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18 Chronic Venous Disease andVaricose Veins
(MOCA) and high ligation and stripping (HL/S) for the treatment of varicosities of
the great saphenous vein (GSV). 24 RCTs with 5135 participants were included.
Duration of follow-up ranged from 5weeks to 8years. The main results were:
• EVLA versus RFA: Technical success was comparable up to 5years (moderatecertainty evidence); over 5years, there was no evidence of a difference (lowcertainty evidence). One study reported recurrence, showing no clear difference
at 3years (low-certainty evidence), but a benet for RFA may be seen at 5years
(low-certainty evidence).
• EVLA versus UGFS: Technical success may be better in EVLA participants up
to 5years (low-certainty evidence), and over 5years (low-certainty evidence).
There was no clear difference in recurrence up to 3years and at 5years.
• EVLA versus HL/S: Technical success may be better in EVLA participants up to
5years (low-certainty evidence). No clear difference in technical success was
seen at 5years and beyond (low-certainty evidence). Recurrence was comparable within 3years and at 5years (moderate-certainty evidence).
• RFA versus MOCA: There was no clear difference in technical success (lowcertainty evidence), or recurrence (low-certainty evidence). Long-term data are
not available.
• RFA versus HL/S: No clear difference in technical success was detected up to
5years (low-certainty evidence); over 5years, there was no evidence of a difference (low-certainty evidence). No clear difference in recurrence was detected up
to 3years (moderate-certainty evidence); but a possible long-term benet for
RFA was seen (low-certainty evidence).
• UGFS versus HL/S: Meta-analysis showed a possible benet for HL/S compared
with UGFS in technical success up to 5years (low-certainty evidence), and over
5years (moderate-certainty evidence). No clear difference was detected in recurrence up to 3years (low-certainty evidence), and after 5years (low-certainty
evidence).
Technical success was comparable between most modalities. EVLA may offer
improved technical success compared to UGFS or HL/S.HL/S may have improved
technical success compared to UGFS.No evidence of a difference was detected in
recurrence, except for a possible long-term benet for RFA compared to EVLA
or HL/S.
Another Cochrane review determined the effects of supercial endovenous abla-
tion on the healing and recurrence of venous leg ulcers and the quality of life of
people with venous ulcer disease [3]. Randomized controlled trials (RCTs) comparing endovenous ablative techniques with compression versus compression therapy
alone for the treatment of venous leg ulcers (VLUs) were eligible for inclusion.
There was a total of 506 participants with an active VLU, with mean durations of
3.1months±1.1months in the EVRA trial and 60.5months±96.4months in the
VUERT trial. There is high-certainty evidence that combined endovenous ablation
and compression compared with compression therapy alone, or compression with
deferred endovenous treatment, improves time to complete ulcer healing. There is
moderate-certainty evidence that the proportion of ulcers healed at 90 days is
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probably higher with combined endovenous ablation and compression compared
with compression therapy alone or compression with deferred endovenous treatment. The addition of endovenous ablation to compression is probably cost-effective at 1 year. Endovenous ablation of supercial venous incompetence in
combination with compression improves leg ulcer healing when compared with
compression alone. This conclusion is based on high-certainty evidence.
A systematic review [4] summarizes the evidence to develop and support forth-
coming updated SVS/AVF/American Vein and Lymphatic Society clinical practice
guideline recommendations on the management of varicose veins. HL/S was associated with higher anatomic closure rates at 30days and 5years when compared with
RFA and UGFS (moderate certainty), while no signicant difference was seen when
compared with EVLA at 5years. UGFS was associated with an increased risk of
recurrence compared with HL/S.EVLA was associated with lower anatomic closure rates at 30days than cyanoacrylate closure (CAC) and higher rates at one and
5years when compared with UGFS.Thermal interventions were associated with
lower generic quality of life scores and an increased risk of adverse events when
compared with CAC or n-butyl cyanoacrylate (low certainty). Thermal interventions were associated with a lower risk of recurrent incompetence when compared
with UGFS and an increased risk of recurrent incompetence than CAC.
