Abstract
Varicose veins are a common disease, with a reported prevalence of 20–40%. 1–3 Their treatment represents one of the most common elective surgical procedures in vascular surgery. Numerous advances have been made in this field, moving away from surgical ligation of the saphenofemoral junction and stripping, towards less invasive options, including ultrasound-guided foam sclerotherapy, radiofrequency ablation (RFA) and endovenous laser ablation (EVLA).
Although these methods all address the truncal incompetence with similar technical success rates, 4 residual superficial varicosities may remain postoperatively and their treatment is still a matter of debate.
There are two schools of thought with regard to treating varicosities in those patients undergoing truncal vein ablation. The first suggests simultaneous truncal treatment and phlebectomy as a single procedure. 5 The second advises delayed phlebectomy after monitoring for varicosity regression. If still present, these can be addressed with ambulatory phlebectomies or foam sclerotherapy. 6
Advocates of the first option suggest that immediate treatment of surface varicosities is advantageous in that it ensures patients are treated in a single session and reduces the varicosity reservoir. However, this may increase operative time, 7 and could be over-treating patients whose varicosities may regress.
Those in favour of delayed phlebectomies claim that this treatment is shorter, saving operative time. However, a variable number of patients do come back with troublesome residual varicosities, which require secondary procedures.
The evidence of the timing for phlebectomy is at best confusing. Carradice et al. 7 's 2009 study showed that while there was no sustained difference in quality-of-life measures between delayed and simultaneous phlebectomy in the context of EVLA treatment, 66% of patients in the truncal ablation only group required secondary interventions. Monahan et al. 6 suggested that after RFA, 13% of patients had spontaneous varicosity regression and 41% of patients did not require further treatment, suggesting that monitoring for regression is the best option.
This appears confusing and contradictory, but both EVLA and RFA truncal ablation have been shown to save 30–40% of patients from having needless phlebectomies. However, Doganci et al.'s 8 comparison of laser wavelengths utilized a delayed approach but 100% of subjects required further intervention.
Part of the issue is that the literature is very heterogeneous, making comparisons between studies challenging. 9 Variations exist in the reporting standards for surgical vs. EVLA/RFA or foam sclerotherapy both in terms of vein classification, as well as length to follow-up, objective assessments and questionnaires. Studies looking at specifically immediate vs. delayed phlebectomies are few in number. 5,10,11 Most randomized studies into catheter type or modality to date have used standardized delayed or simultaneous phlebectomies across their study groups, with no clear definition of the trigger to varicosity treatment. This makes comparison difficult.
Furthermore, there are a number variables that confound the picture. Patient factors such as age, body habits and mobility will influence the result of any intervention on the venous system. Patient preference and expectations, as well as operator experience, may have an effect on patient and operator satisfaction. Pain levels experienced have been assessed in only one study, which showed no statistical difference in pain or return to normal activities. 7 Finally the anatomy of the venous system and its preoperative haemodynamic state 12,13 will also influence the outcome of any intervention, as will the condition of the patient and the venous calf pump. These factors need to be considered when considering treatment options, with the appreciation that any alteration in the venous tree will lead to haemodynamic changes. 14
Ultimately, the aim of procedures for residual venous disease are to provide the maximum symptomatic relief for as long as possible. An ideal treatment would be minimally invasive, safe, effective from a functional and cosmetic point of view, have low recurrence rates and be cost-effective. However, the goal of ambulatory minimally invasive treatment should not preclude the full management of the disease.
Venous disease affects a large proportion of our population. Despite advances in the field, the evidence behind treatment is still unclear; this is particularly true of tributary vein treatment at the time of truncal ablation. Further studies, in terms of randomized controlled trials targeting the questions above, are required to provide evidence to best lead our practice.