Factors Associated with Lack of Clinical Improvement after Vein Ablation in the VQI

Background Insurance companies have adopted variable and inconsistent approval criteria for chronic venous disease (CVD) treatment. While vein ablation (VA) is accepted as the standard of care for venous ulcers, the treatment criteria for patients with milder forms of CVD remain controversial. This study aims to identify factors associated with a lack of clinical improvement (LCI) in patients with less severe CVD without ulceration undergoing VA to improve patient selection for treatment. Methods Retrospective analysis of patients undergoing VA for CEAP C2-C4 disease in the VQI varicose veins database from 2014-2023. Patients who required intervention in multiple veins, had prior interventions, or presented with CEAP C5-C6 disease were excluded. The difference in VCSS score (Δ) (VCSS score prior – VCSS score after the procedure) was used to categorize patients. Patients with VCSS Δ≤ 0 were defined as having LCI after ablation, while patients with at least one point decrease in VCSS after VA (VCSS Δ≥ 1) as having some benefit from the procedure and, therefore, “clinical improvement.” The characteristics of both groups were compared, and multivariable regression analysis was performed to identify factors independently associated with LCI. A second analysis was performed based on the VVSymQ instrument that measures patient-reported outcomes based on five specific symptoms (heaviness, achiness, swelling, throbbing pain, and itching). Patients with LCI showed no improvement in any of the five symptoms, while those with clinical improvement had a decrease in severity of at least one symptom. Results A total of 3,544 patients underwent initial treatment of CVI with a single VA. There were 2,607 patients with available VCSS scores before and after VA, and 16.1% (N=420) had LCI based on ΔVCSS. Patients with LCI were more likely to be significantly older, African American, and have CEAP C2 disease compared to patients with clinical improvement. Patients with clinical improvement were more likely to have reported using compression stockings before treatment. Vein diameters were not different between the two groups. Complications were overall low, with minor differences between groups, but patients with LCI were significantly more likely to have symptoms after intervention than those with improvement. Patients with LCI were more likely to have technical failure defined as vein recanalization. On multivariable regression, age (OR=1.01 [1.00-1.02]) and obesity (OR=1.47 [1.09-2.00]) were independently associated with LCI as well as treatment of less severe disease CEAP C2 (OR=1.82 [1.30-2.56]) compared to more advanced C4 disease. The lack of compression therapy before intervention was also associated with LCI (OR= 6.05 [4.30-8.56]). The analysis based on VVSymQ showed similar results. Conclusion LCI after VA is associated with treating patients with lower CEAP classification (C2 vs C4) disease and lack of compression therapy before intervention. Importantly, no significant association between vein size and clinical improvement was observed.