Surgery Section - Varicose Vein Treatment

IMPORTANT REMINDER

This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

Description

Larger varicose veins, which protrude above the surface of the skin, typically are related to valve incompetence either at the saphenofemoral or saphenopopliteal junction. As the venous pressure in the deep system is generally greater than that of the superficial system, valve incompetence leads to increased hydrostatic pressure transmitted to the unsupported superficial vein system, ultimately resulting in varicosities. Clusters of varicosities may appear at the site of perforating vessels, such as the perforating veins of Hunter and Dodd, located in the mid- and distal thigh, respectively. This pattern of varicosity is typically associated with incompetence at the saphenofemoral junction. In some instances, the valvular incompetence may be isolated to a perforator vein, such as the Boyd perforating vein located in the anteromedial calf. These varicosities are often not associated with saphenous vein incompetence since the perforating veins in the lower part of the leg do not communicate directly with the saphenous vein. Although many varicose veins are asymptomatic, when present, symptoms include itching, heaviness, and pain. In addition, varicose veins may be complicated by peripheral edema due to venous insufficiency, hemorrhage, thrombophlebitis, venous ulceration, and chronic skin changes.

Note: The term "varicose veins" does not apply to the telangiectatic dermal veins, which may be described as "spider veins" or "broken blood vessels."  While abnormal in appearance, these veins typically are not associated with any symptoms, such as pain or heaviness, and their treatment is considered cosmetic in nature.

Varicose veins can usually be treated with non-surgical measures. Symptoms often decrease when the legs are elevated periodically, when prolonged standing is avoided, and when elastic compression stockings are worn.

When conservative treatment measures fail, additional treatment options typically focus first on identifying and correcting the site of reflux, and second on redirecting venous flow through veins with intact valves. Thus conventional surgical treatment of varicosities is based on the following three principles:

• Control of the most proximal point of reflux, typically at the saphenofemoral junction, as identified by preoperative Doppler ultrasonography. Surgical ligation and division of the saphenofemoral or saphenopopliteal junction is performed to treat the valvular incompetence.
• Removal of the refluxing long and/or short saphenous vein from the circulation. The classic strategy for isolation is vein stripping in conjunction with vein ligation and division.
• Removal of the varicose tributaries. Strategies for removal include phlebectomy (i.e., ligation/division/stripping, powered phlebectomy or laser or stab avulsion) or injection sclerotherapy, either at the time of the initial treatment, or subsequently.

Over the years various different minimally invasive alternatives to ligation and stripping have been investigated, including sclerotherapy, endoluminal radiofrequency ablation and laser ablation:

Sclerotherapy

The objective of sclerotherapy is to destroy the endothelium of the target vessel by injecting an irritant solution (either a detergent, osmotic solution, or a chemical irritant), ultimately resulting in the complete obliteration of the vessel. Too little destruction leads to thrombosis without fibrosis and ultimate recanalization. Too much destruction leads to vascular dehiscence. The success of the treatment depends on accurate injection of the vessel, an adequate injectant volume and concentration of sclerosant, and post-procedure compression. Compression theoretically results in direct apposition of the treated vein walls to provide more effective fibrosis and may decrease the extent of the thrombosis formation. Therefore, due to technical limitations, larger veins and very tortuous veins may not be good candidates for sclerotherapy.

While sclerotherapy is an accepted and effective treatment of telangiectatic vessels, it has also been used in the treatment of varicose tributaries without prior ligation, with or without vein stripping. This application of sclerotherapy creates issues regarding its effectiveness in the absence of the control of the point of reflux and isolation of the refluxing saphenous vein. In addition, when the sclerosant is injected into the long or short saphenous vein, sclerotherapy has been investigated as a minimally invasive alternative to vein stripping, either with or without ligation. Since the saphenous vein is not visible with the naked eye, injection is typically guided by ultrasonography, and the combined procedure may be referred to as "echosclerotherapy." Since the long saphenous vein is larger and deeper than telangiectatic dermal veins, sclerotherapy of this vein raises issues regarding appropriate volume and concentration of the sclerosant and the ability to provide adequate post-procedure compression. Moreover, the use of sclerotherapy, as opposed to the physical removal of the vein with stripping, raises the issue of recurrence due to recanalization.

