Varicose veins: further support for endovascular laser ablation

By Nicole MacKee
Laser ablation treatment for varicose veins provides long-term improvement in patients’ quality of life, say researchers who have also found it to be the most cost-effective of three treatment options.

In a UK multicentre randomised trial, published in The New England Journal of Medicine, almost 800 participants with primary varicose veins were followed for five years after treatment with either endovenous laser ablation, ultrasound-guided foam sclerotherapy or surgery.

The researchers found that, compared with baseline, all groups reported improvements in generic quality of life measures. However, in terms of disease-specific quality of life, laser therapy and surgery resulted in greater improvements than foam sclerotherapy. The researchers further found that laser ablation was the most likely of the three modalities to be cost effective.

Associate Professor Kurosh Parsi, President of the International Union of Phlebology (UIP) and Head of the Department of Dermatology at Sydney’s St Vincent’s Hospital, said endovenous thermal ablation (laser or radiofrequency) was the ‘treatment of choice’ in Australia for venous incompetence.

‘We have no question that [endovenous thermal ablation] is the best treatment modality for the treatment of venous disease in 2019,’ he said, noting that the findings reflected recommendations in the UK’s National Institute for Health and Care Excellence guidelines, as well as in US and European guidelines.

He said traditional surgery (stripping and avulsions) was no longer a recommended treatment option in Australia or the world and should be considered the ‘absolute last resort’.

However, Associate Professor Parsi said the UK findings on ultrasound-guided foam sclerotherapy were not generalisable to Australia. He said local phlebologists used advanced techniques when performing foam sclerotherapy, whereas some of the UK clinicians involved in these studies used a much simpler ‘one-shot’ approach.

‘The UIP and the Australian guidelines recommend against that sort of approach because just one injection of foam into the vein is not going to close the vein,’ he said.

Associate Professor Parsi said it was important for GPs to encourage patients to be proactive in seeking treatment for varicose veins. ‘The number one message is that treatment for varicose veins is not cosmetic,’ he said. ‘What may appear as cosmetic varicose veins can very quickly progress to swelling and skin changes, and then to ulcers and skin necrosis.’

The noninvasive therapies now available did not require a general anaesthetic or hospitalisation and were suitable for elderly patients, he added.
N Engl J Med 2019; 381: 912-22.