Journal of Vascular Surgery
Volume 40, Issue 6 , Pages 1166-1173, December 2004

Ultrasound findings after radiofrequency ablation of the great saphenous vein: Descriptive analysis

Presented at the Sixteenth Annual Meeting of the American Venous Forum, Orlando, Fla, Feb 26-29, 2004.

Jobst Vascular Center

Received 6 July 2004; accepted 16 September 2004.

Article Outline

Objective

As an emerging endovascular alternative to ligation and stripping of the incompetent greater saphenous vein (GSV), radiofrequency ablation was monitored with ultrasound scaning to evaluate anatomic results. Neovascularization and inflammation are potential consequences that lead to the appearance of small vessels. The natural history of the below-knee untreated GSV segment may be important in our understanding of ongoing chronic venous disease. An ultrasound follow-up study was conducted to determine the prevalence of small vessel networks, defined as veins and arteries less than 2 mm in diameter, adjacent to the saphenofemoral junction (SFJ); prevalence of small vessel networks adjacent to the treated GSV in the thigh; and fate of the below-knee untreated GSV distal to the ablated segment.

Methods

One hundred six extremities with radiofrequency ablation of the GSV for treatment of superficial venous insufficiency were followed up with high-resolution ultrasound imaging 4 to 25 months (median, 9 months) after the procedure. Ninety-three limbs had concomitant ligation and division of the SFJ and its tributaries, and 13 limbs underwent radiofrequency ablation without SFJ ligation. Ultrasound was used to evaluate patients for small vessel networks, and concomitant findings of small vessel networks and recanalization at the SFJ and adjacent to the treated GSV. The status of the below-knee segment of untreated GSV was evaluated for patency and reflux. Data analysis compared the findings in the ligation group with those in the no-ligation group, with the χ2 test and Fisher exact test.

Results

We found small vessel networks in 65% (n = 69) of extremities: 15% (n = 16) at the SFJ only, 26% (n = 28) in the thigh only, and 24% (n = 25) at both the SFJ and thigh, resulting in a small vessel network prevalence of 39% (n = 41) at the SJF and 50% (n = 53) in the thigh. The prevalence of small vessel networks at the SFJ was significantly less after radiofrequency ablation with SFJ ligation (34%, 32 of 93) than after radiofrequency ablation without ligation (69%, 9 of 13; P = .035). Small vessel networks and GSV recanalization at the SFJ was more common in patients undergoing radiofrequency ablation without ligation (46%, 6 of 13) than after radiofrequency ablation with ligation (14%, 13 of 93; P = .014). The prevalence of small vessel networks in the thigh was not affected by SFJ ligation. The below-knee GSV was patent in 79% (84 of 106), and 58% (61 of 106) demonstrated reflux, a decrease from the pre–radiofrequency ablation rate of 71% (75 of 106), possibly because thrombosis extended distally beyond the ablated segment in 16% (17 of 106) of the legs.

Conclusions

Small vessel networks were detected adjacent to or in connection with most of the radiofrequency ablation–treated GSVs. SFJ ligation was associated with fewer small vessel networks and proximal GSV recanalization. Most below-knee untreated GSV segments remained patent, and most exhibited reflux.

 

The incompetent greater saphenous vein (GSV) in patients with chronic superficial venous insufficiency has been treated with a variety of procedures, including ligation of the saphenofemoral junction (SFJ) and stripping, ligation of the SFJ alone, banding, foam or liquid sclerotherapy, endovascular ablation, and compression stockings.1, 2, 3, 4, 5, 6, 7, 8, 9 The traditional, most widely accepted treatment is ligation and division of the SFJ and its tributaries, with stripping of the GSV trunk.1, 10 Radiofrequency ablation is an endovascular technique designed to ablate the incompetent GSV without the need for stripping.7, 8, 10, 11, 12, 13 Less pain, early discharge, early return to work and normal activities, and potential for cost savings are advantages of this endovascular procedure.11, 12 The vascular surgeons at Jobst Vascular Center implemented a radiofrequency ablation program in February 2001.14 In addition to radiofrequency ablation from the SFJ to just below the knee for ablation of the GSV, ligation with interruption of the GSV and SFJ tributaries was performed uniformly by 1 surgeon and selectively by 2 other surgeons. Follow-up of this novel treatment was performed in the noninvasive vascular laboratory.

