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vascular professional | issue 02 · 2022

Recurrences via side branches in the SFJ area five years standard in Germany. However, the laser technology was
after EVLA occurred more frequently in the EVLA group still in its early days at the beginning of the study (data
(31%) than in the crossectomy and stripping (HL+S) collection started in 2004/2005) and was performed
group (17% neovascularizations) in Gauw et al. (4). with low wavelength lasers (810 nm Rass (15), 980 nm
In 2016, O`Donnell et al. performed a systematic Flessenkämper (3)) and barefiber use. The applied laser
meta-analysis of seven randomized trials (n=686) with the energy was very low in the study by Rass, and there was
aim of determining types of recurrence after endovenous frequent recanalization of the treated great saphenous
therapy. The minimum follow-up period was two years, vein (62% of DUS-detected junctional recurrences!). In
and the recurrence rate after EVLA was comparable to the the study by Flessenkämper, in which we ourselves were
recurrence rate after crossectomy and stripping (HL+S) involved (surgical and endovenous), the laser energy was
and was 22% (n=125). However, the type of recurrence higher, but the distance of the barefiber to the SFJ was
differed: after HL+S, neovascularization occurred in 18% clearly more than 2cm! The methodically very well per-
(n=22), whereas after EVLA, AASV insufficiency occurred formed studies by Flessenkämper and Rass thus show
in 19% (n=23) (13). that HL+S, realized at a very high level, has a low five-year
A meta-analysis by Hamann et al. from 2017 screened risk of SFJ recurrence of less than 10%. But the two stu-
3004 studies on crossectomy and stripping (HL+S) dies do not prove a failure of the endoluminal procedures,
versus endoluminal procedures (EVLA, RFA, and foam but have clearly shown that the laser power and laser
sclerotherapy), twelve of which could be used for the energy as well as the distance of the laser fiber to the SFJ
meta-analysis. The definition of surgical success in the and the nature of the laser fiber play an important role for
groups was „no reflux in the treated vein after five years the endoluminal result.
(anatomic success)“ and showed no significant difference A 2019 review analysis by Anwar et al. showed that
between HL+S compared with EVLA and RFA, and also no untreated side branches in the SFJ area are considered
significant difference in the incidence of SFJ recurrences the most common cause of recurrence after endovenous
detected by duplex ultrasound (DUS). A significant diffe- thermal ablation (between 8% and 32%) (1).
rence in efficiency was shown only when compared with All of the above mentioned studies refer to older ge-
foam sclerotherapy. What the meta-analysis did show, neration lasers with wavelengths of about 980 nm and
however, was that when sapheno-femoral recurrences barefibers.
did occur, they differed between HL+S and EVLA/RFA: Af- The first five-year data regarding the 1470-nm laser
ter HL+S, neoangiogenesis was more likely to develop in with radial probe and segmental RFA were published by
the SFJ area, whereas after EVLA/RFA, recurrence via the Lawson et al. 2018, with 97% (EVLA) and 96% (RFA)
AASV was most common (6). anatomic success. DUS-detected SFJ recurrence occurred
Another 2018 study by Wallace et al. showed ana- in 15% of cases via AASV at five years (n~171 per group)
tomic success at five years with EVLA of 93% and HL+S (10).
of 85% (n=140 per group). The number of recurrences in
the SFJ detected by DUS did not differ between HL+S and But how do the large differences of 8-32% SFJ
EVLA in this study, except that neoangiogenesis formed recurrences over previously sufficient side branches
in equal numbers (~15%) in HL+S and recurrence via the in the recent publications come about?
AASV in EVLA (18). Three possibilities come into consideration here:
Let us now take a look at the two major German stu- 1. Positioning of the EVLA fiber/RFA catheter: Positio-
dies on this topic: Flessenkämper et al. (3) and Rass ning of the laser fiber used to take place with the barefi-
et al. (15) from 2016 and 2015. Both studies concluded bers at least 2cm distal to the SFJ. If post-laser oblitera-
that HL+S produced significantly fewer DUS-detected tion of the proximal portion with flush closure of the SFJ
sapheno-femoral crosse recurrences than EVLA. It is im- area did not subsequently occur, a 1-2cm junction stump
portant to note in these studies that HL+S was perfor- remained. However, some side branches open in the
med by excellent surgeons from vein centers with many 1-2cm area of the SFJ (> fig. 1) (11).
years of experience. This is certainly not the general

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