Radiofrequency venous ablation for symptomatic relief in postural orthostatic tachycardia syndrome: a case series.

Background: Hypovolemic postural orthostatic tachycardia syndrome (POTS) is thought to be caused by dysregulated circulating blood volume. Management is mainly limited to symptom-targeted lifestyle changes. Radiofrequency venous ablation (RFA) represents a minimally invasive method of increasing circulating blood volume. The following case series describes a novel application of RFA to successfully target POTS symptoms in patients demonstrating venous insufficiency. The use of RFA in alleviating POTS symptoms has not previously been reported. Case summary: We describe four patients with either a well-established historical POTS diagnosis or dysautonomia symptoms refractory to both medical management and lifestyle modifications. They all demonstrated venous reflux on lower extremity venous ultrasound testing. Upon vascular surgery referral, all underwent great and small saphenous vein RFA. They each subsequently reported subjective improvement in their dysautonomia symptoms and quality-of-life. Two with symptom recurrence years later were found to have new-onset pelvic venous congestion and are being evaluated for pelvic venous insufficiency interventions. Discussion: Lower extremity venous pooling can exacerbate dysautonomia symptoms in POTS patients. Patients refractory to conventional treatment strategies should undergo venous insufficiency workup, and if positive, should be referred for venous pooling intervention evaluation. The success of RFA at treating refractory POTS symptoms in these four patients with lower extremity venous reflux, including no surgical intervention and no adverse effects, are compelling grounds to further explore this therapy and to quantify and standardize symptom improvement assessment in a larger patient population. Future directions include a demonstration of quality-of-life improvement in randomized clinical trials.