A systematic review and meta-analysis of treatment modalities for anterior accessory saphenous vein insufficiency

Abstract

Objective

To investigate and compare the outcomes of the available treatment modalities for anterior accessory saphenous vein (AASV) incompetence.

Methods

A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Studies reporting the outcomes of patients who were treated for primary AASV incompetence were included. The methodologic quality of the articles was assessed using the Methodological Index for Non-Randomized Studies (MINORS). A random-effects model was used to estimate anatomic success, defined as AASV occlusion. The secondary outcomes were pain during and after treatment, venous clinical severity score, quality of life, esthetic result, time to return to daily activities, and complications.

Results

The search identified 860 articles, of which 16 met the inclusion criteria. A total of 609 AASVs were reported. The included studies were of poor or moderate quality according to MINORS score. The pooled anatomic success rates were 91.8% after endovenous laser ablation and radiofrequency ablation (EVLA, RFA, 11 studies), 93.6% after cyanoacrylate closure (3 studies), and 79.8% after sclerotherapy (2 studies). The non-pooled anatomic success rate was 97.9% after phlebectomy and 82% after CHIVA. Paresthesia was seen after EVLA in 0.7% of patients (6 studies). Phlebitis was seen in 2.6% of patients after RFA (2 studies), 27% after sclerotherapy (1 study), and 12% after the phlebectomy (1 study). Deep venous thrombosis and skin burn did not occur.

Conclusion

Treatment of AASV incompetence is safe and effective. Despite limited evidence, occlusion of the AASV can be achieved with endovenous thermal ablation and cyanoacrylate. There does not appear to be a benefit of EVLA compared to RFA regarding treatment efficacy. Phlebectomy shows promising results if the saphenofemoral junction is competent. Lower results are seen after sclerotherapy and CHIVA. However, studies with sufficient sample sizes of solely treatment of AASV incompetence are needed to draw firm conclusions.

Keywords

Review meta-analysis anterior accessory saphenous vein AASV varicose veins venous insufficiency

Introduction

The treatment of varicose veins has been revolutionized in recent decades by the introduction of minimally invasive endovenous ablation techniques. Although varicose veins are frequently associated with great saphenous vein (GSV) incompetence, anterior accessory saphenous vein (AASV) reflux is responsible for approximately 10% of all varicose vein disease.¹ The AASV, present in 41% of people, lies anterior and lateral to the GSV, superficial to the deep venous system over the proximal anterior thigh, and also drains into the saphenofemoral junction (SFJ). The GSV and the AASV are visualized by Duplex-scanning through the “saphenous eye," however, the AASV lies more anterior and laterally and overlies the femoral vein and artery, the so-called “alignment sign.”²

AASV incompetence possesses similar disease severity and morbidity to that caused by the incompetent GSV.³ However, recently, a large epidemiology study showed a significantly higher incidence of superficial vein thrombosis in patients with isolated AASV reflux compared to patients with GSV incompetence.⁴ This advocates that patients suffering from reflux in the AASV do have a meaningful problem and treatment is necessary. However, whereas many clinical studies report on the outcomes of treatment modalities for GSV insufficiency, valid data are still limited regarding the optimal therapy for AASV incompetence.

This systematic review and meta-analysis summarizes and compares the outcomes of the currently available treatment modalities for incompetent AASVs, such as endovenous thermal ablation (ETA) including endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), cyanoacrylate closure (CAC), sclerotherapy, and surgical excision.

Methods

This report was written in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews and meta-analyses.⁵

Literature search

A systematic search was performed using the MEDLINE, Embase, and the Cochrane Library. The following keywords or abbreviations were used: anterior accessory saphenous vein, vena saphena magna accessoria anterior, vena saphena accessoria, lateral accessory saphenous vein, vena semicircularis. The final search was performed on November 30, 2020. The reference lists of retrieved articles and Google Scholar were used to identify studies that were not found in the original search. A full search strategy can be found in Appendix 1. Individual authors of the included articles were not contacted.

Inclusion and exclusion criteria

Studies: Studies were eligible if they had included patients treated for primary AASV incompetence, had been reported in English, and had the full text available. Exclusion criteria were case reports, commentaries, letters to the editor, surveys, and conference abstracts. Cohorts which not solely treated AASV incompetence were only included if the data for patients with AASV incompetence could be extracted. If more than one study reported the same patient cohort, only the most recent and complete study was included in this review.

Participants: Studies reporting the outcomes of patients who were treated for primary AASV incompetence were included.

Outcome measures: The primary outcome was anatomic success, defined as successful occlusion with no flow through the treated AASV. Terms such as closure, obliteration, ablation, reflux, recanalization, patent or open were also used. Failure rates were deducted from 100% to standardize the primary outcome. The secondary outcomes were pain during and after treatment, venous clinical severity score (VCSS), quality of life, patient satisfaction, esthetic result, time to return to daily activities, and complications (deep venous thrombosis [DVT], skin burn, paresthesia, phlebitis, and hyperpigmentation), which were only reviewed if data for AASV incompetence was extractable.

Data collection and extraction

After duplicates were removed, two authors (TA, EH) screened the titles and abstracts of the identified studies for relevance. Of the relevant studies, the two authors read the full text and made a final selection. Data extraction was performed by the two authors independently. When studies included patients with treatment of AASV and other truncal veins, only the data of patients with AASV were extracted.

Validity assessment

The methodologic quality of the articles was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score, with a global ideal score of 16 for noncomparative studies and 24 for comparative studies.⁶ The MINORS score was reported as a percentage of the global ideal score. For this review, a score of ≤8 was considered poor quality, 9–14 moderate quality, and ≥15 good quality for noncomparative studies. For comparative studies, a score of ≤15 was considered poor quality, 16–22 moderate quality, and ≥23 good quality. Discrepancy between the authors during the search, selection, and quality assessment were resolved by discussion. If necessary, a third author (ÇÜ) was consulted until agreement was reached.

Data analysis

OpenMetaAnalyst software (CEBM, Brown University, Providence, Rhode Island) was used for the meta-analysis. Meta-analysis was performed for the primary outcome of anatomic success. To provide a reliable outcome, only two or more studies of the same treatment modality were used for pooled analyses. Loss to follow-up was not included in the calculation of the anatomic success rates. The DerSimonian–Laird random-effects model was used for pooled data analysis. Results are presented as proportions with the 95% confidence intervals (CIs). Heterogeneity between studies was determined with forest plots and I² indices. The secondary outcomes were calculated for each treatment modality.

