Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials

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1 Systematic Review 201 Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials K. Rass Vein and Skin Center, Eifelklinik St. Brigida, Simmerath/Germany Keywords Endovenous laser ablation, evidence, randomised controlled trial Summary Background: Endovenous laser ablation (EVLA) is globally counted among the most frequently administered methods to treat saphenous vein incompetence. Technical development proceeded in three particular steps: EVLA #1 Diode lasers linearly emitting wavelengths from 810 to 980 nm through optical bare fibres; EVLA #2 Diode or Nd:YAG lasers emitting wavelengths from 1064 to 1500 nm; EVLA #3 Modified optical fibres warranting an optimised emission geometry by centralisation of the fibre tip (Tulip-fibre, Jacket-tip) or radial emission of the laser beam. Due to the number of different EVLA techniques their value compared with standard surgery (high ligation and stripping, ) and other endovascular approaches has to be questioned. Methods: Selective literature analysis based on a systematic PubMed search focussed on randomised controlled trials (RCT) comparing EVLA with and other thermal or nonthermal ablation techniques radiofrequency ablation (RFA), ultrasound guided foam sclerotherapy (), endothermal steam ablation (EStA). Correspondence to: Dr. med. Knuth Rass Vein and Skin Center, Eifelklinik St. Brigida GmbH & Co. KG Kammerbruchstr. 8, Simmerath/Germany Tel / , Fax / knuth.rass@st-brigida.de Results: The search terms endovenous, laser, varicose vein resulted in 509 publications, hereof 57 RCTs, hereof 24 randomised studies comparing EVLA with other treatment approaches: 15 studies comprise comparisons with standard surgery and further 9 studies with other endovenous techniques. 6 RCTs contain long-term followup data on EVLA #1 vs. suggesting superiority of in terms of same site clinical and duplex detected recurrence from the groin. 15 RCTs are reporting short-term results clearly demonstrating inferiority of EVLA #1 against EVLA #2, EVLA #3, and RFA with respect to postoperative complaints and patients quality of life. Conclusions: The first generation endovenous laser systems are disadvantageous or even harmful as compared with more advanced EVLA techniques and RFA in terms of patients complaints and side effects. Furthermore, evidence is rising that EVLA #1 is inferior to standard surgery regarding long-term treatment efficacy. Therefore, the application of EVLA #1 in the treatment of saphenous vein incompetence cannot be recommended any longer. In view of the more recently published RCTs reporting long-term superiority of standard surgery, should still be implemented as control group in studies investigating endovenous treatment approaches. Aktuelle klinische Evidenz zur endovenösen Laserablation (EVLA) aus randomisierten Studien Phlebologie 2016; 45: Received: June 20, 2016 Accepted: June 21, 2016 Schlüsselwörter Endovenöse Laserablation, Evidenz, randomisierte kontrollierte Studien Zusammenfassung Hintergrund: Die Entwicklung der endovenöse Laserablation (EVLA) insuffizienter Stammvenen hat sich bisher in drei Schritten vollzogen: EVLA #1 ( nm), EVLA #2 ( nm) und EVLA #3 optimierte Laseremission (Radialfaser, Tulip, Jacket-Tip). Angesichts der Vielzahl der Verfahren stellt sich die Frage nach dem Stellenwert im Vergleich zu Crossektomie und Stripping (C/S) und anderen endovenösen Therapien. Methoden: PubMed Recherche zum Vergleich von EVLA mit C/S, Radiofrequenzablation (RFA), Schaumsklerotherapie, Dampfablation in randomisierten Studien (RCT). Ergebnisse: Es wurden 24 RCTs identifiziert: n=15 beinhalten Vergleiche mit C/S, n=9 mit anderen Verfahren. Langzeit-Studien (n=6) weisen auf eine Überlegenheit von C/S bzgl. klinischer und duplexsonographischer Rezidive hin. 15 Studien berichten über kurzfristige Ergebnisse, die eine Unterlegenheit der EVLA #1 gegenüber EVLA #2, EVLA #3 und RFA belegen. Schlussfolgerungen: Laser der 1. Generation sind bzgl. Nebenwirkungen und Langzeitwirksamkeit anderen Therapieverfahren unterlegen. Angesichts der jüngsten Publikationen sollte C/S weiterhin als Kontrollarm in RCTs, die die Wertigkeit der EVLA untersuchen, fungieren. Schattauer 2016 Phlebologie 4/2016