Endoluminal Radiofrequency Ablation and Laser Ablation

Endoluminal radiofrequency ablation and laser ablation have been investigated as minimally invasive alternatives to vein ligation and stripping. Both radiofrequency energy and laser therapy are similarly designed to damage the intimal wall of the vessel, resulting in fibrosis and ultimately obliteration of a long segment of the vein. Radiofrequency ablation is performed by means of a specially designed catheter inserted through a small incision in the distal medial thigh to within 1-2 cm of the saphenofemoral junction. High frequency radio waves (200-300 kHz) are delivered through the catheter electrode and cause direct heating of the vessel wall, causing the vein to collapse. The catheter is slowly withdrawn, closing the vein. Laser ablation is performed similarly. A bare tipped laser fiber is introduced into the long saphenous vein under ultrasound guidance; the laser is activated and slowly removed along the course of the saphenous vein.

Policy/Criteria

1. Treatment sessions

Regence considers requests for coverage for each single operative session for either one or both legs.  Additional treatment sessions may be medically necessary when all of the following criteria are met:

1. The clinical outcome of the prior treatment has been established and documented
2. At least one of the following symptoms must be present:
   1. Significant documented limitations of instrumental activities of daily living (for example, meal preparation, household chores) caused by persistent severe lower extremity symptoms attributable to the varicose vein(s) (e.g., pain, cramping, burning). Intermittent occupational tasks that are not required as a daily part of job functioning are not considered instrumental activities of daily living.
   2. Significant recurrent attacks of superficial phlebitis
   3. Hemorrhage from ruptured varix
   4. Ulceration from venous stasis where incompetent varices are a significant contributing factor

2. Ligation/stripping and stab phlebectomy

Ligation/stripping and stab phlebectomy of incompetent veins (including long saphenous, short saphenous, tributaries, accessory saphenous veins, and varicose veins) 4 mm or greater may be medically necessary when all of the following criteria are met:

1. At least one of the following symptoms must be present:
   1. Significant documented limitations of instrumental activities of daily living (for example, meal preparation, household chores) caused by persistent severe lower extremity symptoms attributable to the varicose vein(s) (e.g., pain, cramping, burning). Intermittent occupational tasks that are not required as a daily part of job functioning are not considered instrumental activities of daily living.
   2. Significant recurrent attacks of superficial phlebitis
   3. Hemorrhage from ruptured varix
   4. Ulceration from venous stasis where incompetent varices are a significant contributing factor
2. There is clinical documentation that medically supervised conservative therapy, including at least three months current use of compression (minimum 20 mmHg) stockings (also called surgical hose or surgical stockings), did not successfully treat the patient’s symptoms. Clinical documentation should include the following:
   1. History of present illness, physical examination, and conservative therapy treatment plan
   2. Progress notes documenting patient compliance with and response to conservative therapy
3. There is objective documentation of incompetence in the vein to be treated.
   

3. Endoluminal ablation

1. Endoluminal ablation of incompetent long or short saphenous veins (also called the greater or lesser saphenous veins, respectively) may be considered medically necessary when the all of the following criteria are met:
   1. At least one of the following symptoms must be present:
      1. Significant documented limitations of instrumental activities of daily living (for example, meal preparation, household chores) caused by persistent severe lower extremity symptoms attributable to the varicose vein(s) (e.g., pain, cramping, burning). Intermittent occupational tasks that are not required as a daily part of job functioning are not considered instrumental activities of daily living.
      2. Significant recurrent attacks of superficial phlebitis
      3. Hemorrhage from ruptured varix
      4. Ulceration from venous stasis where incompetent varices are a significant contributing factor
   2. There is clinical documentation that medically supervised conservative therapy, including at least three months current use of compression (minimum 20 mmHg) stockings (also called surgical hose or surgical stockings), did not successfully treat the patient’s symptoms. Clinical documentation should include the following:
      1. History of present illness, physical examination, and conservative therapy treatment plan
      2. Progress notes documenting patient compliance with and response to conservative therapy
   3. There is objective documentation of incompetence in the vein to be treated.   
2. Endoluminal ablation of any veins other than the long or short saphenous veins, including but not limited to the accessory saphenous veins, branch tributaries, varicose veins and perforator veins is considered investigational.
3. Endoluminal ablation of the entire saphenous vein when medically necessary usually can be accomplished in a single treatment session. Multiple separate sessions for ablation of segments of the same vein are considered not medically necessary.
   

