Abstract
After a century of consistency, the treatment of superficial venous incompetence has evolved dramatically in the last 10 years. There is a rapidly growing body of evidence to support the efficacy, reproducibility and safety of endovenous treatment modalities. Recent studies have reported long-term occlusion rates as high as 97.1% for endovenous laser therapy and a six-month greater saphenous vein occlusion rate 99.6% for radiofrequency segmental ablation. 1,2 The early results of the new segmental radiofrequency ablation technique seem favourable to the slow-withdrawal radiofrequency procedure. 3 Interestingly, recent results following open surgery have also been very impressive, perhaps reflecting the widespread availability and increasing expertise in the use of intraoperative duplex scanning. 4 The occlusion rates following foam sclerotherapy are likely to be inferior to laser or radiofrequency ablation and repeat treatments are frequently necessary, 5 but reduced cost and pain are definite advantages. It is clear that foam sclerotherapy, radiofrequency and laser ablation have unquestionably joined traditional surgery as durable and acceptable options for the treatment of superficial venous incompetence. Although novel and minimally invasive procedures are clearly welcomed by surgeons and patients, deciding between treatment modalities has become truly impossible.
Non-clinical outcome measures such as quality of life assessment and cost analysis have often been considered as being of secondary importance to occlusion rates. However, in a highly litigious surgical field, the significance of patient perception as an outcome measure should not be underestimated and cost benefit will always be a powerful driver of changes in clinical practice, particularly in State-funded health-care systems. Studies of endovenous treatments have reported significant improvements in disease-specific quality of life following foam sclerotherapy, laser and radiofrequency ablation, 2,6,7 but improvements seem comparable rather than superior to open surgery. Studies assessing the cost-effectiveness of venous treatments are scarce. Perhaps one reason for this is that such analyses are inherently challenging as there are great variations in procedural technique, type of anaesthesia and location of surgery (i.e. office based or operating theatre), all of which significantly influence the costs incurred. Moreover, as the population affected by varicose veins is often young and employed, the importance of postoperative pain and subsequent return to work should also be considered.
The early assumptions that endovenous techniques would rapidly sweep aside and replace open surgery have not been supported by randomized trials. Recent studies have failed to demonstrate a significant superiority over open surgery. 4,6 It may be that after decades of complacency, the imminent threat of novel treatments has resulted in a new impetus to refine and improve the techniques for open surgery. Certainly, the routine use of intraoperative duplex scanning and tumescent anaesthesia for open surgery is likely to improve the technical outcome and pain scores. Whether new endovenous techniques are introduced, or current surgery is improved, patients, surgeons and device manufacturers are all likely to benefit.
With the widespread introduction of endovenous therapies, it would seem that clinicians and patients are spoilt for choice. Treatment selection is likely to be influenced primarily by clinical outcomes, safety and cost-effectiveness. However, personal preference, patient choice, local availability, marketing and other factors are all likely to have an impact. With such enthusiastic advocates for each modality, it is unlikely that any of the endovenous modalities or open surgery will disappear. It is likely that the new generation of venous surgeon will need to be proficient at numerous venous treatments and offer a selection or combination of techniques tailored to the individual patient. However, further studies are needed, particularly to investigate cost-effectiveness of different venous treatments and to directly compare new endovenous procedures. Only then can we best utilize the wealth of venous treatments that are now available.