Results

Study selection

The search identified 861 studies. After duplicates had been removed and the titles and abstracts screened for relevance, 81 articles were eligible for the full-text review. The full-text reading and application of the inclusion and exclusion criteria resulted in the inclusion of 16 studies in the present systematic review. We excluded 65 studies for the following reasons (Appendix 2): reviews with overlapping data,^7,8 primary outcome not reported,^9–18 not written in English,^19–31 conference abstracts,^32–55 overlapping data with an already included report by same author,⁵⁶ data not yet available,⁵⁷ full text not available,⁵⁸ no distinction between primary and secondary AASV incompetence,⁵⁹ no distinction in outcome between GSV and AASV,^60–62 and other outcome.^63–71 A flow chart of the selection procedure is shown in Figure 1.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for literature search to identify studies reporting on anterior accessory saphenous vein incompetence.

Validity assessment

The included studies were of poor to moderate quality as assessed using the MINORS score. None of the included studies reported a prospective calculation of the study size, none of the studies described an unbiased assessment of the end point, and most of the studies collected data retrospectively (Table 1).

Table 1.

Quality appraisal (MINORS score).

	Aurshina 2018⁸⁰	Aurshina 2018⁷⁹	Bauzá Moreno 2016⁷⁸	Cavallini 2014⁷⁵	Cavallini 2015⁷⁶	Chaar 2011⁷⁷	Erben 2020⁸¹	MacKenzie 2016⁷²	Theivacumar 2009⁷³	Timperman 2005⁷⁴	Yang 2019⁸²	Gibson 2019⁸³	Krnić 2015⁸⁶	Weaver 2019⁸⁴	De Roos 2003⁸⁵	Maldonado-Fernández 2016⁸⁷
1. A clearly stated aim	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2
2. Inclusion of consecutive patients	2	2	2	2	2	2	2	2	2	2	1	2	2	2	2	2
3. Prospective collection of data	0	0	0	0	0	0	0	2	2	2	0	2	2	0	2	2
4. Endpoint appropriate to the aim of the study	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2
5. Unbiased assessment of the study end point	2	2	0	0	0	0	0	0	0	0	0	0	0	0	0	0
6. Follow-up period appropriate to the aim of the study	2	2	2	2	2	2	2	2	1	2	2	2	2	2	2	2
7. Loss to follow-up of <5%	0	2	0	2	2	0	0	2	2	1	1	2	0	0	2	2
8. Prospective calculation of the study size	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Item 9–12 only for comparative studies
9. An adequate control group	2	2					2		2		2				2
10. Contemporary groups	2	2					2		2		2				2
11. Baseline equivalence of groups	1	1					2		2		2				1
12. Adequate statistical analysis	2	1					1		2		1				2
Total MINORS score	17	12	8	10	10	8	15	12	19	11	15	12	10	8	19	12
Maximum possible score	24	16	16	16	16	16	24	16	24	16	24	16	16	16	24	16

0 = not reported; 1 = reported but inadequate; 2 = reported and adequate.

Endovenous thermal ablation

Eleven studies described the results of ETA (Table 2): three prospective studies using EVLA,^72–74 three retrospective studies using EVLA,^75–77 one retrospective study using RFA,⁷⁸ three retrospective studies comparing RFA with EVLA,^79–81 and one retrospective study comparing RFA with CAC.⁸²

Table 2.

Study characteristics and results—Endovenous thermal ablation.

Study	Period	Design	Sample size			Anesthesia	Additional therapy	Follow-up	Success			Complications
Study	Period	Design	RFA	EVLA	Total	Anesthesia	Additional therapy	Follow-up	RFA	EVLA	Total	DVT	Paresthesia	Phlebitis	Skin burn
Aurshina 2018⁸⁰	2012–2014	R	67	42	109	TA	None	1 week	97%	97.6%	97.2%	0%	0%	0%	NR
Aurshina 2018⁷⁹	2012–2015	R	NR	NR	140	LA	None	14 months	NR	NR	85,2%	NR	NR	NR	NR
Bauzá Moreno 2016⁷⁸	2007–2014	R	9	NA	NA	GA, IS or LA	PT	6 months	100%	NA	NA	NR	NR	NR	NR
Cavallini 2014⁷⁵	2011–2012	R	NA	6	NA	TA	PT and/or ST	3 months	NA	100%	NA	0%	0%	0%	0%
Cavallini 2015⁷⁶	2011–2013	R	NA	9	NA	TA	PT	12 months	NA	100%	NA	0%	0%	0%	0%
Chaar 2011⁷⁷	2008–2009	R	NA	53	NA	LA	NR	3 weeks	NA	86.8%	NA	0%	1.8%	0%	0%
Erben 2020⁸¹	1998–2018	R	13	20	33	TA	P	5.6 years	NR	NR	81.8%	NR	NR	NR	NR
MacKenzie 2009⁷²	2006–2008	P	NA	6	NA	None, LA or GA	PT and/or ST	3 months	NA	100%	NA	0%	0%	0%	0%
Theivacumar 2009⁷³	2004–2007	P	NA	21	NA	TA	None	12 months	NA	100%	NA	0%	0%	NR	0%
Timperman 2005⁷⁴	NR	P	NA	16	NA	TA	NR	9 months	NA	87.5%	NA	NR	NR	NR	NR
Yang 2019⁸²	2014–2016	R	9	NA	NA	NR	NR	2 months	100%	NA	NA	0%	0%	25%	0%

FU, follow-up; NR, not reported; NA, not applicable; R, retrospective; P, prospective; GA, general anesthesia; TA, tumescent anesthesia; IS, intravenous sedation; RA, regional anesthesia; PT, phlebectomy; ST, sclerotherapy; wk, week; mo, months; y, year. Complications; DVT, phlebitis and paresthesia.

