I have already done a week of PGY1 year at, let’s just say a certain institution in the NE region. Things have been busy, a little hectic, and definitely what I signed up for. Everyday I learn many new things, and realize how much I don’t know about actual patient care. Things will get smooth and efficient; I am sure.
I have encountered several patients with C6 stage chronic venous insufficiency, with chronic or prior history of DVT, and there are many debates about whether GSV ablation can be safely carried out in these patients. Let me present to you the evidence I’ve found:
- Deep vein reflux from previous DVT may improve in some cases after elimination of the superficial reflux, but it does not disappear. The latter is more prevalent in the presence of axial reflux, such as when there is reflux in continuity from the common femoral vein to popliteal or more distal, no just isolated to the SFJ or SPJ.
- Superficial venous ablation with concurrent chronic DVT is not as forbidden anymore! Traditional advice has been against saphenous vein ablation in the presence of deep venous obstruction, as it was feared that obstructive disease may be made functionally more severe by removing the saphenous vein that might serve as collaterals.
- When testing venous outflow function in patients with previous deep vein thrombosis, Labropoulos et al. demonstrated that only 9.6% of limbs had their venous outflow reduced by occlusion of the superficial veins. The deep collaterals seem to be more important than the superficial venous system in bypassing the obstruction.
- Raju et al.,when comparing patients with and without deep obstruction who underwent saphenectomy, found similar outcomes in the two groups with no clinical deterioration in those with obstruction.
- Risk of DVT following saphenous ablation does not seem to be increased in patients with previous thrombotic events as shown by Puggioni et al. Therefore, the saphenous vein plays an insignificant role as a collateral pathway in patients with deep venous obstruction and can be safely treated to correct underlying hemodynamic pathology.
- When evaluating the superficial veins in patients with deep vein obstruction it is necessary to demonstrate significant reflux in the superficial veins prior to intervening, as superficial veins can be dilated in order to compensate for the deep vein obstruction. In such patients the diameter change should not be compared with the studies on patients with primary superficial vein reflux. Therefore, superficial veins with large diameter should not be removed unless there is significant reflux that may contribute to the patients’ signs and symptoms.
- In patients with advanced CVI (C4-6) and superficial reflux, interrogation of the deep venous system for proximal obstruction, even in the absence of previous DVT, is warranted (get MRV or CTV). Treatment of both superficial and proximal deep vein stenosis should be offered, with excellent outcome.
- Marston et al. found that as many as 30% of patients with chronic venous insufficiency have iliac vein obstruction on CT scan. The presence of such combined disease (superficial reflux and iliac vein obstruction) may warrant treatment of both levels of disease, as it is impossible to identify the pivotal diseased segment that contributes to the clinical presentation. These can be done in a staged or combined fashion.
- Neglen et al. reported combined saphenous ablation and iliac vein stenting in 99 limbs with significantly improved hemodynamic parameters, improved clinical symptoms (pain and swelling) and significant improvement in all quality-of-life categories after treatment. This was achieved with good 4-year patency (>90%) and low complication rate.
- Raju’s group which showed that correcting the obstructive element alone of combined obstructive and deep reflux disease can improve clinical symptoms without deterioration in reflux measures.
All in all, treating superficial vein reflux in presence of chronic, non-occluded DVT or prior history of DVT should not be considered as taboo. Of course, it might offer little help in patients with propensity to clot, terrible post-thrombotic syndrome, active venous ulcers that require intensive wound care, etc. At least GSV ablation won’t hurt them. Who knows, venous research has shown us little about how to improve these patients, but definitely shown us enough about safety of GSV ablation.