High ligation and stripping vs. endothermal ablation of the great saphenous vein: What can be learned from current long-term analyses?

Background: Saphenous vein incompetence is globally treated in different ways, by endovenous ablation, predominantly by endothermal ablation, sclerotherapy or by open surgery. The choice of the respective method seems thereby to depend more on national regulatory requirements e.g. in the British NHS, or on the preference of the particular medical practitioner, than on individual patients' factors. As some more evidence from randomised long-term clinical trials is currently available, it is reasonable to reevaluate the different techniques, especially endothermal ablation vs. open surgery. Methods: Selective literature analysis based on a systematic PubMed search focussed on long-term clinical trials (randomised controlled trials (RCT) and systematic reviews/meta-analyses) with a follow-up of at least 5 years comparing endovenous thermal ablation with high ligation and stripping of the great saphenous vein. Descriptive analysis of long-term results, especially due to recurrence and quality of life. Results: The search terms, surgery" "endovenous" "varicose vein", filtered by RCT, systematic review, and meta-analysis resulted in 74 publications since 01-Jan-2014, hereof 7 long-term RCTs and 2 meta-analyses comparing open surgery with endovenous techniques. In these studies, endovenous ablation was mostly performed by 810-980 nm wavelength lasers using a bare fibre. No differences between treatments were found with respect to venous severity scoring, patients' quality of life, and clinical overall recurrence due to REVAS classification. However, duplex and clinical recurrence from the groin were significantly more frequent after endovenous thermal ablation. Conclusions: Open surgery is more effective than endothermal ablation in the long term warranting lower rates of duplex and clinical same site recurrence. Therefore, rating open surgery as a treatment of second or third choice in current European guidelines seems currently to be no longer justified. However, there is a considerable paucity of randomised trials comparing open surgery with novel endovenous laser (e.g. laser with higher wavelengths and radial fibre) and radiofrequency techniques, which are mandatory by now.