Clinical trial of concomitant vs staged foam sclerotherapy of varicose veins following axial thermal ablation

OBJECTIVES: Endovenous laser ablation (EVLA) of the great saphenous vein may be combined with tributary vein treatment, either during the same session or in a staged manner with deferred foam sclerotherapy (FS) or miniphlebectomy. Despite recent multisociety guidelines favoring a concomitant approach, evidence supporting this recommendation remains limited, and the patient profiles best suited for each strategy are not well defined. This study aimed to compare clinical outcomes, quality of life, and patient-reported results after EVLA with simultaneous vs delayed FS, and to assess whether one strategy offers a clear advantage. METHODS: The study included 152 patients with Clinical Etiological Anatomical Pathophysiological classification C2 to C4 chronic venous disease, allocated to two groups. The concomitant group (CG; n =75) underwent EVLA with simultaneous FS of the tributary veins, and the staged group (SG; n = 77) received FS 3 months after EVLA only if necessary due to inadequate tributary vein regression. Treatment allocation followed a shared decision-making process after detailed patient counseling. Follow-up assessments were conducted at 7 days and 1, 3, and 6 months post EVLA, with analysis of tributary vein regression and procedural characteristics. RESULTS: Complete anatomical success of great saphenous vein ablation was achieved in all patients. After 6 months, the CG demonstrated greater improvement on the Chronic Venous Insufficiency Questionnaire. The revised Venous Clinical Severity score and Aberdeen Varicose Veins Questionnaire scores were comparable at 6 months of follow-up. At 3 months, the CG showed fewer and shorter incompetent tributary veins, although this difference was no longer observed at 6 months. Patient satisfaction was comparable between the groups. In the SG, 36 patients (46%) required no additional FS. When FS was necessary in patients in the SG, lower sclerosant volumes and concentrations were used, treated tributary segments were shorter, and the incidence of hyperpigmentation was significantly reduced. CONCLUSIONS: Deferring tributary vein treatment after EVLA limits the extent of intervention, reduces sclerosant use, and lowers the risk of hyperpigmentation. Both simultaneous and delayed treatment approaches result in favorable final outcomes and are associated with comparable levels of patient satisfaction. Simultaneous EVLA with FS may be offered to patients seeking rapid clinical improvement, whereas a delayed strategy is justified in those accepting longer treatment times to decrease sclerotherapy-related complications.