Debate: should persistent incompetent truncal veins be treated immediately? The case in support of the statement

Background: Debate continues as to the best method of treating patients with varicose veins and which will lead to durable clinical outcomes. Many modern techniques of treating varicose veins rely on ablation of the saphenous vein alone or in combination with phlebectomy or sclerotherapy of varices. However, it has been suggested that methods which leave the saphenous trunk untreated may result in similar outcomes.

Methods: A search of medical databases was made for literature which compared the outcomes of saphenous vein stripping, sclerotherapy and modern methods of vein ablation.

Synthesis: Surgical methods which have been used range from simple phlebectomy, ligation of the saphenous trunk to stripping of the saphenous vein. Systematic comparison of striping of the saphenous vein in addition to ligation of the sapheno-femoral junction appears to improve the outcome of varicose veins surgery compared to saphenous ligation alone. The 21st century endovenous treatments for varicose veins all rely on ablating the saphenous trunk. Duplex ultrasound studies show some variation in the efficacy of saphenous ablation with these methods. However, a randomised clinical trial shows similar patient reported outcomes with all endovenous techniques and surgical stripping of the saphenous vein. A clinical series shows that after endovenous thermal ablation recurrent varices arise in residual sections of saphenous trunk, accessory veins and residual tributaries.

Conclusions: Studies based on clinical criteria require follow-up of about six years to yield reliable data. Before this time varices may be forming but cannot be detected clinically and over-optimistic results of treatment are reported. Data from surgical and endovenous treatment studies suggest that the more extensive and effective the ablation of saphenous trunks, accessory veins and tributaries, the better the long-term outcome that is achieved.