A Systematic Review and Meta–analysis of Thrombotic Events Following Endovenous Thermal Ablation of the Great Saphenous Vein

Healy DA, Kimura S, Power D, Elhaj A, Abdeldaim Y, Cross KS, McGreal GT, Burke PE, Moloney T, Manning BJ, Kavanagh EG. A Systematic Review and Meta-analysis of Thrombotic Events Following Endovenous Thermal Ablation of the Great Saphenous Vein. Eur J Vasc Endovasc Surg. 2018 Sep;56(3):410-424. doi: 10.1016/j.ejvs.2018.05.008. Epub 2018 Jun 9. PMID: 29895399.

Abstract

Objectives: A systematic review and meta-analysis was performed to determine the incidence of thrombotic events following great saphenous vein (GSV) endovenous thermal ablation (EVTA).

Methods: MEDLINE, Embase and conference abstracts were searched. Eligible studies were randomised controlled trials and case series that included at least 100 patients who underwent GSV EVTA (laser ablation or radiofrequency ablation [RFA]) with duplex ultrasound (DUS) within 30 days. The systematic review focused on the complications of endovenous heat induced thrombosis (EHIT), deep venous thrombosis (DVT), and pulmonary embolism (PE). The primary outcome for the meta-analysis was deep venous thrombotic events which were defined as DVT or EHIT Type 2, 3, or 4. Secondary outcomes for the meta-analysis were EHIT Type 2, 3, or 4, DVT and PE. Subgroup analyses were performed for both the RFA and EVLA groups. Pooled proportions were calculated using random effects modelling.

Results: Fifty-two studies (16,398 patients) were included. Thrombotic complications occurred infrequently. Deep venous thrombotic events occurred in 1.7% of cases (95% CI 0.9-2.7%) (25 studies; 10,012 patients; 274 events). EHIT Type 2, 3, or 4 occurred in 1.4% of cases (95% CI 0.8-2.3%) (26 studies; 10,225 patients; 249 events). DVT occurred in 0.3% of cases (95% CI = 0.2%-0.5%) (49 studies; 15,676 patients; 48 events). PE occurred in 0.1% of cases (95% CI = 0.1-0.2%) (29 studies; 8223 patients; 3 events). Similar results were found when the RFA and EVLA groups were analysed separately.

Conclusion: Thrombotic events occur infrequently following GSV EVTA. Given the large numbers of procedures worldwide and the potential for serious consequences, further research is needed on the burden of these complications and their management.

Summary:

My patient came in with chest pain and palpitations following a recent bilateral EVTA for varicose veins. The attending pointed out that it is important to keep PE on your differential since there is a risk of developing PE following this surgery. This article is a systematic review which looked at complications of EVTA, specifically it’s risk of causing endovastic heat-induced thrombosis (EHIT), DVT or PE. It included 52 studies with 16,398 patients, and found that Deep vein thrombotic events in total occurred in only 1.7% of cases, EHIT occurred in 1.4% of cases, DVT in .3% of cases, and PE in only .1% of cases. Thus, though it is probably still important to do a quick workup to r/o PE in this patient given his symptoms (d-dimer,), the fact that he had a recent phlebectomy should not be raising our suspicions of PE so much, since the risk of PE following phlebectomy is so low.

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