Great saphenous vein occlusion rates after combined treatment with laser and foam sclerotherapy



      Endovenous laser ablation (EVLA) and foam sclerotherapy are effective and safe treatments for chronic venous disease with great saphenous vein (GSV) reflux. We report our experience combining both strategies as a merged approach to treat GSV incompetence to potentiate both methods' superiority and benefits. We aimed to determine the effectiveness of this treatment strategy.


      A total of 246 limbs with GSV incompetence (C2-C6) treated with EVLA and foam sclerotherapy between January 2016 and December 2019 were retrospectively analyzed. Outcomes of interest were the International Union of Phlebology (IUP) type of anatomic closure (primary, primary assisted, secondary, and therapeutic failure), identified with ultrasound in the GSV after the procedure. Clinical and ultrasound follow-up was conducted at 2 weeks, 3, 6, and 12 months after intervention. We used the Fisher exact test to determine the significance of the association between the type of anatomic closure and the clinical stage according to the Clinical-Etiology-Anatomy-Pathophysiology classification.


      A total of 67% of the treated limbs were C2-C4 and 33% C5-C6. IUP primary closure was achieved in 229 limbs (93%), IUP primary assisted closure in 10 limbs (4%), IUP secondary closure in 1 limb (0.4%), and therapeutic failure in 6 limbs (2%). A total of 45 limbs (18%) required microthrombectomies of tributary veins due to local induration, 7 (2.8%) developed dyschromia, 4 (1.6%) had type 1 endovenous heat-induced thrombosis, and 1 limb (0.4%) developed deep vein thrombosis, which was successfully treated with anticoagulation.


      Our results demonstrate a high occlusion rate of incompetent GSVs with combined EVLA and foam sclerotherapy with infrequent nonserious complications and one case of subclinical isolated popliteal deep vein thrombosis. Combined therapy effectiveness and safety are comparable with other endovenous treatments for chronic venous disease with GSV reflux. The use of both thermal and chemical ablation combines the benefits of both techniques.


