Clinical results and cost-effectiveness of radiofrequency and cyanoacrylate ablation compared with traditional surgical stripping for treating varicose veins

Published:November 12, 2021DOI:



      Disease of the venous system is an underappreciated public health problem. Minimally invasive treatments such as radiofrequency ablation (RFA) or cyanoacrylate adhesive ablation (CAA) have almost entirely replaced surgical stripping (SS) of the great and small saphenous veins. The purpose of the present study was to compare the outcomes at 3 years after SS, RFA, and CAA by assessing the incidence of complications and reinterventions and performing a cost-effectiveness analysis.


      From February 2016 to February 2019, all consecutive patients with symptomatic varicose veins treated at vascular department of two hospitals using SS, RFA, or CAA were included in the present study. The clinical outcomes were measured by quality-adjusted life years (QALYs), complications, and reintervention. A comparison with conservative treatment was also performed. A detailed resource use was recorded for each procedure. All costs were normalized to May 2020 U.S. dollars and euros. Analysis of the data was by the treatment received. All statistical tests were two-sided, and the significance level was set at 5%. Two perspectives of the analysis were considered: the social perspective and that of the Spanish Public Health System. The study period was 3 years. No discount rate was applied.


      A total of 233 patients were enrolled in the present study: SS, n = 90 (38.6%); RFA, 93 (39.9%); and CAA, n = 50 (21.5%). The number of complications was 11 (12.2%), 3 (3.3%), and 3 (6%) in the SS, RFA, and CAA groups, respectively (P = .06). No patient had required reintervention. The median loss of workdays for the SS, RFA, and CAA group was 15 days (interquartile range [IQR], 10-30 days), 0 days (IQR, 0-6 days), and 0 days (IQR, 0-1 days), respectively (P < .001). The median level of satisfaction for the SS, RFA, and CAA group was 9 (IQR, 8-10), 10 (IQR, 9-10), and 10 (IQR, 9-10), respectively (P < .001). The QALYs was 2.6 years for all three procedures. The median overall cost was €852 (US$926) for SS, €1002 (US$1089) for RFA, and €1228.3 (US$1335) for CAA. The total cost per QALY was €323/QALY (US$351/QALY) for SS, €380/QALY (US$413/QALY) for RFA, and €467/QALY (US$508/QALY) for CAA. The indirect costs were measured by the cost of the workdays lost for each patient and were €1527 (US$1660; IQR, €1018-3054); €0 (IQR, €0-611) for RFA, and €0 (IQR, €0-102) for CAA (P < .001).


      All three techniques were cost-effective (procedures with an incremental cost-effectiveness ratio <€30,000/QALY can be recommended). From the Spanish Public Health System perspective, when considering only the health care costs, the most cost-effective technique was SS. From the social perspective, including the opportunity costs of medical leave, CAA was the most cost-effective technique, saving €1600 per patient, a cost that more than compensated for the savings realized from using SS in direct health care costs.


      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


        • Van Den Oever R.
        • Hepp B.
        • Debbaut I.
        • Simon I.
        Socio-economic impact of chronic venous insufficiency: an underestimated public health problem.
        Int Angiol. 1998; 17: 161-167
        • Lawaetz M.
        • Serup J.
        • Lawaetz B.
        • Bjoern L.
        • Blemings A.
        • Eklof B.
        • et al.
        Comparison of endovenous ablation techniques, foam sclerotherapy and surgical stripping for great saphenous varicose veins: extended 5-year follow-up of a RCT.
        Int Angiol. 2017; 36: 281-288
        • Carradice D.
        • Chetter I.
        Endovenous laser ablation in the management of varicose veins.
        in: Greenhalgh R.M. Vascular and endovascular consensus update. BIBA Medical Ltd, London, UK2008: 581-584
        • Wittens C.
        • Davies A.H.
        • Bækgaard N.
        • Broholm R.
        • Cavezzi A.
        • Chastanet S.
        • et al.
        Editor’s choice: management of chronic venous disease.
        Eur J Vasc Endovasc Surg. 2015; 49: 678-737
        • Shepherd A.C.
        • Ortega M.
        • Gohel M.S.
        • Epstein D.
        • Brown L.C.
        • Davies A.H.
        Cost-effectiveness of radiofrequency ablation versus laser for varicose veins.
        Int J Technol Assess Health Care. 2015; 31: 289-296
      1. INE, Instituto Nacional de Estadistica. Annual survey of salary structure. Year 2019. Available at: Accessed XXX.

        • Gohel M.S.
        • Epstein D.M.
        • Davies A.H.
        Cost-effectiveness of traditional and endovenous treatments for varicose veins.
        Br J Surg. 2010; 97: 1815-1823
        • Carroll C.
        • Hummel S.
        • Leaviss S.
        • Ren S.
        • Stevens J.W.
        • Everson-Hock E.
        • et al.
        Clinical effectiveness and cost-effectiveness of minimally invasive techniques to manage varicose veins: a systematic review and economic evaluation.
        Health Technol Assess. 2013; 17 (1-141): i-xvi
        • Sacristán J.A.
        • Oliva J.
        • Campillo-Artero C.
        • Puig-Junoy J.
        • Pinto-Prades J.L.
        • Dilla T.
        • et al.
        ¿Qué es una intervención sanitaria eficiente en España en 2020?.
        Gac Sanit. 2020; 34: 189-193
        • National Institute for Health and Care Excellence
        Varicose veins in the legs: the diagnosis and management of varicose veins. Costing report.
        National Institute for Health and Care Excellence, London, UK2013
      2. Health Information System. Health in data. Available at: Accessed XXX.

      3. Hospital Health Statistics Online. Available at: Accessed July 1, 2010.

        • Edwards A.G.
        • Baynham S.
        • Lees T.
        • Mitchell D.C.
        Management of varicose veins: a survey of current practice by members of the Vascular Society of Great Britain and Ireland.
        Ann R Coll Surg Engl. 2009; 91: 77-80
        • Corder A.P.
        • Schache D.J.
        • Farquharson S.M.
        • Tristram S.
        Wound infection following high saphenous ligation: a trial comparing two skin closure techniques: subcuticular polyglycolic acid and interrupted monofilament nylon mattress sutures.
        J R Coll Surg Edinb. 1991; 36: 100-102
        • Lattimer C.R.
        • Azzam M.
        • Kalodiki E.
        • Shawish E.
        • Trueman P.
        • Geroulakos G.
        Cost and effectiveness of laser with phlebectomies compared with foam sclerotherapy in superficial venous insufficiency: early results of a randomised controlled trial.
        Eur J Vasc Endovasc Surg. 2012; 43: 594-600
        • Bountouroglou D.G.
        • Azzam M.
        • Kakkos S.K.
        • Pathmarajah M.
        • Young P.
        • Geroulakos G.
        Ultrasound guided foam sclerotherapy combined with sapheno-femoral ligation compared to surgical treatment of varicose veins: early results of a randomised controlled trial.
        Eur J Vasc Endovasc Surg. 2006; 31: 93-100
        • Subramonia S.
        • Lees T.
        Radiofrequency ablation vs. conventional surgery for varicose veins: a comparison of treatment costs in a randomised trial.
        Eur J Vasc Endovasc Surg. 2010; 39: 104-111
        • Marsden G.
        • Perry M.
        • Kelley K.
        • Davies A.H.
        Diagnosis and management of varicose veins in the legs: summary of NICE guidance.
        BMJ. 2013; 24: 347