Factors Associated with Recanalization and Reintervention Following Below Knee Polidocanol Endovenous Microfoam Ablation for Great Saphenous and Small Saphenous Veins

Polidocanol endovenous microfoam (PEM) has been used to treat lower extremity venous reflux for almost a decade with specific advantage in below knee (BK) truncal veins where thermal ablation poses a risk for injury to adjacent nerves. Current literature in the BK segment often examines short-term outcomes with modest sample sizes. We aim to identify factors associated with recanalization and reintervention in this subset of patients.

Methods:

We performed a retrospective study of a relatively large series of patients from a single institution who underwent PEM ablation for BK great saphenous vein (GSV) and small saphenous vein (SSV) reflux. Patients underwent duplex ultrasonography (DU) within 7 days after injection, every 3-6 months for a year, and every 6-12 months thereafter. Patients with symptomatic recanalization underwent reintervention. 26 patients lost to follow up without post ablation DU were excluded. Factors associated with recanalization and reintervention were examined by multivariate and nonparametric analysis.

Results:

Between March 2018 and July 2023, 434 (172 male, 262 female) patients with 594 treated limbs (298 right, 296 left) met study criteria. 90.3% (536) of included limbs had prior AK saphenous ablations. 598 BK GSV and 43 SSV ablations were performed. The most recent DU was performed at a mean of 228 days (range, 2-1758 days). The overall recanalization rate was 9.8% (55 GSV, 8 SSV) at a mean follow up of 100 days (range, 2-952 days). Comparing closed and recanalized veins, there was no significant difference in age (p=0.54), treated laterality (p=0.11), patient BMI (p=0.61), preprocedural CEAP score (p=0.09), administered PEM volume (p=0.17), or use of antithrombotic medications (p=0.08). Recanalized veins had significantly larger preprocedural diameters than veins that remained closed (4.9mm recanalized, 4.3mm closed, p=0.02). Men had higher incidence of recanalization than women (13.7% male, 7.1% female, p=0.002). SSVs recanalized more frequently than GSVs (p=0.018). Early recanalizations at first DU accounted for 50.8% (32) of failures and had significantly lower administered PEM volume when compared to later recanalizations (early 4.28cc, late 4.97cc, p=0.006). There were no significant differences found between the 50.8% (32) of recanalized patients requiring reintervention and those that did not (31). 23 reinterventions were performed with PEM, 100% of which remained closed at a mean of 236 days (range, 7-684 days).

Conclusions:

PEM is successful for the treatment of BK GSV and SSV reflux with a closure rate of 90.2% at a mean of 228 days and shows promise as salvage therapy. Recanalization often occurs early and is associated with lower PEM volume. Larger vein diameter, male sex, and SSV ablation are associated with higher rates of recanalization and reintervention.