      To read this article in full you will need to make a payment
      SVS Member Login
      Society Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ombrellino M.
        • Kabnick L.
        Varicose vein surgery.
        Semin Intervent Radiol. 2005; 22: 185-194
        • Boersma D.
        • Kornmann V.
        • van Eekeren R.
        • Tromp E.
        • Ünlü Ç.
        • Reijnen M.
        • et al.
        Treatment modalities for small saphenous vein insufficiency.
        J Endovasc Ther. 2015; 23: 199211
        • Tsukanov Y.
        • Tsukanov A.
        Diagnosis and treatment of situational great saphenous vein reflux in daily medical practice.
        Phlebolymphology. 2017; 24: 144-145
        • Gujja K.
        • Wiley J.
        • Krishnan P.
        Chronic venous insufficiency.
        Interv Cardiol Clin. 2014; 3: 593-605
        • Hiller H.
        • Ulloa J.H.
        Resultados preliminares de la seguridad y eficacia en el tratamiento híbrido endoluminal de la incompetencia de la vena safena mayor.
        CES Med. 2015; 29: 191-198
        • Paravastu S.C.
        • Horne M.
        • Dodd P.D.
        Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins.
        Cochrane Database Syst Rev. 2016; 11: CD010878
        • Alireza R.
        • Mahtab P.
        • Alireza K.
        • Mohammadreza S.
        Comparison of foam sclerotherapy versus radiofrequency ablation in the treatment of primary varicose veins due to incompetent great saphenous vein: randomized clinical trial.
        J Vasc Nurs. 2019; 37: 226-231
        • Haruta N.
        Recent progress of varicose vein treatment especially about endovascular heat ablation, SEPS and foam sclerotherapy.
        Ann Vasc Dis. 2018; 11: 66-71
        • Oguzkurt L.
        Ultrasonographic anatomy of the lower extremity superficial veins.
        Diag Interv Radiol. 2012; 18: 423-430
        • Yamaki T.
        • Nozaki M.
        • Sakura H.
        Prospective randomized efficacy of ultrasound-guided foam sclerotherapy compared with ultrasound-guided liquid sclerotherapy in the treatment of symptomatic venous malformations.
        J Vasc Surg. 2008; 47: 578-584
        • Medical Advisory Secretariat
        Endovascular laser therapy for varicose veins: an evidence-based analysis.
        Ont Health Technol Assess Ser. 2010; 10: 1-92
        • Zafarghandi M.R.
        • Akhlaghpour S.
        • Mohammadi H.
        • Abbasi A.
        Endovenous laser ablation (EVLA) in patients with varicose great saphenous vein (GSV) and incompetent saphenofemoral junction (SFJ): an ambulatory single center experience.
        Vasc Endovascular Surg. 2009; 43: 178-184
        • Leopardi M.
        • Salerno A.
        • Dante A.
        • Cofini V.
        • Necozione S.
        • Ventura M.
        Endovenous laser ablation with 1,470-nm diode with tumescence anesthesia and saphenofemoral ligation: propensity score match comparison.
        Ann Vasc Surg. 2019; 58: 302-308
        • Timpermann P.E.
        • Sichlau M.
        • Ryu R.
        Greater energy delivery improves treatment success of endovenous laser treatment of incompetent saphenous veins.
        J Vasc Interv Radiol. 2004; 15: 1061-1063
        • Brittenden J.
        • Cotton S.C.
        • Elders A.
        • Tassie E.
        • Scotland G.
        • Ramsay C.R.
        • et al.
        Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of Laser, Surgery and foam Sclerotherapy (CLASS) randomized controlled trial.
        Health Technol Assess. 2015; 19: 1-342
        • Kabnick L.
        • Sadek M.
        • Bjarnason H.
        • Coleman D.
        • Dillavou E.
        • Hingorani A.
        • et al.
        Classification and treatment of endothermal heat-induced thrombosis: recommendations from the American Venous Forum and the Society for Vascular Surgery.
        J Vasc Surg Venous Lymphat Disord. 2021; 9: 6-22
        • Chait J.
        • Kibrik P.
        • Alsheekh A.
        • Ostrozhynskyy Y.
        • Marks N.
        • Rajaee S.
        • et al.
        Radiofrequency ablation increases the incidence of endothermal heat-induced thrombosis.
        Ann Vasc Surg. 2020; 62: 263-267
        • Neglén P.
        • Hollis K.
        • Raju S.
        Combined saphenous ablation and iliac stent placement for complex severe chronic venous disease.
        J Vasc Surg. 2006; 44: 828-833
        • Hernando-Ulloa J.
        • Guerra J.
        • Brun M.
        • Bello M.
        • Navarro P.
        Tasa de oclusión de safena mayor mediante ENOF con cloruro de lapirio: tres años de experiencia.
        Rev Mex Angiol. 2016; 44: 122-128
        • Myers K.A.
        • Jolley D.
        • Clough A.
        • Kirwan J.
        Outcome of ultrasound guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance.
        Eur J Vasc Endovasc Surg. 2007; 33: 116-121
        • Myers K.
        • Jolley D.
        Outcome of endovenous laser therapy for saphenous reflux and varicose veins: medium term results assessed by ultrasound surveillance.
        J Vasc Surg. 2009; 49: 538
        • Davis L.
        • Duffy D.
        Determination of incidence and risk factors for postsclerotherapy telangiectatic matting of the lower extremity: a retrospective analysis.
        J Dermatol Surg Oncol. 1990; 16: 327-330
        • Gloviczki P.
        • Comerota A.
        • Dalsing M.
        • Eklof B.
        • Gillespie D.
        • Gloviczki M.
        • et al.
        The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.
        J Vasc Surg. 2011; 53: 2S-48S
        • Schapira A.
        • Segura J.
        • Patt J.
        • Krapp J.
        • Bauzá H.
        • Nigro J.
        • et al.
        Tratamiento de la vena safena mayor.
        in: Simkin R. Dándolo M. Caldevilla H. Krapp J. Bottini O. Guías latinoamericanas de terapéutica para la patología venosa, insuficiencia venosa crónica. 1st ed. Nayarti, Buenos Aires, Argentina2016: 36-42
        • Navarro L.
        • Min R.J.
        • Bone C.
        Endovenous laser: a new minimally invasive method of treatment for varicose veins—preliminary observations using an 810 nm diode laser.
        Dermatol Surg. 2001; 27: 117-122
        • Belramman A.
        • Bootun R.
        • Lane T.
        • Davies A.
        Endovenous management of varicose veins.
        Angiology. 2018; 70: 388-396
        • Proebstle T.
        • Lehr H.
        • Kargl A.
        • Espinola-Klein C.
        • Rother W.
        • Bethge S.
        • et al.
        Endogenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles.
        J Vasc Surg. 2002; 35: 729-736
        • Min R.J.
        • Khilnani N.M.
        Endovenous laser treatment of saphenous vein reflux.
        Tech Vasc Interv Radiol. 2003; 6: 125-131
        • Mendes-Pinto D.
        • Bastianetto P.
        • Cavalcanti Bragalyra L.
        • Kikuchi R.
        • Kabnick L.
        Endovenous laser ablation of the great saphenous vein comparing 1920-nm and 1470-nm diode laser.
        Int Angiol. 2016; 35: 599-604
        • Rutherford R.B.
        • Padberg Jr., F.T.
        • Comerota A.J.
        • Kistner R.L.
        • Meissner M.H.
        • Moneta G.L.
        Venous severity scoring: an adjunct to venous outcome assessment.
        J Vasc Surg. 2000; 31: 1307-1312
        • Lamping D.L.
        • Schroter S.
        • Kurz X.
        • Kahn S.R.
        • Abenhaim L.
        Evaluating outcomes in chronic venous disorders of the leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life.
        J Vasc Surg. 2003; 37: 410-419
        • Mazayshvili K.
        • Akimov S.
        Early complications of endovenous laser ablation.
        Int Angiol. 2019; 38: 96-101
        • Sufian S.
        • Arnez A.
        • Labropoulos N.
        • Lakhanpal S.
        Endovenous heat-induced thrombosis after ablation with 1470 nm laser: incidence, progression, and risk factors.
        Phlebology. 2014; 30: 325-330
        • Rhee S.J.
        • Cantelmo N.L.
        • Conrad M.F.
        • Stoughton J.
        Factors influencing the incidence of endovenous heat-induced thrombosis (EHIT).
        Vasc Endovascular Surg. 2013; 47: 207-212
        • Zhang X.
        • Wang X.
        • Gao C.
        • Qin J.
        • Zhao H.
        • Li W.
        • et al.
        1470-nm laser combined with foam sclerotherapy in day surgery: a better choice for lower limb varicose veins.
        Lasers Med Sci. 2018; 33: 1505-1511
        • Wang J.
        • Li Y.
        • Li G.
        • Xiao Y.
        • Li W.
        • Ma Q.
        • et al.
        A comparison of concomitant tributary laser ablation and foam sclerotherapy in patients undergoing truncal endovenous laser ablation for lower limb varicose veins.
        J Vasc Interv Radiol. 2018; 29: 781-789
        • Vähäaho S.
        • Halmesmäki K.
        • Albäck A.
        • Saarinen E.
        • Venermo M.
        Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins.
        Br J Surg. 2018; 105: 686-691