Patterns of recurrent varicose veins after surgery (REVAS): a systematic review and network meta-analysis of randomized trials

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09 – Abstract Venous Symposium Europe 2024 [back to abstract list]
AUTHOR(S): Konstantinos Kavallieros1,2, Adam M. Gwozdz1, Benedict Turner1, Giannis Konstantinou2,
Emmanuel Giannas2, Iris Soteriou2, Julianne Stoughton3, Alun H. Davies1
Affiliations: 1. Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom. 2. Faculty of Medicine, Imperial College London, London, United Kingdom. 3. Department of Vascular Surgery, Massachusetts General Hospital, Stoneham, Massachusetts, USA


BACKGROUND/AIM

Recurrence of superficial venous incompetence is common following interventional treatment, and a classification system (Recurrent Varices After Surgery, REVAS) has been developed. However, it is not known whether specific, predictable patterns of reflux occur following treatment or how these may vary by treatment modality. This study aimed to explore varicose vein recurrence patterns according to procedural technique.

METHODS

Following PRISMA guidelines and a registered protocol (CRD42023455512), MEDLINE, Embase, and ClinTrials.gov were searched for randomized clinical trials (RCTs) on surgical or endovenous treatment of primary saphenous vein insufficiency with at least 1-year follow-up and assessment of recurrence patterns. The primary outcome was reflux recurrence as per the REVAS classification. A random-effects network meta-analysis was conducted in R, calculating risk ratios and 95% confidence intervals (CIs).

RESULTS

The 3467 records identified yielded 23 unique RCTs, investigating 8 different modalities. Recurrence rates varied by anatomical section: saphenofemoral junction (SFJ) showed 23.6% cumulative recurrence; thigh perforators, 7.6%; and lower-leg perforators, 4.7% recurrence. Endovenous laser ablation (EVLA) and foam sclerotherapy (FS) had higher risk of SFJ recurrence compared to high ligation and stripping (HLS) with a risk ratio of 2.29 (1.40 – 3.76) and 2.09 (1.20 – 3.62) (I2 = 47.7%). EVLA was associated with a reduced risk of thigh perforator recurrence compared to HLS (0.45 [0.21 – 0.93]) (I2=0%). FS was associated with higher risk of recanalization compared to HLS (4.05 [2.23 – 7.35]) and EVLA (3.14 [1.82- 5.41]). Both EVLA and FS were associated with lower risk of neovascularization, compared to HLS; 0.28 (0.16-0.41) and 0.18 (0.08-0.40), respectively (I2=0%).

CONCLUSIONS

Recurrence patterns varied by treatment modality, with HLS showing lower SFJ and anterior accessory saphenous vein (AASV) recurrence, while endovenous methods had less neovascularization and thigh perforator recurrence. Concerningly, only 13% of RCTs reported recurrence using REVAS. Improved reporting of varicose vein recurrence to delineate reflux sources will allow better technical outcome assessment and enhanced patient care.