Endovenous laser ablation: Eight studies described EVLA of 173 AASVs. ^72,77,80,81 One study had included patients with solely AASV incompetence.⁷⁶ Three studies reported concomitant reflux of the SFJ.^73,75,76 The CEAP clinical score was reported by two studies: 63% C2, 37% C3⁷⁶ and 85% C2, 12% C3, 3% C4, 0% C5/6.⁷³ Studies were heterogeneous regarding energy deliverance. Wavelengths differed between studies: 810 (n = 4),^72–74,77 980 (n = 3),^79–81 and 1540 nm (n = 2).^75,76 Pulsed and continuous modes were both used, and there was no uniform amount of Joules per centimeter (range, 60–120 J/cm). Anatomic success of EVLA after a mean follow-up of 5.7 months ranged from 86.8 to 100%. One study reported a patient-satisfaction score of 84% calculated from a 10-cm visual analog scale and an improvement in Aberdeen Varicose Vein Symptom Severity Scores (AVVSS) of 64.6% (p= 0.001); median 4.1 (IQR: 2.1–5.2) at baseline vs 11.6 (IQR: 6.9–15.1) at 1 year.⁷³ The AVVSS in this group was similar to an age- and sex-matched control group with GSV incompetence. The VCSS, postprocedural pain, and time to return to daily activities were assessed by Cavallini et al.⁷⁶ The VCSS improved from a mean of 3.2 (SD: 1.42) before treatment to 0.13 (SD: 0.35) at day 30, became 0 at 3 months and kept at 0 at every subsequent follow-up. The mean postprocedural pain assessed on a 6-point scale ranging from no pain at all (0) to very painful (5) was 0.1 (SD: 0.4) at day 1, 1.3 (1.6) at day 10, and 0.6 (1.2) at day 30. Analgesics were used by 13% of patients. Patients returned to daily activities after a mean of 3.8 days (SD: 3.5). No DVT was seen in 137 patients and no phlebitis was seen in 116 patients.^{72,73,75–77,80} Postprocedural paresthesia was reported by six studies,^{72,73,75–77,80} of which one study reported paresthesia in 1.8% of patients.⁷⁶

Radiofrequency ablation: Four studies described radiofrequency ablation (RFA) of 98 AASVs.^78,80–82 Yang et al.⁸² compared CAC with RFA retrospectively. Three studies reported results of the ClosureFast device (Medtronic, San Jose, CA, USA/Covidien, San Jose, CA, USA/Medtronic, Minneapolis, MN, USA) and one study reported results of the Venefit Targeted Endovenous Therapy System (Medtronic of Canada Ltd, Vancouver, BC). In one study, the proximal segment of the vein was treated twice to ensure closure.⁷⁹ The anatomic success after a mean follow-up of 2.8 months ranged from 97 to 100%. No DVT and paresthesia were detected in 76 patients.^80,82 Phlebitis occurred in 25% of patients reported by Yang et al.⁸² Other secondary outcomes were not reported.

Non-thermal ablation

Cyanoacrylate closure: Three studies reported the results of CAC in 29 AASVs (Table 3).^82–84 In all studies the VenaSeal Closure System (Medtronoic of Canada Ltd, Vancouver, BC/Medtronic Inc., Minneapolis, MN, USA) was used. Weaver described adjuvant ultrasound-guided foam sclerotherapy of tributary varicose veins leading from the truncal veins 6–12 weeks later as a secondary procedure. The anatomic success of after a mean follow-up of 5.7 months ranged from 92.9 to 100%. Only Yang et al.⁸² reported on DVT, paresthesia, and phlebitis, which were not seen in any of the patients. Other secondary outcomes were not reported.

Table 3.

Study characteristics and results—Non-thermal ablation.

Study	Period	Design	Sample size		Anesthesia	Additional therapy	Follow-up	Success		Complications
Study	Period	Design	Cyanoacrylate	Sclerotherapy	Anesthesia	Additional therapy	Follow-up	Cyanoacrylate	Sclerotherapy	DVT	Paresthesia	Phlebitis	Skin burn
Gibson 2019⁸³	2015	P	14	NA	NR	None	3 months	92.9%	NA	NR	NR	NR	NR
Krnić 2015⁸⁶	2011–2013	P	NA	11	None	NR	19 days	NA	100%	NR	NR	NR	NR*
Weaver 2019⁸⁴	2015–2017	R	7	NA	LA	ST	12 months	100%	NA	NR	NR	NR	NR
Yang 2019⁸²	2014–2016	R	8	NA	NR	NR	2 months	100%*	NA	0%	0%	0%	NR
De Roos 2003⁸⁵	1996–1998	RCT	NA	49	LA	ST	24 months	NA	63.3%	NR	NR	27%	NR

NR, not reported; NA, not applicable; RCT, randomized controlled trial; R, retrospective; P, prospective; LA, local anesthesia; ST, sclerotherapy; DVT, deep venous thrombosis; d, days; mo, months. Complications; DVT, phlebitis and paresthesia. *Persisting skin darkening 1 year after treatment in an unknown amount of patients.

Sclerotherapy: Two studies reported the results of sclerotherapy in 60 AASVs (Table 3).^85,86 De Roos et al.⁸⁵ randomized between ambulatory phlebectomy and sclerotherapy using 3% Polidocanol. The mean Polidocanol dosage was 2.54 mL (range, 1–4 mL). The anatomic success rate after sclerotherapy was 63.3% after 24 months of follow-up. Retreatment with sclerotherapy was allowed 2 and 4 weeks after the initial treatment session. Krnić used a liquid Aethoxysklerol with air at 1:4 ratio and did not administer more than 18 mL of foam per session. If this amount could not solve the entire problem, the treatment was stopped and continued a week later. The anatomic success rate was 100% at 19 days of follow-up. None of the studies reported on DVT and paresthesia. Phlebitis was detected in 27% of patients by De Roos et al.⁸⁵ Persisting skin darkening 1 year after treatment was reported by Krnić et al.⁸⁶ The amount of patients was not reported. Other secondary outcomes were not reported by any of these studies.

Surgery

Two studies described surgical treatment of 114 AASVs (Table 4). Uniformity was lacking among the chosen surgical procedures.

Table 4.

Study characteristics and results—Surgery.

Study	Period	Design	Sample size	Anesthesia	Additional therapy	Follow-up, mo	Success	Complications
Study	Period	Design	Sample size	Anesthesia	Additional therapy	Follow-up, mo	Success	DVT	Paresthesia	Phlebitis, %	Skin burn
Maldonado-Fernández 2016⁸⁷	2010	P	65	LA	NR	12	82%*	0%	0%	0	NR
De Roos 2003⁸⁵	1996–1998	RCT	49	LA	ST	24	97.9%	NR	NR	12	NR

NR, not reported; RCT, randomized controlled trial; P, prospective; LA, local anesthesia; ST, sclerotherapy; DVT, deep venous thrombosis; mo, months. Complications; DVT, phlebitis and paresthesia. *Defined as persistent retrograde flow.

Phlebectomy: One study randomized between sclerotherapy and ambulatory phlebectomy resulting in 49 AASVs treated with ambulatory phlebectomy.⁸⁵ SFJ insufficiency was excluded in this study. Several 2-mm stab incisions were made and the vein was grasped with a Oesch phlebectomy (Salzmann, Sankt Gallen, Switzerland). The vein was fixed with artery clamps and extracted until part of the varicose vein was either extracted or ruptured. This procedure was repeated until the vein was extracted completely. The incisions were closed by surgical tape only. The anatomic success was 97.9% after 24 months of follow-up. Secondary outcomes were not reported, except phlebitis which was seen in 12% of patients.

