ISRCTN99270116 (http://www.controlled-trials.com).

ED (J/cm) of laser delivery is the main determinant of successful GSV ablation following EVLA.

Background: Following above-knee (AK) great saphenous vein (GSV) endovenous laser ablation (EVLA) 40% to 50% patients have residual varicosities. This randomized controlled trial (RCT) assesses whether more extensive GSV ablation enhances their resolution and influences symptom improvement. Method: Sixty-eight limbs (65 patients) with varicosities and above and below-knee GSV reflux were randomized to Group A: AK-EVLA (n ‫؍‬ 23); Group B: EVLA mid-calf to groin (n ‫؍‬ 23); and Group C: AK-EVLA, concomitant below-knee GSV foam sclerotherapy (n ‫؍‬ 22). Primary outcomes were residual varicosities requiring sclerotherapy (6 weeks), improvement in Aberdeen varicose vein severity scores (AVVSS, 12 weeks), patient satisfaction, and complication rates. Results: EVLA ablated the treated GSV in all limbs. Sclerotherapy requirements were Group A: 14/23 (61%); Group B: 4/23 (17%); and Group C: 8/22 (36%); 2 ‫؍‬ 9.3 (2 df) P ‫؍‬ .01 with P A-B ‫؍‬ 0.006; P B-C ‫؍‬ 0.19; P A-C ‫؍‬ 0.14. AVVSS scores improved in all groups as follows: A: 14.8 (9.3-22.6) to 6.4 (3.2-9.1), (P < .001); B: 15.8 (10.2-24.5) to 2.5 (1.1-3.7), (P < .001); and C: 15.1 (9.0-23.1) to 4.1 (2.3-6.8), (P < .001) and P A-B ‫؍‬ 0.011, P A -C ‫؍‬ 0.042. Patient satisfaction was highest in Group B. BK-EVLA was not associated with saphenous nerve injury. Conclusions: Extended EVLA is safe, increases spontaneous resolution of varicosities, and has a greater impact on symptom reduction. Similar benefits occurred after concomitant BK-GSV foam sclerotherapy. ( J Vasc Surg 2008;48:173-8.)

Persistent non-refluxing GSV tributaries at the SFJ did not appear to have an adverse impact on clinical outcome 1 year after successful EVLA of the GSV.

These results show a non-significant increase in stroke rate in patients receiving heparin alone refuting suggestions that protamine is harmful. Conversely post-operative haematoma was more frequent when protamine was withheld but re-operation rates were no different. Thus protamine use appears safe and should remain a matter for individual surgeon preference.