Endovenous microwave ablation versus high ligation and stripping for the treatment of small saphenous vein incompetence. A single center retrospective study

Abstract

Background

The objective of this study was to compare the efficacy and safety of endovenous microwave ablation (EMA) and high ligation and stripping (HLS) for the treatment of small saphenous vein insufficiency..

Methods

This single-center retrospective study consecutively enrolled patients with small saphenous vein insufficiency who underwent either endovenous microwave ablation (EMA) or high ligation and stripping (HLS). Clinical severity was assessed using the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification and the Venous Clinical Severity Score (VCSS). Quality of life was evaluated using the Aberdeen Varicose Vein Questionnaire (AVVQ) and the Chronic Venous Insufficiency Questionnaire-14 (CIVIQ-14). Perioperative complications and vein closure rates were recorded. The primary outcome was technical and anatomical vein closure at 6 and 12 months postoperatively. Secondary outcomes included operative time, postoperative complications, symptom improvement, and quality-of-life changes. Propensity score matching was performed to minimize baseline confounding between groups.The objective of this study was to compare the efficacy and safety of endovenous microwave ablation (EMA) and high ligation and stripping (HLS) for the treatment of small saphenous vein insufficiency.

Results

Following propensity score matching (PSM), the baseline characteristics between the two groups were comparable. EMA demonstrated a significantly shorter operative time compared to HLS (p < 0.001). Improvements in both symptoms and clinical severity scores were significantly greater and occurred more rapidly in the EMA group (p < 0.01). Regarding postoperative complications, the incidence rates of paresthesia and numbness were significantly lower in the EMA group compared to the HLS group (p < 0.05). However, improvements in health-related quality of life and 12-months safety indicators showed no significant differences between the two groups (p > 0.05).

Conclusion

The study findings confirm that endovenous microwave ablation (EMA) significantly improves quality of life in patients with small saphenous vein (SSV) insufficiency. Compared to high ligation and stripping (HLS), EMA demonstrates superior minimally invasive characteristics, facilitates faster recovery, and provides better symptom relief within the first year post-procedure. Furthermore, its long-term safety profile is non-inferior to HLS, collectively resulting in higher patient satisfaction.

Keywords

small saphenous vein varicosities high ligation and stripping (HLS)endovenous microwave ablation (EMA)propensity score matching controlled clinical study

Introduction

Lower extremity venous varicosities (LEVV) represent a prevalent manifestation of chronic venous insufficiency (CVI). The underlying pathological basis is dysfunction of venous valve closure¹ Epidemiological data indicate that approximately half of the adult population experiences mild venous insufficiency, with typical varicose veins observed in about 15% of men and 35% of women.^2,3 The clinical features of this condition are significant; patients commonly report sensory symptoms such as lower limb pain, burning sensations, and pruritus, frequently accompanied by heaviness and nocturnal muscle cramps.⁴ From an anatomical distribution perspective, the great saphenous vein (GSV) is the primary site involved in superficial venous insufficiency of the lower extremities. Notably, primary small saphenous vein (SSV) insufficiency is observed to play an independent pathogenic role in approximately 20% of cases.⁵ The saphenopopliteal junction (SPJ) is typically located 1-2 cm proximal to the popliteal skin crease, visualized in approximately 83% of anatomical dissections, with only 62% exhibiting a normal termination pattern. A common trunk variation with the medial gastrocnemius vein is present in about 25% of cases. The SSV is accompanied along its distal course by the sural nerve. Furthermore, anatomical variations in the SPJ region – including its location, drainage pattern, and common trunk formations – render surgical treatment of the SSV significantly more complex compared to the GSV.^6,7 Therefore, accurate diagnosis and management of the SSV are crucial for symptom relief.

