title: Value of delayed duplex ultrasound assessment after endothermal ablation of the great saphenous vein.
abstract: OBJECTIVE
  Endothermal ablation (ETA) of the great saphenous vein (GSV) is associated with a small but definite risk of endothermal heat-induced thrombosis (EHIT) extending into the common femoral vein. Follow-up duplex ultrasound imaging to detect EHIT after ETA is considered standard of care, although the exact timing of duplex ultrasound imaging to detect EHIT after ETA remains unclear. We hypothesized that an additional duplex ultrasound assessment 1 week after ETA would not identify a significant number of patients with EHIT and would significantly increase health care costs.
  
  
  METHODS
  This was a retrospective review of consecutive ETA GSV procedures from 2007 to 2014. All patients were evaluated with duplex ultrasound imaging on postprocedure day 1, and 79% of patients underwent a second ultrasound assessment 1 week postprocedure. EHIT was considered present when proximal GSV closure progressed to level ≥4, based on a six-tier classification system.
  
  
  RESULTS
  From January 1, 2007, until December 31, 2014, 842 patients underwent GSV ETA. Patients with EHIT were more likely to have had a prior deep venous thrombosis (DVT; P = .002) and a larger GSV (P = .006). Forty-three procedures (5.1%) were classified as having EHIT requiring anticoagulation, based on a level ≥4 proximal closure level. Of the 43 patients with EHIT, 20 (47%) were found on the initial ultrasound assessment performed 24 hours postprocedure, but 19 patients (44%) with EHIT would not have been identified with a single postoperative ultrasound scan performed 24 hours after intervention. These 19 patients had a level ≤3 closure level at the duplex ultrasound scan performed 24 hours postprocedure and progressed to EHIT on the delayed duplex ultrasound scan. Lastly, thrombotic complications in four patients (9%), representing three late DVT and one DVT/pulmonary embolism presenting to another hospital, would not have been identified regardless of the postoperative surveillance strategy. Maximum GSV diameter was the only significant predictor of progression to EHIT on multivariate analysis (P = .007). Based on 2014 United States dollars, the two-ultrasound surveillance paradigm is associated with health care charges of $31,109 per identified delayed venous thromboembolism event.
  
  
  CONCLUSIONS
  Delayed duplex ultrasound assessment after ETA of the GSV comes with associated health care costs but does yield a significant number of patients with progression to EHIT. Better understanding of the timing, risk factors, and significance of EHIT is needed to cost-effectively care for patients after ETA for varicose veins.
authors.affiliation: Department of Endovascular and Vascular Surgery, Geisinger Medical Center, Danville, Pa. Electronic address: ejryer@geisinger.edu.
authors.forename: Evan J
authors.initials: EJ
authors.lastname: Ryer
authors.affiliation: Department of Endovascular and Vascular Surgery, Geisinger Medical Center, Danville, Pa.
authors.forename: James R
authors.initials: JR
authors.lastname: Elmore
authors.affiliation: Department of Endovascular and Vascular Surgery, Geisinger Medical Center, Danville, Pa.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Garvin
authors.affiliation: Department of Endovascular and Vascular Surgery, Geisinger Medical Center, Danville, Pa.
authors.forename: Matthew C
authors.initials: MC
authors.lastname: Cindric
authors.affiliation: Department of Endovascular and Vascular Surgery, Geisinger Medical Center, Danville, Pa.
authors.forename: James T
authors.initials: JT
authors.lastname: Dove
authors.affiliation: Department of Endovascular and Vascular Surgery, Geisinger Medical Center, Danville, Pa.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Kekulawela
authors.affiliation: Department of Endovascular and Vascular Surgery, Geisinger Medical Center, Danville, Pa.
authors.forename: David P
authors.initials: DP
authors.lastname: Franklin
mesh_terms: D055011:Ablation Techniques / Q000009:adverse effects* / Q000191:economics; D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D002908:Chronic Disease; D003362:Cost-Benefit Analysis; D005260:Female; D005268:Femoral Vein / Q000000981:diagnostic imaging*; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania; D011237:Predictive Value of Tests; D011655:Pulmonary Embolism / Q000000981:diagnostic imaging / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D012501:Saphenous Vein / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex / Q000191:economics; D014689:Venous Insufficiency / Q000000981:diagnostic imaging / Q000191:economics / Q000503:physiopathology / Q000601:surgery*; D020246:Venous Thrombosis / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000191:economics / Q000209:etiology
chemical_list: D000925:Anticoagulants