Color-flow, duplex ultrasound has become a common and effective means for preoperative mapping, intraoperative guidance, and postoperative follow-up.2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 The fate of the treated GSV segment has been reported.14 The purposes of this report are to describe the prevalence of small vessel networks at the SFJ and in the thigh after radiofrequency ablation, and the association of small vessel networks and recanalization of the treated GSV at the SFJ and thigh, and to assess whether there are differences in patients undergoing SJF ligation compared with those treated without ligation. The distal untreated GSV segment was also examined and described for patency and reflux.

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Methods 

Patients 

Color-flow ultrasound scanning was performed in 106 extremities in 89 patients (82% women, 18% men; average age, 54 ± 13 years [range, 25-83 years; median, 52 years]) 4 to 25 months (median, 9 months) after radiofrequency ablation. Ultrasound follow-up was offered to patients who had undergone radiofrequency ablation in the 2-year period beginning February 2001. This is a review of all patients who underwent the examination. The study sample population represented 49% of radiofrequency ablation procedures performed during this period. Preoperative CEAP clinical classification23 documented 6 extremities with C6 disease with open ulcers (6%), 15 limbs with C5 disease with healed ulcers (14%), and 23 legs with C4 disease with skin and soft tissue changes ranging from pigmentation to lipodermatosclerosis (22%). Ninety-three extremities (88%) had visible varicose veins. All procedures were performed to treat symptomatic valvular insufficiency of the GSV objectively demonstrated by preoperative duplex ultrasound examination. Reflux longer than 500 msec was detected in the thigh segment of the GSV in all extremities (100%), at the SFJ in 93 extremities (88%), and in the below-knee GSV segment in 75 extremities (71%).

Operative procedure 

A succinct description of the radiofrequency ablation procedure performed at our institution is presented. Other details have been previously described.14 Varicose veins were marked preoperatively with the patient standing. After administration of general or local anesthesia, the saphenous vein was cannulated with ultrasound guidance, most commonly at the mid-calf to upper calf. Preference was given to the use of a 6F versus 8F VNUS radiofrequency ablation catheter. The radiofrequency ablation catheter tip was placed in the proximal GSV, just below the SFJ, with ultrasound guidance. Tumescent anesthesia was used as needed, to develop a skin-catheter separation greater than 1 cm. The catheter was pulled back at a rate of 2 to 3 cm/min. Flush ligation of the GSV with its division, and ligation and division of tributaries of the SFJ was performed in 93 extremities (88%). In some patients ligation was deemed unnecessary if there was a functional valve at the SFJ but the GSV reflux was distal to the SFJ. Post-treatment ablation of the saphenous vein was confirmed with ultrasound imaging. Microphlebectomy was performed routinely to treat varicose veins.

Color-flow duplex ultrasound scanning 

The color-flow venous duplex ultrasound protocol used to evaluate the treated GSV segment has been described.14 Details of the protocol to detect small vessels are emphasized in this section.

A Philips/ATL HDI 5000 was used for ultrasound imaging. A linear array, 4-MHz to 7-MHz probe was preferred. The patient rested on an inclined (10-15 degrees) stretcher, with the feet down enough to dilate the leg veins. A measuring tape was placed over the anterior aspect of the lower extremity from groin to foot. Ultrasound imaging was continuous, and repeated as needed, from groin to ankle. Image depth, focus, zooming, and color-flow sensitivity were optimized in each patient.

In contrast to pre-radiofrequency ablation ultrasound testing, which was performed with standard venous settings, color-flow sensitivity was increased during the follow-up examinations to improve detection of recanalized GSV segments and small vessel networks. Small vessel networks were defined as veins and arteries less than 2 mm in diameter. Flow sensitivity was increased 2-fold by decreasing the velocity scale as affected by pulse repetition frequency. Color gain was maintained just below noise levels, to ensure maximal sensitivity. Due to small vessel tortuosity, velocity signals were used to detect flow characteristics and to differentiate arteries from veins. Flow with venous or arterial characteristics were noted adjacent to thrombosed or occluded GSV segments or within recanalized GSV segments. Muscle vessels, often an artery-vein pair, approaching the treated GSV were observed. Communicating veins and concomitant arteries, tributary veins, or superficial arteries connected to the treated GSV were also observed.

