Comparison of methods for endovenous ablation for chronic venous disease

INTRODUCTION — Endovenous ablation is a minimally invasive, highly effective treatment that can be performed in an office-based setting. Venous ablation is appropriate for patients with persistent symptoms or cosmetic concerns in the great, small, or accessory saphenous veins, collectively known as the axial veins, and with demonstrated venous reflux on duplex ultrasound examination.

Endovenous ablation is recommended as the primary method of treating symptomatic saphenous vein reflux primarily because it is associated with less perioperative morbidity and may be more cost-effective compared with surgical ligation and stripping, which was the primary treatment method prior to the development of endovenous closure techniques. However, long-term outcomes for open and endovenous techniques are similar.

Each method of endovenous ablation (thermal, nonthermal) has unique characteristics that must be taken into consideration to meet patient and provider needs (table 1). Understanding the technical differences and the advantages and disadvantages of each technique helps to create an individualized treatment plan and provide comprehensive care for patients with chronic venous disease.

The essential differences between the various endovenous methods for affecting venous closure, as indicated for the treatment of chronic venous disease, are reviewed here. Specific indications and techniques for their performance are reviewed separately.

●(See "Overview of lower extremity chronic venous disease".)

●(See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins".)

●(See "Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease".)

●(See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease".)

TECHNIQUE SUMMARY

Thermal ablation — Thermal ablation techniques include radiofrequency ablation (indirect or direct) and laser ablation, which require the use of tumescent anesthesia (subcutaneous mixture of lidocaine, epinephrine, and saline). These techniques have been rapidly adopted as the standard of care for treating superficial axial vein reflux. Saphenous vein closure is appropriate when patients have persistent symptoms or cosmetic concerns involving the great, small, or accessory saphenous veins (figure 1 and figure 2) and documented venous reflux (reflux time of >500 msec) on duplex ultrasound exam.

●(See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease".)

●(See "Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease".)

Radiofrequency — Radiofrequency ablation gained early attention in the 1990s for the treatment of tumors, but its application was broadened to include other conditions, including venous disease. The radiofrequency device creates a focal closed-loop alternating electrical current that ultimately induces heat damage to the vein wall endothelium. The first indirect radiofrequency device (ie, ClosureFast) was approved for use in the United States in 1999. First-generation devices were slow to use and had high recanalization rates. However, modifications in 2007 improved their effectiveness. Three-centimeter and 7 centimeter treatment coil radiofrequency catheters are available commercially. The vein is accessed and the radiofrequency catheter (65 or 100 cm length) is introduced into the vein through a 7 French sheath. Tumescent anesthesia is instilled into the perivenous tissue through a series of punctures along the target vein to completely envelope the vessel in tumescence. The use of a micropuncture needle and a motorized pump may lessen pain during delivery of the tumescent, which causes rapid hydrodissection around the vein. A direct radiofrequency catheter (Celon) is available in Europe but has not been approved for use in the United States.

Laser ablation — Endovenous laser ablation was introduced in 1999 and approved for use in the United States in 2001 [1]. Laser parameters of pullback rate, power, linear energy density, wavelength, and fiber type have all been modified to improve outcomes. A linear energy density between 60 and 100 J/cm maximizes efficacy and durability while minimizing periprocedural pain and bruising [2-5].

Initial lasers used lower wavelengths (810, 940, 980, and 1064 nm), based on the hemoglobin chromophore (figure 3) [6]. Hemoglobin absorbs energy from the emitted wavelength energy, resulting in heat and eventual thrombotic occlusion of the vessel. Direct contact to the vessel wall is unnecessary [1]. (See "Basic principles of medical lasers".)

Longer wavelengths have a greater affinity for water as a chromophore and are more efficient in absorbing energy, requiring lower power settings to achieve the same effect, which decreases perioperative pain and bruising compared with shorter wavelengths. One randomized trial compared 980 and 810 nm lasers, both at the same linear energy density [7]. Patients in the 980 nm laser cohort had decreased perioperative pain and bruising, but overall effectiveness was similar between the groups. Other studies have shown similar results with the 1320 and 1470 nm lasers [8,9].

Original laser fiber tips were bare, resulting in an increased incidence of vein wall perforation due to direct contact. Jacketed fibers prevent this and scatter laser energy to increase the treatment diameter. In a retrospective review, symptoms were improved when transitioning from a bare tip to the jacketed tip, and again transitioning to the radial-emitting tip [10]. Moreover, a multivariate analysis evaluating various wavelengths and tips found that increasing wavelength and protected tips correlated directly with less perioperative pain [11]. The choice of tip was a more dominant variable, but the improvement in perioperative symptomology was additive.