Regarding treatment modalities, the traditional high ligation and stripping (HLS) procedure, recognized for its definitive efficacy and technical simplicity, remains a fundamental surgical approach for CVI. Currently, the application of minimally invasive endovenous techniques, such as ultrasound-guided foam sclerotherapy (UGFS), thermal ablation (including radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and endovenous microwave ablation (EMA)), and non-thermal ablation (such as mechanochemical ablation (MOCA) and cyanoacrylate closure), provides options for enhanced precision and reduced invasiveness in the treatment of lower extremity venous disorders.^8,9 Compared to the robust evidence base available for GSV interventions, comparative studies evaluating different treatment modalities for SSV remain relatively scarce. Notably, the European Society for Vascular Surgery (ESVS) guidelines identify EMA as one of the effective treatment options for varicose veins.¹⁰ Therefore, this single-center retrospective cohort study aimed to compare endovenous microwave ablation (EMA) with high ligation and stripping (HLS) for the treatment of small saphenous vein incompetence, with a focus on procedural efficacy, perioperative safety, and health-related quality-of-life outcomes.

Materials and Methods

Data collection

This single-center retrospective cohort study (conducted in accordance with the STROBE statement) was carried out in the Department of Vascular Surgery, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine between January 2020 and January 2024. The study protocol received approval from the Institutional Ethics Committee (Approval No.: 2024KL-249). Consecutive screening of all patients diagnosed with primary small saphenous vein (SSV) varicosities (CEAP clinical class C2-C6) undergoing intervention was performed via the hospital electronic medical record (EMR) system.

Inclusion Criteria:1.Age between 18 and 90 years. 2.Presence of at least one venous-related symptom (e.g., pain, swelling, skin changes). 3.Ultrasound confirmation of:Small saphenous vein (SSV) trunk diameter >4 mm, and SPJ reflux duration >0.5 s 4.Patent deep venous system (peak flow velocity >30 cm/s). 5.Signed informed consent obtained and completed follow-up.

Exclusion Criteria:1.History of concurrent or prior deep vein thrombosis (DVT) or pulmonary embolism (PE). 2.Patients with recurrent varicose veins. 3.Critical limb ischemia (ankle-brachial pressure index, ABPI <0.8). 4.Carriers of cardiac implantable electronic devices (e.g., pacemakers, implantable cardioverter-defibrillators (ICDs)). 5.Chronic anticoagulation therapy (e.g., warfarin, rivaroxaban). 6.Pregnant or lactating women. 7.Inability to comply with follow-up or questionnaire assessments. 8.Life expectancy <1 year (due to advanced malignancy or end-stage organ failure). 9.Active non-melanoma skin cancer or other malignancy requiring ongoing active treatment.

A total of 452 patients were initially enrolled, allocated to the endovenous microwave ablation group (EMA, n = 150) and the conventional high ligation with stripping group (HLS, n = 302). After propensity score matching (PSM), 134 patients were retained in each treatment cohort (EMA: n = 134; HLS: n = 134). All source data underwent blinded independent review via the Picture Archiving and Communication System (PACS) to ensure standardized extraction of imaging parameters.

Procedures

All interventions were performed under ultrasound guidance in accordance with the European Society for Vascular Surgery (ESVS) guidelines for venous treatment.¹⁰ Preoperative duplex ultrasound mapping was performed to delineate the small saphenous vein anatomy, identify reflux sources, and plan the intervention.¹¹

EMA Procedure:Under real-time duplex ultrasound guidance, venous access was obtained by percutaneous puncture of the SSV trunk at the mid-to-upper calf, approximately 10–15 cm distal to the popliteal crease, selecting a straight and superficial segment while avoiding major perforators and adjacent nerves.After adequate local anesthesia, a microwave ablation catheter^12,13 (Model: ECO-100F-2016, Φ2.0 × 1600 mm; Nanjing Yigao Medical Technology) was inserted via Seldinger technique at 2 cm distal to the SPJ. Tumescent anesthesia solution (500 mL normal saline +15 mL 1% lidocaine +0.5 mL epinephrine +10 mL sodium bicarbonate) was infused to establish a 10 mm perivenous fluid barrier, Tumescent volume was limited to one bottle per unilateral case and two bottles per bilateral case. Ablation was performed at 55W power in 5-s cycles using a stepwise pullback technique at 1 cm increments to achieve SSV trunk closure. Proximal 2 cm segments underwent two additional ablation cycles. Immediate post-procedural ultrasound confirmed complete luminal occlusion (absence of Doppler flow signals).

