Outcomes of Saphenous Vein Intervention in the Management of Superficial Venous Incompetence: A Systematic Review and Network Meta-Analysis

Objective: Endovenous therapies have instigated a paradigm shift in the management of superficial venous incompetence (SVI). When compared with open surgery, endovenous interventions (foam sclerotherapy [FS], radiofrequency ablation [RFA], endovenous laser ablation [EVLA], mechanochemical ablation [MOCA], and cyanoacrylate glue [CAE] closure) potentially offer reduced morbidity with similar procedural efficacy. This study aimed to determine the most effective modality of intervention to treat saphenous vein insufficiency. Methods: A systematic review and series of network meta-analyses of randomised controlled trials were performed assessing risks of procedural failure (within six weeks) and recurrence (six weeks to five years), defined by ultrasound, between the different SVI modalities. Treatment comparisons addressing risks of common adverse events, Venous Clinical Severity Score (VCSS), Aberdeen Quality of Life Questionnaire (AVVQ), and pain were also performed. Results: A systematic search identified 51 articles, describing 36 RCTs, incorporating 7 576 limbs. Outcome data on 10 modalities of intervention were analysed up to five year follow up. CAE resulted in the lowest risk of procedural failure within six weeks. Foam sclerotherapy had the highest risks of recurrence while high ligation with stripping [HLS] and CHIVA were ranked best to reduce long term recurrence. No intervention increased risks of venous thromboembolism and there was minimal difference in morbidity between treatments. All interventions improved VCSS (range 1.02 4.95); however, RFA demonstrated the greatest improvement, followed by EVLA and HLS between two and five years. EVLA was associated with the highest risk of pain, while MOCA offered the lowest. Conclusion: While CAE offered the lowest risk of initial procedural failure, HLS resulted in lower rates of long term recurrence without considerably increasing morbidity when compared with other endovenous options.