Frequency of Inappropriate Endovenous Ablation Therapy Within the VQI Varicose Vein Registry

Venous disease affects roughly one-third of the general population and presents with variable severity from asymptomatic disease to limb-threatening venous leg ulcers.  The development of minimally invasive technologies for treatment of venous reflux and the acceptance of office-based endovenous ablation techniques has enabled superficial vein ablation to become the most commonly performed surgical procedures in the United States. Concern exists that there has been a resulting increase in the number of inappropriate ablation procedures performed.

Methods:

All procedures within the Vascular Quality Initiative (VQI) Varicose Vein Registry between 2015 and 2022 were analyzed and assessed for appropriateness, which was defined by the American Venous Forum (AVF), Society for Vascular Surgery (SVS), American Vein and Lymphatic Society (AVLS), and Society of Interventional Radiology (SIR) 2020 Appropriate Use Criteria. Procedures were defined as May be Appropriate (MA), Rarely Appropriate (RA), or Never Appropriate (NA). Recommendations regarding appropriateness of endovenous ablation were mapped to variables within the dataset. We compared differences in demographic, procedural, device, hospital, and payer data. Univariate analyses were performed  to assess associations within each group and logistic regression models were used to determine vein-level predictors of inappropriate treatment. 

Results: We identified 55,740 procedures on 34,721 patients in the VQI, of which 54,148 total procedures on 33,752 patients were included for analysis. Total number of MA was 2195; RA was 601; NA was 433. Procedures characterized as NA included 349 great saphenous vein ablation and 149 anterior accessory saphenous vein procedures performed with no reflux or with no duplex performed. MA procedures were more likely to be performed on patients with insurance ( (OR=1.4, p< .0001), but there no correlation with RA or NA procedures. NA and RA procedures were more likely to be performed as Office-based procedures (OR=2.7 (p< .0001) for NA, OR=1.7 (p=.003) for RA) and Number of veins treated was associated with an increased likelihood of inappropriate intervention (p< .0001). Four out of 36 centers enters accounted for 38% of RA or NA treatments (Figure I).

Conclusions:

Analysis of a large national database demonstrates  low incidence of inappropriate endovenous ablation procedures. Never or rarely appropriate procedures were more likely to be performed in an Office-based setting and when multiple veins are treated. Procedural indication was not associated with private-payer insurance. A small number of centers account for a significant proportion of non-appropriate procedures. Education and quality improvement efforts should focus on maximizing appropriate indications for ablation treatment.