HLS Procedure:Following satisfactory anesthesia, a 1 cm longitudinal incision was made ∼2 cm inferior to the popliteal crease along the ultrasound-mapped SSV course. The SSV trunk was isolated and exposed. High ligation was performed with proximal double ligation. A stripping device was then inserted retrogradely through the distal end and advanced to the mid-calf ultrasound marker. The distal vessel was divided via a 5 mm stab incision, and the stripping device was exteriorized proximally for complete stripping of the proximal/mid SSV segment. Focused compression was applied along the venous pathway for hemostasis control.

Common Procedures:Both groups underwent intraoperative foam sclerotherapy for residual tributaries using polidocanol.¹⁴ The foam was prepared via the Tessari method (1% solution, 1:4 liquid:air ratio), with 1 mL injected per puncture site. The maximum foam volume per limb was capped at 8 mL.¹⁰ This was combined with mini-phlebectomy through ≤3 mm stab incisions.Postoperative protocol included:Postoperatively, patients received prophylactic-dose low-molecular-weight heparin by immediate subcutaneous injection. Compression bandaging was applied for the first 48 h, followed by the use of Class II medical compression stockings (23–32 mmHg), which were worn continuously for 4 weeks.^15–17

Quality Control: Ultrasound verification confirmed complete closure of the SSV trunk (impedance value >500 Ω for the ablation group; no residual lumen for the HLS group). All operators possessed >1,000 cases of experience with the same type of procedures. Standardized equipment was used (microwave generator: ECO-100C, frequency 2450 MHz, effective thermal field 15 mm).

Follow-up and outcome measures

Patients were followed regularly for 12 months after treatment. Follow-up evaluations were scheduled immediately postoperatively, at 48 h, and at 1, 3, 6, and 12 months. At each time point, duplex ultrasound examinations and clinical assessments were performed. For patients unable to attend in-person visits, follow-up data were obtained through telephone or online communication. These patients were instructed to undergo duplex ultrasound examinations at local hospitals, and the imaging reports were subsequently collected and reviewed by the study team.

Primary Outcome Measures Assessment: complete occlusion required closure of the entire treated target vein without discrete open segments exceeding 5 cm in length; occlusion failure was defined if the cumulative length of non-closed venous segments was >3 cm (whether a single segment or multiple segments).^18,19 All assessments were performed by certified vascular surgeons under double-blinded conditions to ensure objectivity.

Secondary outcomes included systematically recorded postoperative complications according to the International Union of Phlebology (UIP) criteria,²⁰ clinical severity assessed using the Venous Clinical Severity Score (VCSS), and health-related quality of life measured using the Aberdeen Varicose Vein Questionnaire (AVVQ)²¹ and the Chronic Venous Insufficiency Questionnaire-14 (CIVIQ-14),the CIVIQ-14 score is expressed as the global index score (GIS), calculated as (total score −14)/56 × 100.^22,23

All assessment timepoints were synchronized with the primary outcome evaluations (postoperative 48 h, 1, 3, 6, and 12 months), with data collection performed under blinded conditions by trained (e.g., Mann–Whitney U test) were applied otherwise. Normally distributed quantitative data are expressed as mean ± standard deviation; non-normally distributed data are described as median (interquartile range). Categorical variables were compared between groups using the chi-square test. A p value ≤0.05 was considered statistically significant.

Results

1. Baseline data

After propensity score matching,, 268 patients were enrolled (134 each in the EMA and HLS groups). Baseline characteristics were comparable between groups, with no significant differences in demographic data (age, height, BMI), disease characteristics (disease duration, comorbidities, CEAP classification), or preoperative scores (median AVVQ, CIVIQ-14, and VCSS) (all p > 0.05) (Table 1).

Table 1.

Baseline data of the study participants in both procedures.

