Clinical Research| Volume 91, P182-190, April 2023

Incidence and Significance of Deep Venous Reflux in Patients Treated with Saphenous Vein Ablation

Published:January 20, 2023DOI:


      • 20% of patients with saphenous vein ablation (VA) had deep venous reflux (DVR).
      • Patients with DVR were more likely to develop endovenous heat-induced thrombosis (EHIT) II-III (26.3% vs. 3.6%).
      • Post-thrombotic DVR patients had more severe disease than those with primary DVR.


      Venous ablation (VA) of the saphenous vein is the most common procedure performed for venous insufficiency. The incidence of concomitant deep venous reflux (DVR) in patients undergoing VA is unknown. Our hypothesis is that patients undergoing saphenous VA with concomitant DVR exhibit a higher clinical, etiology, anatomy, and pathophysiology (CEAP) stage and less relief after VA compared to patients without DVR.


      Electronic medical records of patients treated with saphenous VA at a tertiary care center from March 2012 to June 2016 were reviewed. Patients were divided into 2 groups based on presence or absence of DVR on initial ultrasound (US) before saphenous VA. Patient characteristics and outcomes were compared. A telephone survey was conducted to assess long-term symptomatic relief, compliance with compression, and pain medication use. Subgroup analysis of patients with post-thrombotic versus primary DVR was performed.


      362 patients underwent 497 ablations, and the incidence of DVR (>1 sec) was 20% (N = 71). Patients with DVR were significantly more likely to be male (46.4% vs. 32.1%, P = 0.021) and of Black race (21.2% vs. 5.5%, P = 0.0001) compared to patients without DVR. Patients with DVR were more likely to have a history of deep vein thrombosis (DVT) (15.1% vs. 7.9%, P = 0.045), but there was no difference in other comorbidities. There was no significant difference in presenting symptoms, CEAP stage, or symptom severity based on numeric rating scale (NRS) (0-10) for pain and swelling. Clinical success of saphenous VA was comparable between the 2 groups, but patients with DVR were more likely to develop endovenous heat-induced thrombosis (EHIT) II-IV (6% vs. 1%, P = 0.002). After a mean follow-up of 26 months, there was still no difference in pain or swelling scores, but patients with DVR were more likely to use compression stockings and used them more frequently. Only 11 of 71 patients with DVR had a history of DVT. Patients with post-thrombotic DVR were significantly older than patients with primary DVR (67.3 vs. 57.2, P = 0.038) and exhibited a trend toward more advanced venous disease (C4-C6: 45.4% vs. 33.3%, P = 0.439).