Small vessel networks were ascribed to 2 distinct locations: vessels were classified as being in the SFJ region if detected within 7 cm from the groin crease or adjacent to the SFJ (Fig 1), and vessels detected distal to the SFJ region and proximal to the knee were considered “thigh” vessels.

  • View full-size image.
  • Fig 1. 

    Ultrasound observations of small vessel networks at or near the saphenofemoral junction after radiofrequency ablation of the greater saphenous vein. A, Transverse image of superficial femoral artery (SFA) in red, deep femoral artery (DFA) with mixed red and blue colors, common femoral vein (CFV) in blue, and small arteries and veins superficial to deep vessels. B, Venous flow waveform (top) and arterial flow waveform (bottom) from small vessels shown in A.

Recanalization was interpreted as visualization of color flow with Doppler signals inside a treated GSV. Thickened vein walls with evidence of fibrosis or thrombosis were a factor in differentiating a recanalized segment from an untreated segment. Recanalized segments were commonly short, with small diameters. Others appeared to be filled with small, localized fresh thrombus associated with blood flow, having the characteristics of both arterial venous components. Direction of flow in recanalized segments varied from forward to reversed, or occurred in either direction, with compression maneuvers. In most cases significant reflux could not be ascribed to such small, recanalized segments. GSV tributaries, perforating veins, and communicating veins connected to muscle veins were also detected as an inflow source or drainage from a recanalized GSV. Small vessel networks in both arteries and veins were often traced to vessels immediately below telangiectasias.

Fig 2 shows a series of ultrasound images detected around a recanalized GSV segment in the thigh. Fig 3 is a composite picture that schematically and actually demonstrates the interconnections observed from a newly developed telangiectasia, a valve sinus of a radiofrequency ablation–treated GSV, and vessels originating deep in the muscle.

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  • Fig 2. 

    Ultrasound observations of small vessel networks and recanalization in thigh after radiofrequency ablation of the greater saphenous vein (GSV). Transverse and longitudinal images demonstrate small vessels at or near the treated GSV. Longitudinal images demonstrate recanalization and thickened venous wall. A superficial tributary feeds the recanalized segment. Doppler sample volume placed near a shrunken saphenous vein demonstrates both arterial and venous flow waveforms.

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  • Fig 3. 

    Ultrasound observations of small vessel networks and limited recanalization in thigh after radiofrequency ablation of the greater saphenous vein in a patient with new telangiectasias. A, Longitudinal image demonstrates small artery approaching region under new telangiectasias. B, Longitudinal image demonstrates tributary vein and concomitant artery connection to partially thrombosed vein valve sinus. C, Transverse image of atretic greater saphenous vein and longitudinal representation of small vessels connected to muscular vasculature. D, B-mode, color-flow, and duplex Doppler ultrasound scans of partially thrombosed valve sinus.

The below-knee GSV segment, distal to the radiofrequency ablation–treated GSV, was classified as either occluded, patent without reflux, or patent with persistent reflux greater than 500 msec. In GSVs with mixed findings in the calf (eg, with segmental patency or segmental reflux), the most dominant finding was reported based primarily on length of the segment involved.

Data analysis 

The prevalence of abnormal findings was calculated as the frequency or percentage ratio of the following observations: (1) small vessel networks in the SFJ region, thigh or both; (2) small vessel networks in the SFJ region after radiofrequency ablation with SFJ ligation; (3) small vessel networks in the SFJ region after radiofrequency ablation without ligation; (4) small vessel networks in the thigh after radiofrequency ablation with SFJ ligation; or (5) small vessel networks in the thigh after radiofrequency ablation without ligation.

Prevalence of small vessel networks at the junction (thigh) with SFJ ligation was compared with small vessel network prevalence without ligation with the χ2 test or Fisher exact test. These calculations and comparisons were repeated for combined findings of small vessel networks and recanalization.