	Before PSM				After PSM
	Total (n = 452)	EMA (n = 150)	HLS (n = 302)	p	Total (n = 268)	EMA (n = 134)<	HLS (n = 134)	p
Age	57.83 ± 12.84	56.20 ± 13.27	58.64 ± 12.56	0.057	57.78 ± 12.94	57.61 ± 12.79	57.96 ± 13.14	0.829
Height	163.28 ± 7.57	163.71 ± 7.31	163.07 ± 7.71	0.400	163.20 ± 7.66	163.30 ± 7.06	163.10 ± 8.23	0.833
BMI	23.42 ± 3.28	22.61 ± 3.36	23.83 ± 3.17	<.001	22.79 ± 3.07	22.83 ± 3.28	22.75 ± 2.87	0.824
Duration	10.95 ± 9.46	10.78 ± 9.33	11.03 ± 9.54	0.791	10.78 ± 9.21	10.87 ± 9.49	10.69 ± 8.96	0.872
CIVIQ14	28.00 (23.00, 38.25)	28.50 (23.00, 41.00)	28.00 (23.00, 36.00)	0.162	28.00 (23.00, 39.00)	28.00 (23.00, 40.00)	28.00 (23.00, 38.50)	0.891
AVVQ	14.00 (9.00, 17.00)	13.50 (9.00, 17.75)<	14.00 (9.00, 17.00)	0.424	14.00 (9.00, 17.25)	14.00 (9.00, 18.00)	14.00 (9.00, 17.00)	0.608
VCSS	11.00 (7.00, 15.00)	10.00 (6.00, 14.00)	11.00 (7.25, 15.00)	0.023	11.00 (6.00, 15.00)	11.00 (6.00, 15.00)	11.00 (7.00, 16.00)	0.436
Gender
Male	234 (51.77)	73 (48.67)	161 (53.31)	0.352	139 (51.87)	67 (50.00)	72 (53.73)	0.541
Famale	218 (48.23)	77 (51.33)	141 (46.69)		129 (48.13)	67 (50.00)	62 (46.27)
Hypertension	48 (10.62)	15 (10.00)	33 (10.93)	0.763	25 (9.33)	12 (8.96)	13 (9.70)	0.834
Diabetes	51 (11.28)	15 (10.00)	36 (11.92)	0.543	26 (9.7)	14 (10.45)	12 (8.96)	0.680
CHD	26 (5.75)	8 (5.33)	18 (5.96)	0.788	17 (6.34)	8 (5.97)	9 (6.72)	0.802
SVT	23 (5.09)	4 (2.67)	19 (6.29)	0.099	11 (4.1)	4 (2.99)	7 (5.22)	0.356
CEAP
2	153 (33.85)	61 (40.67)	92 (30.46)	0.042	499 (36.94)	52 (38.81)	47 (35.07)	0.467
3	88 (19.47)	29 (19.33)	59 (19.54)		50 (18.66)	27 (20.15)	23 (17.16)
4	127 (28.1)	41 (27.33)	86 (28.48)		76 (28.36)	39 (29.10)	37 (27.61)
5	62 (13.72)	11 (7.33)	51 (16.89)		31 (11.57)	11 (8.21)	20 (14.93)
6	22 (4.87)	8 (5.33)	14 (4.64)		12 (4.48)	5 (3.73)	7 (5.22)
Limb location
Bilateral	46 (10.18)	19 (12.67)	27 (8.94)	0.217	30 (11.19)	16 (11.94)	14 (10.45)	0.698
Unilateral	406 (89.82)	131 (87.33)	275 (91.06)	0.217	238 (88.81)	118 (88.06)	120 (89.55)	0.698

2. Primary endpoint: Vein closure rate

At 6 months, the overall SSV closure rate was 97.76% (262/268). The closure rate was 97.01% (130/134) in the EMA group and 98.51% (132/134) in the HLS group, with no significant differences between groups ( = 0.680). At 12 months, the overall closure rate was 96.27% (258/268). The closure rates were 95.52% (128/134) in the EMA group and 97.01% (130/134) in the HLS group, respectively, with no significant intergroup difference (p = 0.519) (Table 2).

Table 2.

Vein closure rates at 6 and 12 months postoperatively.

Variables	Total (n = 268)	EMA (n = 134)	HLS (n = 134)	p
M6recurrence, n (%)
0	262 (97.76)	130 (97.01)	132 (98.51)	0.680
1	6 (2.24)	4 (2.99)	2 (1.49)
M12recurrence, n (%)
0	258 (96.27)	128 (95.52)	130 (97.01)	0.519
1	10 (3.73)	6 (4.48)	4 (2.99)

3. Perioperative Outcomes

The EMA group demonstrated a significantly shorter operative time than the HLS group (36 [29–43] min vs 45 [39–52] min, p < 0.01).On postoperative day 2, the absolute incidence rates of all complications were lower in the EMA group than in the HLS group, including deep vein thrombosis (0 vs 3 cases, 2.24%), superficial phlebitis (2.24% vs 5.97%), and ecchymosis (11.94% vs 15.67%). The incidences of paresthesia and pain were significantly lower in the EMA group compared with the HLS group (3.73% vs 11.19%, P = 0.020; 6.72% vs 14.93%, p = 0.031, respectively) (Table 3).

