title: Recurrence of varicose veins after endovenous ablation of the great saphenous vein in randomized trials.
abstract: BACKGROUND
  Recurrence of varicose veins after surgery (REVAS) for saphenous incompetence has been well described after ligation and stripping (L&S) but not after the now most frequently performed method of saphenous ablation, endovenous ablation (EVA). The purpose of this study was to define the overall incidence of REVAS as well as both the sites of reflux and the causes of REVAS through a systematic review and meta-analysis of randomized controlled trials (RCTs) for EVA. These studies have the advantage of prospectively collected data and a uniform duplex follow-up.
  
  
  METHODS
  We searched databases (January 1, 2000 through July 1, 2014) for published RCTs evaluating EVA treatment of great saphenous vein (GSV) incompetence that employed endovenous laser ablation or radiofrequency ablation. RCTs were eliminated that (1) did not have follow-up of at least 2 years, (2) did not obtain postoperative duplex scans, (3) did not clearly report the incidence of recurrent varicosities after GSV ablation, and (4) treated the small saphenous or anterior accessory saphenous veins.
  
  
  RESULTS
  Of the 68 studies screened, 20 RCTs that employed EVA of the GSV were identified. Eight had a follow-up of at least 2 years, but one was eliminated because of lack of information on both the site and cause of REVAS. The resultant seven RCTs provided eight comparisons (one study compared both types of EVA to a comparator arm): three used radiofrequency ablation, and five employed endovenous laser ablation. Overall recurrent varicose veins developed in 125 limbs after EVA (22%), with no difference in the incidence vs the L&S group (22%) based on the number of limbs available at the time of the development of recurrence for both groups, but this incidence is dependent on the length of follow-up after the initial treatment. The two studies with serial follow-up showed an approximate doubling of REVAS over time for both EVA and L&S. By contrast, the cause of REVAS was different between the two methods. Neovascularization occurred in only two limbs (2%) after EVA vs 18 (18%) in the L&S group. Recanalization was the most common cause of REVAS for EVA (32%; 40 of 125 limbs), followed by the development of anterior accessory saphenous vein incompetence (19%; 23 of 125 limbs). In contrast to other reports, incompetent calf perforating veins were an infrequent cause of REVAS (7%; eight of 125).
  
  
  CONCLUSIONS
  There is no difference in the incidence of REVAS for EVA vs L&S, but the causes of REVAS are different with L&S, which has important implications for treatment.
authors.affiliation: CardioVascular Center, Tufts Medical Center, Boston, Mass. Electronic address: todonnell@tuftsmedicalcenter.org.
authors.forename: Thomas F
authors.initials: TF
authors.lastname: O'Donnell
authors.affiliation: Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass.
authors.forename: Ethan M
authors.initials: EM
authors.lastname: Balk
authors.affiliation: CardioVascular Center, Tufts Medical Center, Boston, Mass.
authors.forename: Meghan
authors.initials: M
authors.lastname: Dermody
authors.affiliation: CardioVascular Center, Tufts Medical Center, Boston, Mass.
authors.forename: Erica
authors.initials: E
authors.lastname: Tangney
authors.affiliation: CardioVascular Center, Tufts Medical Center, Boston, Mass.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Iafrati
mesh_terms: D017115:Catheter Ablation; D005268:Femoral Vein; D005500:Follow-Up Studies; D006801:Humans; D053685:Laser Therapy; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012501:Saphenous Vein; D016896:Treatment Outcome; D014648:Varicose Veins / Q000628:therapy*