4. Sclerotherapy

1. Sclerotherapy of incompetent veins (including the short saphenous vein, tributaries, accessory saphenous veins, and varicose veins) 4 mm or greater may be considered medically necessary when both of the following criteria are met:
   1. At least one of the following symptoms must be present:
      1. Significant documented limitations of instrumental activities of daily living (for example, meal preparation, household chores) caused by persistent severe lower extremity symptoms attributable to the varicose vein(s) (e.g., pain, cramping, burning). Intermittent occupational tasks that are not required as a daily part of job functioning are not considered instrumental activities of daily living.
      2. Significant recurrent attacks of superficial phlebitis
      3. Hemorrhage from ruptured varix
      4. Ulceration from venous stasis where incompetent varices are a significant contributing factor
   2. There is clinical documentation that medically supervised conservative therapy, including at least three months’ current use of compression (minimum 20 mm Hg) stockings (also called surgical hose or surgical stockings), did not successfully treat the patient’s symptoms. Clinical documentation should include the following:
      1. History of present illness, physical examination, and conservative therapy treatment plan
      2. Progress notes documenting patient compliance with and response to conservative therapy
2. Sclerotherapy of the following veins is considered investigational:
   1. The long saphenous vein
   2. Perforator veins
3. Sclerotherapy of small (less than 4 mm) superficial reticular veins and/or telangiectasias (spider veins) is considered cosmetic

Scientific Background

Sclerotherapy

Several controlled trials comparing sclerotherapy of varicose tributaries or the saphenous vein, with and without associated ligation and stripping have reported that the absence of ligation and stripping are associated with an increased frequency of recurrence. These trials are difficult to interpret because frequently it is not clear which vein – either the varicose tributaries or the saphenous vein itself – have undergone sclerotherapy. Nonetheless, these trials established the importance of control of the site of reflux (ligation) and isolation of the refluxing portion of the saphenous vein (stripping). For example, in a frequently cited article, Hobbs reported on the results of a trial that randomized 500 patients with varicose veins to undergo either sclerotherapy alone or ligation and stripping of the saphenous vein followed by avulsion of the varicose tributaries. (2) The injection site for sclerotherapy was the point where the incompetent perforating veins joined the superficial veins. Therefore, this trial essentially tested the concept that varicose veins could be treated without addressing the source of reflux. The author reported that after one year 82% of patients were adequately treated with sclerotherapy. However, after 6 years the cure rate was only 7%. Specifically, the sclerotherapy soon failed when there was incompetence of the saphenofemoral junction. In another frequently cited article, Einarrson and colleagues reported on the results of a trial of 164 patients with varicose veins who were randomized to receive either sclerotherapy alone or ligation and stripping. (3) Although not described in detail, it appears that the sclerotherapy was injected into the superficial tributaries. After 5 years, the failure rate of sclerotherapy was approximately 74% compared to 10% in the operative group.

