A systematic review of management of superficial venous reflux in the setting of deep venous obstruction

Background: Because of the fear of obliterating the collateral outflow path and thus worsening venous hypertension, many physicians believe that deep venous obstruction (DVO) is a contraindication for the treatment of superficial venous reflux (SVR). In the present review, we have described the available clinical data for this important group of patients. Methods: A literature search was performed of PubMed, Web of Science, and Google Scholar to identify clinical research studies reported between 1991 and 2021 that had evaluated the concomitant management of SVR and DVO. Studies were excluded if they had included fewer than five patients, had not specified the interventions used to treat SVR, or had no follow-up data available. All the studies included were observational, and their quality was assessed using the Newcastle-Ottawa scale. Results: Ten retrospective cohort studies were included, with a total of 2476 limbs in 2428 patients, with concurrent SVR and DVO or a known history of deep vein thrombosis treated in 944 limbs. Of the 10 studies, 8 were comparative. The level of DVO was suprainguinal, when specified, in most cases. The mean age range was 42 to 65 years, 1432 patients (59%) were women, and advanced chronic venous disease (ie, CEAP [clinical, etiologic, anatomic, pathophysiologic] class 4-6) was present in 614 limbs (70%), with two studies reporting uniquely on C6 patients. Of the 944 limbs treated for concomitant SVR and DVO, a combination of saphenous vein ablative procedures and deep venous stenting was performed in 483 limbs (51.2%), saphenous vein ablative procedures alone in 293 limbs (31%), and deep venous stenting alone in 168 (17.8%). Of the five studies comparing the different treatment strategies to treat concurrent SVR and DVO, four reported better outcomes after a combination of deep venous stenting and saphenous vein ablation compared with ablation alone. Studies comparing the outcomes of saphenous ablation for patients with reflux alone vs patients with concurrent reflux and DVO did not find any significant differences in clinical improvement and postoperative complication rates. Conclusions: The current evidence is weak owing to the limited number of studies and small sample size but suggests that ablation of SVR is safe for patients with concurrent DVO. Patients with advanced venous disease and iliac vein obstruction had better results when SVR ablation was combined with treatment of iliac vein obstruction. Additional contemporary studies are needed to confirm the safety and specifically investigate the efficacy of SVR ablation in relieving the symptoms of patients with concurrent infrainguinal obstruction.