Nonthermal ablation — Nonthermal techniques (polidocanol endovenous microfoam [PEM], mechanochemical ablation [MOCA], and cyanoacrylate glue) provide endovenous options for veins, including those that are not amenable to thermal ablation. Nonthermal ablation eliminates the risk of thermal nerve or skin injury, and requires no tumescent anesthesia, also eliminating the need for additional needle sticks. Procedure times may also be reduced. (See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency".)

Polidocanol endovenous microfoam — Polidocanol endovenous microfoam (PEM) has been approved to treat great saphenous vein reflux and varicose veins. PEM is especially useful for very tortuous veins since it is the only method of endovenous saphenous closure that does not require catheter placement along the length of the vein. Varicose veins can also be treated using PEM in the same session as saphenous ablation.

PEM is commercially available as a standardized (uniform microbubbles) propriety foam sclerosant (ie, Varithena; 1% polidocanol foam), which was approved for use in the United States in 2013. While a physician-compounded foam (PCF) can be created using polidocanol or sodium tetradecyl sulfate with room air or carbon dioxide (CO₂), the bubbles created are larger and less stable. PCF is an off-label use of these sclerosants and is associated with a higher incidence of neurologic complications compared with PEM.

PEM is typically administered through a micropuncture sheath or intravenous catheter placed near the knee, above the proximal calf perforating veins. When PEM treatment is used for great saphenous vein ablation, caution should be used to avoid extravasation of foam into large perforating veins, which could potentially cause deep vein thrombosis (DVT).

Endovenous mechanochemical ablation — Endovenous mechanochemical ablation (MOCA; ie, ClariVein) uses mechanical injury at the saphenofemoral junction to induce closure while simultaneously injecting sclerosant distally to damage the endothelium. Either polidocanol or sodium tetradecyl sulfate can be used. MOCA was approved for use in the United States in 2008.

The procedure involves venous cannulation at the knee or ankle and passage of a catheter through the target vein. An agitating wire is introduced and activated near the saphenofemoral junction injuring the vein enhancing exposure to the chemical sclerosant while simultaneously inducing spasm that traps the sclerosant to facilitate closure.

MOCA is applicable to virtually all veins that are straight enough to allow catheter placement but is especially useful for very superficial veins and those below the knee since there is no chance of nerve injury and no residual foreign body (ie, as with glue).

Cyanoacrylate glue — Cyanoacrylate glue sealing (ie, VenaSeal) was approved for use in the United States in 2015. This technique seals the vein from the saphenofemoral/popliteal junction distally by injecting microbeads of cyanoacrylate glue during segmental pullback of a catheter combined with ultrasound probe compression. This tumescent-free technique is well tolerated and has been demonstrated to be safe and effective. However, the sealant remains within the vein permanently, which constitutes a foreign body. A small proportion of patients will have an allergic reaction or intolerance of the glue. There is a high cross-reactivity with other adhesive allergies. Skin testing may be indicated for patients with a tape or adhesive allergy to ensure safe use of cyanoacrylate.

OUTCOME COMPARISONS — Prior to endovenous techniques, the standard of care for managing superficial venous reflux was high ligation and stripping. Major trials demonstrating the safety and effectiveness for each endovenous treatment method are summarized (table 2) [12-17]. Several systematic reviews have concluded that the effectiveness of minimally invasive ablation techniques and surgical high ligation and stripping is similar for treating saphenous vein reflux, but minimally invasive techniques can achieve these outcomes with less pain, fewer resources, and more rapid return to normal activities [18-20].

Radiofrequency ablation was the first technique to be compared with surgical stripping in randomized trials. In the EVOLVEeS trial, quality-of-life scores were significantly improved for radiofrequency compared with surgical stripping and ligation [21,22].

