Combined endovenous ablation with phlebectomy or foam sclerotherapy versus endovenous ablation alone for lower limb varicose veins: A systematic review and meta-analysis

Background The optimal timing of tributary treatment in varicose vein management remains debated. Concomitant endovenous therapy may reduce the need for subsequent procedures and accelerate recovery, whereas a staged approach may spare some patients unnecessary interventions. Objective To evaluate the efficacy, effectiveness, and safety of combined endovenous therapy with phlebectomy or foam sclerotherapy compared to endovenous therapy alone for lower limb varicose veins. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing concomitant combined endovenous therapy (ablation with immediate phlebectomy or foam sclerotherapy) versus ablation alone. The primary outcome was re-intervention. Secondary outcomes included clinical improvement (VCSS and AVVQ), postoperative complications, pain, and serious adverse events. Data were pooled using random-effects models. Results Six RCTs involving 432 patients were included. Combined endovenous therapy significantly reduced re-intervention rates (RR = 0.33, 95% CI: 0.18–0.62) compared with ablation alone. Combined endovenous treatment also provided superior short-term improvement in quality of life (AVVQ at 6 weeks: MD = 5.24, 95% CI: 2.53–7.94) and longer-term clinical severity (VCSS at 12 months: MD = 0.86, 95% CI: 0.40–1.31). There were no significant differences in superficial thrombophlebitis, nerve-related events, postoperative pain, or serious adverse events. Conclusions Combined endovenous therapy offers greater efficacy and effectiveness than endovenous therapy alone, reducing re-intervention and improving both short- and longer-term outcomes without compromising safety. Staged treatment may remain reasonable for selected patients, but from a patient-centered perspective, additional procedures represent a treatment burden. Most patients are likely to see better outcomes from combined endovenous therapy with phlebectomy or foam sclerotherapy compared to endovenous therapy alone.