2 202 K. Rass: Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials Introduction With a prevalence of % in the adult population, chronic venous insufficiency (CVI) of the leg veins is one of the most frequent clinical affections in Western European countries (12, 24). Primary saphenous vein insufficiency with clinically visible varicosis constitutes the major proportion of venous disease. In addition to congestion symptoms, which develop over years, and the cosmetic impairment associated with a marked fall in patients quality of life, the potential complications are of particular medical and socio-economic significance: deep venous thrombosis of the leg, pulmonary embolism, postthrombotic syndrome, venous leg ulcer, arthrogenic congestive syndrome, secondary lymphoedema, increased susceptibility to skin infections and epidermal sensitisation (overview in 11). In order to counteract these severe sequelae of CVI, current guidelines recommend early active therapy of saphenous vein insufficiency, whether it be surgical or interventional (38). The therapeutic measures aim to eradicate venous reflux by removing the refluxing veins through conventional varicose vein surgery or through obliteration by means of catheter-based endovenous ablation procedures. High ligation and stripping () are considered the therapeutic standard for insufficiency of the great () and small saphenous veins (SSV) requiring treatment. Although the endovenous procedures are frequently used in routine clinical practice, conventional surgery can be used without restriction, in contrast to the catheter techniques, e.g. in postphlebitic changes or aneurysmatic vascular dilatation (15). Nevertheless, endovenous ablation procedures do offer potential benefits: a less invasive procedure, little postoperative pain and rapid recovery. This was shown, for example, for radiofrequency ablation (RFA) compared with of the in a study with identical perioperative conditions (25). Today, endovenous laser ablation (EVLA) is one of the most frequently used procedures worldwide for the treatment of saphenous vein incompetence (33). With 1st generation lasers (EVLA #1), which work with optical glass fibres (bare-tip fibres), diode lasers with wavelengths of 810, 940 and 980 nm were used. Their energy absorption by haemoglobin leads to warming of the blood with subsequent vascular wall damage and consecutive thrombus formation (23). In contrast to RFA and lasers of the next development stage, punctate and slit-shaped perforations of the venous wall are frequent with 1st generation lasers (37). 2nd generation lasers (EVLA #2) transfer effects due to their higher wavelengths (diodes and neodymiumdoped yttrium aluminium garnet [Nd:YAG] lasers with nm) with maximum absorption in water more likely in the venous wall than heating of the blood. 3rd generation lasers (EVLA #3), with a wavelength range of nm, are characterised by an optimised emission geometry of the laser light, e.g. by centralisation of the laser beam in the middle of the vessel using tulip or jacket-tip fibres or radial emission at a 90 angle to the longitudinal axis with the radial and double-ring fibre lasers. In view of the extremely rapid technical development and the variety of methods used in the three laser generations, the question arises as to the current position of EVLA with regard to safety, postoperative comfort and long-term efficacy compared with conventional varicose vein surgery and other catheter-based thermal or nonthermal ablation procedures. This article therefore presents the current status of comparative, randomised controlled trials (RCTs) investigating EVLA of saphenous varicosis. Methods A selective literature analysis, limited to RCTs, was conducted as a PubMed search, in order to compare EVLA with other procedures for treatment of saphenous insufficiency: high ligation and stripping (), laser of the same or other development stages, radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (), mechanochemical ablation, endovenous steam ablation (EStA) and cyanoacrylate embolisation. The only RCTs considered were those written in English or German or those for which at least an English abstract was available. The following search terms were used: endovenous, laser, varicose vein. The search period was not limited. Trials comparing different procedures intraindividually (e.g. ipsilateral, contralateral EVLA) were excluded. In addition, trials in which EVLA was conducted only in combination with inguinal crossectomy were not considered. The aim of this overview is a descriptive comparison of the procedures with regard to the most frequently reported study variables, i.e. complications/side effects, quality of life, venous scoring and recurrence rate. The paper examines in particular what evidence is already available for the different laser methods, in