Results of the present study demonstrate that
patients undergoing RFA for the treatment of GSV
insufficiency experience significantly less pain on the
first postoperative day, and they return to their daily
routine significantly sooner compared to patients
undergoing HLS. Our analysis also revealed excellent
success rates for both procedures in a 30-day follow-up.
These findings correlate with previous research
reporting better or comparable short- and long-term
outcomes with RFA compared to HLS.[
7-
9] In a
randomized clinical trial of 88 patients, Subramonia
and Lees[
7] concluded that RFA was superior to HLS in
terms of short-term outcomes, including postoperative
pain and time to return to full level of household
activities. However, they also concluded that this
superiority would not be significant in the long term
if recurrence and risk of reoperation were taken into
account.[
7] Another randomized clinical trial by Helmy
ElKaffas et al.[
8] reported lower complication rates
for RFA in the short term and similar recurrence
rate in the long term compared to HLS. Shaikadov
et al.[
9] revealed that patients undergoing RFA had
significantly less postoperative pain compared to
patients undergoing HLS in their multicenter analysis.
One-year recurrence rates were also reported to be
similar in that study.[
9] We only had 30-day follow-up
data, therefore cannot comment on long-term success
rates.
Both groups had similar clinical and radiological
features except for a significantly larger median GSV
diameter in the RFA group. This significant difference
was a direct result of reimbursement regulations
regarding endovenous RFA treatment, as the Social
Security Institution requires patients to have a GSV
diameter of ≥5.5 mm for the compensation of an RFA
device. Although it was not an objective of our study,
considering that patients with larger and smaller veins (RFA and HLS groups, respectively) had similar
demographic, clinical, and radiological findings and
outcomes, our results show that vein diameter should
not be an indicator of necessity for intervention for
venous insufficiency. A prospective cohort study
from a national registry reported similar results.[10]
They compared CEAP classes, VCSS scores, and
patient-reported outcomes before and after treatment
in patients with a vein diameter of ≥5 mm versus
<5 mm, revealed similar symptomatic improvement
rates between groups, and concluded that patients
should not be denied for intervention based on
vein size.[10] There is a discrepancy regarding the
inclusion/exclusion of patients based on vein size
among previous research. Sincos et al.[6] included
patients with a vein diameter of 5 to 12 mm,
whereas Subramonia and Lees[7] included those with
3- to 12-mm veins. Helmy ElKaffas et al.[8] did not
apply a minimal threshold for the vein diameter,
and their maximal threshold was 18 mm. We were
able to successfully treat patients with relatively
large veins using RFA, therefore believe that large
GSV diameter should not discourage surgeons from
utilizing this minimally invasive technique for their
patients. In fact, Shaikadov et al.[9] demonstrated
improved outcomes after RFA compared to HLS in
patients with a GSV diameter of ≥14 mm.
Our analysis showed that the majority of
patients in the RFA group underwent above-knee
treatment, unlike the HLS group, in which the
majority underwent complete stripping. We observed
similar rates of paresthesia in both groups. There
is conflicting evidence from previous research
regarding treatment length and nerve injury.[11-15] A
recent single-center, retrospective analysis by Liu et
al.[11] revealed better outcomes, including less nerve
injury, less operative bleeding, reduced operative
time, and shorter hospitalization in patients treated
with a modified above-knee technique versus those
treated by complete stripping. On the contrary,
Uncu[12] reported acceptable nerve injury rates in
his single-surgeon experience of 102 procedures.
There is also ongoing debate on whether proximal or
distal stripping is superior to each other with regards
to nerve injury.[13-15] Below-knee treatment with
endovenous thermal ablation techniques has been
mainly avoided due to close anatomical relationship
of sensory nerves with superficial veins in the crus.
Nerve injury during endovenous thermal ablation
treatment of the small saphenous vein is well-studied, unlike during below-knee GSV ablation.[16,17]
However, there are recent reports with successful
thermal ablation treatment of whole-length or
below-knee GSV insufficiency with acceptable nerve
injury rates.[18,19] We performed below-knee RFA in
patients with crural GSV insufficiency and did not
observe nerve injury afterward. Further research is
needed to assess safety of thermal venous ablation of
below-knee superficial veins.
Groups were comparable in terms of
complications, and our complication rates were
similar to or lower than results of previous
reports.[20-26] This result could have been altered
depending on complication definitions. For example,
ecchymosis or hematoma, adverse events that are
expected to be more common after HLS, were not
included in our analysis.
Other researchers reported shorter
postintervention hospitalization durations after RFA
compared to HLS, whereas length of hospital stay
was similar between groups in our study.[6,8] This
was most probably due to widespread use of spinal
anesthesia in our cohort, which rendered patients
to stay longer in the bed after procedures. Others
mostly used local anesthesia during RFA, and spinal
block or general anesthesia during HLS, therefore
observed significantly shorter lengths of stay after
RFA.[6,8] Unlike conventional surgery, endovenous
ablation techniques can also be performed in
outpatient settings.[23] When performed under local
anesthesia in the office setting, RFA is associated
with significantly reduced hospitalization rates and
reduced costs compared to HLS performed in the
operating theater.[27-29] Cost-effectiveness was out
of the scope of our study. Future research should
include this variable when comparing different
treatment modalities for venous disease.
There are some limitations to this study. The
follow-up duration was short; therefore, we were
not able to analyze more robust outcome measures,
such as long-term obliteration rates, long-term
patient-reported outcomes, and long-term CEAP
and VCSS scores. Cost-effectivity analysis could not
be performed.
In conclusion, radiofrequency ablation is associated
with significantly less postoperative pain and earlier
return to daily activities compared to HLS in patients
with symptomatic GSV insufficiency. Both procedures
have high success and low complication rates in a
30-day follow-up.
Ethics Committee Approval: The study protocol was
approved by the Kartal Dr. Lütfi Kırdar City Hospital
Clinical Research Ethics Committee (date: 24.04.2019;
no: 2019/514/152/4). The study was conducted in accordance
with the principles of the Declaration of Helsinki.
Patient Consent for Publication: A written informed
consent was obtained from each patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept, design, control/
supervision, data collection and/or processing, analysis and/
or interpretation, literatüre review, writing the article, critical
review, references and funding, materials, approval of the
final version: A.C.T.; Idea/concept, design, critical review,
approval of the final version: A.O.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.