title: A review of randomised controlled trials comparing ultrasound-guided foam sclerotherapy with endothermal ablation for the treatment of great saphenous varicose veins.
abstract: OBJECTIVE
  The last 10 years have seen the introduction into everyday clinical practice of a wide range of novel non-surgical treatments for varicose veins. In July 2013, the UK National Institute for Health and Care Excellence recommended the following treatment hierarchy for varicose veins: endothermal ablation, ultrasound-guided foam sclerotherapy, surgery and compression hosiery. The aim of this paper is to review the randomised controlled trials that have compared endothermal ablation and ultrasound-guided foam sclerotherapy to determine if the level 1 evidence base still supports an "endothermal ablation first" strategy for the treatment of varicose veins.
  
  
  METHODS
  A PubMed and OVID literature search (until 31 January 2015) was performed and randomised controlled trials comparing endothermal ablation and ultrasound-guided foam sclerotherapy were obtained.
  
  
  RESULTS
  Although anatomical success appeared higher with endothermal ablation than ultrasound-guided foam sclerotherapy, clinical success and patient-reported outcomes measures were similar. Morbidity and complication rates were very low and not significantly different between endothermal ablation and ultrasound-guided foam sclerotherapy. Ultrasound-guided foam sclerotherapy was consistently less expensive that endothermal ablation.
  
  
  CONCLUSIONS
  All endovenous modalities appear to be successful and have a role in modern day practice. Although further work is required to optimise ultrasound-guided foam sclerotherapy technique to maximise anatomical success and minimise retreatment, the present level 1 evidence base shows there is no significant difference in clinical important outcomes between ultrasound-guided foam sclerotherapy and endothermal ablation. As ultrasound-guided foam sclerotherapy is less expensive, it is likely to be a more cost-effective option in most patients in most healthcare settings. Strict adherence to the treatment hierarchy recommended by National Institute for Health and Care Excellence seems unjustified.
authors.affiliation: Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK huw.davies@heartofengland.nhs.uk.
authors.forename: Huw Ob
authors.initials: HO
authors.lastname: Davies
authors.affiliation: Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Popplewell
authors.affiliation: North Devon District Hospital, Barnstaple, Devon, UK.
authors.forename: Katy
authors.initials: K
authors.lastname: Darvall
authors.affiliation: Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK.
authors.forename: Gareth
authors.initials: G
authors.lastname: Bate
authors.affiliation: Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Bradbury
mesh_terms: D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D016032:Randomized Controlled Trials as Topic; D015911:Sclerotherapy / Q000379:methods*; D014463:Ultrasonography / Q000379:methods*; D014648:Varicose Veins / Q000000981:diagnostic imaging / Q000628:therapy
keywords: Varicose veins; endovenous technique; endovenous thermal ablation; foam sclerotherapy; randomised controlled trial