Commentary on ‘Predictors for Recanalization of the Great Saphenous Vein in RCTs 1 Year After Endovenous Thermal Ablation’: The Dark Side of Systematic Reviews

Abstract

Natura inest in mentibus nostris insatiabilis quaedam cupiditas very vivendi" (Cicero, Tusculanes,1, 19) "Nature has put in our minds an insatiable desire to know the truth"The paper by van der Velden et al., authors with extensive experience of chronic superficial venous insufficiency (CVI) therapy, published in this issue, is excellent. 1 Beyond congratulating the editors of EJVES for its publication, the world of venous publications gives us the opportunity to comment on systematic review papers.It is obvious that endovenous procedures have been introduced for treating varicose veins in order to reduce post-operative complications. Their main advantages are quicker recovery, fewer complications, and improvement in quality of life compared with conventional surgery. 2 As has been the rule, many physicians around the world have enthusiastically adopted those new methods. Nevertheless, as is clear in the paper by van der Velden et al., we do not know much about the prognostic factors for success. 1,3 Moreover, is there an appropriate patient for these technologies? Despite this obvious limited knowledge, almost all doctors, sometimes not specialists, have dared to manage these patients.The previous comments support the fact that this widespread use of endovascular procedures produces a huge variety of papers, probably to back their practice. Unfortunately, numerous papers are published, but papers with adequate methodology are few, as proven in many systematic reviews. 2,4,5 As previously mentioned, the majority of these reviews have favoured endovenous procedures; however, none of them gives information regarding how many patients are not appropriate for endovenous treatment.This lack of information introduces bias, as pooling effects are limited to long saphenous vein (LSV) outcome.The paper by van Der Velden et al. also proves what has already been stated: there are too many venous publications under the heading of endothermal ablation with methodological flaws. 1 Moreover, not all published papers have enough information with which to assess results properly and, surprisingly, these low quality papers are accepted in many reputable medical journals. Lack of evidence is particularly common in venous publications for almost all comparisons among different procedures (radiofrequency ablation [RFA], endovenous laser ablation, surgery, and ultrasound venous ablation). 5 van Der Velden et al.'s paper looks at a relevant problem: prognostic factors for recanalisation of the LSV after endothermal ablation. 1 However, should we consider LSV recanalisation as the only parameter for success or failure? Many readers will agree that it is a relevant parameter with which to explain the recurrence of varicose veins, but recurrence of varicose veins is a complex phenomenon in which many other factors contribute, among them below knee LSV reflux, reflux in the tributaries, neovascularisation, saphenopopliteal reflux, and perforator insufficiency. Neovascularisation might differ between the procedures, which may influence l...