Neglen and colleagues reported on a trial that compared the outcomes of three different treatment strategies: 1) sclerotherapy alone; 2) ligation and stripping, or 3) ligation combined with sclerotherapy. (4) It is difficult to determine the target of the sclerotherapy. As described in the article, sclerosant was injected into all points of control (presumably at the junction of the perforator veins) and, "if possible, into the main stem of the long saphenous vein." Thus, it seems that the intent of the sclerotherapy was not the obliteration of the long saphenous vein as an alternative to stripping, but as a treatment of the varicose tributaries. Therefore, among those patients who underwent ligation plus sclerotherapy, this trial tested whether or not stripping could be eliminated from the overall approach. In the group who received sclerotherapy alone, almost 70% of patients self-reported a cure immediately postoperatively, which declined to about 30% after 5 years. This gradual recurrence rate for sclerotherapy alone is similar to that reported in the above studies. For the ligation and sclerotherapy group, 70% reported a cure immediately postoperatively, dropping to 50% after 5 years. The best long-term results were reported for the ligation and stripping group, which reported an 80% immediate cure rate, dropping to 70% after five years. The physician assessment of treatment outcome showed greater differences among the three groups. For example, based on physician assessment (observation and foot volumetric measurements), only 5% of the sclerotherapy group were considered cured after 5 years, compared to 10% in the ligation and sclerotherapy group and 60% in the ligation and stripping group. Rutgers and colleagues reported on a trial that randomized 156 patients with varicose veins and saphenofemoral incompetence to undergo either ligation and stripping or ligation and sclerotherapy. (5) The site of sclerotherapy was not described. At 3 years, the cosmetic results were better in those limbs that had undergone stripping. Additionally, the clinical and Doppler ultrasound evidence of reflux was significantly less in those undergoing stripping.

The results of the above studies have established ligation and stripping as the gold standard treatments for saphenofemoral incompetence. Sclerotherapy is used primarily as an adjunct to treat varicose tributaries. The superiority of ligation and stripping is primarily related to improved long-term recurrence rates.

More recently, there has been interest in injecting sclerosant into the saphenous vein either in conjunction with ligation as an alternative to stripping, as a stand-alone procedure, or as an alternative to both ligation and stripping. Kanter and Thibault reported on a case series of 172 patients with 202 limbs with varicose veins with associated saphenofemoral incompetence. (6) Using ultrasound guidance, sclerosant was injected into the long saphenous vein 3-4 cm distal to the saphenofemoral junction. Injections were given at 30- to 90-second intervals, proceeding distally as previously injected segments were observed to spasm. Immediately after therapy, a thigh compression stocking was applied. Two weeks after the initial procedure, patients were reevaluated with Duplex ultrasound and were re-treated if found to have persistent reflux. There was a clinical recurrence rate of 22.8% at 1 year. Bishop and colleagues reported on a case series of 55 patients with 89 limbs with saphenofemoral incompetence who underwent sclerotherapy to the long saphenous vein as an alternative to ligation and stripping. (7) The follow-up time is not provided, but only 20% of the long saphenous veins were obliterated after the procedure, as assessed by Duplex ultrasound. The authors conclude that sclerotherapy of the long saphenous vein in the presence of saphenofemoral reflux is unlikely to remain successful in the long term.

Vin and colleagues described a technique involving ligation of the long saphenous vein some 10 cm from the saphenofemoral junction, preceded by injection of sclerosant both proximally and distally. (8) A total of 108 elderly patients who had refused surgery were followed for 1 year; good results were reported in 95% of patients after 1 year. In a review of the literature on sclerotherapy of the long saphenous vein, much of which is reported in the international literature, Kanter reports a recanalization rate between 19% and 48% over follow-up of 1 to 3 years. (9)

An updated Cochrane Review, based primarily on randomized controlled trials from the 1980’s, concluded that, “The evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins.” (20) Other uses of sclerotherapy in the management of varicose veins could not be determined from the available literature. A comprehensive systematic review commissioned and funded by the United Kingdom’s National Institute for Health and Clinic Excellence (NICE) concluded that, “there is insufficient evidence to allow a meaningful comparison of the effectiveness of this treatment with that of other minimally invasive therapies or surgery.” (21)

Myers and colleagues reported three-year follow-up from a prospective observational study of sclerotherapy in 489 patients with refluxing saphenous veins and related tributaries. (22) Out of 807 veins treated, 56% were associated with the great saphenous vein and 22% with the small saphenous vein; 22% were tributaries alone. Ultrasound at three to five days after each treatment showed successful occlusion in an average of 1.5 sessions for the group as a whole (65% in one session and 26% in two sessions). Kaplan-Meier analysis showed three-year survival rates of 83% for tributaries, 53% for great saphenous veins, and 36% for small saphenous veins. These results do not support the use of sclerotherapy for refluxing saphenous veins.