The effectiveness of other endovenous techniques has often been compared with radiofrequency ablation. In the ClosureFast RFA RECOVERY postmarket study, laser ablation was associated with higher rates of postprocedural pain, ecchymosis, and minor complications [23,24]. Radiofrequency ablation patients often recovered faster and were able to return to work earlier than laser patients. In a large trial that randomly assigned 500 consecutive patients with great saphenous vein reflux to radiofrequency ablation, laser ablation, ultrasound-guided foam sclerotherapy, or surgical stripping, all treatment methods were effective, but immediate technical failure was more common after foam sclerotherapy [24]. Both radiofrequency ablation and foam sclerotherapy were associated with less postoperative pain and faster recovery compared with laser ablation and vein stripping. Radiofrequency and laser ablation are also more durable compared with sclerotherapy-based ablation at long-term follow-up, requiring fewer re-interventions [25-28]. A randomized trial compared direct (Celon) and indirect (ClosureFast) radiofrequency ablation with laser ablation (980 nm) and found that indirect and laser ablation were both superior to direct closure [29].

The VeClose trial demonstrated similar improved clinical and quality-of-life scores for glue compared with radiofrequency ablation, without any difference in the effectiveness of vein closure at three months, but with significantly less ecchymosis and lower intraprocedural pain scores [12,30].

The first trial to compare endovenous mechanochemical ablation (MOCA) with radiofrequency ablation demonstrated significantly less postoperative pain for MOCA and also an earlier return to daily activities (1.2 versus 2.4 days) [31]. Similar results of less postoperative pain and improved quality-of-life measures were noted in other studies [32,33]. In the MARADONA trial (mechanochemical endovenous ablation versus radiofrequency ablation in the treatment of primary great saphenous vein incompetence), MOCA had high technical success rates, short recovery time, and improved quality-of-life measures [32]. At one-year follow-up, 88.2 percent of the treated veins remained closed. The trial continues to enroll patients and is designed to compare clinical success and five-year follow-up data between the two cohorts.

In the LAMA trial (endovenous laser ablation versus mechanochemical ablation), the technical success was comparable between MOCA and laser ablation (92 and 94 percent, respectively), without any difference in quality-of-life measures, including early return to daily activities [30]. The intraprocedural experience of MOCA was significantly less painful for patients compared with laser ablation, but overall postprocedural pain was not significantly different.

A global multiarmed, postmarket trial is underway (VenaSeal Spectrum) to further characterize cyanoacrylate glue closure compared with vein stripping and endothermal closure across the range of subjects with chronic venous disease.

Clinical outcomes of interest, including technical success, vein recurrence, quality of life, ulcer healing, patient experience and cost for radiofrequency ablation, laser ablation, and sclerotherapy, are discussed below. Additional technical notes regarding performance of the procedures can be found in the linked topics.

●(See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease".)

●(See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins".)

●(See "Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease".)

Vein closure — All methods of endovenous ablation have high initial technical success rates (table 3) [12-14,17,24].

Radiofrequency ablation — Closure rates with radiofrequency ablation have steadily improved with operator experience and later-generation technologies. Two meta-analyses evaluating anatomic vein closure using continuous pullback radiofrequency catheters found immediate closure rates between 89 and 94 percent for great saphenous vein ablation [34,35]. Reopening of previously occluded veins occurred in 15 to 19 percent of veins at three years and in 26 to 30 percent of veins at three- to five-year follow-up. Alterations in closure technique, and increasing probe temperature (VNUS Closure, 90^ºC; ClosureFast, 120^ºC) and ablation time, have improved immediate closure rates with reported rates as high as 99.6 percent; however, long-term data are not available for later-generation devices [13].

Immediate closure rates for the small saphenous vein are similar to those of the great saphenous vein [36]. Immediate occlusion of perforating veins occurs in 70 to 80 percent of treated veins [37,38]. In one prospective study, at five years' follow-up, recurrent reflux developed in 19 percent of perforators previously confirmed closed [39]. Interestingly, of the total number of perforators identified with reflux, 19 percent were newly identified [39].

Laser ablation — Following laser ablation, initial technical and short-term success for treatment of the great saphenous vein ranges from 90 to 100 percent [35,40-44]. Failure of endovenous laser ablation for the great saphenous may be higher with vein diameters >11 mm [45,46], but this is not always the case [47-50].

Laser ablation of the accessory saphenous vein and small saphenous vein have shown closure rates similar to the great saphenous vein with minimal complications [51-56]. Primary success rates are 87 to 98 percent for the anterior saphenous vein and 91 to 93 percent for the small saphenous vein [47,53,57,58]. However, in one single-center retrospective review of 732 laser ablations, the failure rate was significantly higher for the anterior saphenous vein and small saphenous vein, compared with the great saphenous vein (8.8 and 13.2 percent versus 1.6 percent, respectively) [47]. In a trial that randomly assigned 106 patients with unilateral, primary small saphenous vein reflux to laser ablation or surgery, reflux was eliminated in significantly more patients treated with laser ablation (96 versus 72 percent) [59]. The high failure rate in the surgery group was primarily due to an inability to strip the small saphenous vein because of tortuosity or vein breakage. Symptomatic improvement was similar in both groups and remained the same after two years.