A systematic review and meta-analysis on RCTs or follow-up studies of RCTs
with a minimum follow-up of 5years was presented by Hamann etal. [5] to compare long-term outcomes, such as technical success, recurrent reux at the groin,
venous clinical severity score (VCSS), and quality of life of the different treatments
for incompetent great saphenous veins (GSVs). Three RCTs and 10 follow-up studies of RCTs were included of which 12 were pooled in the meta-analysis. In total,
611 legs were treated with EVLA, 549 with HL+S, 121 with UGFS, and 114 with
HL+EVLA.UGFS had signicantly lower pooled anatomical success rates than
HL+S, EVLA, and EVLA with high ligation: 34% versus 83%, 88%, and 88%
respectively; p≤.001. The pooled recurrent reux rate at the saphenofemoral junction (SFJ) was signicantly lower for HL+S than UGFS (12% vs. 29%; p≤.001)
and EVLA (12% vs. 22%; p= .038). VCSS scores were pooled for EVLA and
HL+S, which showed similar improvements. Based on this meta-analysis EVLA
and HL+S are the preferred treatment options for GSV incompetence, both with
superior long-term results than UGFS (Table18.4). For the moment pooled data
was only available for EVLA, but other forms of EVTA may appear to be equally
effective at long term.
Aherne etal. [6] compared the outcomes of both concomitant and staged super-
cial varicose tributary (SVT) interventions as an adjunct to endovenous truncal
ablation in the management of symptomatic venous incompetence. Fifteen studies
(6915 limbs) were included in this systematic review for analysis. Meta-analysis
established that concomitant treatment strategies (6.3%) were associated with signicantly fewer reported reinterventions than those undergoing a staged approach
(36.1%). Additionally, 12 studies reporting the lower limb thrombotic outcomes of
5735 limbs identied deep venous thrombosis (DVT) rates of 1.8% in the concomitant and 2.8% in the staged group with no difference between groups regarding
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Table 18.4 Five year results of treatment options for great saphenous vein incompetence. Only
RCTs or follow-up studies of RCTs are included (according to [5])
Pooled proportion of
Comparison
EVLA vs.
HL+S
EVLA vs.
HL+EVLA
EVLA vs.
UGFS
HL+S vs.
HL+ EVLA
HL+S vs.
UGFS
HL+ EVLA vs.
UGFS
EVLA endovenous laser ablation, HL high ligation, S stripping, UGFS ultrasound guided foam
sclerotherapy
anatomical success P
0.88 vs. 0.83 .170 0.22 vs. 0.12 .038
0.88 v. 0.88 .500 0.22 vs. 0.24 .404
0.88 vs. 0.34 <.001 0.22 vs. 0.29 .133
0.83 vs. 0.88 .409 0.12 vs. 0.24 .058
0.83 vs. 0.34 <.001 0.12 vs. 0.29 <
0.88 vs. 0.34 <.001 0.24 vs. 0.29 .269
18 Chronic Venous Disease andVaricose Veins
Pooled proportion of recurrent reux
at the saphenofemoral junction/groin P
.001
DVT, endovenous heat induced thrombosis (EHIT), or other procedural complications. In this analysis, truncal ablation alone was sufcient therapy for 63.9% of
those assessed. While meta-analysis suggested that concomitant intervention offers
signicantly lower rates of re-intervention, this benet was not reected by the randomised trial subgroup analysis, which identied no difference in re-intervention.
18.2.1.2 Thromboprophylaxis forEndovenous Varicose
Vein Interventions
The primary objective of a systematic review and meta-analysis was to elucidate the
rate of venous thromboembolism (VTE) after endovenous interventions for varicose
veins in the presence of pharmacological and mechanical thromboprophylaxis versus mechanical thromboprophylaxis alone [7]. There were 221 trials included in the
review (47 randomized trial arms, 105 prospective cohort studies, and 69 retrospective studies). In randomized trial arms, the rate of deep venous thrombosis with
additional pharmacological thromboprophylaxis was 0.52% versus 2.26% with
mechanical thromboprophylaxis alone. The rate of pulmonary embolism in randomized trial arms with additional pharmacological thromboprophylaxis was 0.45%
versus 0.23% for mechanical measures alone. The rate of endovenous heat-induced
thrombosis (EHIT) grade III to IV was 0.35% versus 0.88%. There was 1 VTErelated mortality and 1 instance of major bleeding, with low rates of minor bleeding.
The rate of VTE after endovenous varicose vein intervention may be higher than
previously anticipated and carries a small but signicant morbidity and mortality.
There is evidence that additional pharmacological thromboprophylaxis reduces the
rate of DVT and it is recommended that anticoagulant agents are considered for
endovenous varicose vein procedures.
