Letter regarding “novel basilic vein access for ablation in pelvic venous disorders”

I read with interest but also with great concern “A Novel Endovascular Thermal Ablation Technique for Pelvic Venous Disorders via Basilic Vein Access: A Prospective Descriptive Study,” by Moreno and colleagues.¹

Their use of an endovenous laser to occlude an incompetent gonadal vein is fraught with potential risks. I note that they imaged the ureter to ensure it was >3 mm from the vein being treated, but, of course, the gonadal vein lies adjacent to many other structures that are at risk of damage—not least the bowel and, in its lower section, iliac vessels.

The fact that tumescence was not used (and cannot be used easily in this situation) not only increases the risk of collateral damage to adjacent structures but also makes it very likely that residual blood remains within the vein lumen while treatment is performed.²

The quoted linear endovenous energy density ranges from very low to relatively high (30-80 J/cm) when compared with the use of a 1470-nm laser in an empty saphenous vein (empty due to the Trendelenburg position and tumescence). As residual blood will be present in these gonadal veins based on the methodology described by the authors, one can be certain that the “successful occlusion” will be due to thrombus rather than vein wall ablation in some, if not all, of these veins.

As such, I suspect that longer term follow-up will result in recanalization and recurrence within 1 to 3 years in most, if not all, of these cases. More worryingly, I suspect that in an effort to improve the long-term results, increased linear endovenous energy densities will be used, and thermal damage to adjacent structures will ensue.

I note that the authors conclude that further studies are required, with a longer follow-up of more than 12 months and multicenter evaluation, and that they also note that energy delivery parameters need to be defined. However, with the probability of high recanalization and recurrence rates with low energies and intraluminal blood, and more significantly, the risk of damage to adjacent structures if higher energies are used, I would suggest that any doctor who wishes to perform this procedure should do so only within a registered research study, with adequate insurance coverage for any collateral thermal damage, long-term follow-up, and careful reporting of recurrence rates and complications. Also, any patients being offered this should be fully consented to such risks.

Disclosures

None.