Similarly, prevalence of below-knee untreated GSV patency without reflux, patency with reflux, or occlusion were calculated as the frequency of each occurrence. These observations were compared with pre–radiofrequency ablation findings.

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Results 

Sixty-five percent of extremities had small vessel networks, which were detected either in the SFJ, thigh, or both (Table I).

Table I. Ultrasound findings after radiofrequency ablation of great saphenous vein: Prevalence of small vessel networks by location
LocationPrevalence
n%
Total60 of 10665
SFJ only1615
Thigh only2826
SFJ and thigh2524

SFJ, Saphenofemoral junction, defined as region within 7 cm from groin crease.

Small vessels were detected in 41 of 106 SFJs (39%), and proximal GSV recanalization was detected in 19 extremities (18%). Small vessel networks were detected in 34% (32 of 93) of extremities treated with ligation of the SFJ (Table II). Of these 32 extremities, 14 (44%) also had recanalization of the proximal GSV. In the group without SFJ ligation, small vessel networks were detected in 69% (9 of 13) of extremities. Of these 9 extremities with small vessel networks, 6 (67%) had recanalization of the proximal GSV. Despite the mismatch in numbers of extremities, the prevalence of small vessel networks and of small vessel networks with recanalization was significantly lower in the group with ligation of the SFJ (P < .05, Fisher exact test). All recanalized segments started within 4 cm from the junction, and their average length was 6 cm. The proximal and distal ends of the recanalized segments were associated with small veins and small arteries adjacent to these veins.

Table II. Ultrasound findings after radiofrequency ablation of GSV: Prevalence of small vessel networks and recanalization at SFJ
SFJ ligationP
YesNo
n%n%
Small vessel networks32 of 93349 of 1369.035
Small vessel networks and GSV recanalization13 of 93146 of 1346.014

GSV, Greater saphenous vein; SFJ, saphenofemoral junction, defined as region within 7 cm from groin crease.

Small vessels were detected in 53 thighs (50%), and recanalization was detected in 37 thigh segments of the GSV (35%). SFJ ligation did not affect the prevalence of small vessel networks in the thigh or the prevalence of GSV recanalization (Table III). Small vessel networks were detected in 47% (44 of 93) of extremities treated with ligation of the SFJ. Of these 44 extremities, 31 (70%) also had recanalization of the GSV segment in the thigh. In the group without ligation, small vessel networks were detected in 69% (9 of 13) of extremities. Of these 9 cases, 6 (67%) had recanalization of the GSV in the thigh. Seven veins had 2 distinct recanalized segments. The recanalized segment started, on average, 17 cm from the groin, and average length was 5 cm. Recanalized segments were associated with a network of small veins at the proximal and distal ends of the reopened channel. Small arteries were commonly noted concomitant with the recanalized veins.

Table III. Ultrasound findings after radiofrequency ablation of GSV: Prevalence of small vessel networks and recanalization in treated thigh segment
SFJ ligationP
YesNo
n%n%
Small vessel networks44 of 93479 of 1369.24
Small vessel networks and GSV recanalization31 of 93336 of 1346.55

GSV, Greater saphenous vein; SFJ, saphenofemoral junction.

The outcome of the below-knee GSV segments is shown in Table IV. Most GSVs were patent in the calf (84 of 106, 79%), and most had reflux (61 of 106, 58%). Comparison with preoperative findings of reflux in the below-knee segment is presented in Table V. The actual prevalence of reflux decreased from 71% (75 of 106) before radiofrequency ablation to 58% (61 of 106) after radiofrequency ablation. Although most below-knee untreated GSVs remained patent and had reflux, radiofrequency ablation of a proximal segment abolished reflux in 20% (n = 15) of calf GSVs with reflux before radiofrequency ablation. In contrast, new reflux was noted in 39% (n = 12) of calf GSVs that did not have reflux before radiofrequency ablation, demonstrating the progressive nature of this disease. A variety of refluxing networks were observed involving the GSV, the posterior arch of the GSV, other tributaries and perforator vessels, which probably kept the calf GSV patent and refluxing. The reduction in prevalence of reflux may be related to thrombosis extending distally beyond the ablated segment in 17 legs (16%) and the 5 calf GSVs that were stripped.

