Department of Vascular Surgery, Tufts Medical Center, Boston, MA.
Department of Vascular Surgery, Boston University Medical Center, Boston, MA.
J Vasc Surg Venous Lymphat Disord. 2023 Jan;11(1):193-200.e6. doi: 10.1016/j.jvsv.2022.06.006. Epub 2022 Aug 6.
The Society of Vascular Surgery and the American Venous Forum recommend duplex ultrasound (DUS) following endovenous ablation. However, this screening may not be cost-effective or clinically indicated. The most common abnormal finding, endovenous heat-induced thrombosis (EHIT level 1-2), represents extension of thrombus from the saphenous <50% across the femoral or popliteal vein, which is thought to have a benign course regardless of intervention. The likelihood of venous thromboembolism (VTE) after thermal and non-thermal ablations was explored to determine the utility of routine postoperative DUS.
This is an updated and expanded systematic review including data from randomized trials and large observational studies (≥150 patients) of thermal and non-thermal ablations, examining the incidence of VTE. Using PubMed and EMBASE, 4584 publications were screened from 2000 through 2020. After applying inclusion and exclusion criteria, 72 studies were included. Random effects DerSimonian-Laird method was conducted to obtain the pooled incidence. We calculated the number of tests needed to detect one VTE, and the cost was derived from Center for Medicare Services tables.
A total of 31,663 patients were included. The pooled incidence of EHIT II-IV, deep venous thrombosis (DVT), and pulmonary embolism (PE) was 1.32% (95% confidence interval [CI], 0.75%-2.02%); DVT (excluding EHIT), 0.20% (95% CI, 0.0%-0.2%); EHIT (I-IV), 2.51% (95% CI, 1.54%-3.68%); and EHIT (II-IV), 1.00% (95% CI, 0.51%-1.61%). There was no mortality. There was a lower DVT rate in thermal vs non-thermal ablations (0.23% vs 0.43%; P = .02); however, for all VTE (EHIT I-IV + DVT + PE), thermal techniques had more thrombosis (2.5% vs 0.5%; P <.001). When clinical significance is defined as DVT + EHIT (II-IV), 175 studies are needed to identify one VTE, costing $21,813 per "significant VTE." Patients receiving pharmacological prophylaxis had less EHIT I-IV compared with those who did not (3.04% vs 1.63%; P < .001); those who received DUS during the first post-op week had three times higher EHIT incidence compared with those whose first DUS was >7 days postoperative (6.6% vs 2.4%; P < .001).
For thermal and non-thermal endovenous ablations, the incidence of VTE diagnosed with routine DUS is small and without clear clinical significance but caries a high cost. The Society of Vascular Surgery and the American Venous Forum recommendation to perform DUS within 72 hours is not justified by these data. We recommend a more targeted post-ablation scanning protocol including symptomatic patients and those at high risk.
血管外科学会和美国静脉论坛建议在静脉内消融后进行双功能超声（DUS）检查。然而，这种筛查可能并不具有成本效益或临床意义。最常见的异常发现是静脉内热诱导血栓形成（EHIT 1-2 级），代表血栓从隐静脉延伸<50%穿过股静脉或腘静脉，无论是否进行干预，都被认为具有良性过程。探讨了热消融和非热消融后静脉血栓栓塞（VTE）的发生几率，以确定常规术后 DUS 的实用性。
这是一项更新和扩展的系统评价，包括来自热消融和非热消融的随机试验和大型观察性研究（≥150 例患者）的数据，检查了 VTE 的发生率。使用 PubMed 和 EMBASE，从 2000 年到 2020 年筛选了 4584 篇文献。在应用纳入和排除标准后，纳入了 72 项研究。采用随机效应 DerSimonian-Laird 方法获得汇总发生率。我们计算了检测到一个 VTE 所需的检测次数，并从医疗保险服务中心的表格中得出了成本。
共纳入 31663 例患者。EHIT II-IV、深静脉血栓形成（DVT）和肺栓塞（PE）的汇总发生率为 1.32%（95%置信区间[CI]，0.75%-2.02%）；DVT（不包括 EHIT）为 0.20%（95%CI，0.0%-0.2%）；EHIT（I-IV）为 2.51%（95%CI，1.54%-3.68%）；EHIT（II-IV）为 1.00%（95%CI，0.51%-1.61%）。没有死亡病例。热消融与非热消融相比，DVT 发生率较低（0.23% vs. 0.43%；P =.02）；然而，对于所有 VTE（EHIT I-IV + DVT + PE），热技术的血栓形成更多（2.5% vs. 0.5%；P<.001）。当临床意义定义为 DVT + EHIT（II-IV）时，需要 175 项研究才能发现一个 VTE，每次“显著 VTE”的成本为 21813 美元。与未接受药物预防的患者相比，接受药物预防的患者 EHIT I-IV 发生率较低（3.04% vs. 1.63%；P<.001）；与术后第一周内首次接受 DUS 的患者相比，首次 DUS 检查>7 天后的患者 EHIT 发生率高 3 倍（6.6% vs. 2.4%；P<.001）。
对于热消融和非热消融，常规 DUS 诊断的 VTE 发生率较小，且无明确的临床意义，但成本较高。血管外科学会和美国静脉论坛建议在 72 小时内进行 DUS 检查的建议，这些数据无法证明其合理性。我们建议采用更有针对性的消融后扫描方案，包括有症状的患者和高风险患者。