For perforating veins, the SeCure Trial reported that laser ablation with a 1470 nm 400 micron fiber successfully closed 95 percent of treated veins at 10 days [60]. This rate was higher compared with perforator closure rates for radiofrequency ablation (58 percent) [61], and chemical ablation (54 percent) [62].

Polidocanol endovenous microfoam — Although commercially available polidocanol endovenous microfoam (PEM; Varithena) and physician-compounded foam (PCF) are both polidocanol foam sclerotherapy preparations, the more uniform microbubbles make PEM more effective and less likely to cause complications compared with PCF [16,63]. PEM has reported closure rates of 85 percent when treating the great saphenous vein [16], which was similar to closure rates with PCF in one prospective randomized trial [24]. However, saphenous closure rates with foam sclerotherapy appear overall lower compared with thermal methods (77.4 versus 93.4 percent, in one laser study [64]) [64-68]. Sclerotherapy is less effective for larger veins [69-72]. Other studies have reported higher long-term success with one or more treatment sessions [73-75]. In one of these studies, 90 percent of great saphenous veins were free of recanalization with two sclerotherapy sessions over a mean 39 months of follow-up [73]. For the small saphenous vein, closure rates of 91 to 94 percent at 12 months follow-up have been reported [76,77]. Foam sclerotherapy is also an effective and durable method of eliminating reflux in perforator veins. In one observational study, 98 percent of incompetent perforators were successfully obliterated at the time of treatment; 75 percent of limbs showed persistent occlusion of perforators up to five years following treatment [78].

Vein recurrence — Up to one third of patients treated with saphenous stripping have residual or recurrent varicose veins [36,79]. Following thermal ablation, randomized trials have reported a varying incidence of recurrent varicose veins ranging from 10 to 40 percent (table 3) [43,80-84]. In large retrospective reviews of laser ablation, long-term (two to seven years) varicose vein recurrence occurred in 7 to 14 percent of patients [1,53]. Although there is some evidence that laser ablation has higher recanalization rates compared with radiofrequency ablation, this has not been borne out in high-quality studies [79]. In a comparative review, clinical recurrence rates were the same for high ligation combined with stripping of the great saphenous vein, high ligation of the saphenofemoral junction combined with laser ablation of the great saphenous vein, and laser ablation of the great saphenous vein alone over the six-year follow-up period [81].

For foam sclerotherapy, a systematic review identified a median recurrence rate of 8.1 percent among 69 studies [85]. Foam sclerotherapy is associated with lower rates of recanalization compared with liquid sclerotherapy [69-72]. For either liquid or foam sclerotherapy, recurrence of clinical symptoms may be lower than vein recurrence [86-88].

Quality of life — Improvement in symptoms and appearance of varicose veins is reflected by venous clinical severity scales (eg, Venous Clinical Severity Score, Aberdeen Varicose Vein Symptom Score) and quality of life scores (eg, Medical Outcomes Study Short Form-36). These have been used to compare outcomes of endovenous ablation techniques [23,27,40,41,89,90]. (See "Classification of lower extremity chronic venous disorders", section on 'Measures of clinical severity'.)

Small trials have compared quality of life after radiofrequency or laser ablation. Patients with saphenous vein reflux were randomly assigned to radiofrequency ablation (using ClosureFAST; 67 patients) or laser ablation (using 980 nm wavelength laser; 64 patients) [91]. There were no significant differences in quality of life outcomes measures at six weeks' follow-up. However, a small trial that assigned 20 patients with bilateral symptomatic great saphenous vein reflux to laser ablation for one leg and vein stripping for the other leg found that 70 percent of the patients preferred laser ablation [92]. In another trial that compared laser ablation with foam sclerotherapy or surgical stripping, laser ablation was associated with fewer complications and a trend for improved quality of life (eg, primarily prolonged bruising, tenderness, staining, hematoma) [93,94]. Among participants who completed questionnaires at five years (75 percent), disease-specific quality-of-life at five years (Aberdeen Varicose Vein Questionnaire [AVVQ]) was improved compared to baseline for all groups, but was better for laser ablation or surgery compared with foam sclerotherapy [95].

