Proximal tumescence during treatment of saphenous veins with polidocanol endovenous microfoam provides successful ablation of larger veins and predicts reduced microfoam volume

Abstract

Background

Perivenous tumescence with saline or a dilute lidocaine solution is used routinely for thermal ablation of refluxing superficial lower extremity veins to displace sensitive structures away from the thermal probe and provide better contact with the treated venous endothelium. In this study, we introduce an adjunctive technique of tumescence infiltration at the most efferent segment of refluxing saphenous veins treated with 1% polidocanol endovenous microfoam (PEM). We hypothesize that, by reducing the vein diameter, proximal tumescence (PT) prolongs apposition time of PEM to the endothelium by delaying venous outflow and microfoam propagation speed. We evaluated PT effects on vein closure and volume of PEM used as well as the incidence of superficial venous thrombosis and ablation-related thrombus extension (ARTE).

Methods

A single institution retrospective study was performed with PEM ablations for the above-knee great saphenous vein (GSV), below-knee GSV, and small saphenous vein (SSV) by two operators over a 12-month period. Duplex ultrasound (DUS) within 3 to 7 days after ablation followed by a serial surveillance DUS schedule were used to evaluate for vein closure, venous thrombosis, and ARTE per institutional protocol. Any treated vein segment found to be completely or partially patent with reflux after treatment was deemed an ablation failure. Demographics and outcomes of tumescent PEM (T-PEM) ablations were compared with nontumescent PEM (NT-PEM) ablations through univariate and generalized estimating equation modeling.

Results

Between June 2023 and May 2024, 183 adult patients (64 male, 119 female) treated with 1% PEM in 246 lower extremities (113 right, 133 left) met the study criteria. Nineteen patients without documented follow-up DUS examinations were excluded from this study. Overall, 293 ablations (23 above-knee SV, 199 below-knee GSV, 71 small saphenous vein) were performed with a mean PEM volume of 2.8 ± 0.6 mL per ablation with a combined closure rate of 91.8% (269 of 293). One hundred nineteen ablations (40.6%) were augmented with PT (mean tumescence volume, 6 ± 2.4 mL; range, 3-16 mL). Veins treated with T-PEM were significantly larger (mean vein diameter, 4.8 ± 1.3 mm) than veins treated with NT-PEM (mean vein diameter, 4.0 ± 0.9 mm; P < .001). There were no significant differences in patient age (P = .37), sex (P = .06), laterality (P = .29), preoperative Clinical-Etiology-Anatomy-Pathophysiology clinical severity scores (P = .34), PEM volume used (P = .09), venous thrombosis (P = .65), ARTE (P = .41), or rate of treatment success (P = .16) on univariate comparison of T-PEM and NT-PEM ablations. Generalized estimating equation regression predicts lower microfoam volume use with PT (B = −0.4; P = .003) and similar treatment success rates when correcting for interoperator variability.

Conclusions

PT is a safe and effective adjunct to PEM ablation that provides high short- and mid-term closure rates with low ARTE incidence for large and small saphenous veins. PT is associated with lower microfoam volume use.