Morphofunctional Evaluation of Lower Limb Tributaries After Great Saphenous Vein Treatment with Endovascular Laser Ablation: A Prospective Longitudinal Observational Study

Introduction, Objectives, and/or Purpose: For years, the standard treatment of great saphenous vein (GSV) insufficiency was the ligation of the saphenofemoral junction (SFJ), upper saphenectomy, and phlebectomy, performed under spinal anesthesia and requiring hospitalization. However, this treatment has been disused because of its prolonged and painful recovery and the possibility of developing neovascularization in JSF. In 1999, endovenous laser ablation (EVLA) for the treatment of superficial venous reflux was approved in the US, and it has become one of the pillars of treatment for GSV venous insufficiency; it is associated with lower morbidity, has been proven more efficacious than traditional surgery, and can be performed as an outpatient under local anesthesia. Although EVLA has become the gold standard for treating GSV reflux, little has been studied about its impact on the hemodynamics of the superficial venous system regarding the effects on the GSV tributaries veins.

Objective: To evaluate the hemodynamic changes in the great saphenous vein tributaries after
great saphenous vein endovascular laser ablation.

Methods:

Method: In this prospective longitudinal study, we studied 30 patients submitted to GSV by EVLA in the Vascular Surgery Service of the Hospital das Clínicas/EBSHER–UFPE (HC/EBSERH-UFPE) from April 2022 to March 2023. All patients had lower limbs’ chronic venous disease, classified at least as a C2 in the CEAP classification (Clinical – Etiology – Anatomy – Pathophysiology) with reflux into the GSV and JSF seen with Doppler ultrasonography (DUS). Patients with reflux into the deep venous system were excluded. The participants were also classified according to the Revised Venous Clinical Severity Score.
The patients were submitted to venous mapping using DUS preoperatively and ninety days after surgery. We performed imaging of the GSV and its tributary veins, distributed into four groups: anterior thigh, posterior thigh, anterior leg, and posterior leg. The GSV tributaries were analyzed
according to the following parameters: diameter, presence of reflux, and presence of occlusion.
Under local anesthesia, they were then submitted to GSV EVLA using a 1470nm diode generator and 600m radial fiber. The HC/EBSERH-UFPE Human Research Ethics Committee approved the research study.

Results:

Results: Patients’ ages ranged from 27 to 69 years old (mean of 50), 54% were female, and 120 areas of 30 lower limbs were evaluated. Regarding the distribution of patients according to the CEAP classification chronic venous disease, 8% of the patients were classified as C2, 45% as C3, 37% as C4, and 4% as C5. The extent of GSV treated by EVLA ranged between 18 and 80cm, and the lowest reflux point defined this extension. On average, the Revised Venous Clinical Severity Score was 9.7 points preoperatively and 4.3 points postoperatively.
During the 90-day follow-up period, one patient (3%) had superficial thrombophlebitis.
Comparing the DUS exams pre and postoperatively, the following findings were observed. The JSF diameter measurements preoperatively were between 62 and 203 mm (mean of 105mm) and average values of 43 mm (range from 29 to 88 mm) postoperatively. All the saphenous veins
treated segments were occluded, and there were no cases of deep vein thrombosis in the study period. All patients had pervious residual GSV in the segment not treated by EVLT after 90 days.
Breaking it down into the four groups listed above, we found the following results (see table).
- For the anterior thigh, the average diameter of the tributaries varied from 62 mm to 25mm, pre and postoperatively; the reflux present in all 13 tributaries in the preoperative evaluation was found in 2 (15%) tributaries postoperatively. Regarding occlusion, all 13 tributaries were open preoperatively, while 8 (62%) were occluded postoperatively.
- In the posterior thigh, the average diameter of the tributaries decreased from 53 mm preoperatively to 14.9 mm postoperatively, and the reflux was present in 10 (83%) of the 12 tributaries preoperatively was found in 2 (17%) postoperatively. As for occlusion, all 12 tributaries were open preoperatively, while 4 (33%) were occluded after the intervention.
- In the anterior leg, the average diameter of the tributaries varied from 46mm preoperatively to 21mm postoperatively; reflux was present in 16 (76%) of the 21 tributaries in the preoperative evaluation and found in 7 (33%) postoperatively. As for occlusion, all 12 tributaries were open preoperatively, while three (14%) were occluded postoperatively.
- The analysis of the posterior leg area showed that the average diameter of the tributaries changed from 47 to 25mm pre and postoperatively; reflux was present in 23 (68%) of the 34 tributaries in the preoperative evaluation and 9 (26%) postoperatively. Regarding
occlusion, all 34 tributaries were open in the preoperative period, while 5 (14%) were occluded postoperatively.

Conclusion(s):

Conclusion: Endovenous laser ablation is known to be an effective, safe, and durable treatment option for great saphenous vein reflux that can be performed in an outpatient setting under local anesthesia; patients also benefit from the shorter operating time and decreased postoperative
pain. The endovascular treatment of the great saphenous vein without directly treating the tributaries, waiting for their potential reduction, also prevents unnecessary scars from multiple access points. Some authors have also suggested that, with the reduction of hypertension and
venous reflux in the great saphenous vein, its tributary veins could become normal in diameter and shape; this similar physiological phenomenon that can happen after pregnancy, where varicose veins tend to regress or disappear.
This study showed a decrease in the diameter of the GSV tributaries in the four lower limb areas evaluated, posterior and anterior thigh and posterior and anterior leg, ninety days after its treatment by endovascular laser ablation. The occlusion of the tributary veins occurred in the
minority of cases, but most patients had no reflux postoperatively. Also, there were no complications such as deep venous thrombosis, and the untreated great saphenous veins were pervious in all studied patients. The anterior leg and thigh had the lowest rate of decrease in
tributary diameter. The most significant reduction in diameter, the greatest disappearance of reflux, and the highest occlusion rate were found in posterior thigh tributaries. Long-term clinical assessment and imaging follow-up are needed to assess the absolute need for a second surgical
procedure to remove tributary veins that were not treated by laser ablation of the great saphenous vein.