title: Reflux in the below-knee great saphenous vein can be safely treated with endovenous ablation.
abstract: BACKGROUND
  Intervention on the great saphenous vein (GSV) has traditionally been limited to the above-knee (AK-GSV) segment for fear of saphenous neuralgia in spite of incompetence demonstrated in the below-knee (BK-GSV) segment. Residual symptoms and need for reintervention are reported to result in nearly half the patients if the refluxing BK-GSV is ignored. Experience with endovenous ablation of the BK-GSV at the time of AK-GSV treatment is sparsely reported in the literature. The aim of this study was to evaluate the safety of endovenous ablation of the refluxing BK-GSV.
  
  
  METHODS
  Data from consecutive patients treated with superficial venous ablation during a 48-month period from January 2010 to December 2013 were retrospectively reviewed. Demographic and procedure-related outcome and complication data were analyzed specifically for patients undergoing BK-GSV interventions.
  
  
  RESULTS
  A total of 550 patients were treated with superficial venous ablation during the study period. Of those, 61 (79 limbs) underwent BK-GSV ablation for reflux at this site. There were 36 women and 25 men (mean age, 55 years). Median Clinical, Etiologic, Anatomic, and Pathologic (CEAP) score was 3.4; 43 limbs were treated for symptomatic varicose veins (C 1-3) and 36 for advanced venous insufficiency (C 4-6); 14 limbs (18%) were treated for recurrent symptomatic varicose veins or venous insufficiency after prior superficial venous intervention with AK-GSV ablation, sclerotherapy, or stripping. Comorbidities included obesity (54%) with mean body mass index of 30.7 (range, 19 to 52), obstructive sleep apnea (10%), pulmonary hypertension (3%), and congestive heart failure (3%). Ablation was performed in 77 limbs (99%) with the VenaCure EVLT laser vein treatment (AngioDynamics, Queensbury, NY) and in two limbs by radiofrequency ablation with ClosureFAST system (VNUS Medical Technologies, San Jose, Calif). The mean length of GSV ablated was 51.2 cm (range, 26-67 cm). Endovenous ablation was performed concomitantly on 22 accessory GSVs (28%) and 10 incompetent perforators (13%). Ambulatory stab phlebectomy of branch varicosities was performed simultaneously in 59 limbs (75%). All veins treated were evaluated with ultrasound on postprocedure day 1, and no evidence of endovenous heat-induced thrombosis was detected. Eight patients (10%) went on to have preplanned sclerotherapy treatment for small-branch varicosities. Postoperative paresthesia occurred in three patients (4%) and resolved within 4 weeks. Wound infection in three (4%) stab phlebectomy wounds resolved with oral antibiotic therapy. Follow-up surveillance ultrasound was available in 32 of 79 limbs that were >6 months from the procedure. Partial late recanalization was noted in four of 32 limbs, but no patient had recurrent symptoms requiring repeated endovenous ablation during this period.
  
  
  CONCLUSIONS
  Endovenous ablation of the refluxing BK-GSV segment can be performed safely with minimal complications. Consideration should be given to concomitant ablation of the BK-GSV in treatment of patients with varicose veins with reflux extending to the BK segment of the GSV to improve long-term outcomes.
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address: gifford.shaun@mayo.edu.
authors.forename: Shaun M
authors.initials: SM
authors.lastname: Gifford
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Manju
authors.initials: M
authors.lastname: Kalra
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Peter
authors.initials: P
authors.lastname: Gloviczki
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Audra A
authors.initials: AA
authors.lastname: Duncan
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Gustavo S
authors.initials: GS
authors.lastname: Oderich
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Fleming
authors.affiliation: Department of Biostatistics, Mayo Clinic, Rochester, Minn.
authors.forename: Scott
authors.initials: S
authors.lastname: Harmsen
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Bower