Comparative early outcomes following primary radiofrequency ablation and polidocanol microfoam ablation of symptomatic, incompetent small saphenous veins

Background

Radiofrequency ablation (RFA) of symptomatic, incompetent small saphenous veins (SSVs) is supported by clinical practice guidelines, but polidocanol microfoam ablation (MFA) is not addressed in these guidelines owing to the absence of high-quality clinical data. However, some anatomical variations and clinical scenarios in patients with SSV reflux may be associated with equivalent or superior results when MFA is used compared with RFA. This study aims to compare early outcomes after the treatment of SSV incompetence in patients with Clinical-Etiology-Anatomy-Pathophysiology (CEAP) 2 class to 6 disease using either RFA or MFA.

Methods

A retrospective review of a prospectively maintained database was conducted among patients who underwent treatment of incompetent SSVs with either RFA or MFA. Limbs that underwent concomitant phlebectomy were included. All patients underwent postoperative duplex ultrasound at 48 to 72 hours and at least one follow-up visit by a vascular surgery provider. Primary outcomes were immediate SSV closure and ablation-related thrombus extension. Secondary outcomes analyzed included demographic data, CEAP clinical class, Venous Clinical Severity Score (VCSS), deep venous thrombosis, and adverse events.

Results

Between March 2018 and July 2024, 182 SSVs treated for symptomatic reflux with either RFA (n = 120) or MFA (n = 62) were identified. Age, gender, body mass index, reflux times, and SSV diameters were similar between both groups. The mean preoperative VCSSs were 9.4 ± 3.0 and 10.8 ± 3.7 in the RFA and MFA groups, respectively (P = .05). More venous ulcers were present at the time of MFA (n = 16 [26%]) than RFA (n = 14 [12%]) (P = .015). Median follow-up was 164.5 days in the RFA cohort and 156 days after MFA. Symptomatic improvement after RFA and MFA was 91% and 88%, respectively. The mean postoperative VCSS decreased from 9.4 to 7.3 in the RFA group (P < .001) and from 10.9 to 9.2 after MFA (P < .001). Immediate vein closure was achieved in 98% of limbs in both groups; two late recanalizations occurred after MFA, but none after RFA. The number of ulcers healed at last follow-up was greater after MFA (n = 13 [81%] vs n = 10 [71%]; P = .02). The incidence of ablation-related thrombus extension was 4.8% (n = 3) after MFA and 1.7% (n = 2) after RFA (P = .52). One gastrocnemius deep venous thrombosis occurred in the MFA group. No pulmonary emboli or central nervous complications occurred. All adverse thrombotic events were asymptomatic and resolved with short-term anticoagulation. Superficial phlebitis was higher after MFA (n = 11 [17.7%] vs n = 5 [4.2%]; P = .002) One postoperative sural neuralgia occurred after RFA.

Conclusions

RFA and MFA are both safe and effective treatments for patients with symptomatic, incompetent SSVs. Both resulted in excellent clinical relief and early truncal vein closure rates. The number of ulcers healed was higher in the MFA group, but this difference was significant on univariate analysis only. Adverse thrombotic events after RFA were low and consistent with other contemporary studies, although superficial phlebitis was more frequent after MFA.