1. Endovenous Laser Ablation (EVLA) to Treat Recurrent Varicose Veins (RVVS)

2. Setting: United Kingdom (Leeds) Target Population/Sample: Non-randomized sample of 95 patients (104 limbs) attending the venous clinic at the General Infirmary at Leeds with RVVS. (Inclusion criteria: presence of a residual GSV, AAGSV, or SSV demonstrating significant reflux). Study Design: Causal-comparative design. Comparison of various measures of symptom severity (VCSS, CEAP Classification, AVVSS) and treatment details (length of vein treated, laser energy delivered, and administration of foram schlerotherapy to neo-vessels) across four patient groups defined based on pattern of reflux. Statistical Analysis: The VCSS and AVVSS before and after laser ablation were compared within a group using a Wilcoxon test. Additionally, a comparison of in improvement in AVVSS between groups was done using Mann-Whitney u test.

3. Background
Recurrent varicose veins (RVVS) following surgery are relatively common, and their treatment accounts for ~20% of venous workload.
Surgery is usually considered the standard therapy, but it is technically challenging, time-consuming, and is associated with greater risk of complications.
This study assesses the efficacy of EVLA.

4. Materials and Methods The following data were collected:
Venous Clinical Severity Score (VCSS)
CEAP Classification
Aberdeen Varicose Vein Severity Scores (AVVSS)
Length of Vein Treated
Laser energy delivered (J/cm)
Administration of foam schlerotherapy
Post-treatment VCSS and AVVSS were determined at 12 weeks.
A log of complications was held throughout the study

5. Materials and Methods The patients were divided in groups as follows:
Group GR: Patients who underwent EVLA for RVVS associated with great saphenous vein (GSV)
Group SR: Patients who underwent EVLA for RVVS associated with small saphenous vein (SSV)
Groups GP and SP: These were control groups, matched by age and sex to groups GR and SR, respectively. They included patients that had EVLA for primary varicose veins.

6. Results

7. Results
Number of Patients by Type of Recurrence
Group GR
Group SR

8. Results – Description of groups

9. Results
Both GR and SR groups experienced significant improvements in AVVS from pre-to post-treatment (p<0.001) in both cases, with a 78% and 83% improvement, respectively.
Significant improvements were also observed for the AAGSV and Perforator groups.

10. Results
No significant difference between GR and GP in ablation rates (98%) or AVVSS improvement. Also, no significant differences in use of schlerotherapy (37% vs. 39%), or in patient satisfaction (86% vs. 82%)
SSV treatment was successful for 100% of limbs both in groups SR and SP. No significant differences were observed between these two groups in terms of improvement in AVVSS (83% vs. 84%), use of scherotherapy (33% vs. 25%), or satisfaction (88% vs. 90%).

11. Results
Significant improvements in AVVSS persisted in the 1-year followup.
No instances of recanalisation were observed at that time.

12. Conclusions

13. Discussion
In appropriate patients, EVLA is a safe and effective treatment for RVVS due to recurrent SFJ and SPJ reflux, perforator incompetence, and pelvic vein reflux.
Ablation of responsible axial veins improves symptoms, and is associated with high levels of patient satisfaction, both at 3-month and 1-year follow-up.
The technique could be preferred to surgery whenever it is possible.

14. Limitations Small sample sizes for AAGSV and Perforator groups.
No multivariable analysis to assess the impact of patient demographics on outcomes.
No comparison with outcomes of patients treated with surgery.
Longer-term follow up is required to assess the effectiveness of the treatment beyond 1 year.

15. Thoughts
The study presents important results, because EVLA is much more straightforward than surgery, which is currently the standard treatment.
However, the design of the study was not optimal. The outcomes should be compared between patients treated with EVLA and patients treated with surgery.
The fact that the study was not designed that way prevents us from concluding that EVLA is superior to surgery. Further research is required.

16. Summary
This study assesses the efficacy of EVLA for the treatment of RVVS.
AVVSS was compared between pre- and post-treatment on patients with various types of recurrence.
Significant improvements in AVVSS and high levels of patient satisfaction were observed for all groups.