Strategies to reduce rates of severe endothermal heat-induced thrombosis following radiofrequency ablation

Baqir J Kedwai; Joshua T Geiger; Daniel J Lehane; Roan J Glocker; Karina A Newhall; Grayson S Pitcher; Jennifer L Ellis; Adam J Doyle

doi:10.1016/j.jvsv.2024.101864

Strategies to reduce rates of severe endothermal heat-induced thrombosis following radiofrequency ablation

J Vasc Surg Venous Lymphat Disord. 2024 Mar 20:101864. doi: 10.1016/j.jvsv.2024.101864. Online ahead of print.

Authors

Baqir J Kedwai¹, Joshua T Geiger¹, Daniel J Lehane¹, Roan J Glocker¹, Karina A Newhall¹, Grayson S Pitcher¹, Jennifer L Ellis¹, Adam J Doyle²

Affiliations

¹ Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
² Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY. Electronic address: Adam_doyle@urmc.rochester.edu.

PMID: 38518986
DOI: 10.1016/j.jvsv.2024.101864

Abstract

Objective: Endothermal heat-induced thrombosis (EHIT) is a potential complication of radiofrequency ablation (RFA). Data on effective prophylaxis of EHIT are limited. In 2018, a high-volume, single institution implemented strategies to decrease the incidence of EHIT, including a single periprocedural prophylactic dose of low-molecular-weight heparin to patients with a great saphenous vein (GSV) diameter of ≥8 mm or saphenofemoral junction (SFJ) diameter of ≥10 mm and limiting treatment to one vein per procedure. The size threshold was derived from existing literature. The study objective was to evaluate the effects of these institutional changes on thrombotic complication rates after RFA.

Methods: A retrospective cohort control study was conducted using the Vascular Quality Initiative database. Data were collected for patients who underwent RFA with a GSV diameter of ≥8 mm or SFJ diameter of ≥10 mm from January 2015 to July 2022. The clinical end points were thrombotic complications (ie, thrombophlebitis, EHIT, deep vein thrombosis) and bleeding complications. Patient demographic and procedural variables were included in the analysis, and significant variables after univariable logistic regression were included in a multivariable logistic regression.

Results: After the policy change, the overall vein center EHIT rate decreased from 2.6% to 1.5%, with a trend toward significance (P = .096). The inclusion criterion of a GSV diameter of ≥8 mm or an SFJ diameter of ≥10 mm yielded 845 patients, of whom 298 were treated before the policy change and 547 after. There was a significant reduction in the rate of EHIT classified as class ≥III (2.34 vs 0.366; P = .020) after the institutional changes. Treatment of two or more veins and an increased vein diameter were associated with an increased risk of EHIT (P = .049 and P < .001, respectively). No significant association was found between periprocedural anticoagulation and all-cause thrombotic complications or EHIT (P = .563 and P = .885, respectively).

Conclusions: The institutional policy changes have led to lower rates of EHIT, with a reduction in severe EHIT rates in patients with an ≥8-mm diameter GSV or a ≥10-mm diameter SFJ treated with RFA. Of the changes implemented, restricting treatment to one vein was associated with a reduction in severe EHIT. No association was found with periprocedural low-molecular-weight heparin, although a type 2 error might have occurred. Alternative strategies to prevent thrombotic complications should be explored, such as increasing the dosage and duration of periprocedural anticoagulation, antiplatelet use, and nonpharmacologic strategies.

Keywords: Ablation; Anticoagulation; Thrombosis; Vein.