Sclerotherapy is also effective in relieving pain in the treated veins with high rates of patient satisfaction [86,96,97]. As a method of eliminating incompetent perforator veins, foam sclerotherapy significantly reduces symptoms and signs as determined by venous clinical scores. In the only available long-term patient series, clinical improvement was sustained at a mean follow-up of 20.1 months [78].

It is important to note that improvements in quality of life and patient satisfaction scores do not necessarily mirror closure rates (see 'Vein closure' above), with patients reporting satisfaction and relief of symptoms after partial closure or even after recanalization [16,86-88,98,99]. This has been demonstrated in the PEM VANISH trials [16], and also in randomized trials for thermal ablation techniques, one of which showed that only a small fraction of patients with recanalization after any treatment needed repeated treatment for symptoms [24,42,80,90]. In one prospective trial, saphenous vein recanalization occurred in 27 and 64 percent of patients treated with PCF at one and five years, respectively [87]. However, 70 percent of patients did not have recurrent clinical symptoms. Repeat treatment was needed in only 16.5 percent of patients between one and two years, and fewer than 10 percent in subsequent years (up to five years). These consistent data imply that closure of symptomatic varicosities and venules, which is common with any foam preparation due to the ability to fill small lumens, may be a key to symptom relief.

Ulcer healing — Surgical trials have demonstrated that saphenous stripping reduces ulcer recurrence rates [100-102]. An early trial comparing endovenous ablation with compression therapy likewise demonstrated that patients suffered fewer recurrences following endovenous saphenous vein ablation, but also that ulcers healed faster [103].

Persistent reflux in perforating veins following the management of saphenous reflux is a risk factor for venous ulcer nonhealing or recurrence [100,104].

Although perforator ablation should not be the first management strategy in the treatment of venous ulcers, there is good evidence that following treatment of axial reflux, treatment of pathologic perforators speeds ulcer healing [39,62,100,104-107]. Healing rates of venous ulcers following foam sclerotherapy appear to be similar to those reported after surgery [108]. In an observational study, ulcer healing was ultimately observed in 32 of 37 limbs treated by foam sclerotherapy [78]. This group of patients did not have concomitant axial vein reflux. More than one treatment session was required due to the development of recurrent perforators in 12 of 37 limbs treated. In another study, 79 percent of active ulcers healed following foam sclerotherapy of associated varicose veins [109]. By contrast, a small trial found healing of venous ulcers in 17/22 patients treated with four-layer compression bandages alone and 12/13 patients treated with compression bandaging plus foam sclerotherapy to incompetent truncal veins, but the difference was not significant [110].

Patient experience and satisfaction — Comparisons between procedural pain scores have not demonstrated clear advantages of the nonthermal techniques over thermal ablation [12]. However, one clear advantage of the nonthermal ablation technique is the avoidance of tumescent anesthesia during the procedure. Not only does this eliminate needle sticks and pressure from the anesthetic infiltration, it expedites the procedure, benefitting both the patient and physician. In addition to avoiding tumescent anesthesia, cyanoacrylate glue sealing does not require compression stockings postprocedurally. This is particularly advantageous to patients who have difficulty tolerating compression. However, in spite of not using tumescence, the VeClose trial (ie, VenaSeal) demonstrated similar intraprocedural pain scores to radiofrequency ablation [12]. Other aspects of the nonthermal ablation procedures may be uncomfortable. Some thin patients are bothered by the agitation and possible valve traction during mechanochemical ablation (MOCA). Pressure held on the vein during cyanoacrylate glue use can be bothersome, and polidocanol can be irritating, especially if extravasation occurs.

The patient experience with laser ablation is very similar to radiofrequency ablation, including tumescence. Multiple randomized trials have shown that immediate postoperative quality-of-life measures (pain, ecchymosis, tenderness) are significantly better following treatment of the saphenous vein using radiofrequency ablation compared with endovenous laser ablation [22,23,91,111-113], although some newer laser wavelengths (eg, 1470 nm) are associated with fewer postoperative symptoms [114]. Pain and ecchymosis remain the dominant complaints associated with laser ablation and likely correlate with microperforations occurring along the vein wall, related to thermal injury.