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18.2.1.3 Compression Therapy Following Endovenous Thermal Ablation
Ma etal. [8] conducted a systematic review and meta-analysis of RCTs to evaluate
the benet of compression therapy with elastic stockings on clinical and patients
self-reported outcomes following endovenous thermal ablation (EVTA) for varicose
veins. Six RCTs with 1045 subjects were included. Overall, postoperative compression therapy signicantly reduced the mean pain in the rst 10days post-EVTA, and
the time to return to normal activities. In terms of the bruising score, the venous
clinical severity score, complications, quality of life at 2weeks and 6months, and
the saphenous vein occlusion rate, there were no signicant differences between the
compression and control groups.
A second meta-analysis was conducted by Hu etal. [9] to compare the outcomes
of endovenous thermal ablation of primary varicose veins with or without postprocedural compression therapy. A total of seven randomized controlled trials
(RCTs) comprising 1146 patients were included. Wearing compression stockings
was correlated with lower post-operative pain scores. No difference was observed
between wearing compression stockings or not in quality of life, target vein occlusion rates, or time to return to work. The conclusion was that given the discomfort
and difculty of applying compression stockings, they are probably unnecessary
after endovenous thermal ablation.
18.2.1.4 Thermal Versus Non-thermal Endovenous Ablation
Shahzad etal. [10] conducted a meta-analysis of randomized controlled trials to
compare effectiveness and complications of thermal vs. non-thermal endovenous
ablation techniques for treatment of supercial venous incompetence (endovenous
thermal ablation: laser or radiofrequency / non-thermal ablation: MOCA or CAC).
Eight randomized controlled trials met the selection criteria. These comprised a
total of 1956 patients, of whom 1042 underwent endovenous thermal ablation and
915 underwent endovenous non-thermal ablation. There was no statistically signicant difference in occlusion rate at all time points. Relative risk at 4weeks and 1 to
2years was 0.99 (95% CI 0.96–1.02) and 0.95 (95% CI 0.88–1.01), respectively.
Non-thermal ablation was tolerated better and had less risk of nerve injury. There
was no statistically signicant difference in risk of endothermal heat induced thrombosis (EHIT). There was improvement in quality of life scores post-procedure but
there was no statistically signicant difference in thermal vs. non-thermal ablation.
The quality of evidence assessed using GRADE methodology showed high quality
for occlusion rate at 4weeks and 1 to 2years, moderate quality for nerve injury and
peri-procedural pain, and low quality for EHIT.This study showed that there is no
statistically signicant difference in vein occlusion rate between thermal and glue
ablation of truncal varicose veins. Although the occlusion rate using MOCA, considered in isolation, is statistically signicantly worse than for thermal ablation,
improvement in quality of life after both thermal and non-thermal endovenous ablation is similar. In the early post-operative period, non-thermal endovenous ablation
demonstrates the advantages of causes less pain and less risk of nerve injury.
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18 Chronic Venous Disease andVaricose Veins
18.2.1.5 Mechanochemical Ablation Versus Endothermal Ablation
A meta-analysis compared the clinical and technical outcomes after MOCA and
EVTA [11]. Four RCTs were included in the meta-analysis comprising 654 patients.
The anatomical occlusion rate at 1year was lower after MOCA than EVTA (risk
ratio 0.85, 95 per cent c.i. 0.78 to 0.91; P<0.001). No signicant differences were
detected in procedural pain (mean difference−3.25, −14.25 to 7.74; P=0.560) or
postprocedural pain (mean difference−0.63, −2.15 to 0.89; P=0.420). There were
no signicant differences in Aberdeen Varicose Vein Questionnaire score at 1year
(mean difference 0.06, −0.50 to 0.62; P=0.830) or in incidence of venous thromboembolism (risk ratio 0.72, 95 per cent c.i. 0.14 to 3.61; P=0.690). The rate of
successful anatomical occlusion after MOCA is signicantly lower than that after
EVTA, but there is no difference in procedural and postprocedural pain between the
two interventions. Long-term data are required to assess the impact of the reduced
vein occlusion rate on clinical outcomes such as quality of life and reintervention.
18.2.1.6 Cyanoacrylate Ablation (CA)
Cyanoacrylate ablation (CA) consists of delivery of cyanoacrylate adhesive to the
vein, which induces an inammatory reaction of the vein wall to the foreign body.
