What can we learn from randomized trials comparing endovenous and open surgery for primary varicosis? an overview Prof. Dr. Thomas M.

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1 What can we learn from randomized trials comparing endovenous and open surgery for primary varicosis? an overview Prof. Dr. Thomas M. Proebstle Department of Dermatology, University Medical Center Mainz, Germany Privatklinik Proebstle, Mannheim, Germany

2 Disclosure Speaker name:.thomas Proebstle I have the following potential conflicts of interest to report: X x X Consulting, Speaker Bureau Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest 2

3 Recommendations of Scientific Societies NICE, ESVS, AVF,...: Endovenous... over Foam... over Surgery Why??? 3

4 4

5 5

6 6

7 Occlusion of GSV Hautklinik 7

8 Reflux at SFJ Hautklinik 8

9 Proportion of non-refluxing Ultrasound-detectable Anterior Accessory Saphenous Veins (AASVs) in Patients with Ablation of a Refluxing GSV at T = 0. + O Donnell TF et al J Vasc Surg Venous Lymphat Disord 2016;4: after endothermal Tx + Garner JP et al, 2003 after surgery Proebstle TM, Möhler T. J Vasc Surg Venous Lymphat Disord. 2015;3:265-9

10 Ann R Coll Surg Engl 2003; 85: Audit The lateral accessory saphenous vein a common cause of recurrent varicose veins JP Garner, PSJ Heppell*, PW Leopold Department of Vascular Surgery, Frimley Park Hospital, Camberley, Surrey GU16 5UJ, UK 3Y-Follow-Up Background: Varicose veins commonly recur after surgery and present a large burden to the NHS. The aim of this study was to demonstrate that the 1ateral accessory saphenous vein is the commonest cause of groin recurrence of varicose veins and we discuss a possible anatomical reason for this. Patients and Methods: The case notes of all patients presenting to two vascular surgeons with recurrent varicose veins over a 3-year period were studied. All limbs were assessed by duplex ultrasound scanning. These scans were reviewed to identify the site of recurrence. When recurrence occurred in the groin, the scans were further evaluated to identify the cause of groin recurrence. Results: A total of 216 limbs in 186 patients were evaluated over a 36-month period. Of these, 141 (65%) demonstrated a recurrence in the groin: 56 (26%) recurrences were due to either incompetent thigh or calf perforators and there were 19 (9%) cases of saphenopopliteal or short saphenous vein incompetence. Out of 141 groin recurrences, 61 (43%) were due to a persistent lateral accessory saphenous vein. Conclusions: The lateral accessory saphenous vein is the commonest cause of recurrence in the groin of varicose veins. It should be looked for specifically during pre-operative assessment duplex scanning and at primary surgery. If identified at operation, we believe it should be either stripped or avulsed to reduce the risk of recurrence. N =216 limbs N = 143 (63%) groin recurrences N = 61 of 216 (28%) due to incompetent AASV 10

11 The Accessory Anterior Saphenous Vein Issue Overtreatment with HL/Stripping Undertreatment with EVLA? -> Focus on AASV during Follow-up Duplex As long as AASV directed RCTs are missing 11

12 CONCLUSION What can we learn from randomized trials comparing endovenous and open surgery for primary varicosis? 12

13 At 5Y Follow-Up USG Foam shows significantly worse anatomical results. Equal clinical results for HL/S and EVLA... with less morbidity for EVLA?! Slightly more SFJ recurrences in the EVLA Group compared to HL/S -- mainly due to AASV reflux 13

14 However, current 5Y-Meta-Analysis reflects ancient technology status, almost 10Y (Laser) vs > 100Y (HL/S) Throwback EVLA mostly with bare fiber technology no comparison to RF (segmental ablation) no comparison to non-thermal ablation methods 14

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