A retrospective cohort study has demonstrated clinical improvement in chronic venous disease following treatment with thermal and nonthermal ablation of unilateral, great saphenous vein (GSV)-truncal veins; however, patients treated with the latter experienced greater improvement in Clinical, Aetiology, Anatomy, and Pathophysiology (CEAP) class and pain improvement from severe to mild or moderate.
Conducted by Ankita Katukota (University of Florida, Gainesville, USA) et al and subsequently published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders, the analysis included a total of 23,247 patients. Identified using the Vascular Quality Initiative Varicose Vein Registry (VQI-VVR), 14,277 patients undergoing 17,504 procedures between 2014 to 2026 met inclusion criteria, with 39% of patients failing to meet these criteria because of missing procedural data regarding ablation technique, laterality, or truncal vein status.
Eighty-three percent of procedures were thermal ablations compared with 3,023 (17%) nonthermal ablations, state the study authors. Nonthermal ablation patients tended to be older (61 [48–70 years] vs. 58 [46–68 years]) and white (85%). Katukota and colleagues also report that a higher proportion of thermal ablations occurred in hospitals (34% vs. 28%) compared with ambulatory/office-based settings.
The authors also state that thermal ablations performed in hospital settings predominantly utilised general or regional anaesthesia, compared to local anaesthesia used during nonthermal ablations in office-based settings.
“This confirms the utility of nonthermal techniques in the ambulatory setting, avoiding the resource utilisation of tumescent anaesthesia and operating rooms, and potentially lowering the barrier to treatment for patients who may not need to undergo sedation. This shift toward the office-based setting reflects a broader transition in venous practice, as the historical reliance on hospital operating rooms has largely been superseded by streamlined outpatient models,” Katukota and colleagues write.
The research team highlights that this shift inevitably exacerbates socioeconomic disparities through variations in insurance coverage, referencing a recent study that revealed stricter reimbursement criteria for nonthermal compared to thermal ablation. Furthermore, they note that non-white patients are more likely to receive thermal ablation—a pattern that “aligns with national VQI data showing that Black or African American patients—who present with more advanced venous disease and are treated more often in hospital-based settings—experience less symptomatic improvement after ablation compared with white and Hispanic patients”.
Their results demonstrated that thermal ablation patients differed from nonthermal ablation patients with respect to prophylactic procedural anticoagulation utilisation (low–molecular-weight heparin: 9% vs. 6%; and unfractionated heparin: 3% vs. 1%) and rates of multiple anaesthetic modalities (55% vs. 17%) and regional/tumescent (35% vs. 4%) utilisation. The authors note the importance of this finding, given that that thermal cohort demonstrated a lower baseline prevalence of prior deep vein thrombosis and previous venous interventions compared to the nonthermal cohort.
“This suggests that the use of anticoagulation in thermal ablation may not be strictly necessitated by patient-specific thrombotic history,” state Katukota et al. “Instead, it likely reflects clinician-driven prophylactic strategies aimed at mitigating the risk of endothermal heat-induced thrombosis—a complication unique to thermal modalities that is not a factor in nonthermal procedures.”
Katukota and colleagues state that thermal ablation patients were more likely to have above-knee GSV (89% vs. 78%) and a larger-diameter vein (7.3 [6–9.1] vs. 6 [4–8]) treated. Patients in the nonthermal group had lower rates of paraesthesia in the treated extremity (3% vs. 1%) and were more likely to have improvements in CEAP scores from C3 to C1 or C3 to C0 (8% vs. 6%). Nonthermal patients were also more likely to have pain improvements from severe to mild/moderate (3% vs. 2%); the authors note, however, that the superior pain reduction in the nonthermal cohort “may be attributed to the absence of thermal injury and the elimination of tumescent anaesthesia, which can contribute to intraprocedural discomfort”.
Among limitations of their study, the authors acknowledge “critical” anatomic and clinical heterogeneity between above-knee and below-knee GSV segments within their cohort. They state that, morphologically, the below-knee GSV typically exhibits “a smaller luminal calibre and involves shorter treatment lengths compared with the above-knee segment, variables that are recognised determinants of technical success and postoperative sequelae, such as saphenous nerve paraesthesia”.
Overall, Katukota et al write that the national registry identifies significant improvements in quality-of-life metrics following nonthermal truncal ablation compared with thermal ablation. This result, they note, suggests a therapeutic advantage in symptom resolution and functional recovery with nonthermal ablation techniques. They add that future studies should explore long-term recurrence rates, incorporating patient-reported outcomes and stratified analyses by anatomic segment and disease severity.
