Varicose tributary treatment as a single procedure may avoid saphenous ablation: an evidence review and prediction checklist

Growing evidence suggests that, in selected varicose vein patients, isolated tributary treatment (by phlebectomy, sclerotherapy, laser or disconnection) may avoid the sacrifice of the great saphenous vein, thereby simplifying varicose vein management and preserving saphenous capital. Patient selection relies primarily on detailed ultrasound assessment of venous haemodynamic, with particular attention to the Sapheno-Femoral Junction (SFJ), and re-entry perforators evaluated using the Reflux Elimination Test (RET). A structured checklist to predict surgical success may assist surgeons and support shared decision-making with patients by integrating anatomical, hemodynamic, clinical, and technical factors.

1. Belramman A, Bootun R, Lane TRA, Davies AH. Foam sclerotherapy versus ambulatory phlebectomy for the treatment of varicose vein tributaries: study protocol for a randomised controlled trial. Trials 2019;20:392. DOI: https://doi.org/10.1186/s13063-019-3398-0

2. Mekako A, Hatfield J, Bryce J, et al. Combined endovenous laser therapy and ambulatory phlebectomy: refinement of a new technique. Eur J Vasc Endovasc Surg 2006;32:725-9. DOI: https://doi.org/10.1016/j.ejvs.2006.06.002

3. Monahan DL. Can phlebectomy be deferred in the treatment of varicose veins? J Vasc Surg 2005;42:1145-9. DOI: https://doi.org/10.1016/j.jvs.2005.08.034

4. Carradice D, Mekako AI, Hatfield J, Chetter IC. Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins. Br J Surg 2009;96:369e75. DOI: https://doi.org/10.1002/bjs.6556

5. Mohamed A, Leung C, Hitchman L, et al. A prospective observational cohort study of concomitant versus sequential phlebectomy for tributary varicosities following axial mechanochemical ablation. Phlebology 2019;34:627-35. DOI: https://doi.org/10.1177/0268355519835625

6. Lane TRA. Ambulatory Varicosity Avulsion Later or Synchronized (AVULS): a randomized clinical trial. Annals of Surgery 2015;261:4. DOI: https://doi.org/10.1097/SLA.0000000000000790

7. Schanzer H. Endovenous ablation plus microphlebectomy/sclerotherapy for the treatment of varicose veins: single or two-stage procedure? Vasc Endovascular Surg 2010;44:545-9. DOI: https://doi.org/10.1177/1538574410375126

8. Welch HJ. Endovenous ablation of the great saphenous vein may avert phlebectomy for branch varicose veins. J Vasc Surg 2006;44:601-5. DOI: https://doi.org/10.1016/j.jvs.2006.06.003

9. Aherne TM, Ryan EJ, Boland MR, et al. Concomitant vs. staged treatment of varicose tributaries as an adjunct to endovenous ablation: a systematic review and meta-analysis. European Journal of Vascular and Endovascular Surgery 2020;60:430-42. DOI: https://doi.org/10.1016/j.ejvs.2020.05.028

10. Hager ES, Ozvath KJ, Dillavou ED. Evidence summary of combined saphenous ablation and treatment of varicosities versus staged phlebectomy. J Vasc Surg Venous Lymphat Disord 2017;5:134-7. DOI: https://doi.org/10.1016/j.jvsv.2016.07.009

11. Muller R. Treatment of varicose veins by ambulatory phlebectomy. Phlebologie 1966;19:277-9.

12. Salih M, Tan M, Lane T, et al. Tributary treatment: Foam or phlebectomy? Phlebology 2024;39:578-9. DOI: https://doi.org/10.1177/02683555241259638

13. Alòs J, Carreño P, López JA, et al. Efficacy and safety of sclerotherapy using polidocanol foam: a controlled clinical trial. Eur J Vasc Endovasc Surg 2006;31:101-7. DOI: https://doi.org/10.1016/j.ejvs.2005.08.018

14. Gianesini S, Delfrate M, Cappelli M, Mendoza E. “CHIVA. Surgical tips and tricks”. In: “Saphenous Vein-Sparing Strategies in Chronic Venous Disease”, Zamboni P, Mendoza E, Gianesini S (eds.). Springer Nature; Berlin, Germany; 2018. DOI: https://doi.org/10.1007/978-3-319-70638-2_7

15. Hirokawa M, Utoh J, Sugiyama S, et al. Supplement of clinical practice guidelines for endovenous thermal ablation for varicose veins 2019: laser ablation of varicose tributaries. Ann Vasc Dis 2025;18:25-00053. DOI: https://doi.org/10.3400/avd.gl.25-00053

16. Ricci S. Ambulatory phlebectomy: sixty-year-old but still looking great. JTAVR 2022;7:138. DOI: https://doi.org/10.24019/jtavr.138

17. Gloviczki P, Lawrence P, Wasan S, et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2024;12:101670. DOI: https://doi.org/10.1016/j.jvsv.2023.08.011

18. Quill RD, Fegan WG. Reversibility of femorosaphenous reflux. Br J Surg 1971;58:389e93. DOI: https://doi.org/10.1002/bjs.1800580520

19. Hobbs JT. Surgery and Sclerotherapy in the treatment of varicose veins: a random trial. Arch Surg 1974;109:793-6. DOI: https://doi.org/10.1001/archsurg.1974.01360060063016

20. Franceschi C. La cure Conservatrice et Hémodynamique del’Insuffisance Veineuse en Ambulatoire. Editions de L’Armançon; Precy-sous-Thil, France; 1988.