Table IV. Ultrasound findings after radiofrequency ablation of GSV: Outcome of below-knee GSV
ConditionPrevalence
n%
GSV patent (N = 106)8479
Patent without reflux2321
Patent with reflux6158
GSV occluded or absent (N = 106)2221
Stripped55
Thrombosed, atretic, or absent1716
Perforating vein reflux (N = 106)3028

GSV, Greater saphenous vein.

Table V. Outcome of below-knee greater saphenous vein: Comparison of pre–radiofrequency ablation vs follow-up ultrasound findings
Before radiofrequency ablationRadiofrequency ablation follow-up
RefluxNo refluxOccluded*
n%n%n%
Reflux (N = 75)496515201115*
No reflux (N = 31)12398261135†
Total (N = 106)615823212221†

* Occluded or absent: 5 below-knee greater saphenous veins with reflux were stripped and thrombosis propagated distally beyond radiofrequency ablation–treated segment in 6.

† Distally propagated thrombosis in 11 of 11 and 17 of 22, respectively.

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Discussion 

Color-flow duplex ultrasound has become a standard means of evaluating the veins of the lower extremity for deep venous thrombosis, valvular insufficiency, preoperative mapping, intraoperative imaging, and posttreatment follow-up.2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27 This investigation focused on ultrasound observations after radiofrequency ablation of the GSV, with specific attention given to detection of small vessel networks and follow-up of the below-knee untreated segment. We think that the use of the term “small vessel networks” is more accurate than neovascularization. However, it may well represent the same process. Small vessel networks were not detected preoperatively in connection with the GSV. However, the refined imaging technique was not used until the follow-up examination. The development of small vessel networks appears to be a dynamic process likely related to inflammation.

The initial approach taken by surgeons a the Jobst Vascular Center was that radiofrequency ablation substituted for stripping, but not necessarily for ligation, of the SFJ and its tributaries. Therefore ligation of the SFJ and tributaries was performed in most patients to avert thrombus propagation in the common femoral vein, to eliminate reflux via SFJ tributaries, and potentially to reduce recurrence of varicose veins. Most of the treated vein length was obliterated in 99% of extremities.14 However, recanalization of small segments of the treated GSV occurred in about half of the extremities.

The issue of whether the SFJ junction and the tributaries should be ligated and divided is not yet settled.13 There appears to be a trend away from ligation when performing radiofrequency ablation. In this series most patients had incompetent valves at the SFJ. In the experience of others, a significant proportion of radiofrequency ablation–treated extremities had reflux limited to segments of the GSV, starting in the thigh, distal to a normal, nonrefluxing SFJ.15, 22 After radiofrequency ablation without ligation in such extremities we would expect to find a patent SFJ and proximal segment of the GSV.8, 11, 12, 13, 15, 21, 22 It is not yet known whether concurrent SFJ and tributary ligation reduces recurrence in the groin region. Another question is whether ligation reduces complications of radiofrequency ablation, specifically, thrombosis. Hingorani et al27 reported that thrombus extended into the common femoral vein after radiofrequency ablation with a frequency much higher than previously described.

Patterns of small arteries and veins underneath telangiectasias and their venous drainage have been detected at ultrasound scanning.25 In our experience these vessels are often smaller than 1 mm in diameter and are detected as close as a few millimeters from the skin. A communicating or perforating vein adjacent to a communicating or perforating artery commonly drains these small veins. In this series a continuous line of small arteries and veins was observed linking deep vessels, radiofrequency ablation–treated GSV segments, and newly formed telangiectasias (Fig 3). In addition to the connection with inflow and outflow tributaries, recanalized GSV segments were adjacent to or in connection with small arteries. Small arteriovenous connections or malformations may contribute to the cause of varicose veins, and identification of arteriovenous anastomoses with ultrasound scanning has guided treatment.26