CHIVA: In the other study, the ambulatory conservative hemodynamic correction of venous insufficiency (CHIVA, Conservatrice Hemodynamique de l’Insuffisance Veineuse en Ambulatoire) was used to treat 65 AASVs. The baseline CEAP clinical classification was: 58% C2, 26% C3 and 15% C4–6.⁸⁷ Disconnection of the varicose veins from the AASV with extensive phlebectomy with multiple incisions was performed. The CHIVA-method is based on the theory that removal of the side-branches of the truncal veins will abolish the reflux in the truncal vein. The basic thought for this treatment is that development of varicose and refluxing side-branches of the truncal veins finally leads to truncal insufficiency. Postoperative low molecular weight heparin at prophylactic doses (bemiparin 2500–3500 units/day) was prescribed for 10 days. The anatomic success was 82% after 12 months of follow-up. At 12 months, the CEAP clinical score was improved (C1-3) in all patients. Fifty-seven percent of patients were asymptomatic, in 80% of patients no varicosities were visible, and aesthetics was good to excellent, all assessed by means of the Fligelstone scale.⁸⁸ DVT, phlebitis, and paresthesia did not occurred in this study. Results on skin burn and hyperpigmentation were not reported.

Pooled data

Data on the primary outcome, anatomic success, was pooled for ETA, CAC, and sclerotherapy (Figure 2). The pooled anatomic success rate was 91.8% (95% CI, 87.6–96.0%) after ETA, 93.6% (95% CI, 85.0–102.2%) after CAC, and 79.8% (95% CI, 47.9–111.7%) after sclerotherapy. The pooled data of CAC showed no heterogeneity (I² = 0%), the pooled data of ETA were associated with moderate heterogeneity (I² = 52%), and the pooled data for sclerotherapy showed substantial heterogeneity (I² = 92%).

Figure 2.

Forest plots of pooled data on anatomic success (A) endovenous thermal ablation, (B) cyanoacrylate closure, and (C) sclerotherapy. CI = confidence interval. The solid squares denote the mean difference, the horizontal lines represent the 95% CI, the diamonds denote the weighted mean differences, and the tips indicate the 95% CI.

Discussion

The present systematic review and meta-analysis summarizes the currently available literature on the different treatment modalities of AASV insufficiency. The pooled anatomic success rates were 91.8% at a mean follow-up of 4.3 months, 93.6% at a mean follow-up of 5.7 months, and 79.8% at a mean follow-up of 12 months after ETA (RFA, EVLA), CAC, and sclerotherapy, respectively. The non-pooled anatomic success rate was 97.9% at 24 months after phlebectomy and 82% at 12 months after the CHIVA procedure.^85,87

The available AASV data remains heterogeneous regarding the technical procedure. ETA shows a high pooled anatomic success rate, however, the mean follow-up was relative short. In the EVLA studies, three different laser wavelengths were used. Although previous studies have shown comparable anatomic success of different laser wavelengths, there may be differences in adverse effects.^89,90 Furthermore, the position of the laser tip varied from 1 to 5 cm below the SFJ. It is known that a residual saphenofemoral stump can contribute to the formation of recanalization.⁹¹ The high pooled anatomic success rate after CAC was derived from a small sample of 29 AASVs, nevertheless this non-thermal and tumescentless technique should be considered promising regarding its patient-friendly character. Regarding sclerotherapy different types of sclerosans were used in the included studies. This is of importance as previous studies showed that foam sclerotherapy is more effective than liquid sclerotherapy.⁹⁶ This was also noticed in the current review as there was a substantial difference in anatomic success of 63.3 vs 100% after liquid versus foam sclerotherapy, respectively. Although no crossectomy was performed during both procedures, the anatomic success rate after phlebectomy was higher compared with CHIVA. The high anatomic success rate after phlebectomy could be explained by the fact that there was no SFJ insufficiency and concomitant total or partial extraction of the AASV might have been performed. Another previous study reporting on CHIVA in patients with incompetence of the SFJ and reflux in the GSV, showed recurrence of GSV reflux in 53 of 58 patients after 3 years ⁹² Last, is the use of additional treatments may influence the anatomic success and contribute to the risk of side effects. No data on the innovative mechanochemical endovenous ablation (e.g., ClariVein and Flebogrif) of AASV is available. However, this relatively new technique shows fewer incidence of nerve injury, deep vein thrombosis, and skin burns compared to ETA in the treatment of GSV/SSV.⁹³

Secondary outcomes could not be analyzed because of the poor quality of the data. The VCSS, postprocedural pain, and time to return to daily activities after EVLA were assessed by Cavallini et al.⁷⁶ Symptoms and esthetic outcome were only assessed after CHIVA.⁸⁷ However, these outcome measures are of importance as EVLA of the small saphenous vein (SSV) showed a higher success rate, fewer complications, and earlier return to work compared with surgery but no significant differences in quality of life measures.⁹⁴

The risk of paresthesia may be an important limitation of ETA of AASV due to anatomy. In most cases, there is only a short proximal intrafascial segment and continuing treatment of the suprafascial segments gives a higher risk of skin nerve damage. However, paresthesia was detected in 0.7% of patients after EVLA.^{72,73,75–77,80} Which is lower than reported after EVLA of the GSV.⁹⁵ In this review skin burn was not seen, reported by three studies using EVLA.^72,75,76 Hyperpigmentation was seen after foam sclerotherapy in an unknown amount of patients.⁸⁶ Phlebitis was seen in 2.6% of patients after RFA,^80,82 27% after liquid sclerotherapy,⁸⁵ and 12% after phlebectomy.⁸⁵ It is known that sclerotherapy can lead to blood clot formation and inflammation which could be an explanation for the higher rate of “phlebitis” after sclerotherapy.⁷¹ Phlebitis after phlebectomy can occur if some residual parts of the vein could not be extracted. No DVT was reported in any of the studies. A note of caution is due here since from some of the included studies we could not extract the complications rates specifically reported on AASV. This can result in an underestimation or overestimation of the true complications rates.

Due to the quality of the included studies, the ability to draw firm conclusions is limited. The small amount of studies per treatment modality and the small sample sizes in most of the studies can be considered the major drawback of this review. Moreover, two-thirds of the included studies failed to report on loss to follow-up, thereby inducing potential bias regarding the calculation of anatomic success rates during follow-up. Statistical power calculations were not performed in any of the prospective cohort studies and most of the studies were retrospective analyses. In addition, the pooled data included studies with different follow-up periods. Interpretation of this review might have been hampered by publication bias and selective reporting cannot be excluded.

