Varicose veins today.

A decade ago a doctor’s advice to a patient with varicose veins was easy: the alternatives are injection sclerotherapy or surgery. Only these techniques have existed long enough to know about both their shortand long-term results. Results have generally been disappointing, with high recurrence rates as time goes by1. The past few years have witnessed an explosion in types of minimally invasive treatment technique and this has made decisions about varicose vein treatment more difficult. These techniques include thermal ablation in the form of endovenous laser ablation or radiofrequency ablation (RFA), and foam sclerotherapy2. The introduction of these new methods has been rapid, before any adequate scientific evaluation. It is based on the enthusiasm of practitioners and some short-term trials that demonstrate equivalence of outcome with conventional surgery, but with less postoperative discomfort and speedier return to normal activity. In addition, the new techniques can be employed under local anaesthetic, often in an outpatient setting, thereby freeing operating theatre time and potentially improving cost efficacy. Increasing access to information has encouraged patients to seek these new treatments, often after visiting commercially sponsored websites. Many feel bewildered by the available choice, while being seduced by the prospect of involvement in decision making. Evidence-based medicine demands controlled trials, particularly of new techniques. Such trials are sparse and often underpowered in venous surgery, a regrettable situation when one considers the large number of patients treated each year. Proper evaluation of the new methods would require huge trials over 5–10 years, which might well be compromised by further evolution in methodology. Conventional varicose vein operations are high volume and low risk, and are typically carried out on an ambulant basis under general anaesthesia. These operations have changed little over decades. There is a low rate of complication and a high rate of patient satisfaction. The Randomized and Economic Assessment of Conservative and Therapeutic Interventions for Varicose Veins (REACTIV) trial suggests that the cost of varicose vein surgery in the UK is within National Institute of Health and Clinical Excellence (NICE) guidelines for quality-adjusted life years3. Yet general anaesthesia carries risk, albeit small, and serious wound complications occasionally arise. The few long-term studies confirm that there is a relatively high recurrence rate and about 20 per cent of patients request reoperation1,4. Conventional surgery is, however, the standard procedure against which new treatments should be compared. Thermal ablation techniques destroy the venous endothelium, heat being produced by either laser or radiofrequency energy. Controlled trials show that the great saphenous vein is permanently obliterated in over 90 per cent of patients5,6. Yet thermal ablation is usually possible only in long, straight veins, meaning that typically it is only the truncal vein that is treated thermally. An alternative method must be used to obliterate residual varices, although many patients obtain symptomatic improvement without this additional step. Thermal ablation techniques do not usually treat the tributaries at the saphenofemoral junction and, although recent research suggests that these may not become incompetent in the short term7, there remains a suspicion that they will eventually be a source of recurrence. There are several different laser and RFA devices; specific training and experience are required for their use. Thermal ablation is usually carried out under ‘tumescent’ local anaesthesia, in which the volume of anaesthetic agent injected not only provides pain relief but also moves the vein away from nerve and skin to reduce the chance of thermal damage to these structures. The early randomized trials suggest a reduction in pain after the procedure comparedwith conventional operation5,6. Thermal ablation, however, requires skills not traditionally taught to vascular surgeons, namely duplex ultrasonography and duplex-guided venous cannulation. So far there are no official guidelines for training and accreditation in these methods. Liquid sclerotherapy was popular 30 years ago but was found to have high recurrence rates in clinical trials. Modern foam sclerotherapy is a variation on this theme. The foam is produced by mixing air with conventional liquid sclerosant, usually sodium tetradecyl sulphate. The concept is that foam should enhance contact between active agent and vein