Neovascularization, a cause of truncal varicose vein recurrence after endovenous laser ablation

Endovenous ablation techniques (EVA) have become increasingly common and have taken the place of surgical treatment for truncal vein incompetence. We set out to investigate and identify outcome, complications, and incidence of recurrence, and possible causes of truncal recurrence in patients treated with Endovenous Laser Ablation (EVLA).

A cohort study of 307 consecutive patients (119M/188F) with varicose veins and great saphenous vein incompetence, (C3-C6), were treated with EVLA. Clinical and duplex ultrasound assessment was performed for all patients. Post-procedure patients were placed in compression stockings for 2 weeks, and given enoxaparin for DVT prophylaxis. Patients were also assessed for deep venous thrombosis (DVT), and successful obliteration.

Median initial vein diameter was 6.9 (range 3.7-12.6) mm, and the median ablation energy was 57.8 (range 44.3 to 83.1) J/cm in all 307 patients. Complete truncal occlusion was noted in 301 patients. Truncal occlusion was demonstrated in all patients at initial and 2-week scan, however six patients with were noted to have developed truncal recurrence observed at 6-weeks to 3-months. The median energy delivered was 40.9 (range 35.6 to 41.7) J/cm, significantly less compared to non-recurrent GSV (P=0.02). We observed multiple tiny arteriovenous fistulae with arterialized signals within the lasered vein that became confluent, resulting in truncal recurrence.

Venous re-canalization after EVLA occurs as a result of neovascularization. This takes the form of multiple tiny AV fistulae, that eventually join and becomes a confluent reflux. The triggers for this phenomenon are unclear, but probably related to linear endovenous energy density.