Despite these limitations, the present systematic review provides a helpful overview of the available data on treatment options of primary AASV insufficiency collected from a number of independent studies. This saves time for clinicians because they would not need to perform their own research which could be a challenge since most treated AASVs have been included in GSV clinical trials.

Conclusion

Treatment of primary anterior accessory saphenous vein (AASV) incompetence is safe and effective. Despite limited evidence, occlusion of the AASV can be achieved with endovenous thermal ablation and cyanoacrylate. There does not appear to be a benefit of EVLA compared to RFA regarding treatment efficacy. Phlebectomy shows promising results if the saphenofemoral junction is competent. Lower results are seen after sclerotherapy and CHIVA. However, studies with sufficient sample sizes of solely treatment of AASV incompetence are needed to draw firm conclusions.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Guarantor

Contributorship

Conception and design: TA, EH, MS, MCM, CJV, WW, ÇÜ.

Analysis and interpretation: TA, EH.

Data collection: TA, EH.

Writing the article: TA.

Critical revision of the article: TA, EH, MS, MCM, CJV, WW, ÇÜ.

Final approval of the article: TA, EH, MS, MCM, CJV, WW, ÇÜ.

Statistical analysis: TA.

ORCID iD

Tamana Alozai

Search strategy.

Excluded studies.

Database	Search terms
MEDLINE	Anterior accessory saphenous vein[tiab] OR AASV [tiab] OR Vena saphena magna accessoria anterior[tiab] OR "Anterior saphen" [tiab] OR "Anterior accessor" [tiab] OR "Accessory saphen" [tiab] OR Vena saphena accessor[tiab] OR Lateral accessory saphen[tiab] OR Vena semicircul[tiab] OR VSMAA [tiab] OR VSAA [tiab]
Embase	‘anterior accessory saphenous vein'/exp OR ‘anterior accessory saphenous vein':ti, ab OR ‘Vena saphena magna accessoria anterior‘:ti, ab OR ‘Anterior saphen‘:ti, ab OR ‘Anterior accessor’:ti, ab OR ‘Accessory saphen’:ti, ab OR ‘Vena saphena accessor‘:ti, ab OR ‘Lateral accessory saphen’:ti, ab OR ‘Vena semicircul’:ti, ab OR VSMAA:ti, ab OR VSAA:ti,ab
Cochrane	Anterior accessory saphenous vein[tiab] OR AASV [tiab] OR Vena saphena magna accessoria anterior[tiab] OR "Anterior saphen" [tiab] OR "Anterior accessor" [tiab] OR "Accessory saphen" [tiab] OR Vena saphena accessor[tiab] OR Lateral accessory saphen[tiab] OR Vena semicircul[tiab] OR VSMAA [tiab] OR VSAA [tiab]

First author	Reason for exclusion
Azpiazu 2019	Conference abstract
Borsuk 2016	Conference abstract
Boyle 2013	Conference abstract
Bush 2012	Conference abstract
Charitable 2020	Conference abstract
Corcos 2012	Conference abstract
Darvall 2012	Conference abstract
Erben 2020	Conference abstract
Gibson 2016	Conference abstract
Gibson 2017	Conference abstract
Gibson 2018	Conference abstract
Hao 2017	Conference abstract
Hirsch 2008	Conference abstract
Kaspar 2013	Conference abstract
Kaspar 2016	Conference abstract
Liu 2015	Conference abstract
Lobastov 2019	Conference abstract
Matar 2018	Conference abstract
Pitta 2017	Conference abstract
Sermsathanasawadi 2020	Conference abstract
Tan 2016	Conference abstract
Yang 2019	Conference abstract
Kibrik 2020^a	Conference abstract
Kibrik 2020	Conference abstract
Nct 2013	Data not yet available
King 2009	Full text nog available
Davis 2018	No distiction in outcome between GSV and AASV
Shadid 2015	No distiction in outcome between GSV and AASV
Steyaert 2014	No distiction in outcome between GSV and AASV
Badham 2018	Primary outcome not reported
Bush 2014	Primary outcome not reported
Jimenez 2020	Primary outcome not reported
Keo 2019	Primary outcome not reported
Kim 2020	Primary outcome not reported
Merchant 2005	Primary outcome not reported
Ravi 2009	Primary outcome not reported
Spiliopoulos 2015	Primary outcome not reported
Thomasset 2010	Primary outcome not reported
Whiteley 2017	Primary outcome not reported
Belentsov 2013	Not available in English
Bernardini 2007	Not available in English
Borsuk 2020	Not available in English
Davy 1985	Not available in English
Fokin 2019	Not available in English
Fokin 2016	Not available in English
Fokin 2020	Not available in English
Hirsch 2018	Not available in English
Krnić 2011	Not available in English
Prinz 2001	Not available in English
Raskin 2020	Not available in English
Recke 2017	Not available in English
Shaidakov 2013	Not available in English
Chait 2020	Other outcome
Corcos 2014	Other outcome
Gibson 2020	Other outcome
Jagtman 2003	Other outcome
Rasmussen 2010	Other outcome
Rass 2011	Other outcome
Sermsathanasawadi 2019	Other outcome
Sufian 2015	Other outcome
Winokur 2016	Other outcome
De Maeseneer 2019	Reviews with overlapping data
Rigby 2004	Reviews with overlapping data
Gibson 2017^b	Overlapping data with an already included report by same author
Bradbury 2010	No distinction between primary and secondary AASV incomptence

^aKibrik P, Chait J, Arustamyan M, Alsheekh A, Rajaee S, Marks N, et al. Value and Limitations of Postoperative Duplex Ultrasound Checks After Endovenous Thermal Ablation. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2020; 8 (2):319–320; ^bGibson K, Ferris B. Cyanoacrylate closure of incompetent great, small and accessory saphenous veins without the use of post-procedure compression: Initial outcomes of a post-market evaluation of the VenaSeal System (the WAVES Study). Vascular. 2017; 25 (2):149–156.

References

Garcia-Gimeno

Rodriguez-Camarero

Tagarro-Villalba

, et al. Duplex mapping of 2036 primary varicose veins. J Vasc Surg 2009; 49: 681–689.

Cavezzi

Labropoulos

Partsch

, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. part II. anatomy. Eur J Vasc Endovasc Surg 2006; 31(3): 288–299.

Schul

Schloerke

Gomes

. The refluxing anterior accessory saphenous vein demonstrates similar clinical severity when compared to the refluxing great saphenous vein. Phlebology 2016; 31: 654–659.

