Commentary to Accompany ‘Cost and Effectiveness of Laser with Phlebectomies Compared with Foam Sclerotherapy in Superficial Venous Insufficiency. Early Results of a Randomised Controlled Trial’

Abstract

Dr. Lattimer and colleagues have presented the results of what appears to be a well designed randomized study comparing ultrasound guided foam sclerotherapy to endovenous laser ablation of the great saphenous vein and stab phlebectomy, adequately powered based on precedent estimates. The analysis and presentation are clear. However, I am struck by the high rate of persistent and/or recurrent reflux in the axial great saphenous vein in the EVLA. Their observation that 26% of subjects in the laser arm of the study had reflux at 3 months is much greater than any previous study. In general the rate of reflux in those precedent studies is 10% or less even at two years and the authors cite a metaanalysis with a figure of 4.6% at 5 years. Their results with foam sclerotherapy seem consistent with the precedent literature. Indeed power calculations at the time of study acknowledged these precedents. On further consideration of this study compared to the precedent articles it occurs to me that it is possible that this may reflect a stricter definition of hemodynamic success than was the case in the precedent articles. As Dr. Lattimer points out he and colleagues define failure as the presence of reflux in any segment of the above knee great saphenous vein, whereas the precedent articles may have graded a procedure as a success if refluxwas no longer present in the saphenofemoral junction and adjacent upper great saphenous vein. If indeed the precedents used amore forgiving definition for hemodynamic treatment failure then readers must decide whether reflux in a segment of the great saphenous vein despite occlusion (and no reflux) in the saphenofemoral junction and