Combined technique for sapheno-femoral junction recurrences

BACKGROUND: Endovenous laser ablation (EVLA) represents the gold standard in treating both great and small saphenous veins (GSV and SSV) incompetence, despite few data have been reported on treatment of saphenous-femoral junction recurrences (JRec) by laser endovascular technique and even less by combined laser/foam technique. The aim of this study was to collect JRec treatment outcomes after EVLA and ultrasound guided foam sclerotherapy (UGFS), highlighting technical notes and decision making for the treatment.METHODS: From February 2014 to March 2024, all consecutive patients with JRec matching with inclusion criteria for endovenous ablation and foam sclerotherapy were selected and treated. A 1470-nm diode laser (LASEmaR® 1500; Eufoton, Trieste, Italy), with a kit including 400-600-micron frontal optical fibers (Eufoton, Italy) was used. The optimal linear endovenous energy density (LEED) for the treatment was set according to target vein diameter measured in an upright position in transversal section at the level of the saphenic stump (SS). The fiber tip was placed 1 cm from the saphenous-femoral junction (SFJ). Foam prepared with poloidocanol 1-2% (depending on diameter) with liquid/air ratio of 1-4 was injected before laser energy delivery. JRec characteristics as well as concomitant endovenous procedures were collected. Patients were evaluated clinically and by duplex scan 7 days, 1-3-6 months, and at 1 year after the procedure, assessing JRec closure rate and adverse events.RESULTS: During the study period, a total of 320 JRec were treated (241 women, 79 men with a mean age of 54 years [range: 32 to 84 years] with CEAP classes of C2 [89], C3-C4 [164], C5-C6 [67]). The mean JRec diameter was 9.35 mm (range: 6.0 to 12.5). The LEED was adjusted from 60 J/cm (6.0 mm) up to 80 J/Cm (12.5 mm). Concomitant procedures were anterior saphenous vein (AASV)/anterior thigh circumflex vein (ATCV)/ posterior accessory saphenous vein (PASV)/posterior thigh circumflex vein (PTCV) with EVLA ablation (34) or UGFS (286). At 7-day follow-up period, the closure rate was 98% and remained constant 1 year after the treatment in 240 JRec (75.1%); additional UGFS was required in 2% of cases two months after the first intervention. In 223 (69.8%) cases, residual fibrous cord was noted, indicating successful treatment. No major complications were reported, such as thrombotic complications (from proximal JRec ablation extension to deep system, to deep/ superficial vein thrombosis), but ecchymosis was observed in 50 (15.6%) patients. All ecchymoses disappeared within 50 days after the treatment.CONCLUSIONS: The EVLA and UGFS of JRec with a 1470-nm diode laser and a frontal fiber seems to be an extremely safe technique, particularly when the applied LEED is calculated as a function of the SS diameter. Careful decision making is essential in choosing to treat JRec, balancing venous hemodynamic changes and clinical outcomes.