Schul

Vayuvegula

Keaton

. The clinical relevance of anterior accessory great saphenous vein reflux. J Vasc Surg Venous Lymphat Disord 2020; 8(6): 1014–1020.

Moher

Liberati

Tetzlaff

, et al. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. Biomed J 2009; 339: b2535.

Slim

Nini

Forestier

, et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 2003; 73(9): 712–716.

De Maeseneer

. What a phlebologist should know about the anterior accessory saphenous vein Phlebolymphology 2019; 26(2): 66–72.

Rigby

Palfreyman

SSJ

Beverley

, et al. Surgery versus sclerotherapy for the treatment of varicose veins. Cochrane Database Syst Rev 2004; 18: CD004980.

Badham

Dos Santos

Lloyd

LBA

, et al. One-year results of the use of endovenous radiofrequency ablation utilising an optimised radiofrequency-induced thermotherapy protocol for the treatment of truncal superficial venous reflux. Phlebology 2018; 33(5): 298–302.

10.

Bush

Flanagan

, et al. Factors associated with recurrence of varicose veins after thermal ablation: results of the recurrent veins after thermal ablation study. Scientific World J 2014; 2014: 505843.

11.

Jimenez

Lawrence

Woo

, et al. Adjunctive techniques to minimize thrombotic complications following microfoam sclerotherapy of saphenous trunks and tributaries. J Vasc Surg Venous Lymphat Disord 2020; 9(4): 904–909.

12.

Keo

Spinedi

Staub

, et al. Safety and efficacy of outpatient endovenous laser ablation in patients 75 years and older: a propensity score-matched analysis. Swiss Med Weekly 2019; 149: w20083.

13.

Kim

Elias

Gasparis

, et al. Results of polidocanol endovenous microfoam in clinical practice. J Vasc Surg Venous Lymphat Disord 2020; 9(1): 122–127.

14.

Merchant

Pichot

. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005; 42; 502–509.

15.

Ravi

Trayler

Barrett

, et al. Endovenous thermal ablation of superficial venous insufficiency of the lower extremity: single-center experience with 3000 limbs treated in a 7-year period. J Endovascular Ther 2009; 16(4): 500–505.

16.

Spiliopoulos

Theodosiadou

Sotiriadi

, et al. Endovenous ablation of incompetent truncal veins and their perforators with a new radiofrequency system. Mid-term outcomes. Vascular 2015; 23(6): 592–598.

17.

Thomasset

Butt

Liptrot

, et al. Ultrasound guided foam sclerotherapy: factors associated with outcomes and complications. Eur J Vasc Endovasc Surg 2010; 40(3): 389–392.

18.

Whiteley

Shiangoli

Dos Santos

, et al. Fifteen year results of radiofrequency ablation, using VNUS closure, for the abolition of truncal venous reflux in patients with varicose veins. Eur J Vasc Endovasc Surg 2017; 54(3): 357–362.

19.

Belentsov

Veselov

Chukin

, et al. [Criteria for selection of patients for radiofrequency ablation of major venous trunks in varicose disease, short- and long-term outcomes]. Angiol Sosud Khir 2013; 19(4): 177–181.

20.

Bernardini

Piccioli

De Rango

, et al. Ambulatory and haemodynamic treatment of venous insufficiency by ultrasound-guided sclerotherapy (ESEC cure): 14 years results. Phlebologie 2007; 36(4): 186–195.

21.

Borsuk

Fokin

. [Possibilities of using the colibri system for endovenous laser ablation]. Angiol Sosud Khir 2020; 26(2): 103–109.

22.

Davy

Ouvry

Guenneguez

. The anterior saphenous veins of the thigh. Phlébologie 1985; 38(2): 279–292.

23.

Fokin

Borsuk

. Truncal ablation without concomitant phlebectomy: What happens with remained branches? Flebologiya 2019; 13(1): 28–35.

24.

Fokin

Borsuk

Kazachkov

. [Efficacy of using rivaroxaban for treatment of heat-induced thrombosis after endovenous laser ablation]. Angiol Sosud Khir 2016; 22(4): 97–101.

25.

Fokin

Borsuk

Zhdanov

. [Possibilities of endovenous laser obliteration of subcutaneous veins with tumescence by cold saline solution]. Angiol Sosud Khir 2020; 26(1): 56–61.

26.

Hirsch

. Anterior accessory saphenous vein: include in the treatment in the thermal ablation of the great saphenous vein. Vasomed 2018; 30(1): 22–24.

27.

Krnic

Sucic

. Bipolar radiofrequency induced thermotherapy and 1064 nm Nd:Yag laser in endovenous occlusion of insufficient veins: short term follow up results. Vasa J Vasc Dis 2011; 40(3): 235–240.

28.

Prinz

Selzle

Kamionek

, et al. Surgery of the lateral accessory saphenous vein. Zentralblatt Fur Chirurgie 2001; 126(7): 526–527.

29.

Raskin

Semenov

Kurginyan

. Endovenous laser obliteration in the prevention of recurrence of varicose veins in the anterior saphenous vein pool. Profilakticheskaya Meditsina 2020; 23(3): 98–103.

30.

Recke

Frendel

Kahle

. Operative and postoperative risks of combined interventions by phlebectomy and foam sclerotherapy: a retrospective analysis of the example of isolated anterior accessory vein incompetence. Phlebologie 2017; 46(2): 75–79.

31.

Shaidakov

Petukhov

Iliukhin

, et al. [Radiofrequency obliteration of veins in surgical treatment of varicose disease]. Angiol Sosud Khir 2013; 19(2): 74–82.

32.

Azpiazu

Lambea

Martin

, et al. A prospective study of 1,500 cases of varicose veins treated with endovenous laser ablation with up to 1-year follow-up. Lasers Surg Med 2019; 51: S54.

33.

Borsuk

Fokin

. The efficacy of rivaroxaban for endovenous heat-indused thrombosis treatment after endovenous laser ablation. Phlebology 2016; 31(2): 29–30.

34.

Boyle

O’Leary

O’Neill

, et al. Endovenous laser therapy (EVLT)-evolving patterns of treatment. Irish J Med Sci 2013; 182: S68–S9.

35.

Bush

Flanagan

, et al. Factors associated with recurrence of varicose veins after thermal ablation: 3-year results of the revata (recurrent veins after thermal ablation) study. J Vasc Surg 2012; 55(1): 297.

36.

Charitable

Rockman

Jacobowitz

, et al. A single-center experience of anterior accessory great saphenous vein endothermal ablation demonstrates safety and efficacy. J Vasc Surg 2020; 72(1): e244–e245.

