Impact of Junctional Reflux on the Effectiveness of Endovenous Ablation in Patients with Great Saphenous Vein Insufficiency

BACKGROUND: JURY proved that venous clinical severity scores (VCSS) are similar in patients with great saphenous vein (GSV) reflux, with or without saphenofemoral junction (SFJ) reflux. Most studies testing the efficacy of endovenous ablation have simply required the presence of truncal reflux for inclusion, and limited data exist on whether junctional reflux impacts benefit. JURY-2 hypothesizes that patients with GSV reflux, with or without SFJ reflux, will derive similar benefit from endovenous ablation. METHODS: JURY-2 was a prospective longitudinal multicenter study of patients undergoing GSV ablation. INCLUSION CRITERIA: 18-80 years age; reflux of ≥0.5 seconds in ≥2 contiguous segments of the GSV above the knee; and C2 or C3 disease. EXCLUSION CRITERIA: prior DVT; prior vein ablation on the index leg; concomitant obstruction of the iliocaval system; or known renal, hepatic or cardiac failure. The primary outcome, sample size, and analytic plan, were determined pre-hoc. The primary outcome was three-month post-procedural change in VCSS. The outcome in patients with isolated GSV reflux versus combined GSV and SFJ reflux were considered equivalent if the difference in VCSS change-scores was within the minimum detectable change of ±1.4 points. Change-scores were also compared between groups. The multivariable regression model adjusted for baseline VCSS, demographic, clinical, and therapeutic covariates. Statistical analyses were two-tailed and p<0.05 was considered significant. RESULTS: 252 patients were enrolled; most were female (75.00%) and white (78.57%). 207 patients (82.14%) had combined SFJ+GSV reflux, while 45 (17.86%), had isolated GSV reflux. Thermal ablation was used predominantly in both groups, but more so in the SFJ+GSV reflux group (77.78% vs. 57.78%). GSV ablation was successful in nearly all cases (99.51% in the SFJ+GSV reflux group; 100% in the isolated GSV reflux group) with no complications. Both groups demonstrated significant reduction in post-procedural VCSS (6.17 ± 2.20 to 1.86 ± 2.04). The change-score in the SFJ+GSV reflux group was equivalent to the GSV group three months post-endovenous ablation (a difference of -0.54 between groups, 95% CI -1.36, +0.27). There was no statistical difference in the VCSS change-scores between the two groups (p = 0.12). CONCLUSION: In this prospective multicenter study with full accounting of important clinical covariates, patients with isolated GSV reflux derived equivalent benefit after endovenous ablation compared to those with combined GSV+SFJ reflux. These data support the clinical recommendation that venous ablation must be guided by symptomatic severity rather than the presence or absence of junctional reflux.