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N Engl J Med. 2018 May 31;378(22):2105-2114. doi: 10.1056/NEJMoa1801214. Epub 2018 Apr 24.

A Randomized Trial of Early Endovenous Ablation in Venous Ulceration.

Collaborators (193)

Read D, Hargreaves S, Dhillon K, Anwar M, Liddle A, Brown H, Mercer K, Gill F, Liu A, Jepson W, Wormwell A, Rafferty H, Davies AH, Kaur R, Solomon E, Sritharan K, Velineni R, Lim CS, Busuttil A, Bootun R, Bicknell C, Jenkins M, Lane T, Serjeant E, Waldron J, Wolfrey G, Slim F, Davies C, Emerson L, Grasty M, Whyman M, Wakeley C, Cooper A, Clapp J, Hogg N, Howard J, Dyer J, Lyes S, Teemul D, Harvey K, Pride M, Kindon A, Price H, Flemming L, Birch G, Holmes H, Weston J, Joseph T, Eiffel R, Ojimba T, Wilson T, Hodgson A, Robinson L, Todhunter J, Heagarty D, Mckeane A, McCarthy R, Barwell J, Northcott C, Elstone A, West C, Chong P, Gerrard D, Croucher A, Levy S, Martin C, Craig T, Carradice D, Firth A, Clarke E, Oswald A, Sinclair J, Chetter I, El-Sheikha J, Nandhra S, Leung C, Scott J, Dewhirst N, Woods J, Russell D, Darwood R, Troxler M, Thackeray J, Bell D, Watson D, Williamson L, Coulston J, Eyers P, Darvall K, Hunter I, Stewart A, Moss A, Rewbury J, Adams C, Vickery L, Foote L, Durman H, Venn F, Hill P, James K, Luxton F, Greenwell D, Roberts K, Mitchell S, Tate M, Mills H, Garnham A, McIntosh D, Green M, Collins K, Rankin J, Poulton P, Isgar V, Trivedi M, Kafeza M, Parsapour S, Moore H, Najem M, Connarty S, Albon H, Lloyd C, Trant J, Vohra R, McCormack J, Marshall J, Hardy V, Rogoveanu R, Goff W, Gidda R, Merotra S, Shiralkar S, Jayatunga A, Pathak R, Rehman A, Randhawa K, Lewis J, Fullwood S, Jennings S, Cole S, Wall M, Ranaboldo C, Hulin S, Clarke C, Fennelly R, Cooper R, Boyes R, Draper C, Harris L, Mead D, Kelly L, Bate G, Davies H, Popplewell M, Claridge M, Gannon M, Khaira H, Scriven M, Wilmink T, Adam D, Nasr H, Dodd D, Nawaz S, Humphreys J, Barnes M, Sorrell J, Swift D, Phillips P, Trender H, Fenwick N, Rittoo D, Baker S, Mitchell R, Andrews S, Williams S, Stephenson J, Holloway S, Hayes W, Day J, Clayton C, Harding D, Thompson A, Gibson A, Murphy Z, Smith T, Brittenden J, Winterborn RJ, Nelson A, Haynes R, Ley-Greaves B, Stansby G, Smith F, Flather M, Nunney I.

Author information

From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.).



Venous disease is the most common cause of leg ulceration. Although compression therapy improves venous ulcer healing, it does not treat the underlying causes of venous hypertension. Treatment of superficial venous reflux has been shown to reduce the rate of ulcer recurrence, but the effect of early endovenous ablation of superficial venous reflux on ulcer healing remains unclear.


In a trial conducted at 20 centers in the United Kingdom, we randomly assigned 450 patients with venous leg ulcers to receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group) or to receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group). The primary outcome was the time to ulcer healing. Secondary outcomes were the rate of ulcer healing at 24 weeks, the rate of ulcer recurrence, the length of time free from ulcers (ulcer-free time) during the first year after randomization, and patient-reported health-related quality of life.


Patient and clinical characteristics at baseline were similar in the two treatment groups. The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group; more patients had healed ulcers with early intervention (hazard ratio for ulcer healing, 1.38; 95% confidence interval [CI], 1.13 to 1.68; P=0.001). The median time to ulcer healing was 56 days (95% CI, 49 to 66) in the early-intervention group and 82 days (95% CI, 69 to 92) in the deferred-intervention group. The rate of ulcer healing at 24 weeks was 85.6% in the early-intervention group and 76.3% in the deferred-intervention group. The median ulcer-free time during the first year after trial enrollment was 306 days (interquartile range, 240 to 328) in the early-intervention group and 278 days (interquartile range, 175 to 324) in the deferred-intervention group (P=0.002). The most common procedural complications of endovenous ablation were pain and deep-vein thrombosis.


Early endovenous ablation of superficial venous reflux resulted in faster healing of venous leg ulcers and more time free from ulcers than deferred endovenous ablation. (Funded by the National Institute for Health Research Health Technology Assessment Program; EVRA Current Controlled Trials number, ISRCTN02335796 .).

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