CEAP-Guided and Kistner-Refined Selection of Deep Venous Intervention for Primary Lower-Limb Venous Valvular Incompetence: A Two-Center Cohort Study.

OBJECTIVE: To evaluate whether Clinical-Etiological-Anatomical-Pathophysiological (CEAP) clinical class and Kistner grade could guide the selection of deep venous intervention for primary lower-limb venous valvular incompetence. DESIGN: Two-center retrospective cohort study. METHODS: A total of 578 consecutive eligible limbs with primary lower-limb venous valvular incompetence and available venographic and clinical records between 2015 and 2025 were grouped as conservative management (n = 241), superficial-only treatment (n = 240), deep-only treatment (n = 44), or combined treatment (n = 53). Deep intervention mainly consisted of femoral vein valvoplasty; combined treatment comprised femoral valvoplasty plus superficial treatment, most often radiofrequency ablation, with high ligation and stripping when indicated. The primary outcome was VCSS improvement. Analyses were performed hierarchically in C3 group, the overall C4-C6 population, the C4-C6 Kistner grade 3-4 isolated deep reflux subgroup, and an all-CEAP Kistner grade 3-4 sensitivity population. RESULTS: In C3 group, combined treatment provided no additional VCSS benefit versus superficial venous-only treatment (adjusted β 0.1, 95% CI -1.6 to 1.9; p = .872). In C4-C6 population, combined treatment achieved greater VCSS improvement than superficial venous-only treatment (adjusted β 1.8, 95% CI 0.5 to 3.1; p = .007). In C4-C6 limbs with Kistner grade 3-4 isolated deep venous reflux, combined treatment showed greater benefit than superficial venous-only treatment (adjusted β 3.9, 95% CI 1.1 to 6.6; p = .008) and conservative management (adjusted β 4.2, 95% CI 1.3 to 7.0; p = .005). All-CEAP Kistner grade 3-4 sensitivity analyses showed directionally consistent results. CONCLUSION: Selective femoral vein valvoplasty combined with superficial venous treatment may be clinically justified in C4-C6 disease, especially with Kistner grade 3-4 reflux, but is not supported in C3 disease.