37.

Corcos

Aloi

Alonzo

, et al. Residual tributaries are the main cause for groin and popliteal surgical recurrence of varicose veins. A retrospective and prospective study of 610 limbs. Preliminary results of a multicentre study of the Italian Society of Phlebolymphology. Phlebology 2012; 27(6): 311.

38.

Darvall

KAL

Bate

Bradbury

. Two-year follow-up after ultrasound-guided foam sclerotherapy for varicose veins: clinical, duplex and health-related quality of life. Phlebology 2012; 27(6): 314.

39.

Erben

Vasquez

, et al. Long-term saphenous vein occlusion rate after endovenous ablation. J Vasc Surg Venous Lymphatic Disord 2020; 8(2): 329–330.

40.

Gibson

. Cyanoacrylate closure of incompetent great, small and accessory saphenous veins without the use of post-procedure compression: a post-market evaluation of the venaseal system (WAVES trial): three month data. Phlebology 2016; 31(2): 5–6.

41.

Gibson

42.

Gibson

Ferris

Gunderson

. Frequency and severity of hypersensitivity reaction in patients after cyanoacrylate treatment of superficial venous insufficiency. Phlebology 2018; 33(1): 18–19.

43.

Hao

Cox

Monahan

, et al. Double prepuncture as a valuable adjunctive technique for complex endovenous ablation. J Vasc Surg Venous Lymphatic Disord 2017; 5(4): 507–513.

44.

Hirsch

. Endovenous laser therapy of the superficial accessory saphenous vein. Phlebology 2008; 23: 11–12.

45.

Kaspar

. Infrequent indications of endovenous laser therapy. Phlebolymphology 2013; 20(1): 62.

46.

Kaspar

. Endovenous laser therapy of varicose veins-13-year Czech experience. J des Malad Vascul 2016; 41(2): 138.

47.

Kibrik

Chait

Arustamyan

, et al. Value and limitations of postoperative duplex ultrasound checks after endovenous thermal ablation. J Vasc Surg Venous Lymphatic Disord 2020; 8(2): 319–320.

48.

Kibrik

Chait

Arustamyan

, et al. Safety and efficacy of endovenous ablations in octogenarians, nonagenarians, and centenarians. J Vasc Surg Venous Lymphatic Disord 2020; 8(1): 95–99.

49.

Liu

Fong

Narayanan

. Anterior accessory saphenous vein-to treat or not to treat? Ann Acad Med Singapore 2015; 44(10): S161.

50.

Lobastov

Vorontsova

Barinov

, et al. Unexpected frequency and clinical significance of nontarget superficial and deep vein occlusion after foam-form sclerotherapy. J Vasc Surg Venous Lymphatic Disord 2019; 7(2): 305.

51.

Matar

. Modifed venaseal^™ technique for treating small diameter straight veins. Int Angiol 2018; 37: 76.

52.

Pitta

Kandaswamy

Venkateswaran

. Early efficacy and safety outcomes of radiofrequency ablation: results from vein practice in rural academic hospital. J Vasc Interv Radiol 2017; 28(2): e5.

53.

Sermsathanasawadi

Jieamprasertbun

Pruekprasert

, et al. Factors that influence venous leg ulcer healing and recurrence rate after endovenous radiofrequency ablation of incompetent saphenous vein. J Vasc Surg Venous Lymphatic Disord 2020; 8(3): 452–457.

54.

Tan

Lingam

, et al. Comparison of monopolar versus segmental radiofrequency ablation in endovenous treatment of lower limb chronic venous insufficiency. Ann Acad Med Singapore 2016; 45(9): S306.

55.

Yang

Lin

Kung

, et al. Four-year duplex ultrasound follow-up of trunk incompetent saphenous veins treated with high ligation and reversed catheter-directed foam sclerotherapy. Eur J Vasc Endovasc Surg 2019; 58(6): e835–e836.

56.

Gibson

Ferris

. Cyanoacrylate closure of incompetent great, small and accessory saphenous veins without the use of post-procedure compression: Initial outcomes of a post-market evaluation of the VenaSeal System (the WAVES Study). Vascular 2017; 25(2): 149–156.

57.

Surgery Nct . Versus sclerotherapy for isolated accessory great saphenous vein varicosis, https://clinicaltrialsgov/show/NCT02010723, 2013.

58.

King

Coulomb

Goldman

, et al. Experience with concomitant ultrasound-guided foam sclerotherapy and endovenous laser treatment in chronic venous disorder and its influence on health related quality of life: interim analysis of more than 1000 consecutive procedures. Int Angiol 2009; 28(4): 289–297.

59.

Bradbury

Bate

Pang

, et al. Ultrasound-guided foam sclerotherapy is a safe and clinically effective treatment for superficial venous reflux. J Vasc Surg 2010; 52(4): 939–945.

60.

Davis

Phillips

Kolluri

. Use of polidocanol endovenous microfoam to improve hemodynamics and symptomology in patients with challenging clinical presentations: a case series. Ann Vasc Surg 2018; 52: 176–182.

61.

Shadid

Nelemans

Lawson

, et al. Predictors of recurrence of great saphenous vein reflux following treatment with ultrasound-guided foamsclerotherapy. Phlebology 2015; 30(3): 194–199.

62.

Steyaert

De Letter

Lanckneus

, et al. Endovenous laser ablation of the great saphenous vein with a 1470 nm wavelength laser: results of a prospective, single centre cohort study other outcome. Acta Chirurgica Belgica 2014; 114(4): 256–260.

63.

Chait

Kibrik

Alsheekh

, et al. Radiofrequency ablation increases the incidence of endothermal heat-induced thrombosis. Ann Vasc Surg 2020; 62: 263–267.

64.

Corcos

Aloi

Garavello

, et al. Postoperative varicose recurrence at the junctions. A multicentric study of 1056 patients by the Italian society of phlebolymphology. conclusive considerations. Acta Phlebologica 2014; 15(2): 69–78.

65.

Gibson

Minjarez

Rinehardt

, et al. Frequency and severity of hypersensitivity reactions in patients after venaseal^™ cyanoacrylate treatment of superficial venous insufficiency. Phlebology 2020; 35(5): 337–344.

66.

Jagtman

Tazelaar

De Leeuw

. Compression sclerotherapy of anterolateral thigh primary varicose veins (lateral accessory saphenous varicose veins): a prospective five-year follow-up study. Phlebology 2003; 18(2): 65–69.

67.