order to determine their significance in the treatment repertoire of saphenous vein incompetence. In accordance with the UIP consensus document, the available trials are classified as shortterm (<2 years), mid-term (2 to <5 years) and long-term (5 years and longer) trials with regard to the follow-up period (7). Trials published several times either by topic or with varying follow-up times are summarised as one study. The trials were classified according to the longest reported follow-up time, in accordance with the UIP consensus document. Results The search terms endovenous, laser and varicose vein yielded 509 publications (cut-off date ), of which 57 were RCTs. Excluded from the review were publications that did not compare EVLA with other therapeutic procedures (n=18), those reporting several times on different aspects of trials (n=12), those comparing with HL/EVLA (n=2) and those performing intraindividual analyses of different procedures (n=1). Thus, a total of 24 randomised trials comparing EVLA with other therapeutic procedures were identified, for which only the publication with the longest follow-up time is cited in each case (1 5, 8 10, 13, 14, 16 20, 22, 25 28, 31, 32, 35, 36). In 22 trials, the was treated, in one trial the SSV (20) and in a further trial both the and the SSV (2) were treated. A Phlebologie 4/2016 Schattauer 2016

3 K. Rass: Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials 203 Tab. 1 Selection of randomised trials comparing endovenous laser ablation (EVLA) with high ligation/stripping () with a sample size of n 100. First Author Treatment groups No. (legs) FU Time FU rate (%) Target vessel Main results Rasmussen (26) Less pain after EVLA; no difference in primary (open refluxing segments 5 cm) or secondary study variables (clinical recurrence, reoperations, VCSS, QoL) Disselhoff (8) HL/cS Less pain after EVLA; no difference in primary study variables (using insufficiency confirmed by duplex examination, VCSS, QoL) Darwood (7) mos 90 No differences with regard to elimination of saphenous reflux; faster recovery and shorter sick leave period after EVLA Gauw (14) Less pain after ; clinical recurrence originating in the saphenofemoral region more common after EVLA; no differences with regard to CEAP and QoL Christenson (4) yrs 97 Open refluxing segments more common after EVLA; no differences with regard to VCSS and QoL Carradice (3) yr 85 Less pain, fewer infections, better perioperative QoL, faster recovery, shorter sick leave period and lower clinical recurrence rate after EVLA Rass (27) Less pain after ; saphenofemoral junction recurrence confirmed by duplex ultrasound examination and clinical recurrence originating in the saphenofemoral region more common after EVLA; no differences with regard to HVVSS and QoL Flessen - kämper (13) HL/EVLA ,6 yrs ca. 45 No differences with regard to recurrence of varicosis; saphenofemoral clinical recurrence more frequent after EVLA; clinical recurrence not originating in the saphenofemoral region more frequent after Nandhra (20) yrs 83 SSV Successful elimination of axial saphenous reflux more frequent after EVLA; no differences with regard to clinical recurrence rate and QoL Van der Velden (32) EVLA #1 940 nm EVLA and are more effective than in the elimination of saphenous vein reflux; poorer QoL after ; anatomical treatment success (obliteration of the after EVLA, elimination after ) greater after compared with EVLA and Brittenden (2) EVLA #1 oder # mos 86 SSV (7,1 %) No differences with regard to QoL between EVLA and ; lower complication rate after EVLA compared with and ; successful elimination of saphenous vein reflux better after compared with Rasmussen (25) EVLA #1 oder #2 RFA yr 82 Rate of open refluxing saphenous veins highest after, no differences between the other groups; less pain and faster recovery after RFA and compared with EVLA and Abbr.: FU = Follow-up; cs = Cryostripping; RFA = Radiofrequency ablation; = ultrasound guided foam sclerotherapy; = Great saphenous vein; SSV = Small saphenous vein; VCSS = Venous Clinical Severity Score; QoL = quality of life; HVVSS = Homburg Varicose Vein Severity Score; CEAP = Clinical-Etiologic-Anatomic-Pathophysiologic Classfication; mos= months; yrs= years total of 15 trials contain comparisons of EVLA with the standard operation ( Tab. 1): EVLA #1 vs. (n=12) EVLA #1 or #2 vs. vs. (n=2) EVLA #1 or #2 vs. vs. RFA vs. (n=1) In a further nine trials, EVLA is compared with other endovenous procedures: EVLA #1 vs. RFA (n=4) EVLA #1 vs. EStA (n=1) EVLA #1 vs. EVLA #2 (n=1) EVLA #1 vs. EVLA #3 (n=1) EVLA #2 vs. (n=1) Six trials provide long-term data (follow-up 5 years, only EVLA #1), 15 trials report on short-term treatment results (follow-up <2 years). Three trials contain intermediate follow-up times. Postoperative complications, side effects A comparison of EVLA #1 and high ligation and stripping shows no consistent differences between them: More severe pain is reported after both (n=5) and Schattauer 2016 Phlebologie 4/2016

