Is Endovenous Ablation Therapy (EVAT) indicated for a patient with a patent and incompetent short saphenous vein?

Endovenous Ablation Therapy for Incompetent Short Saphenous Vein

Endovenous ablation therapy (EVAT) is indicated for the incompetent short saphenous vein with a diameter of 3.1mm and reflux time of 2.3 seconds, as these findings demonstrate significant venous insufficiency requiring intervention. 1

Diagnostic Criteria Supporting EVAT

• The patient's ultrasound findings show a patent and incompetent short saphenous vein with a diameter of 3.1mm and reflux time of 2.3 seconds, which meets criteria for significant reflux (>0.5 seconds) 1
• The sapheno-femoral junction being patent and competent indicates that the pathology is isolated to the short saphenous system, making it an appropriate target for focused intervention 2
• Venous reflux lasting >0.5 seconds is considered pathological, and the patient's reflux of 2.3 seconds represents severe insufficiency warranting treatment 1

Treatment Options for Short Saphenous Vein Incompetence

Endovenous Thermal Ablation (First-Line)

• Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) have largely replaced surgical ligation and stripping as the main invasive methods to treat varicose veins 3
• Both EVLA and RFA demonstrate excellent occlusion rates ranging from 91% to 100% within 1-year post-treatment 3
• For short saphenous vein specifically, EVLA has shown high success rates with no clinical or duplex evidence of recurrence in follow-up studies 2

Non-Thermal Ablation Options (Second-Line)

• Foam sclerotherapy shows lower occlusion rates (72-89%) compared to thermal ablation techniques 3
• Mechanochemical ablation has closure rates of 88-94%, which is slightly lower than thermal techniques 3
• Cyanoacrylate glue ablation is another non-thermal option with comparable closure rates to EVLA (96.6% vs 94.1% at 12 months) 4

Safety Considerations for Short Saphenous Vein EVAT

• When treating the short saphenous vein, sparing the saphenopopliteal junction is recommended to reduce risk of paresthesias while maintaining low recanalization rates 5
• The risk of deep vein thrombosis following EVLA is very low (0.3% of cases) and pulmonary embolism is rare (0.1% of cases) 3
• Postoperative duplex ultrasound scanning 24-72 hours after the procedure is recommended to assess for successful closure and rule out deep venous thrombosis 6, 7
• Potential complications specific to short saphenous vein treatment include paresthesias (2%) and superficial phlebitis (4%) 5

Treatment Algorithm

1. Confirm diagnosis with venous Doppler ultrasound showing reflux >0.5 seconds 1
2. For short saphenous vein with diameter >3mm and significant reflux (>0.5 seconds), endovenous thermal ablation is indicated 1, 2
3. Choose between EVLA or RFA based on availability and provider experience (both show similar efficacy) 3
4. Consider concomitant phlebectomy if there are large (>3mm) symptomatic incompetent tributaries 6
5. Perform post-procedure ultrasound within 24-72 hours to confirm successful closure and rule out deep vein thrombosis 6, 7

Common Pitfalls and Caveats

• Failure to perform post-procedure ultrasound may miss thrombus extension into the common femoral vein, which occurs in approximately 0.3% after EVLA and 2.1% after RFA 7
• Treating too close to the saphenopopliteal junction increases risk of neurovascular injury; sparing the deep segment in the popliteal fossa reduces complications while maintaining efficacy 5
• Bilateral procedures can be safely performed under local anesthesia in the same session if needed 2