No studies have directly compared sclerotherapy of the saphenous vein as an alternative to ligation and stripping. In general, reported outcomes of uncontrolled studies have varied, as have the periods of follow-up. In many studies the outcomes are reported in terms of cure rates, but the criteria for cure or failure are poorly defined. Studies also report both subjective patient-assessed outcomes or physician assessment, both of which may be poorly defined. More recent studies include results of Doppler or duplex ultrasonography. The relationship between finding ultrasonographic evidence of recurrent reflux and clinical symptoms is uncertain. Finally, it should be noted that sclerotherapy of the long saphenous vein is a fundamentally different approach than stripping. With stripping, recurrences are likely related to an incomplete surgical procedure or to revascularization. With sclerotherapy, recurrences may be additionally related to recanalization of an incompletely fibrosed saphenous vein.

Radiofrequency Ablation

Endoluminal radiofrequency ablation of varicose veins has been proposed as an alternative to ligation and stripping, or to stripping alone. The available literature consists primarily of case series and registry data. Outcomes of interest include short and long term recurrence rates, related either to recannulization of the saphenous vein or neovascularization. In terms of safety, relevant outcomes include the incidence of paresthesias, thermal skin injuries, thrombus formation, thrombophlebitis and wound infection.

Several case series have reported on endoluminal radiofrequency ablation. (10-13) The largest was reported by Merchant and colleagues, who analyzed the data collected in an ongoing registry focusing on the treatment of reflux of the long saphenous vein. Data were available on 890 patients and 1,078 limbs treated at 32 centers. Clinical and duplex ultrasound follow-up was performed at one week, six months, and yearly for four years. The vein occlusion rates were 91% at one week and 88.8% at four years, although only 98 limbs had been followed up to the four year mark. These results suggest that radiofrequency ablation results in durable occlusion. Radiofrequency ablation has typically been limited to vessels less than 12 mm in diameter. The rationale behind this patient selection criterion is that the electrodes must remain in direct contact with the vein wall during treatment and the largest diameter of the deployed radiofrequency electrodes is 12 mm. The authors note that exsanguinations, perivenous tumescent infiltration, and external compression may promote electrode and vessel wall contact such that larger veins can be treated. However, in this large case series, there were only 58 limbs with vein sizes larger than 12 mm, and only 29 available for follow-up at six months or one year. While the occlusion rate was similar to that seen in smaller vessels, long-term data are inadequate to determine if this effect is durable.

A small trial randomized 28 patients to undergo either radiofrequency ablation or conventional ligation and stripping. (14) Mean follow up was 50 days. A total of 7 minor postoperative complications were seen in each group, none of which required specific treatment. In all cases, radiofrequency ablation was considered successful based on the absence of Duplex detected flow in the treated segments of the long saphenous veins. Postoperative average pain was significantly less severe in the radiofrequency ablation group. Patients in the radiofrequency group also recovered faster, based on sick leave times and physical function. While this study suggests that radiofrequency ablation is associated with a faster postoperative recovery, long term recurrence rates were not addressed in this trial. Lurie and colleagues reported the results of a larger trial that randomized 85 patients (86 limbs) to undergo either radiofrequency ablation or stripping and ligation. (15) By ultrasonic evaluation after four months of follow-up, reflux was eliminated in all patients undergoing stripping and ligation, compared to 97% in the radiofrequency group. Time to return to normal activity and return to work were significantly improved in the radiofrequency group.

In 2005, Lurie reported on the two year follow-up of the above trial. (16) A total of 36 limbs of the original 46 undergoing radiofrequency ablation were assessed and 36 of the 40 undergoing ligation and stripping were assessed. Cumulative rates of recurrent varicose veins at combined one and two years follow-up were 14% for radiofrequency ablation and 21% for ligation and stripping. The authors concluded that radiofrequency ablation was associated with similar long term outcomes compared to ligation and stripping.