It is a non-thermal, non-tumescent endovenous ablation technique. In a metaanalysis three comparative studies, two randomized controlled trials and one observational study comprising 1057 participants were included for effectiveness
assessment purposes [12]. Available evidence allowed comparison of CA with
radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) but not with
other treatments. The analysis showed that whereas all three treatments reduced
disease severity, none was signicantly better than any other in terms of effectiveness. In terms of safety, however, CA devices gave rise to fewer adverse events and
less severity at 12months of follow-up than did EVLA or RFA.Other important
advantages of CA over EVLA or RFA were linked to quality of care; patients
reported less pain during intervention with CA than with RFA or EVLA devices and
registered shorter intervention and recovery times. Furthermore, tumescent anesthesia and compression bandages were not necessary, making this technique more
comfortable for the patients than endothermal techniques.
The aim of a network meta-analysis was to compare VenaSeal closure system
(cyanoacrylate embolization, CAE) with EVLA, RFA, mechanochemical ablation,
sclerotherapy, and surgery for management of chronic venous insufciency [13].
The ndings from this study suggested CAE to be a promising therapeutic option in
terms of superior outcomes as assessed by anatomic success (complete closure of
treated vein), reduction of pain score, and lesser chance of occurrence of adverse
events (including hyperpigmentation, bruising, pruritus, skin irritation, rash, phlebitis, paresthesia, wound infection, thrombophlebitis, DVT, groin infection, and PE)
in patients treated with CVI compared with other interventions (EVLA, RFA,
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MOCA, sclerotherapy, and surgery). The existing evidence is robust to demonstrate
the safety and effectiveness of CAE (VenaSeal system) in treating these patients.
One cohort study and three randomized controlled trials, including a total of
1457 participants were included in a meta-analysis by Guo etal. [14] to analyze the
efcacy of cyanoacrylate ablation (CA) in comparison with endovenous thermal
ablation (ETA) for the treatment of incompetent saphenous veins. There was no
statistical difference in closure rates between CA and ETA after pooled analysis.
Similar symptom alleviation was observed. However, the CA group showed a lower
ecchymosis rate than RFA and a signicantly lower incidence of adverse events,
such as ecchymosis, phlebitis, and paresthesia, than EVLA.Compared with ETA,
patients receiving CA treatment exhibited lower pain scores without needing compression stocking, returned to normal life sooner, and had signicantly better quality of care. CA had better overall outcomes than ETA and offered superior clinical
benets in the treatment of incompetent saphenous veins.
18.2.1.7 Mechanochemical Ablation, Cyanoacrylate Ablation,
andThermal Ablation
A meta-analysis and systematic review of comparative trials aimed to assess the
efcacy of endovenous nonthermal (including MOCA and CA) and thermal (EVLA
and RFA) ablative procedures in the management of lower limb supercial venous
incompetence [15]. Six studies describing the outcomes of 1236 participants and
1256 truncal ablations were included for analysis. Nonthermal techniques (NTA)
were as effective as standard thermal ablation (TA) in the rst year and, in some
studies, may be associated with less procedural pain. These data suggested that
NTA offers an alternative and safe means to treat supercial venous disease. There
is, however, a need for further powered trials with larger numbers of patients and
longer follow-up to denitively examine this hypothesis.
A Health Technology Assessment on nonthermal endovenous procedures for
varicose veins was developed by a multidisciplinary team from Ontario Health [16].
19 primary studies reported in 25 publications comparing either MOCA or CAC
with at least one other invasive treatment for symptomatic varicose veins were
included. No studies compared MOCA with CAC. This report concluded:
Cyanoacrylate adhesive closure (CAC) and MOCA produced similar patientimportant outcomes, and slightly shorter recovery compared with thermal ablation.
CAC yielded similar anatomical outcomes as thermal endovenous ablation, but the
technical outcomes of MOCA were slightly poorer. Compared with surgical vein
stripping, all endovenous treatments were more effective and less expensive. With
respect to the most cost-effective strategy, EVLA is most likely to be cost-effective.
For people with varicose veins, the CAC procedure was seen as a positive treatment
method that reduced their symptoms and improved their quality of life.
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18 Chronic Venous Disease andVaricose Veins
18.2.2 Randomized Trials
18.2.2.1 Radiofrequency (RF) Thermal Ablations withThree RF Devices
The randomized Radiofrequency (3RF) study compared three radiofrequency
devices, Venet (Closurefast), Radiofrequency Induced Thermal Therapy (RFITT),
and Endovenous Radiofrequency (EVRF) for treatment of incompetent great saphenous veins [17]. The 3RF long term study showed better closure rates and better
patient reported varicose veins scores 72months after treatment with Venet and
RFITT compared with EVRF.Failure of GSV closure on 72month DUS was 16%,
21%, and 37% for Venet, RFITT, and EVRF, respectively. When all technical failures were compared (including DUS results from re-treated participants), failure
rates were eight of 57 (14%), 11 of 64 (17%), and 26 of 59 (44%) after Venet,
RFITT, and EVRF, respectively (p<.001). However, no differences were demonstrated between the three groups when quality of life (QoL) scores were compared
using the EQ-5D or AVVQ tools.
18.2.2.2 Compression after Radiofrequency Ablation
In the randomized COMETA trial [18], patients with saphenous vein reux undergoing treatment with endothermal ablation (with or without concurrent phlebectomies) were randomized to receive either 7days of compression stockings or no
stockings. In total, 206 patients were randomized, 49% of them to the compression
group. The median pain score in the compression group using a visual analog scale
was signicantly lower on days 2–5, compared to the no compression group. Those
having concurrent phlebectomies and compression stockings also had signicantly
better pain scores on days 1–3, day 5, and day 7. Improvement in the median venous
clinical severity score was noted at 6-month follow-up, but this was not signicant.
No difference in the generic- or disease-specic quality of life was observed and the
time to return to activities was similar. These results indicate that wearing compression stockings after endothermal ablation is advantageous in the rst few days after
treatment and is especially benecial for those having concurrent phlebectomies.
18.2.2.3 Long-Term Outcomes ofLaser Ablation, Foam Sclerotherapy,
andSurgery
In a randomized, controlled trial involving 798 participants with primary varicose
veins at 11 centers in the United Kingdom, Brittenden etal. [19] compared the outcomes of laser ablation, foam sclerotherapy, and surgery. Initial results from this
CLASS trial had been published in 2014, and now the 5-year results have been
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presented. Quality-of-life questionnaires were completed by 595 (75%) of the 798
trial participants. There were signicant differences between the treatments with
respect to disease-specic quality of life. Aberdeen Varicose Vein Questionnaire
scores were better among participants treated with laser ablation or surgery than
among those treated with foam sclerotherapy. Laser ablation was similar to surgery
with respect to quality of life and of the three treatments had the highest chance of
being cost-effective.
18.2.2.4 RFA Vs. EVLA
In a comparative prospective monthly altering-treatment cohort study of 311
patients (346 treated legs), each leg with incompetence of the GSV was treated with
either RFA (158 patients, 175 legs) or EVLA (153 patients, 171 legs) [20]. The total
primary obliteration rate after 36 and 60months was 96.2% with RFA and 96.7%
with EVLA.There was no difference in postoperative pain scores after both treatments during the rst 14days. The median time for return to work was 1day after
both treatments. No severe adverse events were observed. In conclusion, RFA and
EVLA had similarly high GSV obliteration rates in the long term, and the treatments were equally effective clinically. Both treatments were associated with similar minimal postprocedural pain scores and short recovery times (Table18.5).
18.2.2.5 Mechanochemical (MOCA) andEndovenous Thermal Ablation
The MARADONA trial is a multicenter prospective randomized controlled trial
comparing MOCA (n= 105) with RFA (n=104) to treat great saphenous vein
incompetence [21]. Overall median pain scores during the rst 14days were lower
after MOCA (0.2 vs 0.5 after RFA; P=.010), although the absolute difference was
small. At 30days, similar complication numbers and HRQoL scores were observed.
Hyperpigmentation was reported in seven patients in the MOCA group and two
patients in the RFA group (P=.038). In the MOCA group, there were four complete
failures (3.8%) compared with none in the RFA group (P=.045), although in one
patient at 1 year, the vein showed occlusion. Median 30-day Venous Clinical
Severity Score (VCSS) was signicantly lower at 30 days after MOCA (1.0 vs
2.0in the RFA group; P=.001). At 1 and 2years, anatomic success rate was lower
after MOCA (83.5% and 80.0%) compared with RFA (94.2% and 88.3%; P=.025
and .066) because of partial recanalizations. Similar clinical success rates (MOCA,
88.7% and 93.0%; RFA, 93.2% and 90.4%; P=.315 and .699) were observed. The
study suggests that MOCA is a good alternative for treatment of great saphenous
vein incompetence at 2years of follow-up, although partial recanalization is more
frequent than after RFA.
