What is the recommended treatment for lower Great Saphenous Vein (GSV) insufficiency?

Treatment of Lower Great Saphenous Vein Insufficiency

Endovenous thermal ablation (either radiofrequency ablation or laser ablation) is the recommended first-line treatment for lower Great Saphenous Vein (GSV) insufficiency due to its higher efficacy, lower complication rates, faster recovery times, and better patient outcomes. 1

Diagnosis and Assessment

• Duplex ultrasound is the gold standard for evaluating venous reflux

  • Diagnostic criteria: valve closure times exceeding 500 milliseconds 1
  • Complete assessment should include evaluation from inguinal ligament to ankle

• CEAP Classification should be used to categorize venous disease by:

  • Clinical severity (grades 0-6)
  • Etiology (congenital, primary, or secondary)
  • Anatomical distribution (superficial, deep, or perforator veins)
  • Pathophysiological dysfunction 1

Treatment Algorithm

First-Line Treatment:

1. Endovenous Thermal Ablation
   • Radiofrequency ablation (RFA) or Endovenous laser ablation (EVLA)
   • Both methods show high success rates (98.4% for RFA and 98.1% for EVLA) 2
   • Long-term success rates at 5 years remain high (83-88%) compared to other methods 3

Adjunctive Treatments:

1. Ultrasound-guided foam sclerotherapy (UGFS)

   • Used for tributary veins and varicosities
   • Less effective as primary treatment (only 34% anatomical success at 5 years vs. 88% for EVLA) 3
   • Best used in combination with thermal ablation 1

2. Microphlebectomy/Phlebectomy

   • Recommended for visible varicosities
   • Can be performed during the same procedure as thermal ablation 1

Comparative Effectiveness

• EVLA vs. RFA: Both show similar technical success rates up to 5 years, though RFA may have better long-term outcomes with lower recurrence rates at 5 years 4

• EVLA vs. UGFS: EVLA demonstrates significantly better technical success rates both short-term and long-term 3, 4

• Thermal Ablation vs. High Ligation and Stripping: Endovenous thermal methods show higher efficacy, fewer complications, and faster recovery 1, 4

Post-Procedure Management

1. Compression Therapy

   • Thigh-high compression stockings (30-40 mmHg)
   • Should be continued after the procedure 1

2. Follow-up

   • Early follow-up ultrasound within 1-2 weeks to confirm successful closure
   • Crucial to rule out complications like endovenous heat-induced thrombosis (EHIT) 1
   • Regular follow-up to monitor disease progression and adjust treatment plans

3. Lifestyle Modifications

   • Weight management
   • Regular exercise
   • Leg elevation
   • Non-restrictive clothing 1

Potential Complications

• Thrombotic complications: Overall rate 10.5%, including:

  • Endovenous heat-induced thrombosis (EHIT): 5.9% (true rate 1.16% when excluding Class 1)
  • Acute superficial venous thrombosis: 4.6% 2

• Risk factors for thrombotic complications:

  • Larger vein diameter (particularly >7 mm)
  • Type of vein (GSV has higher complication rate at 11.8% vs. 5.5% for SSV) 2
  • EVLA may have slightly higher thrombotic complication rate than RFA (11.4% vs. 7.7%) 2

• Other complications: Bruising, pain, hematoma, edema, and cellulitis 5

Special Considerations

• Early duplex scanning is recommended for all patients after endovenous saphenous ablations to detect potential thrombus extension 5
• DVT prophylaxis may be considered in patients >50 years old 5
• Patients with extensive SVT, history of VTE or SVT, active cancer, or recent surgery may require anticoagulant therapy 1

Endovenous thermal ablation represents the most effective treatment approach for lower GSV insufficiency with high success rates and favorable long-term outcomes compared to other treatment modalities.