The time to return to normal activities or return to work is variable among the available clinical trials [22,23,41]. The low incidence of adverse effects and complications with radiofrequency ablation results in a significantly lower number of days to return to normal activities and work compared with vein stripping (1.5 versus 3.9 days, 4.7 versus 12.4 days) [22,23]. Similarly, in a trial of 99 patients, time to return to normal activity and return to work was decreased for laser ablation compared with great saphenous vein ligation and stripping (2 versus 7 days and 4 versus 17 days, respectively) [41]. On the other hand, two trials involving 200 and 121 patients found no significant differences in return to normal activity or work for laser ablation compared with surgical stripping (average, 7 days) [90,115]. In another trial, the time to return to work was longer for laser ablation compared with great saphenous vein ligation and stripping (20 versus 14 days) [40].

In a study comparing radiofrequency ablation and cyanoacrylate, despite similar efficacy and a higher rate of postprocedural thrombophlebitis in cyanoacrylate-treated patients, patients were able to return to work significantly more quickly compared with radiofrequency ablation-treated patients [116].

Similar results have been noted for small saphenous vein laser ablation. In a trial comparing small saphenous laser ablation with surgery, significantly less postoperative pain occurred after laser ablation allowing an earlier return to work and normal function [117]. Fewer minor sensory disturbances occurred in those who underwent laser ablation compared with surgery (7.5 versus 26.4 percent). However, both groups demonstrated similar improvements in Venous Clinical Severity Score and quality of life.

Complications — Complications from endovenous ablation are uncommon and usually straightforward to manage. Although there are many studies that report complication rates with the different techniques (table 4), there are few clear differences. Sclerotherapy is associated with unique complications that are generally preventable using optimal techniques. Nerve injury is increased for thermal compared with non-thermal techniques. (See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease", section on 'Complications' and "Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease", section on 'Complications'.)

Cost — Cost analysis of minimally invasive venous ablation methods have varied [118]. Reimbursement for venous procedures is an ever-shifting landscape. Depending on the proportion of cash-pay versus insurance and other local factors, a private office may not be able to offer every technique.

The most cost-effective method for an interventionalist is likely bare-tipped laser as these can be used with a one-time generator purchase, lease, or gift from the catheter manufacturer. Fibers are generally inexpensive, and some can have the tip cut off and the remaining catheter re-sterilized and reused up to four additional times. The supplies for nonthermal techniques are generally more expensive to purchase. An exception is physician-compounded foam (PCF), which is very inexpensive, especially if the sclerosant is purchased from a compounding pharmacy.

One trial evaluated differences in cost between laser ablation and ligation and stripping of the great saphenous vein and found no significant differences between these procedures [90]. Another trial used a Markov model to estimate costs of foam sclerotherapy, laser ablation, and surgical stripping. Costs were significantly decreased for laser ablation compared with surgical stripping but were more than sclerotherapy [93]. However, because of overall greater improvements in health-related quality of life, laser ablation was judged to be the more cost-effective treatment.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic venous disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Vein ablation (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Venous ablation – Vein closure (ablation) is appropriate for patients with persistent symptoms or cosmetic concerns related to venous reflux in the great, small, or anterior saphenous veins, collectively known as the axial veins. Endovenous ablation techniques, rather than open surgical ligation and stripping, are recommended as the primary method of treating symptomatic reflux in these veins. (See 'Introduction' above and "Overview of lower extremity chronic venous disease", section on 'Management' and "Approach to treating symptomatic superficial venous insufficiency", section on 'Technique selection by axial vein'.)

●Techniques – Techniques for endovenous ablation include thermal (radiofrequency ablation, laser ablation) and nonthermal (polidocanol endovenous microfoam [PEM], endovenous mechanochemical ablation [MOCA], and cyanoacrylate) techniques. Each method of vein ablation has unique characteristics (table 1). (See 'Technique summary' above.)

●Outcomes comparisons – Understanding the technical differences and the advantages and disadvantages of each technique helps to create an individualized treatment plan and helps to provide comprehensive care for patients with chronic venous disease. All methods of endovenous ablation have high initial technical success rates (table 3). Recanalization of the treated vein is most likely to occur with foam sclerotherapy. The rate of new vein formation is similar for all methods. It is important to note that clinical success as measured by quality of life and patient satisfaction scores often persists in spite of less than complete closure with initial treatment, later recanalization of the treated veins, or new vein formation. (See 'Outcome comparisons' above.)

●Complications – The overall complication rates for endovenous ablation are low (table 4). The types of complications are similar; however, sclerotherapy is associated with unique complications that are generally preventable using optimal techniques. Nerve injury is increased for thermal compared with non-thermal techniques. (See 'Complications' above.)