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Table 18.5 Prospective comparative cohort study evaluating incompetent great saphenous vein
closure using RFA or EVLA (Varico 2 study). According to Lawson etal. [20]
Parameter RFA EVLA P value
Cohort (n) 158 patients/175 legs 153 patients/172 legs
CEAP class (n)
– C2 40 35
– C3 115 116
– C4 18 18
– C5 2 3
Postoperative pain medication in rst 14days (%)
– No medication 76.1 73.4
– 1-5units 17.8 20.3
Postoperative complications (%)
– Bruising 14.9 18.7 .39
– Temporary paresthesia 1.8 2.3 .72
– Permanent paresthesia 0.5 2.9 .21
– Deep venous thrombosis 0 0.6 (n=1/crural vein)
Persistent obliteration (%)
– At 36months / 60months 96.2/96.2 96.7/96.7
VCSS
– Preoperative 3.75 4.04
– At 12months 1.98 1.96
– At 60months 1.77 2.13
AVVQ scores (mean)
– Preoperative 11.45 12.97 .13
– At 1year 5.00 4.98 .96
– At 5years 5.20 5.98 .48
VCSS Venous Clinical Severity Score, AVVQ Aberdeen Varicose Vein Questionnaire
18 Chronic Venous Disease andVaricose Veins
18.2.2.6 Mechanochemical Ablation Vs Cyanoacrylate Adhesive
The MOCCA trial [22] was a prospective multicenter randomized clinical trial comparing MOCA with cyanoacrylate adhesive injection (CAE) for the treatment of
primary truncal saphenous veins incompetence. All interventions (MOCA n=83,
CAE n=84) were performed under ultrasonography guidance using local anesthesia. A total of 73 patients (47%) underwent adjunctive treatment of varicosities. The
primary outcome of this study was pain score after truncal ablations as measured by
VAS.Maximum and average pain score were low and similar between the MOCA
and CAE groups. There was no statistically signicant difference between treatment
groups in pain experienced in the 10days postoperatively, return to normal activities or work, ecchymosis score, and occlusion rates. The median clinical and QoL
scores signicantly improved in both groups after treatment with no difference
between the groups. The duration of procedure was signicantly longer in patients
treated with CAE (17 vs 21minutes; P<.001). This study found no difference in
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outcomes following MOCA or CAE.This would suggest that the main determinant
as to which interventions to use would be surgeon and patient preference and the
cost-effectiveness of each technique.
18.2.2.7 Isolated Ambulatory Phlebectomy Versus Saphenous
Thermal Ablation
Ambulatory selective varices ablation under local anaesthesia (ASVAL) is a method,
in which the incompetent tributaries are treated by means of phlebectomy, with
preservation of the saphenous trunk. The aim of the SAPTAP Trial was to determine
whether single ambulatory phlebectomy with or without delayed endovenous truncal ablation (SAP) is non-inferior to thermal endovenous ablation with concomitant
phlebectomy (TAP), and whether SAP is a cost-effective alternative to TAP [23].
Some 464 patients received the allocated treatment (SAP 227, TAP 237). Follow-up
visits were scheduled at 3months, 9months (SAP group only), and 12months after
the initial treatment. VEINES-QOL scores were 52.7 (95% c.i. 51.9 to 53.9) for
SAP and 53.8 (53.3 to 55.1) for TAP; VEINES-Sym scores were 53.5 (52.6 to 54.4)
and 54.2 (54.0 to 55.6) respectively. Fifty-eight patients (25.6 per cent) in the SAP
group received additional truncal ablation. Treatment with SAP was less costly than
treatment with TAP.One year after treatment, participants who underwent SAP had
non-inferior health-related quality of life compared with those who had
TAP. Treatment with SAP was a cost-effective alternative to TAP at 12months.
Treating patients with SAP instead of TAP has several advantages. First, only 25.6%
of those in the SAP group required additional treatment 9months after ambulatory
phlebectomy. Additional truncal treatment was not required in 73.5% of the patients
as they had no symptoms (with or without truncal reux) at 9-month follow-up.
Thus, three-quarters of the patients were relieved of symptoms after one instead of
two treatments. Second, the GSV/AASV was spared in these 73.5% of patients by
being treated with SAP.Sparing the saphenous trunk may result in abolishment of
reux, owing to reduction of blood volume in the trunk after isolated phlebectomy.
Therefore, it is given the opportunity to regain its function as one of the main veins
of the supercial venous system.
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18.3 Conclusions forClinical Practice
1. For patients with supercial venous incompetence presenting with symptomatic
varicose veins (CEAP clinical class C2S), interventional treatment is
recommended.
2. For patients with great saphenous vein incompetence requiring treatment, endo-
venous thermal ablation is recommended as rst choice treatment, in preference
to high ligation/stripping and ultrasound guided foam sclerotherapy.
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