Rasmussen

Bjoern

Lawaetz

, et al. Randomised clinical trial comparing endovenous laser ablation with stripping of the great saphenous vein: clinical outcome and recurrence after 2 years. Eur J Vasc Endovascular Surg 2010; 39(5): 630–635.

68.

Rass

Daschzeren

Gräber

, et al. Construction and evaluation of a multidimensional score to assess varicose vein severity—the homburg varicose vein severity score (HVVSS). Eur J Dermatol 2011; 21(4): 577–584.

69.

Sermsathanasawadi

Pitaksantayothin

Puangpunngam

, et al. Incidence, risk factors, progression, and treatment of endovenous heat-induced thrombosis class 2 or greater after endovenous radiofrequency ablation. Dermatol Surg 2019; 45(4): 573–580.

70.

Sufian

Arnez

Labropoulos

, et al. Endovenous heat-induced thrombosis after ablation with 1470nm laser: Incidence, progression, and risk factors. Phlebology2015; 30(5): 325–330.

71.

Winokur

Khilnani

Min

. Recurrence patterns after endovenous laser treatment of saphenous vein reflux. Phlebology 2016; 31(7): 496–500.

72.

MacKenzie

Cassar

Brittenden

, et al. Introducing endovenous laser therapy ablation to a national health service vascular surgical unit—the aberdeen experience. Eur J Vasc Endovasc Surg 2009; 38(2): 208–212.

73.

Theivacumar

Darwood

Gough

. Endovenous laser ablation (EVLA) of the anterior accessory great saphenous vein (AAGSV): abolition of sapheno-femoral reflux with preservation of the great saphenous vein. Eur J Vasc Endovasc Surg 2009; 37(4): 477–481.

74.

Timperman

. Prospective evaluation of higher energy great saphenous vein endovenous laser treatment. J Vasc Interv Radiol 2005; 16(6): 791–794.

75.

Cavallini

Marcer

Ferrari Ruffino

. Endovenous ablation of incompetent saphenous veins with a new 1,540-nanometer diode laser and ball-tipped fiber. Ann Vasc Surg 2014; 28(3): 686–694.

76.

Cavallini

Marcer

Ruffino

. Endovenous treatment of incompetent anterior accessory saphenous veins with a 1540 nm diode laser. Int Angiol 2015; 34(3): 243–249.

77.

Chaar

CIO

Hirsch

Cwenar

, et al. Expanding the role of endovenous laser therapy: results in large diameter saphenous, small saphenous, and anterior accessory veins. Ann Vasc Surg 2011; 25(5): 656–661.

78.

Bauzá Moreno

Dotta

Katsini

, et al. Endovascular radiofrequency ablation. Effect on the vein diameter using the ClosureFast(^®) catheter. Cir Esp 2016; 94(6): 353–357.

79.

Aurshina

Alsheekh

Kibrik

, et al. Recanalization after endovenous thermal ablation. Ann Vasc Surg 2018; 52: 158–162.

80.

Aurshina

Ascher

Victory

, et al. Clinical correlation of success and acute thrombotic complications of lower extremity endovenous thermal ablation. J Vasc Surg Venous Lymphatic Disord 2018; 6(1): 25–30.

81.

Erben

Vasquez

, et al. A multi-institutional review of endovenous thermal ablation of the saphenous vein finds male sex and use of anticoagulation are predictors of long-term failure. Phlebology 2020; 36(4): 283–289.

82.

Yang

Parapini

Gagnon

, et al. Comparison of cyanoacrylate embolization and radiofrequency ablation for the treatment of varicose veins. Phlebology 2019; 34(4): 278–283.

83.

Gibson

Minjarez

Gunderson

, et al. Need for adjunctive procedures following cyanoacrylate closure of incompetent great, small and accessory saphenous veins without the use of postprocedure compression: three-month data from a postmarket evaluation of the venaseal system (the WAVES Study). Phlebology 2019; 34(4): 231–237.

84.

Weaver

. Audit of the efficacy and complications of cyanoacrylate glue embolisation to treat varicose veins in primary care. J Primary Health Care 2019; 11(3): 249–258.

85.

de Roos

Nieman

Neumann

. Ambulatory phlebectomy versus compression sclerotherapy: results of a randomized controlled trial. Dermatol Surg 2003; 29(3): 221–226.

86.

Krnić

. Ultrasound guided foam sclerotherapy—the simplest, least invasive and cheapest method for varicose vein treatment. Acta Clinica Croatica 2015; 54(2): 136–142.

87.

Maldonado-Fernández

Linares-Palomino

López-Espada

, et al. Clinical results of a new strategy (modified CHIVA) for surgical treatment of anterior accessory great saphenous varicose veins. Cirugia Espanola 2016; 94(3): 144–150.

88.

Fligelstone

Carolan

Pugh

, et al. An assessment of the long saphenous vein for potential use as a vascular conduit after varicose vein surgery. J Vasc Surg 1993; 18(5): 836–840.

89.

Kabnick

. Outcome of different endovenous laser wavelengths for great saphenous vein ablation. J Vasc Surg 2006; 43(1): 88–93.

90.

Proebstle

Moehler

Gül

, et al. Endovenous treatment of the great saphenous vein using a 1,320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Dermatol Surg 2005; 31(12): 1678–1683.

91.

Geier

Stücker

Hummel

, et al. Residual stumps associated with inguinal varicose vein recurrences: a multicenter study. Eur J Vasc Endovasc Surg 2008; 36(2): 207–210.

92.

Escribano

Juan

Bofill

, et al. Durability of reflux-elimination by a minimal invasive CHIVA procedure on patients with varicose veins. A 3-year prospective case study. Eur J Vasc Endovasc Surg 2003; 25(2): 159–163.

93.

Nugroho

Wardhana

Ghea

. Mechanical occlusion chemically assisted ablation (MOCA) for saphenous vein insufficiency: a meta-analysis of a randomized trial. Int J Vasc Med 2020; 29(1): 20208758905.

94.

Roopram

Lind

Van Brussel

, et al. Endovenous laser ablation versus conventional surgery in the treatment of small saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord 2013; 1(4): 357–363.

95.

Vos

Ünlü

Bosma

, et al. A systematic review and meta-analysis of two novel techniques of nonthermal endovenous ablation of the great saphenous vein. J Vasc Surg Venous Lymphat Disord 2017; 5(6): 880–896.

96.

Ouvry

Allaert

Desnos

, et al. Efficacy of polidocanol foam versus liquid in sclerotherapy of the great saphenous vein: a multicentre randomised controlled trial with a 2-year follow-up. Eur J Vasc Endovasc Surg 2008; 36(3): 366–370.