Table 3.

Procedure-related parameters and postoperative day 2 complications in EMA and HLS groups.

	Total (n = 268)	EMA (n = 134)	HLS (n = 134)	p
Surgicaltime	40.50 (32.00, 50.00)	36.00 (29.00, 43.00)	45.00 (39.00, 52.00)	<.001
dvt	3 (1.12)	0 (0.00)	3 (2.24)	0.246
Phlebitis	11 (4.10)	3 (2.24)	8 (5.97)	0.124
Ecchymosis	37 (13.81)	16 (11.94)	21 (15.67)	0.376
Induration	20 (7.46)	9 (6.72)	11 (8.21)	0.642
Paresthesia	20 (7.46)	5 (3.73)	15 (11.19)	0.020
Pain	29 (10.82)	9 (6.72)	20 (14.93)	0.031
Edema	29 (10.82)	11 (8.21)	18 (13.43)	0.169
Hyperpigmentation	14 (5.22)	6 (4.48)	8 (5.97)	0.583

4. Symptom and quality of life follow-up

During the 12-months follow-up, AVVQ, CIVIQ-14, and VCSS scores decreased significantly from baseline in both groups (all p < 0.01). AVVQ scores declined from baseline in both groups, and were lower in the EMA group than in the HLS group from 1 month postoperatively (7.51 ± 0.33 vs 10.06 ± 0.40, p < 0.001), with the difference maintained at 3 months (4.03 ± 0.16 vs 4.81 ± 0.16, P < 0.001). CIVIQ-14 scores decreased from approximately 31 at baseline to approximately 15 in both groups. At 1 and 3 months, scores were lower in the EMA group than in the HLS group (19.34 ± 0.28 vs 20.99 ± 0.34, p < 0.001; 16.47 ± 0.15 vs 17.42 ± 0.16, p < 0.001). For VCSS, scores in the EMA group were lower than those in the HLS group from 1 month postoperatively (6.57 ± 0.29 vs 8.24 ± 0.38, p < 0.001), and this difference persisted at 3 months (3.16 ± 0.13 vs 3.91 ± 0.15, p < 0.001). No significant between-group differences were observed between 6 and 12 months (Table 4). (Figure 1).

Table 4.

The comparison of AVVQ,CIVIQ-14 and VCSS scores between the two groups.

Questionnaire/Time-point	EMA	HLS	p
AVVQ
Baseline	13.03 ± 0.50	13.63 ± 0.49	0.395
1 month	7.51 ± 0.33	10.06 ± 0.40	<0.001
3 months	4.03 ± 0.16	4.81 ± 0.16	<0.001
6 months	2.01 ± 0.09	2.31 ± 0.09	0.022
12 months	1.63 ± 0.09	1.83 ± 0.08	0.095
CIVIQ-14
Baseline	31.51 ± 0.97	31.31 ± 0.95	0.882
1 month	19.34 ± 0.28	20.99 ± 0.34	<0.001
3 months	16.47 ± 0.15	17.42 ± 0.16	<0.001
6 months	15.15 ± 0.09	15.44 ± 0.10	0.033
12 months	14.77 ± 0.08	14.80 ± 0.07	0.778
VCSS
Baseline	10.75 ± 0.43	11.25 ± 0.45	0.424
1 month	6.57 ± 0.29	8.24 ± 0.38	<0.001
3 months	3.16 ± 0.13	3.91 ± 0.15	<0.001
6 months	1.81 ± 0.09	1.87 ± 0.09	0.628
12 months	1.37 ± 0.08	1.46 ± 0.08	0.404

Values are mean ± standard error (SEM); p values from two-tailed independent-sample t tests; lower scores indicate milder symptoms or better quality of life.

Figure 1.