4 204 K. Rass: Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials EVLA (n=3), although other RCTs (n=5) show no significant differences. Moreover, no advantage was identified for either therapy with regard to haematoma, phlebitis, dysaesthesia, dyspigmentation or major complications (thrombosis, pulmonary embolism). In three trials, postoperative infections are observed more frequently after with infection rates of % (2, 3, 32), although the majority of trials (n=9) report no significant differences. In a comparison of EVLA #1 with RFA, EVLA #2 and EVLA #3, there are clear indications of more severe side effects in the first 7 10 postoperative days, particularly for pain and/or impaired postoperative quality of life after EVLA with 1 st generation fibres ( nm) in all trials (n=8). To date, only two trials are available for EVLA #2. They report more severe pain compared with EVLA #3 and. Long-term change in disease severity (severity scores) and quality of life A synopsis of all available RCTs with a follow-up time of at least two years (n=9) shows that EVLA and are equally suitable, both medium and long term, in achieving a significant improvement in disease severity, as measured by severity scores (e.g. VCSS, HVVSS), and in diseaserelated quality of life (e.g. the Aberdeen Varicose Vein Questionnaire [AVVQ] and the Chronic Venous Insufficiency quality of life Questionnaire [CIVIQ]). One available long-term trial showed superiority of EVLA #1 to regarding quality of life (32). No medium- or long-term trials are available for the newer procedures EVLA #2 und EVLA #3. Duplex detected saphenofemoral recurrence (DSR) Saphenofemoral recurrence detected by duplex ultrasound is regarded as a surrogate parameter for the development of subsequent clinical recurrences originating from the saphenofemoral junction area (6). Varying inguinal recurrence patterns are seen after endovenous ablation procedures and. After EVLA, recanalisation of ablated veins and neorefluxes over hitherto sufficient saphenofemoral junction side branches are more likely to occur, while neovascularisation is more common after correctly performed crossectomy (30). Both phenomena, which can be confirmed by duplex ultrasound examination, are potential starting points for the development of clinical recurrence. Comparing EVLA and, ten trials report DSR as a defined study variable. Five trials show a significantly higher rate of DSR after EVLA #1. In the only trial considering SSV treatment, a higher DSR rate was observed after. No difference was determined in the other four trials. Without exception, the RCTs considering EVLA in comparison to other endovenous procedures are trials with a short follow-up. None of these trials clearly defines DSR as a study endpoint. There is no significant difference between the various ablation procedures with regard to reported occlusion rates of the treated saphenous veins during a follow-up period of up to 12 months. Clinical recurrence As a rule, clinically relevant recurrences do not become clinically manifest until some years after surgery or an intervention. In this respect, only long-term studies can provide evidence on this study endpoint. As the primary disease can progress over time, it is useful to distinguish between a recurrence associated with the treatment performed and one due to natural disease progression, in order to allow comparison of the longterm efficacy of various therapies. To date, six trials have been published with long-term follow-up observations. All include a comparison between EVLA #1 and ; one trial makes an additional comparison with. No differences were reported with regard to varicose vein recurrence on the operated leg (progression and recurrence). Two trial groups defined clinical recurrence as study endpoint, due to recurrence of saphenofemoral incompetence confirmed by duplex ultrasound examination (14, 27). Both trials showed a significantly higher clinical recurrence rate five years after EVLA compared with. Discussion Nesbitt and colleagues already reported two years ago in their Cochrane review that endovenous procedures (EVLA, RFA and ) are