Endovascular Laser Ablation

The bulk of the clinical trials on laser ablation of varicose veins are case series (17, 23-26) and registry data (27). Three randomized trials from Europe (combined total of 316 patients) compared endovenous laser ablation to ligation and stripping of the great saphenous vein. (28-30) No differences in reflux from the saphenofemoral junction or in quality of life at up to twelve months’ follow-up were observed between the two treatment groups. Return to work following ligation and stripping took an average of 7 to 14 days. Days to return to work following laser ablation were found to be less than (17; 2 days), similar to (18; 7 days), or greater than (19; 20 days) surgical treatment. Differences in use of ligation and stab avulsion/mini-phlebectomy in conjunction with endovenous laser ablation may underlie these discrepancies. Continued follow-up is needed to assess whether adjunct treatment of tributaries alters long-term efficacy of endovenous laser ablation for varicose veins.

Using historical controls for comparison is difficult since treatment outcomes are variably reported. There are no consistent definitions of success vs. failure, either based on patient or clinical assessment. In general, recurrence rates after ligation and stripping are estimated at around 20%. Doppler or Duplex ultrasound are perhaps the most objective form of assessment of recurrence, but many of the reports of the long term outcomes of ligation and stripping did not use ultrasound studies for postoperative assessment. Only two studies have reported objective results of ligation and stripping at 12 and 24 months. Jones and colleagues reported on the results of a study that randomized 100 patients with varicose veins to undergo either ligation alone or ligation in conjunction with stripping. (18) The results of the ligation and stripping group are relevant to this discussion. At one year, reflux was detected in 9% of patients, rising to 26% at two years. Rutgers and Kitslaar reported on the results of a trial that randomized 181 limbs to undergo either ligation and stripping or ligation combined with sclerotherapy. (19) The results of the ligation and stripping group are reviewed here. At two years, Doppler ultrasound demonstrated reflux in approximately 10% of patients, increasing to 15% at three years. Therefore, based on this crude assessment, the reflux rate of 13% for radiofrequency ablation at one year (14) and 6% for laser ablation at two years (17) is roughly comparable to the reflux rate of 9-10% reported by Jones et al and Rutgers and Kitslaar.

In summary, the data supporting endoluminal ablation of the long saphenous vein, using either radiofrequency or a diode laser, is based on the following:

1. Adherence to the basic surgical principle of treating reflux disease; i.e., control of the point of reflux and isolation of the refluxing saphenous vein from the circulation;
2. Data suggesting that, in comparison to ligation and stripping, endoluminal ablation is associated with decreased perioperative morbidity; and
3. Data from historical controls that the long term recurrence rate of ligation and stripping and endoluminal ablation are similar.

July 28, 2008, the published literature on the effect of laser ablation of perforator veins consists of early reports on technical feasibility (31).  No studies were found that demonstrated the clinical effectiveness of radiofrequency or laser ablation of perforator or tributary veins; therefore, it is not possible to reach conclusions concerning the safety and efficacy of this procedure in these vessels.  No new clinical trials were identified that alter the conclusions reached above.

References

1. BlueCross BlueShield Association Medical Policy Reference Manual, Policy Nos. 7.01.55, 7.01.76
2. Hobbs JT. Surgery and sclerotherapy in the treatment of varicose veins. A random trial. Arch Surg 1974;109(6):793-6
3. Einarsson E, Eklof B, Neglen P. Sclerotherapy or surgery as treatment for varicose veins: a prospective randomized trial. Phlebology 1993;8:22-6
4. Neglen P, Einarsson E, Eklof B. The functional long-term value of different types of treatment for saphenous vein incompetence. J Cardiovasc Surg (Torino) 1993;34(4):295-301
5. Rutgers PH, Kitslaar PJ. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. Am J Surg 1994;168(4):311-5
6. Kanter A, Thibault P. Saphenofemoral incompetence treated by ultrasound-guided sclerotherapy. Dermatol Surg 1996;22(7):648-52
7. Bishop CC, Fronek HS, Fronek A et al. Real-time color duplex scanning after sclerotherapy of the greater saphenous vein. J Vasc Surg 1991;14(4);505-10
8. Vin F, Chleir, F, Allaert FA. An ambulatory treatment of varicose veins associating surgical section and sclerotherapy of large saphenous veins (3S Technique). Preliminary study with results at one year. Dermatol Surg 1996;22(1):65-70
   