Follow-up changes in quality of life and clinical severity after percutaneous microwave ablation (EMA, blue) versus high ligation and stripping (HLS, red). (a) Aberdeen Varicose Vein Questionnaire (AVVQ) total score; (b) Chronic Venous Insufficiency Questionnaire-14 (CIVIQ-14) total score; (c) Venous Clinical Severity Score (VCSS).

Discussion

This study compared EMA with HLS for the treatment of small SSV insufficiency.The principal findings of this study indicate that EMA achieved comparable 6 and 12 months vein closure rates to HLS, was associated with a shorter operative time and lower early postoperative complication rates, and that both techniques resulted in significant improvements in symptom severity and quality of life during follow-up.

In terms of the primary endpoint, SSV closure rates at 6 and 12 months were high in both groups, with no significant differences between EMA and HLS. These findings suggest that EMA provides mid-term anatomical success comparable to conventional surgery. The closure rates observed in this study are consistent with previously reported outcomes for different treatment modalities in SSV disease.²⁴ For instance,a multicenter randomized trial comparing UGFS with EVLA in isolated SSV insufficiency reported similar clinical and anatomical outcomes.²⁵ Similarly, A randomized controlled trial comparing EVLA with conventional surgery showed that the complete elimination rate of SSV reflux was 96.2% in the EVLA group versus 71.7% in the conventional surgery group at 6 weeks.²⁶

With regard to nerve-related complications, the sural nerve runs in close proximity to the SSV, making it vulnerable to procedural injury. In the present study, the incidence of paresthesia was significantly lower in the EMA group compared with the HLS group, suggesting a reduced risk of nerve irritation or injury. In addition, postoperative pain was also significantly lower in the EMA group, further supporting its minimally invasive nature. These findings indicate that EMA may offer advantages in terms of early postoperative recovery and nerve-related outcomes.

In terms of symptom relief and quality of life, AVVQ, CIVIQ-14, and VCSS scores declined significantly in both groups during follow-up, reflecting marked clinical improvement. During the early postoperative period (1–3 months), scores on all three scales were lower in the EMA group than in the HLS group, indicating a faster improvement in symptoms and clinical severity with EMA. However, no significant between-group differences were observed at later follow-up time points.^19,25 These results suggest that although EMA may facilitate more rapid early recovery, both treatments achieve comparable long-term improvements in overall health-related quality of life.

Both groups showed marked reductions in AVVQ, CIVIQ-14, and VCSS scores during follow-up, indicating substantial clinical improvement. Notably, AVVQ and VCSS scores were lower in the EMA group during early follow-up, suggesting a more rapid alleviation of symptoms and clinical severity. However, long-term health-related quality of life, as measured by CIVIQ-14, did not differ significantly between groups at later follow-up stages. These findings indicate that although EMA may offer faster symptomatic recovery, the long-term overall quality-of-life outcomes are comparable between the two treatment modalities.^8,27,28

The potential advantages of EMA may be attributed to its mechanism of action. Microwave energy induces controlled thermal injury to the venous wall, leading to collagen contraction and irreversible occlusion while minimizing collateral tissue damage when performed under adequate tumescent protection. Standardized power settings and stepwise pullback techniques allow consistent energy delivery along the treated segment, contributing to reliable vein closure.

Advantages and limitations

This study utilized propensity score matching with standardized mean difference testing to confirm balance across baseline variables, thereby partially controlling for confounders and enhancing internal validity in intergroup comparisons. Simultaneously reporting patient-reported outcomes across three dimensions—VCSS, AVVQ, and CIVIQ-14—strengthens clinical interpretability. Limitations include: the single-center retrospective design may retain unmeasured confounders (e.g., venous diameter, operator experience); 12-months follow-up is insufficient to assess long-term recanalization and valve function recovery; exclusion of cost-benefit analyses and cosmetic appraisal; post hoc sample size estimation may lack power to detect differences in rare complications (Figure 2).

Figure 2.

Flow chart.

Conclusion

EMA represents an effective minimally invasive treatment option for SSV. In summary, EMA demonstrates superiority over conventional HLS in terms of symptom relief speed, operative time, and complication profile, while being not inferior to HLS in long-term health-related quality of life and safety.

Footnotes

Acknowledgements

We thank our colleagues from Vascular Surgery for their insightful discussions. Special thanks are due to Wei Zeng and Chun-shui He for their critical reading of the manuscript.

