Tributary treatment: Foam or phlebectomy?

Chronic venous disease (CVD) can cause patients to experience a broad spectrum of symptoms and clinical presentations. Management of these, from varicose veins to venous ulcers, presents an increasing burden on patients and the healthcare system, estimated to cost approximately £1 billion per annum. ¹ Superficial venous insufficiency (SVI) typically occurs secondary to reflux or obstruction, causing subsequent venous hypertension. Reflux can affect the great saphenous vein (GSV), small saphenous vein (SSV) or anterior accessory saphenous vein (AASV), tributary or perforator veins. ¹

First-line treatment for symptomatic varicose veins is in the form of endovenous thermal ablation (ETA) of truncal vein insufficiency. ¹ In the UK, NICE guidelines suggest consideration of treatment of tributary varicosities when treating the truncal veins with ETA, although this does not specify a treatment modality when doing so. ¹ Similarly, the most recent US and UK guidelines from both the AVF and EJVES suggest considering combined treatment of truncal and tributary varicose veins in patients with symptomatic reflux and, again, the guidelines make no differentiation between phlebectomy and ultrasound-guided foam sclerotherapy (UGFS).^2,3 There is currently varying evidence concerning the benefit of concomitant treatment of tributaries and this has caused debate amongst vascular surgeons regarding best clinical practice.

Watanabe et al reviewed patients receiving endovenous laser ablation (EVLA) and concomitant tributary treatment with UGFS, reporting good patient outcomes and prevention of second stage intervention. ⁴ This supports a previous trial carried out in 2009 by Carradice et al., reporting that concomitant treatment of EVLA with phlebectomies had an overall longer operative time, but reduced the need for subsequent interventions and significantly improved patient quality of life (QOL). ⁵ A further single-centre retrospective study by Alder et al demonstrated favourable patient self-reported outcomes, including that of symptom recurrence and QOL, in combined treatment of ablation with phlebectomies. Once more, this highlights the benefit of treating symptomatic tributaries, by offering symptom relief and the possibility of reducing the overall costs incurred from a second visit. ⁶

Lane et al. reviewed outcomes in patients receiving staged versus concomitant tributary treatment (UGFS or phlebectomy) with radiofrequency ablation (RFA), finding those who had concomitant treatment in a single visit had significantly improved QOL scores at follow-up. ⁷ Interestingly, this study noted difficulty in patient recruitment, predominantly due to patient preference for a single visit and, when possible, concomitant treatment. These results also recognised the inference that combined truncal and tributary treatment had better overall patient outcomes, better suited patient preference and could be more cost-effective, by reducing the total number of visits needed for treatment and subsequently reducing the overall cost of care.

Interestingly, concomitant treatment within these studies has been done without comparing outcomes between UGFS and phlebectomies when treating tributaries. Both treatment modalities have been used interchangeably in all the articles referenced and, as such, highlights a lack of guidelines for clinicians to adhere to when using the evidence base to make clinical decisions regarding tributary treatment.

Current evidence suggests less reintervention rates in phlebectomies, although this type of procedure must be done in a ‘clean’ room, rendering some centres incapable of offering this treatment and arguably negating the cost-effectiveness of avoiding multiple reinterventions. ⁸ Additionally, whilst varicose vein treatment is usually for symptomatic relief and not for cosmetic purposes, small scars post-phlebectomy have been known to cause issues for some patients. ⁸ In comparison, treatment by foam sclerotherapy can be carried out in a clinic setting. Patients also typically report less pain and more satisfaction post-procedure, although the limit to the volume of sclerosant that can be used at one time can also lead to multiple treatment visits in some cases. ⁹ The most notable complication of UGFS was pigmentation, both residual and secondary to extravasation, which can cause cosmetic issues for patients and have an impact on their reported QOL. The impact on QOL from cosmetic issues is typically more frequently reported in UGFS despite the low overall incidence rate, likely due to the scarring secondary to phlebectomies being smaller and, therefore, less noticeable.

Although there are no set clinical features that deem one treatment modality more suitable than the other, phlebectomy typically tends to be carried out on larger, more visible varicosities and may not be suitable in some patients, especially those with known bleeding disorders.

Interestingly, whilst the main topic of interest in this editorial focuses of UGFS versus phlebectomies, multiple comparisons between foam and liquid sclerotherapy have been carried out and demonstrate higher success rates and patient satisfaction with foam sclerotherapy, especially in those with varicosities with larger diameters.

It is worth noting that a clinical trial investigating superiority in phlebectomy versus UGFS in a single centre in the UK reported difficulties in the recruitment of patients during COVID, suspending the trial early and further highlights a continued lack of evidence within the literature. ¹⁰

Overall, further investigation into whether there is any significant benefit between the two treatment modalities would still need to be performed to guide decision-making and ensure best clinical practice. The absence of guidelines causes disagreement in decision making and allows for varied practice and outcomes, all of which can have negative outcomes on patient care.