From Pages to Practice
Jan, a 50-year-old waitress who works long hours in a busy diner, notices an infomercial on laser ablation surgery for varicose veins and looks down at the network of indigo-hued bulges along her legs. Jan has had varicose veins for most of her adult life, but they worsened with each of her three pregnancies, and her legs have become heavier and even more achy of late. On the next visit to her primary care physician, she mentions the commercial and asks if laser-ablation surgery is something she should consider.
Older age, female sex, and pregnancy are significant risk factors for the development of varicose veins. Other important contributors include prolonged standing, increased body mass index, and familial predisposition. Consideration of long-term outcomes, complications, and cost will be important in Jan’s decision.
Surgical interventions such as vein stripping or phlebectomy for the treatment of varicose veins have increasingly been replaced by minimally invasive techniques, such as endovascular laser therapy or foam sclerotherapy. In the 2014 multicenter Comparison of Laser, Surgery and Foam Sclerotherapy (CLASS) trial, 798 patients with varicose veins were randomized to receive foam, laser, or surgical treatment. After 6 months of follow-up, patients who received surgical or laser treatments had better disease-specific quality-of-life scores than those receiving foam sclerotherapy, and endovascular laser treatment resulted in fewer complications than either surgery or foam sclerotherapy.
Recently, the authors published 5-year outcomes in NEJM and concluded that the original findings held true after 5 years. Laser treatment methods not only perform better on quality-of-life and complication comparisons but were also more cost-effective than surgery or foam sclerotherapy.
The following NEJM Journal Watch summary explains the study and results further:
Allan S. Brett, MD reviewing Brittenden J et al. N Engl J Med 2019 Sep 5
In a previously published, three-way randomized trial that involved 798 patients with symptomatic varicose veins of one or both legs, disease-specific quality of life at 6 months improved slightly more with laser ablation or with surgical ligation/stripping than with foam sclerotherapy (NEJM JW Gen Med Nov 1 2014 and N Engl J Med 2014; 371:1218). Now, the researchers report 5-year follow-up data.
At 5 years, disease-specific quality of life (as recorded on questionnaires that documented pain, swelling, skin changes, and interference with activity) improved significantly more with laser ablation or with surgery than with foam sclerotherapy. Improvement was similar in the laser ablation and surgery groups. Laser ablation was more cost-effective than surgery.
Comment: Considering both treatment efficacy and cost-effectiveness, laser ablation appears to be the winner in this comparison of treatments for patients with varicose veins.