ORCID iDs

Yu-qian Xie

Li-feng Zhang

Yao Lin

Yu Xie

Chun-shui He

Ethical considerations

This study has been approved by the ethics committee of Hospital of ChengduUniversity of Traditional Chinese Medicine (Approval No. 2024KL-149).

Author contribution

Yao Lin and Li-feng Zhang contributed to the study conception and design. Material preparation and data collection were performed by Yu-qian Xie. Analysis was performed by Yu-qian Xie. The first draft of the manuscript was written by Yu-qian Xie and all authors commented on previous versions. All authors read and approved the final manuscript.

Funding

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

Declaration of conflicting interests

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

Guarantor

Wei Zeng and Chun-shui He are the guarantor for this work.

References

Tauraginskii

Lurie

Agalarov

, et al. Blood flow from competent tributaries is likely contributor to distally increasing reflux volume in incompetent great saphenous vein. J Vasc Surg Venous Lymphat Disord 2022; 10(1): 69–74. https://doi.org/10.1016/j.jvsv.2021.04.010

Healy

Kimura

Power

, et al. A systematic review and meta-analysis of thrombotic events following endovenous thermal ablation of the great saphenous vein. Eur J Vasc Endovasc Surg 2018; 56(3): 410–424. https://doi.org/10.1016/j.ejvs.2018.05.008

Kemp

Obi

Henke

, et al. A narrative review on the epidemiology, prevention, and treatment of venous thromboembolic events in the context of chronic venous disease. J Vasc Surg Venous Lymphat Disord 2021; 9(6): 1557–1567. https://doi.org/10.1016/j.jvsv.2021.03.018

Wittens

Davies

Bækgaard

, et al. Editor's choice - Management of chronic venous disease: clinical practice guidelines of the European society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49(6): 678–737. https://doi.org/10.1016/j.ejvs.2015.02.007

Maurins

Hoffmann

Lösch

, et al. Distribution and prevalence of reflux in the superficial and deep venous system in the general population--results from the Bonn vein study, Germany. J Vasc Surg 2008; 48(3): 680–687. https://doi.org/10.1016/j.jvs.2008.04.029

Uhl

Gillot

. Anatomy and embryology of the small saphenous vein: nerve relationships and implications for treatment. Phlebology 2013; 28(1): 4–15. https://doi.org/10.1258/phleb.2012.012j08

O'Donnell

Jr. Iafrati

. The small saphenous vein and other 'neglected' veins of the popliteal fossa: a review. Phlebology 2007; 22(4): 148–155. https://doi.org/10.1258/026835507781477172

Huang

Zeng

Lin

, et al. Comparison of one-year outcomes and quality of life between endovenous microwave ablation and high ligation and stripping of the great saphenous vein. Phlebology 2024; 39(2): 108–113. https://doi.org/10.1177/02683555231214338

van den Bos

Arends

Kockaert

, et al. Endovenous therapies of lower extremity varicosities: a meta-analysis. J Vasc Surg 2009; 49(1): 230–239. https://doi.org/10.1016/j.jvs.2008.06.030

10.

De Maeseneer

Kakkos

Aherne

, et al. Editor's choice - European society for vascular surgery (ESVS) 2022 clinical practice guidelines on the management of chronic venous disease of the lower limbs. Eur J Vasc Endovasc Surg 2022; 63(2): 184–267. https://doi.org/10.1016/j.ejvs.2021.12.024

11.

Gloviczki

Lawrence

Wasan

, et al. The 2022 society for vascular surgery, American venous forum, and American vein and lymphatic society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. duplex scanning and treatment of superficial truncal reflux: endorsed by the society for vascular medicine and the international union of phlebology. J Vasc Surg Venous Lymphat Disord 2023; 11(2): 231–261. https://doi.org/10.1016/j.jvsv.2022.09.004

12.

Fan

Cong

Dong

, et al. Comparison of 5-year outcomes and quality of life between endovenous laser (980 nm) and microwave ablation combined with high ligation for varicose veins. Front Surg 2022; 9: 1022439. https://doi.org/10.3389/fsurg.2022.1022439

13.

Yang

Bai

, et al. Endovenous microwave ablation versus radiofrequency ablation for the treatment of lower limb varicose veins. Ann Vasc Surg 2024; 98: 301–308. https://doi.org/10.1016/j.avsg.2023.06.024

14.

