Anatomic Success of Treatment Modalities for Small Saphenous Vein Incompetence: A Systematic Review and Network Meta-analysis

Objective: High quality comparative studies on treatments of the small saphenous vein (SSV) are lacking. Therefore, the primary aim of this study was to evaluate anatomic success across different SSV treatment modalities at short, mid, and long term follow up using a network meta-analysis (NMA) and pooled results from a meta-analysis. Data Sources: MEDLINE and Embase. Review Methods: Cohort studies (prospective and retrospective) and randomised controlled trials (RCTs) were included. Studies reported on the primary outcome of anatomic success (occlusion, absence of reflux) for all thermal, non-thermal, and surgical SSV treatment modalities. Secondary outcomes included complications, peri-procedural pain, time to return to daily activities or work, Venous Clinical Severity Score, and quality of life. Anatomic success was assessed at short term (up to and including three months), midterm (three months to one year), and long term (more than one year) follow up. A risk of bias and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evaluation were done. Results: Sixty eight articles were included (28 retrospective studies, 26 prospective studies, four RCTs, and nine studies of unknown design), comprising a total of 6 793 limbs at baseline. The NMA ranked endovenous laser ablation (EVLA) as superior treatment at short term follow up, and radiofrequency ablation (RFA) at midterm follow up. Data were insufficient to perform a NMA for long term outcomes. The meta-analysis reported the highest anatomic success rates for RFA at short term follow up (98.4%) and for EVLA at both mid and long term follow up (96.1% and 94.3%, respectively). Of the secondary outcomes, only major complications could be pooled. Deep venous thrombosis was found in 0.2% of all patients and nerve injury in 3.0%. Although risk of bias in the NMA was low, most network estimates were of low or very low GRADE quality. Conclusion: The limited number of high quality comparative studies on the SSV complicates ranking treatments based on anatomic success. However, RFA and EVLA showed the highest anatomic success.