Of interest, SFJ ligation was associated with a decreased prevalence of small vessel networks and less recanalization of the proximal GSV. These observations raise several issues with implications regarding the cause of small vessel networks. Apparently even SFJ ligation and resection cannot prevent some recanalization of the treated GSV. Whether this has clinical relevance remains to be seen. Large and small vessels may appear adjacent to the SFJ at variable times after radiofrequency ablation. Without SFJ ligation, radiofrequency ablation or thrombosis may induce an inflammatory process capable of inducing neovascularization and recanalization. The small vessel networks observed in this study contain serpentine arterial and venous components, and bear similarity to the neovascularization described after ligation and stripping procedures, a process thought to be a cause of recurrent varicose veins.28, 29, 30, 31, 32, 33, 34 At patient follow-up after ligation and stripping of the GSV we have detected arterial flow signals within the thrombosed and partially recanalized channel of the stripped saphenous vein (Fig 4). Mitchell et al35 reported vascularization of the hematoma tract after GSV stripping as a new cause of recurrent varicose veins. Reid et al36described arterial signals found within the lumen of thrombosed femoral veins undergoing physiologic lysis. These findings are consistent with the appearance of small vessel networks in association with the inflammatory process associated with thrombosis. Labropoulos et al37 reported that the severity of chronic venous insufficiency parallels changes noted with an inflammatory process. Hyperemic venous flow and increased arterial diastolic flow were noted in large vessels of extremities with skin changes and ulcers (C4-6). Skin blood flow also increases with the severity of chronic venous disease, and may correlate with a previous incidence of deep venous thrombosis.38 Arterial flow may also increase in the asymptomatic extremity of patients with contralateral venous insufficiency, perhaps as a consequence of released inflammatory substances or changes in vasomotor tone.39 The small vessel networks we detected may be a consequence of a thrombotic, inflammatory process. Whether these lead to arteriovenous communications and venous hypertension needs to be further evaluated.

  • View full-size image.
  • Fig 4. 

    Ultrasound observations of arterial flow within channel of previously stripped greater saphenous vein. A, Transverse B-mode image of thrombosed channel of previously stripped greater saphenous vein at mid-thigh. B, Transverse color-flow or power Doppler image shows small vessel (artery) in contact with thrombus. C, Doppler flow waveform confirms arterial characteristics of vessel within channel.

Treatment of the thigh segment of the GSV may abolish reflux in the below-knee untreated GSV. Reflux of the distal GSV may have been abolished either because radiofrequency ablation eliminated a proximal source of reflux or because thrombosis extended distally beyond the ablated segment. However, for each GSV with elimination of reflux, 3 veins remained refluxing. Despite radiofrequency ablation, venous insufficiency may progress, and new reflux was noted in some patients during follow-up. Patients were uniformly improved postoperatively, regardless of findings at the distal GSV. These findings emphasize the progressive nature of venous insufficiency and justify patient monitoring to determine clinical evolution and future treatment. The fundamental question relates to the implications of findings of small vessel networks. If we assume that small vessels appear as a consequence of inflammation, technical details that reduce thrombus formation and inflammation may be helpful.

In summary, patients treated with radiofrequency ablation of the GSV had a high prevalence of small vessel networks at the SFJ and thigh within 2 years of treatment. Ligation of the SFJ and its tributaries decreased the prevalence of small vessel networks and recanalization of the proximal GSV. The below-knee untreated GSV most likely remains patent, with incompetent valves; however, the clinical relevance of this observation is not yet clear. In conclusion, monitoring the development of small vessel networks and the outcome of the below-knee untreated GSV may add to our understanding of the outcome in patients who undergo radiofrequency ablation when correlated with arteriovenous shunts, telangiectasias, inflammation, and recurrence of varicose veins or other signs and symptoms of chronic venous disease. The study of small vessel networks and their relationship to thrombosis and inflammation and the details of the ablative procedure may reveal fundamental information about short-term and long-term outcome.39

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 Competition of interest: Drs Dosick, Gale, and Seiwert received stipends as speakers at an educational and training conference held by VNUS Medical Technologies, Inc, in 2002.

PII: S0741-5214(04)01241-8

doi:10.1016/j.jvs.2004.09.015

Journal of Vascular Surgery
Volume 40, Issue 6 , Pages 1166-1173, December 2004

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