Cost analysis and implications of routine deep venous thrombosis duplex ultrasound scanning after endovenous ablation

Duplex ultrasound (DUS) is performed by the majority of physicians after endovenous ablation (EVA) of the great saphenous vein to screen for endovenous heat-induced thrombosis (EHIT) at the saphenofemoral junction extending into the femoral vein. Several factors should be considered in assessing the value and cost of routine DUS after EVA: the natural history of EHIT is poorly defined, the incidence appears low, and the majority are both asymptomatic and Kabnick type 2 (projecting only slightly into the femoral vein). Moreover, routine postoperative DUS screening is not recommended for procedures with higher thromboembolic complication rates, such as joint replacement or bariatric surgery.

Data on the incidence of death, EHIT, and deep venous thrombosis (DVT) were derived from a systematic review after either radiofrequency or laser ablation of the saphenous vein from two sources: (1) EVA randomized controlled trials (N = 1482) and a (2) large (>150 patients) EVA case series (N = 12,363). The number of tests required to detect one case of EHIT/DVT was calculated from the incidence in the EVA and case series data bases; the cost to detect a case was estimated using the 2013 Medicare global fee schedule for the cost of a unilateral venous DUS study.

This analysis included 13,845 EVA-treated limbs. There were no reported deaths. The incidence of DUS-detected venous thromboembolism after EVA is 0.7%. The cost of unilateral DUS according to the Medicare global reimbursement fee for office-based studies is $106.71. The total cost of performing DUS in this study population is estimated to be at least $1,477,399, and the amount of dollars expended per venous thromboembolism detected is $14,667.

The current Society for Vascular Surgery/American Venous Forum recommendation is to perform screening DUS after EVA within 72 hours postoperatively with a weak level of recommendation (grade 2C). The current analysis demonstrates a low incidence of EHIT/DVT with a corresponding high cost to detect each case with routine DUS screening. These data combined with the unclear clinical significance of EHIT suggest that the policy of universal post-EVA screening should be revised in the near future.