Clinical Question

What is the best approach to treat varicose veins?

Bottom Line

For symptomatic varicose veins at least 3 mm in diameter with evidence of saphenous vein reflux, laser ablation is the preferred initial therapy. (Level of Evidence = 1b)

Synopsis

The researchers identified 798 adults with primary symptomatic varicose veins at least 3 mm in diameter in at least one leg, plus evidence of reflux of the saphenous veins by more than one second by duplex ultrasonography. Patients with deep or superficial thrombosis were excluded. If both legs were involved, the most severely affected leg was evaluated in the study. Participants were randomized to one of three treatment options: foam sclerotherapy, laser ablation (followed by foam sclerotherapy if needed), and surgery. Of 11 centers, three offered foam sclerotherapy or surgery leading to an imbalance in the number in each group, with only 212 in the laser ablation group compared with 292 to 294 in the other groups. Follow-up with the primary outcome questionnaire was 87% to 92% at six weeks, 82% to 88% at six months, and 73% to 76% at five years. There were more early withdrawals in the surgery group. Data from case notes were available for 96% of patients. Groups were balanced, with a mean age of 49 years, 57% women, and about three-fourths having involvement in only one leg. Analysis was by intention-to-treat. After five years, the Aberdeen Varicose Vein Questionnaire score had decreased more in the laser ablation and surgery groups than in the foam sclerotherapy group. The effect sizes were clinically and statistically significant. A cost-effectiveness analysis favored laser ablation over the other two approaches.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (any)

Reference: Brittenden J, Cooper D, Dimitrova M, et al. Five-year outcomes of a randomized trial of treatments for varicose veins. N Engl J Med. 2019;381(10):912–922.

Editor's Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell.