By Mr Alastair Lewis, BSc(Hons), MD, FRCSI
Consultant Phlebologist
My last two blog posts discussed Endovenous laser ablation, commonly known as EVLA, and ultrasound-guided foam sclerotherapy in the treatment of varicose veins.
They are often presented as competing treatments for varicose veins. In reality, they are different tools with different strengths and weaknesses.
The most appropriate treatment depends on which veins are affected, their size and shape, whether previous treatment has been performed and, most importantly, the findings on duplex ultrasound.
What is EVLA?
EVLA is used mainly to treat reflux in a relatively straight superficial vein, most commonly the great or small saphenous vein.
Under ultrasound guidance, a fine laser fibre is passed into the vein through a needle puncture. Local anaesthetic is placed around the vein before laser energy is used to seal it from within.
EVLA provides reliable and durable closure of suitable truncal veins. NICE recommends endothermal ablation as the first treatment to consider for people with confirmed truncal venous reflux. The procedure is performed under local anaesthetic, avoids surgical incisions and normally allows a rapid return to everyday activities. (NICE)
What is foam sclerotherapy?
Foam sclerotherapy uses a sclerosant medicine mixed with a gas to create a foam. Under ultrasound guidance, the foam is directed into the abnormal vein, where it damages the internal lining and causes the vein to close.
Unlike a laser fibre, foam can pass through winding veins and branching networks. It is therefore particularly useful for recurrent varicose veins, tortuous veins, visible tributaries and veins that cannot easily be treated using a catheter.
Several connected veins can sometimes be treated through a small number of needle punctures. Further treatment may occasionally be required if a vein does not close completely or subsequently reopens. (NICE)
Which treatment lasts longer?
For a suitable, relatively straight saphenous trunk, EVLA generally produces more dependable long-term closure than foam sclerotherapy.
Randomised evidence has also shown that disease-specific quality of life five years after treatment was better following laser ablation than following foam sclerotherapy. (New England Journal of Medicine)
This does not mean that foam sclerotherapy is ineffective. In fact, in expert hands foam sclerotherapy has closure rates and safety profile comparable to thermal ablation (Journal of Vascular Surgery)
Firstly, most trials comparing the two treatments do not utilise foam sclerotherapy in an optimal fashion meaning that significant segments of vein are undertreated.
Secondly, despite this, patient reported outcomes after non-thermal treatment often exceed those after EVLT (Journal of Vascular Surgery).
Foam is a less invasive procedure, that when performed correctly has the ability to produce better results.
Is the recovery different?
Both procedures are minimally invasive and are normally performed as walk-in, walk-out treatments.
EVLA requires local anaesthetic injections along the course of the vein and may cause temporary tightness, bruising or tenderness. Foam usually requires fewer injections, although inflammation, lumpiness, pigmentation and the need for further treatment can occur.
Neither treatment is completely risk-free. Potential complications include superficial thrombophlebitis, skin staining, nerve irritation and deep-vein thrombosis. Temporary headaches or visual symptoms have been reported after foam, while significant neurological complications are rare. These risks should be explained during the consent process. (NICE)
Can EVLA and foam be combined?
Yes. In many patients, the most effective approach is to use EVLA to close the main refluxing saphenous trunk and foam sclerotherapy to treat associated tributaries, residual veins or recurrent disease. The objective should not be to favour one treatment automatically. It should be to select the most appropriate technique for each part of the venous problem.
Why duplex ultrasound matters
Treatment should never be selected simply by looking at the veins visible beneath the skin.
A detailed duplex ultrasound scan identifies the source and pattern of venous reflux and establishes whether a vein is suitable for laser treatment. The practitioner’s ability to interpret the scan and plan treatment is at least as important as the technology being used.
Which treatment is best?
EVLA is often for a suitable refluxing saphenous trunk because it offers reliable long-term closure in the hands of practitioners who are not experts in venous disease. It is advantageous in the treatment of bilateral varicose veins and in the short saphenous veins behind the knee.
Foam sclerotherapy is particularly valuable for winding, recurrent and branching veins, and as an addition to laser treatment. Foam sclerotherapy in the hands of an expert can perform as least as well as EVLA in achieving long term closure of truncal veins. For many patients, therefore, the best answer is not EVLA or foam, but a carefully planned combination of both.
A specialist consultation and duplex ultrasound assessment can establish which approach is most appropriate for your individual pattern of venous disease.
This article provides general information and does not replace an individual medical consultation.
Review Date: 31st July 2027
For more information on EVLA click here
For more information on Foam Sclerotherapy click here
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