CEAP-guided and Kistner-refined selection of deep venous intervention for primary lower-limb venous valvular...

To evaluate whether the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) clinical class and Kistner grade could guide the selection of deep venous intervention for primary lower-limb venous valvular incompetence.

A two-center retrospective cohort study of 578 consecutive eligible limbs with primary lower-limb venous valvular incompetence and available venographic and clinical records between 2015 and 2025 categorized into the following four groups was conducted: conservative management (n = 241), superficial-only treatment (n = 240), deep-only treatment (n = 44), and combined treatment (n = 53). Deep intervention mainly consisted of femoral vein valvuloplasty; combined treatment comprised femoral valvuloplasty plus superficial treatment, most often radiofrequency ablation, with high ligation and stripping performed when indicated. The primary outcome was Venous Clinical Severity Score (VCSS) improvement. Analyses were conducted across several populations: hierarchically in the C3 group, the overall C4-C6 population, the C4-C6 Kistner grade 3-4 isolated deep reflux subgroup, and an all-CEAP Kistner grade 3-4 sensitivity population.

In the C3 group, combined treatment provided no additional VCSS benefit compared with superficial venous-only treatment (adjusted β, .1; 95% CI, -1.6 to 1.9; P = .872). However, in the C4-C6 population, combined treatment achieved greater VCSS improvement than superficial venous-only treatment (adjusted β, 1.8; 95% CI, 0.5-3.1; P = .007). In C4-C6 limbs with Kistner grade 3-4 isolated deep venous reflux, combined treatment showed greater benefit than both superficial venous-only treatment (adjusted β, 3.9; 95% CI, 1.1-6.6; P = .008) and conservative management (adjusted β, 4.2; 95% CI, 1.3-7.0; P = .005). All CEAP Kistner grade 3-4 sensitivity analyses showed directionally consistent results.

Selective femoral vein valvuloplasty combined with superficial venous treatment may be clinically justified in C4-C6 disease, especially with Kistner grades 3-4 reflux; however, it is not supported in C3 disease.