Treatment Modalities for Small Saphenous Vein Insufficiency: Systematic Review and Meta-Analysis

Prevalence of superficial vein reflux in the adult population is 21% (Maurins U et al, J Vasc Surg 2008;48:680-7). The SSV is responsible for about 15% of all varicose vein disease (Almgren B et al, Acta Chirurg Scand 1990;156:69-74). Open techniques for surgical treatment of small saphenous vein incompetence are technically more demanding and associated with higher recurrence and complication rates than those associated with long saphenous vein treatment (Winterborn RJ et al, Eur J Vasc Endovasc Surg 2004;28:400-3). There have been many clinical studies of endothermal ablation of the greater saphenous vein with excellent results. There is, however, less known about optimal therapy for SSV incompetence. In this study, the authors performed a meta-analysis to investigate and compare anatomic success rates and complications of treatment modalities for SSV incompetence. They performed a systematic literature review using PubMed, EMBASE, and the Cochrane Library on therapies for treatment of incompetence of SSVs. These included surgery, endovenous laser ablation (EVLA), radio frequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS), steam ablation and mechanochemical endovenous ablation (MOCA). The authors search resulted in 49 articles including five randomized control trials and 44 cohort studies. Nine articles evaluated open surgery, 28 EVLA, 9 RFA, 6 UGFS, and 1 MOCA. The authors utilized a random effects model to estimate the primary outcome of anatomic success defined as closure of the treated vein on follow up duplex ultrasound imaging. Secondary outcomes were technical success and major complications (paresthesia and deep vein thrombosis) evaluated as weighted means. Pooled anatomic success rate was 58.0% (95% confidence interval [CI], 40.9%-75%) for surgery in 798 SSVs, 98.5% (95% CI, 97.7%-99.2%) for EVLA in 2950 SSVs, 97.1% (95% CI, 94.3%-99.9%) for RFA in 386 SSVs, and 63.6% (95% CI, 47.1%-80.1%) for UGFS in 494 SSVs. The study reported results of MOCA with anatomic success rate of 94%. Neurological complications were most frequently reported after surgery (mean, 19.6%) compared to thermal ablation (EVLA: mean, 4.8%; RFA: mean, 9.7%). Deep venous thrombosis was a rare complication (0%-1%).