at least equally as effective as the traditional crossectomy and stripping operation in the treatment of incompetence (21). Although this systematic analysis points out that available studies contain deficiencies and that the evidence is not robust, one result of the assertion that endovenous therapy and open surgery are equally effective is that current international guidelines, e.g. the guideline of the British health care system (NICE), recommend endovenous thermoablation with radiofrequency or laser as first-line therapy. As long-term studies from four working groups (13, 14, 27, 32) have appeared since publication of the NICE guideline and the Cochrane review, critical re-assessment of the current status of the available evidence seems advisable. The 1 st generation EVLA cause more severe side effects (pain) and lead to a poorer quality of life in the initial postoperative days compared with radiofrequency ablation and more modern laser procedures. Compared with traditional surgery, no clear differences emerge in this respect. Only a few RCTs reported and EVLA being performed using the same anaesthetic procedure, i.e. tumescent local anaesthesia. If one only considers these trials (14, 25 27), more severe pain was actually reported more often after EVLA #1 than after. Furthermore, in the long term, EVLA #1 is inferior to surgery, which was shown for duplex detected saphenofemoral recurrence and/or clinical saphenofemoral recurrence (4, 13, 14, 27, 32). It can thus be concluded that use of endovenous laser therapy with 1st-generation equipment/ fibres can no longer be recommended for treatment of varicosis. Indeed, as shown in several RCTs 2 nd and 3 rd generation lasers are superior to EVLA #1 regarding postoperative comfort. However, it is currently not possible to de- Phlebologie 4/2016 Schattauer 2016

5 K. Rass: Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials 205 fine the position of the more recent laser generations compared with radiofrequency ablation and surgery, due to a lack of corresponding comparative studies. There is thus a clear deficit, particularly considering that EVLA #2 and EVLA #3 have already been used for 8 and 11 years, respectively, in the treatment of saphenous vein incompetence. Given that the latest long-term studies have, for the first time, shown superior efficacy of compared with 1st generation lasers, available meta-analyses should, on the one hand, now be updated. On the other hand, this shows that traditional surgery with high ligation and stripping should be retained as control in RCTs investigating the new laser generations and that long-term follow-up should be planned in the study design. However, considerable variations in the quality of surgery seem to be apparent in the available studies, e.g. with infection rates of 0 to 9.4 % after crossectomy (2) or an unsuccessful operation rate of 0 to 7.1 % (3). Performing as part of RCTs should definitely be reserved for experienced surgeons, just as a learning curve is necessary for performing the endovenous techniques. Furthermore, in view of the data from already published studies, it must be ensured that identical perioperative conditions exist in the study groups, as e.g. different anaesthetic procedures (tumescent versus general anaesthesia) can have a potential effect on the postoperative result, e.g. postoperative pain, quality of life. Nevertheless, due to their minimal invasiveness and the good standardisation they have now achieved, the latest laser technologies have a great therapeutic potential, which was shown for the radial fibres compared with EVLA #2 (10). In future, criteria will have to be defined to ensure the correct allocation of patients to the different treatment procedures, both in RCTs and in routine clinical practice, so that an individually optimised treatment can be offered. Two recently published papers are groundbreaking in this respect. In a summary of data obtained from more than 1,200 treated legs from 15 randomised trials, Van der Velden et al. showed that saphenous vein diameter and the C class of the CEAP classification are strong prognostic factors for recanalisation following endovenous thermoablation and are therefore inversely proportional to therapeutic efficacy (34). In a prospective cohort study with threshold values for the diameter of 9 mm at the confluence and the C class of C4, Spreafico and colleagues defined independent predictors for recanalisation of the laser-ablated saphenous vein (EVLA #3: nm radial fibres) (29). 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