9. Kanter A. Clinical determinants of ultrasound-guided sclerotherapy outcome. Part I: The effects of age, gender, and vein size. Dermatol Surg 1998;24(1):131-5
   
10. Chandler JG, Pichot O, Sessa C, et al. Treatment of primary venous insufficiency by endovenous saphenous vein obliteration. Vasc Surg 2000;34:201-14
    
11. Goldman M. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: preliminary 6 month follow-up. Dermatol Surg 2000;26:452-56
    
12. Manfrini S, Gasbarro V, Daniellsson G, et al. Endovenous management of saphenous vein reflux. Endovenous Management Reflux Group. J Vasc Surg 2000;32:330-42
    
13. Merchant RF, Pichot O, Myers KA. Four year follow-up on endovascular radiofrequency obliteration of great saphenous reflux.  Dermatol Surg 2005;31(2):129-34
    
14. Rautio T, Ohinmaa A, Perala J et al. Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs. J Vasc Surg 2002;35(5):958-65
    
15. Lurie F, Creton D, Eklof B et al. Prospective randomized study of endovenous radiofrequency obliteration (closure procedure) versus ligation and stripping in a selected patient population. J Vasc Surg 2003;38:207-14
    
16. urie F, Creton D, Eklof B et al. Prospective randomized study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): Two-year follow-up.  Eur J Endovasc Surg 2005;29:67-73
17. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux. Long term results J Vasc Interv Radiol 2003;14:991-96
18. Jones L, Braithwaite BD, Selwyn D et al. Neovascularization is the principal cause of varicose vein recurrence: results of a randomized trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg 1996;12:442-45
    
19. Rutgers PH, Kitslaar PJ. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of incompetent greater saphenous vein. Am J Surg 1994;168:311-15
20. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2006;(4):CD001732
21. Jia X, Mowatt G, Burr JM et al. Systematic review of foam sclerotherapy for varicose veins. Br J Surg 2007;94(8):925-36
22. Myers KA, Jolley D, Clough A et al. Outcome of ultrasound-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg 2007;33(1):116-21
23. Myers K, Fris R, Jolley D. Treatment of varicose veins by endovenous laser therapy: assessment of results by ultrasound surveillance. Med J Aust 2006;185(4):199-202
24. Theivacumar NS, Dellagrammaticas D, Mavor AI et al. Endovenous laser ablation (EVLA) of great saphenous vein to abolish "paradoxical reflux" in the Giacomini vein: a short report. Eur J Vasc Endovasc Surg 2007;34(2):229-31
25. Gibson KD, Ferris BL, Polissar N et al. Endovenous laser treatment of the short saphenous vein: efficacy and complications. J Vasc Surg 2007;45(4):795-801
26. Ravi R, Rodriguez-Lopez JA, Trayler EA et al. Endovenous ablation of incompetent saphenous veins: a large single-center experience. J Endovasc Ther 2006;13(2):244-8
27. Merchant RF, Pichot O; Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005;42(3):502-9
28. Darwood RJ, Theivacumar N, Dellagrammaticas D et al. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg 2008;95(3):294-301
29. Rasmussen LH, Bjoern L, Lawaetz M et al. Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results. J Vasc Surg 2007;46(2):308-15
30. Kalteis M, Berger I, Messie-Werndl S et al. High ligation combined with stripping and endovenous laser ablation of the great saphenous vein: Early results of a randomized controlled study. J Vasc Surg 2008;47(4):822-9
31. Proebstle TM, Herdemann S. Early results and feasibility of incompetent perforator vein ablation by endovenous laser treatment. Dermatol Surg 2007;33(2):162-8

Cross References

None

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