Ulloa

Comerota

Figueroa

, et al. Great saphenous vein occlusion rates after combined treatment with laser and foam sclerotherapy. J Vasc Surg Venous Lymphat Disord 2021; 9(6): 1437–1442. https://doi.org/10.1016/j.jvsv.2021.06.007

15.

Turner

BRH

Machin

Salih

, et al. An updated systematic review and meta-analysis of the impact of graduated compression stockings in addition to pharmacological thromboprophylaxis for prevention of venous thromboembolism in surgical inpatients. Ann Surg 2024; 279(1): 29–36. https://doi.org/10.1097/SLA.0000000000006096

16.

Tang

Jiang

Hong

, et al. Effect of short-term compression therapy after thermal ablation for varicose veins: study protocol for a prospective, multicenter, non-inferiority, randomized controlled trial. Trials 2023; 24(1): 669. https://doi.org/10.1186/s13063-023-07609-1

17.

Chwala

Szczeklik

, et al. Varicose veins of lower extremities, hemodynamics and treatment methods. Adv Clin Exp Med 2015; 24(1): 5–14. https://doi.org/10.17219/acem/31880

18.

Muller

Debus

Karsai

, et al. Technique and early results of endovenous laser ablation in morphologically complex varicose vein recurrence after small saphenous vein surgery. PLoS One 2024; 19(10): e0310182. https://doi.org/10.1371/journal.pone.0310182

19.

Belramman

Bootun

Tang

, et al. Pain outcomes following mechanochemical ablation vs cyanoacrylate adhesive for the treatment of primary truncal saphenous vein incompetence: the MOCCA randomized clinical trial. JAMA Surg 2022; 157(5): 395–404. https://doi.org/10.1001/jamasurg.2022.0298

20.

Vasquez

Rabe

McLafferty

, et al. Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American venous forum ad hoc outcomes working group. J Vasc Surg 2010; 52(5): 1387–1396. https://doi.org/10.1016/j.jvs.2010.06.161

21.

Smith

Garratt

Guest

, et al. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg 1999; 30(4): 710–719. https://doi.org/10.1016/s0741-5214(99)70110-2

22.

Le Moine

Fiestas-Navarrete

Katumba

, et al. Psychometric validation of the 14 items ChronIc venous insufficiency quality of life questionnaire (CIVIQ-14): confirmatory factor analysis. Eur J Vasc Endovasc Surg 2016; 51(2): 268–274. https://doi.org/10.1016/j.ejvs.2015.08.020

23.

Kuet

Lane

Anwar

, et al. Comparison of disease-specific quality of life tools in patients with chronic venous disease. Phlebology 2014; 29(10): 648–653. https://doi.org/10.1177/0268355513501302

24.

Oud

Tamana

Jamaludin

. Anatomical success of treatment modalities for small saphenous vein incompetence: a systematic review and network meta-analysis. Eur J Vasc Endovasc Surg 2025; 71: 135–145.

25.

Hamel-Desnos

Nyamekye

Chauzat

, et al. FOVELASS: a randomised trial of endovenous laser ablation versus polidocanol foam for small saphenous vein incompetence. Eur J Vasc Endovasc Surg 2023; 65(3): 415–423. https://doi.org/10.1016/j.ejvs.2022.11.021

26.

Samuel

Carradice

Wallace

, et al. Randomized clinical trial of endovenous laser ablation versus conventional surgery for small saphenous varicose veins. Ann Surg 2013; 257(3): 419–426. https://doi.org/10.1097/SLA.0b013e318275f4e4

27.

Mohamed

Howitt

Rae

, et al. Ten-year outcomes of a randomized clinical trial of endothermal ablation versus conventional surgery for great saphenous varicose veins. Br J Surg 2024; 111(8): znae195. https://doi.org/10.1093/bjs/znae195

28.

Nelzen

Skoog

Bernfort

, et al. Editor's choice - short term cost effectiveness of radiofrequency ablation and high ligation and stripping for great saphenous vein incompetence. Eur J Vasc Endovasc Surg 2024; 67(5): 811–817. https://doi.org/10.1016/j.ejvs.2024.01.085