Laser ablation superior for treating varicose veins

Lower rates of recurrence are reported compared with foam sclerotherapy and surgery

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A large, randomised study in the UK has confirmed that laser ablation is the superior treatment for varicose veins over both surgery and sclerotherapy.

 The study, which was published in the NEJM, randomised around 800 patients with varicose veins to receive surgery, laser ablation or foam sclerotherapy.

 Five years after treatment, the patients who underwent laser ablation or surgery had a better self-reported quality of life score than those who received foam sclerotherapy.

 This was probably due to the lower rates of recurrence in the laser ablation (58%) and surgery groups (54%) compared with the foam sclerotherapy group (47%), the authors said.

“It’s been known for a long time that the best treatment option for varicose veins in general is ablation methods – endovenous laser ablation and radiofrequency ablation,” Associate Professor Kurosh Parsi, phlebologist and vascular dermatologist at St Vincent’s Hospital in Sydney and the president of the International Union of Phlebology, said.

 “This message has been repeated over and over again in pretty much all the international guidelines,” he said.

 The NICE guidelines recommended laser ablation over other therapies, as did the equivalent American, and European guidelines, he said.

 Surgery is quickly becoming “obsolete” for the treatment of varicose veins, with minimally invasive procedures being preferred by clinicians and patients alike, Professor Parsi said.

 “If ablation treatments are not available or there is a contraindication for those treatments, then you drop down to foam sclerotherapy and, if that is not available, you do surgery.

 “So, surgery is kind of the last resort for patients with varicose veins.”

 A 2016 study showed that patients who underwent surgery for varicose veins had an 82% recurrence rate at five years, which was much higher than the rate reported in the NEJM study (54%). 

 “The advantage of laser ablation is that pretty much it’s a walk in-walk out procedure,” Professor Parsi said.

“There is no down time. There is no risk of infection. The deep vein thrombosis risk is not even comparable because with surgery where you get about 5-15% risk of deep vein thrombosis, but with laser ablation it’s less than 0.2%.”

 The NEJM study suggested that surgery was more successful from a patient perspective than foam sclerotherapy, but that could be related to the study design, Dr Simon Thibault, a practising phlebologist based in Newcastle, said.

 Foam sclerotherapy was indicated for the treatment of smaller veins up to about 5mm, but in all three arms of the study patients had varicose veins significantly larger than 5mm, Dr Thibault said.
‘[The study is] a bit unfair on ultrasound-guided sclerotherapy,” he said.

 “We’ve known for quite a long time that the larger trunks, laser is superior to ultrasound-guided sclerotherapy but in smaller trunks we find that the results are equivalent.”

 Dr Thibault is a general practitioner who later undertook the four-year training course to become a fellow of the Australasian College of Phlebology.

 However, some GPs that lack training in phlebology are also offering these procedures, often with poor results.

 “[Some GPs] think, wrongly, that treating venous disease is also an extension of doing Botox or fillers,” Professor Parsi said.

“That is totally the wrong attitude. The descriptors for the Medicare rebate say that people using these item numbers need to be appropriately trained.”

 Professor Parsi said he saw patients “day in, day out” who had been referred to him with complications after an inexperienced practitioners attempted to treat their varicose veins.

 If the procedures weren’t done correctly, they could result in nerve damage or significant tissue necrosis, he said. 

 “The consequences have been absolutely terrible,” he said. “One particular case I can tell you about is where a doctor injected veins around the eyes and the patient went blind. 

“All venous procedures can have significant complications, so people need to be trained.”

NEJM 2019, 5 September