Radiofrequency ablation with concomitant stab phlebectomy increases risk of endovenous heat-induced thrombosis

Endovenous heat-induced thrombosis (EHIT) is a well-documented phenomenon that follows endovenous ablation, but the treatment, surveillance, and risk factors for EHIT have yet to be comprehensively elucidated. We sought to identify characteristics that may put patients at higher risk for development of EHIT after radiofrequency ablation (RFA) for the treatment of symptomatic superficial venous insufficiency.

A retrospective review was performed of all consecutive patients undergoing treatment with RFA to the great saphenous vein by a single surgeon from July 2013 through October 2015. On postprocedural day 2, a surveillance venous duplex ultrasound examination was obtained and the presence of EHIT was recorded. Demographics of the patients, venous thromboembolism (VTE) risk factors, and procedural details were compared between patients with EHIT and those with no EHIT using multivariable logistic regression for risk adjustment. As a sensitivity analysis, propensity score matching on the basis of 18 demographic and perioperative variables was then used to confirm significant findings.

There were 299 patients who underwent RFA for symptomatic chronic venous insufficiency (median age, 55 years; 65% female; 46% right lower extremity). Concomitant stab phlebectomy was performed in 71%. EHIT occurred in 12% (n = 35) of patients (class 1, 5%; class 2, 4%; class 3, 1%; class 4, 2%). The incidence of EHIT was significantly higher after RFA with concomitant stab phlebectomy vs RFA alone (14% vs 6%; P = .04). There were also nonsignificant trends toward a higher incidence of EHIT in patients with a history of VTE (20% vs 10%; P = .06), worsening venous disease (Clinical, Etiology, Anatomy, Pathophysiology [CEAP] class >2, 37% vs 26%; P = .13), and history of tobacco use (43% vs 31%; P = .18). On multivariable analysis, RFA with concomitant stab phlebectomy (odds ratio, 3.46; 95% confidence interval, 1.36-10.8) and history of VTE (odds ratio, 3.48; 95% confidence interval, 1.22-9.25) were independently associated with EHIT (P ≤ .02). After propensity matching of 60 pairs of similar patients, RFA with concomitant stab phlebectomy had a persistently higher incidence of EHIT compared with RFA alone (23% vs 7%; relative risk, 3.48; P = .01).

Concomitant stab phlebectomy and the patient's history of VTE are independent risk factors for EHIT after endovenous ablation with RFA. History of tobacco use and advanced stages of venous disease may also play a role. For patients with these high-risk features, care should be taken to prevent, identify, and treat EHIT early.