The endovenous revolution

More than 25 per cent of the general population suffers from varicose veins or more advanced stages of chronic venous disease (Fig. 1). Although often underestimated, chronic venous disease has a considerable impact on quality of life. Worsening clinical grade corresponds strongly with deterioration of disease-specific as well as generic quality of life1. Varicose veins of the left leg For most of the 20th century, varicose veins were treated predominantly by surgery. This was challenged in the 1990s with the introduction of catheter-based systems of endovenous heating of the great saphenous vein (GSV) with radiofrequency (RF) energy. Early reports established the efficacy of this procedure, showing that venous ablation could be achieved without high ligation of the saphenofemoral junction2. Endovenous RF ablation was quickly followed by endovenous laser ablation (EVLA), initially using an 810-nm diode laser. Many other laser devices appeared subsequently, using different wavelengths, varying power settings, pulsed or continuous withdrawal, and a variety of laser-tip designs. In the past few years, user-friendly RF technologies and endovenous steam have been added to the therapeutic repertoire. Requirements for the introduction of a new device are far less stringent than for the introduction of a new drug. Moreover, if a new device is similar to ones that have already been approved, companies can use a fast-track system to introduce it into clinical practice, with relatively little evidence of effectiveness3. The introduction of many endovenous thermal ablation (EVTA) devices provides good examples of this behaviour, resulting in widespread use based on small numbers of inadequately powered studies. It was not until 2007 that the first randomized clinical trial comparing EVLA and stripping was published4. It must also be acknowledged that research in EVTA is often sponsored by manufacturers, influencing the dissemination of information in scientific papers and at medical conferences. This probably explains why so much of the existing literature is focused on short-term outcomes and technical safety. In the meta-analysis by van den Bos and colleagues5, 16 of the 30 included EVLA studies had a follow-up of 6 months or less. At about the same time as the introduction of EVTA, another revolution took place in the field of varicose vein treatment with the introduction of ultrasound-guided foam sclerotherapy (UGFS). Injection of sclerosant foam proved feasible in all kinds of veins, main trunks as well as tributaries, primary or recurrent varicose veins and tortuous veins. It proved to be easily performed. It can be repeated and is cheap—in spite of recent cost-effectiveness studies suggesting the contrary6. Although risks of deep vein thrombosis, visual disturbance, migraine and rare transient neurological problems have been the subject of considerable debate, side-effects are usually minor, such as teleangiectatic matting, superficial thrombus and residual pigmentation. Treating a patient with UGFS supposes a good initial agreement between the patient and the physician, who will have to explain the philosophy of the step-by-step approach, replacing the classical ‘one-stop’ treatment concept. Meta-analysis may not be entirely reliable for determining the optimal endovenous treatment, and whether the final outcome will really be superior or equal to well performed surgery5. Direct comparison of different techniques might be more relevant than analysing old data. In this BJS issue, Rasmussen and co-workers7 undertook a randomized trial to compare four treatment methods for varicose veins. They randomized 500 patients to EVLA, RF ablation, UGFS or stripping under tumescent local anaesthesia and looked at immediate postoperative recovery as well as outcome after 1 year. This study showed very little clinical difference between the methods. UGFS appeared cheapest, but longer follow-up will be needed before drawing definitive conclusions. Long-term follow-up is important, in particular for a chronic condition such as varicose veins, in which progression of the disease is known to be a major contributing factor. Another article in this BJS issue reports the 5-year results of a randomized trial comparing EVLA with cryostripping of the GSV and delayed phlebectomies or sclerotherapy of varicose tributaries after 6 weeks8. Again, clinical outcomes were no different, although duplex results suggested that the pathophysiological mechanism did differ between the groups, with more neovascularization in the cryostripping group. An important benefit of the EVTA and foam revolution is the widespread introduction of routine use of duplex ultrasonography into varicose vein practice. In this issue Blomgren and colleagues9 report the late results of a trial examining the usefulness of routine preoperative duplex imaging in patients with varicose veins treated by surgery. After 7 years, not only was duplex-detected recurrent reflux less frequent, but also the number of reoperations was significantly lower in the group that had duplex ultrasonography before surgery. Duplex imaging should be considered an essential component in the training of vascular surgeons and other specialists treating varicose veins. Another positive effect of the endovenous revolution is that varicose vein treatment has moved from in-hospital to outpatient treatment. All endovenous interventions can be performed under local anaesthesia, or without any anaesthesia in the case of UGFS. Modern varicose vein surgery can also be performed in the same way, as shown in the study by Rasmussen and co-workers7. This may considerably reduce the global costs for varicose vein treatment and merits careful analysis from a health economic viewpoint. The main risk of the endovenous revolution is that this could induce a tendency to overtreat patients with varicose veins, by offering chemical or thermal ablation far too prematurely. A small-diameter refluxing trunk may not need treatment and focusing on the tributaries may be sufficient10. ‘Don't treat the duplex, treat the patient’ remains a suitable adage for good care of the patient with varicose veins. The author wishes to thank Jonothan Earnshaw for his advice about this manuscript. The author declares no conflict of interest.