From the Guidelines
Ablation of the great saphenous vein (GSV) is typically recommended when reflux duration exceeds 0.5 seconds, particularly when accompanied by symptomatic chronic venous insufficiency, as stated in recent guidelines 1. This threshold represents pathological retrograde blood flow that contributes to venous hypertension and associated symptoms. Patients should also demonstrate clinical manifestations such as varicose veins, edema, skin changes, or venous ulcers (CEAP classification C2-C6) to justify intervention. The decision to ablate should consider both the hemodynamic significance of the reflux and its correlation with clinical symptoms. Before proceeding with ablation, a comprehensive duplex ultrasound evaluation should confirm the reflux duration and anatomical extent. Conservative measures like compression therapy should be attempted first in mild cases. Various ablation techniques are available, including endovenous laser ablation, radiofrequency ablation, and chemical ablation (sclerotherapy), with selection based on vein characteristics, patient factors, and physician expertise, as noted in a recent study 1. Some key points to consider when deciding on ablation include:
- The efficacy of endovenous ablation, with occlusion rates ranging from 91% to 100% within 1-year post-treatment 1
- The safety profile of endovenous ablation, with low rates of thrombotic events, such as DVT and pulmonary embolism 1
- The importance of patient selection, with ablation recommended as first-line treatment for nonpregnant patients with symptomatic varicose veins and documented valvular reflux 1 Post-procedure compression therapy for 1-2 weeks is typically recommended to improve outcomes and reduce complications. It is essential to weigh the benefits and risks of ablation and consider individual patient factors, such as the severity of symptoms and the presence of comorbidities, when making treatment decisions, as supported by recent evidence 1.
From the Research
Great Saphenous Reflux Ablation
The level of reflux at which ablation is recommended for great saphenous vein (GSV) reflux is not strictly defined, but several studies provide insights into the treatment of GSV reflux:
- A study from 2009 2 found that although above-knee (AK) endovenous laser ablation improved symptoms regardless of persisting below-knee (BK) reflux, the latter was associated with residual symptoms and a greater need for sclerotherapy.
- Another study from 2014 3 suggested that endovenous ablation of the refluxing BK-GSV segment can be performed safely with minimal complications, and consideration should be given to concomitant ablation of the BK-GSV to improve long-term outcomes.
- The decision to perform ablation may depend on the presence of symptoms and the severity of reflux, rather than a specific reflux level:
- A 2015 study 4 reported successful treatment of GSV reflux using ultrasound-guided catheter-directed foam sclerotherapy.
- A 2010 study 5 found that duplex ultrasound-guided foam sclerotherapy can eradicate reflux in the AK and BK-GSV in over 95% of patients with symptomatic primary GSVV.
- A comparative study from 2016 6 found that both radio-frequency ablation and duplex ultrasound-guided, catheter-directed foam sclerotherapy were effective in managing GSV varicose veins, with no significant difference in outcomes between the two modalities.
Treatment Considerations
When considering ablation for GSV reflux, the following factors may be taken into account:
- Presence and severity of symptoms
- Extent of reflux (AK and/or BK)
- Presence of comorbidities
- Patient preferences and lifestyle
- Availability of treatment options and expertise
Reflux Levels and Treatment
While there is no specific reflux level at which ablation is recommended, treatment may be considered for patients with:
- Symptomatic GSV reflux
- Reflux extending to the BK segment of the GSV
- Residual symptoms or varicosities after AK-GSV treatment
- Advanced venous insufficiency (CEAP C4-6)