantly lower in the clinical failure group (-1.3 vs. +4.2, P< 0.001). Complications were overall low, with minor differences between groups, but patients with clinical failure were significantly more likely to have symptoms after intervention than those with improvement. On multivariable regression, patients belonging to racial groups other than white or African American (OR=0.4 [0.32-0.49]) demonstrated a reduced likelihood of experiencing clinical failure compared to white patients. Patients with CEAP C2 were associated with a higher likelihood of clinical failure (OR=1.45 [1.18-1.79]) than more advanced C4 disease. The lack of compression therapy before intervention (OR= 4.14 [3.39-5.07]) and the presence of deep venous reflux (OR=2.98 [2.59-3.44]) were also associated with clinical failure.

Conclusions:

Clinical failure after VA is associated with treating patients with lower VCSS before the procedure, CEAP classification (C2) disease, concomitant deep venous reflux, and lack of compression therapy before intervention. Importantly, no significant association between vein size and clinical improvement was observed.