      In this study, 20% of patients undergoing saphenous VA demonstrated DVR, which was more common in Black men. Presence of DVR is associated with increased risk of EHIT after saphenous VA but does not seem to impact disease severity or clinical relief after ablation. Larger studies are needed to understand outcome differences between post-thrombotic and primary DVR.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Shammeri O.
        • Alhamdan N.
        • Al-Hothaly B.
        • et al.
        Chronic venous insufficiency: prevalence and effect of compression stockings.
        Int J Health Sci. 2014; 8: 231-236
        • Maurins U.
        • Hoffmann B.
        • Losch C.
        • et al.
        Distribution and prevalence of reflux in the superficial and deep venous system in the general population–results from the Bonn Vein Study, Germany.
        J Vasc Surg. 2008; 48: 680-687
        • Labropoulos N.
        • Leon L.
        • Kwon S.
        • et al.
        Study of the venous reflux progression.
        J Vasc Surg. 2005; 41: 291-295
        • Abi-Chaker A.
        • Aguirre P.
        • Almeida J.
        Strategies to treat venous reflux disease.
        in: Chaar C. Current Management of Venous Diseases. Springer International Publishing, Cham2018: 185-206
        • Labropoulos N.
        • Tassiopoulos A.
        • Kang S.
        • et al.
        Prevalence of deep venous reflux in patients with primary superficial vein incompetence.
        J Vasc Surg. 2000; 32: 663-668
        • Maleti O.
        • Lugli M.
        Valve reconstruction for deep venous reflux.
        in: Chaar C. Current Management of Venous Diseases. Springer International Publishing, Cham2018: 217-229
        • Maleti O.
        • Lugli M.
        • Tripathi R.K.
        Deep venous reconstructive surgery.
        Semin Vasc Surg. 2015; 28: 39-46
        • Danielsson G.
        • Arfvidsson B.
        • Eklof B.
        • et al.
        Reflux from thigh to calf, the major pathology in chronic venous ulcer disease: surgery indicated in the majority of patients.
        Vasc Endovasc Surg. 2004; 38: 209-219
        • Valencia I.C.
        • Falabella A.
        • Kirsner R.S.
        • et al.
        Chronic venous insufficiency and venous leg ulceration.
        J Am Acad Dermatol. 2001; 44: 401-424
        • Vasudevan T.
        • Robinson D.A.
        • Hill A.A.
        • et al.
        Safety and feasibility report on nonimplantable endovenous valve formation for the treatment of deep vein reflux.
        J Vasc Surg Venous Lymphat Disord. 2021; 9: 1200-1208
        • Sales C.M.
        • Bilof M.L.
        • Petrillo K.A.
        • et al.
        Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux.
        Ann Vasc Surg. 1996; 10: 186-189
        • Eklöf B.
        • Rutherford R.B.
        • Bergan J.J.
        • et al.
        Revision of the CEAP classification for chronic venous disorders: consensus statement.
        J Vasc Surg. 2004; 40: 1248-1252
        • Kabnick L.S.
        • Sadek M.
        • Bjarnason H.
        • et al.
        Classification and treatment of endothermal heat-induced thrombosis: recommendations from the American venous Forum and the society for vascular surgery.
        J Vasc Surg Venous Lymphat Disord. 2021; 9: 6-22
        • Myers K.A.
        • Ziegenbein R.W.
        • Zeng G.H.
        • et al.
        Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux.
        J Vasc Surg. 1995; 21: 605-612
        • Welch H.J.
        • Young C.M.
        • Semegran A.B.
        • et al.
        Duplex assessment of venous reflux and chronic venous insufficiency: the significance of deep venous reflux.
        J Vasc Surg. 1996; 24: 755-762
        • Labropoulos N.
        • Delis K.
        • Nicolaides A.
        • et al.
        The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency.
        J Vasc Surg. 1996; 23: 504-510
        • Bradbury A.
        • Evans C.J.
        • Allan P.
        • et al.
        The relationship between lower limb symptoms and superficial and deep venous reflux on duplex ultrasonography: the Edinburgh Vein Study.
        J Vasc Surg. 2000; 32: 921-931
        • Yilmaz S.
        • Cakir Pekoz B.
        • Dincer N.
        • et al.
        Classification of reflux patterns in patients with great saphenous vein insufficiency and correlation with clinical severity.
        Diagn Interv Radiol. 2021; 27: 219-224
        • Tripathi R.
        Surgical repair of primary deep vein valve incompetence.
        in: Gloviczki Peter Dalsing Michael C. Eklöf Bo Handbook of Venous and Lymphatic Disorders. CRC Press, Cham2017 (Ch 43)
        • Raju S.
        • Fredericks R.K.
        • Neglèn P.N.
        • et al.
        Durability of venous valve reconstruction techniques for "primary" and postthrombotic reflux.
        J Vasc Surg. 1996; 23: 357-367
        • Galanaud J.-P.
        • Monreal M.
        • Kahn S.R.
        Epidemiology of the post-thrombotic syndrome.
        Thromb Res. 2018; 164: 100-109
        • Asbeutah A.M.
        • Asfar S.K.
        • Shawaz N.J.
        • et al.
        Is venous reflux a common disease in post-thrombotic patients with unilateral deep vein thrombosis episode?.
        Phlebology. 2007; 22: 8-15
        • Labropoulos N.
        • Leon M.
        • Nicolaides A.
        • et al.
        Venous reflux in patients with previous deep venous thrombosis: correlation with ulceration and other symptoms.
        J Vasc Surg. 1994; 20: 20-26
        • Shaydakov M.E.
        • Comerota A.J.
        • Lurie F.
        Primary venous insufficiency increases risk of deep vein thrombosis.
        J Vasc Surg Venous Lymphat Disord. 2016; 4: 161-166
        • Rhee S.J.
        • Cantelmo N.L.
        • Conrad M.F.
        • et al.
        Factors influencing the incidence of endovenous heat-induced thrombosis (EHIT).
        Vasc Endovasc Surg. 2013; 47: 207-212
        • Ryer E.J.
        • Elmore J.R.
        • Garvin R.P.
        • et al.
        Value of delayed duplex ultrasound assessment after endothermal ablation of the great saphenous vein.
        J Vasc Surg. 2016; 64: 446-451.e1
        • Harlander-Locke M.
        • Jimenez J.C.
        • Lawrence P.F.
        • et al.
        Management of endovenous heat-induced thrombus using a classification system and treatment algorithm following segmental thermal ablation of the small saphenous vein.
        J Vasc Surg. 2013; 58: 427-432
        • Korepta L.M.
        • Watson J.J.
        • Mansour M.A.
        • et al.
        Outcomes of a single-center experience with classification and treatment of endothermal heat-induced thrombosis after endovenous ablation.
        J Vasc Surg Venous Lymphat Disord. 2017; 5: 332-338
        • Lawrence P.F.
        • Chandra A.
        • Wu M.
        • et al.
        Classification of proximal endovenous closure levels and treatment algorithm.
        J Vasc Surg. 2010; 52: 388-393
        • Hong K.-P.
        • Kim D.-K.
        The effect of saphenous vein ablation on combined segmental popliteal vein reflux.
        Korean J Thorac Cardiovasc Surg. 2018; 51: 338-343
        • Puggioni A.
        • Lurie F.
        • Kistner R.L.
        • et al.
        How often is deep venous reflux eliminated after saphenous vein ablation?.
        J Vasc Surg. 2003; 38: 517-521
        • Passman M.
        • McLafferty R.
        • Lentz M.
        • et al.
        Validation of venous clinical severity score (VCSS) with other venous severity assessment tools from the American venous Forum, National venous screening program.
        J Vasc Surg. 2011; 54: 2S-9S