21. Zamboni P, Cisno C, Marchetti F, et al. Reflux elimination without any ablation or disconnection of the saphenous vein. A haemodynamic model for venous surgery. Eur J Vasc Endovasc Surg 2001;21:361-9. DOI: https://doi.org/10.1053/ejvs.2001.1338

22. Escribano JM, Juan J, Bofill R, et al. Durability of reflux-elimination by a minimal invasive CHIVA procedure on patients with varicose veins. A 3-year prospective case study. Eur J Vasc Endovasc Surg 2003;25:159-63. DOI: https://doi.org/10.1053/ejvs.2002.1825

23. Pittaluga P, Rea B, Barbe R. Méthode ASVAL (Ablation Sélective des Varices sous Anesthésie Locale): principes et résultats préliminaires. Phlébologie 2005;2:175-81. DOI: https://doi.org/10.1016/S0398-0499(05)86322-X

24. Pittaluga P Midterm results of the surgical treatment of varices by phlebectomy with conservation of a refluxing saphenous vein. J Vasc Surg 2009;50:107-18. DOI: https://doi.org/10.1016/j.jvs.2008.12.067

25. Pittaluga P, Chastanet S Persistent incompetent truncal veins should not be treated immediately. Phlebology 2015;30:98-106. DOI: https://doi.org/10.1177/0268355515569141

26. Pittaluga P, Chastanet S. Treatment of varicose veins by ASVAL: results at 10 years. Ann Vasc Surg 2017;38:10 DOI: https://doi.org/10.1016/j.avsg.2016.07.021

27. Pittaluga P. Saphenous sparing treatments: The ASVAL Method. JTAVR 2023;8:43-50. DOI: https://doi.org/10.24019/jtavr.173

28. Zamboni P, Gianesini S, Menegatti E, et al. Great saphenous varicose vein surgery without saphenofemoral junction disconnection. Br J Surg 2010;97:820-5. DOI: https://doi.org/10.1002/bjs.7022

29. Abu-Own A, Scurr JH, Coleridge Smith PD. Saphenous vein reflux without incompetence at the saphenofemoral junction. Br J Surg 1994;81:1452-4. DOI: https://doi.org/10.1002/bjs.1800811016

30. Pieri A, Vannuzzi A, Duranti A, et al. Role central de la valvule pre-ostiale de la veine sapheene interne dans la genese des varices tronculaires desmembres inferieurs. Phlebologie 1995;48:227-9.

31. Cappelli M, Molino Lova R, Ermini S, Zamboni P. Hemodynamics of the sapheno-femoral junction. Patterns of reflux and their clinical implications. Int Angiol 2004;23:25-8.

32. Somjen GM, Donlan J, Hurse J, et al. Venous reflux at the sapheno-femoral junction. Phlebology 1995;10:132-5. DOI: https://doi.org/10.1177/026835559501000402

33. Baldazzi G, Tessari M, Zamboni M. The sex prevalence of lower limb varicose vein networks. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2024;12:101944. DOI: https://doi.org/10.1016/j.jvsv.2024.101944

34. Biemans AA, van den Bos RR, Hollestein LM, et al. The effect of single phlebectomies of a large varicose tributary on great saphenous vein reflux. J Vasc Surg Venous Lymphat Disord 2014;2:179-87. DOI: https://doi.org/10.1016/j.jvsv.2013.11.003

35. Scheerders ERY, van der Velden SK, Goossens LMA, et al. A randomized clinical trial of isolated ambulatory phlebectomy versus saphenous thermal ablation with concomitant phlebectomy (SAPTAP Trial). Br J Surg 2023;110:333-42. DOI: https://doi.org/10.1093/bjs/znac388

36. Scheerders ERY, van Klaveren D, Malskat WSJ, et al. Development and external validation of a prediction model for patients with varicose veins suitable for isolated ambulatory phlebectomy. European Journal of Vascular and Endovascular Surgery 2024;68:387-94. DOI: https://doi.org/10.1016/j.ejvs.2024.05.001

37. Cappelli M. Factors affecting the evolution of type III shunts of the greater saphenous vein after the first step of the CHIVA 2 strategy. Veins and Lymphatics 2024;13:13043. DOI: https://doi.org/10.4081/vl.2024.13043

38. Passariello F, Cappelli M, Ermini S. The Vasculab manoeuvre: simulating walking in venous investigations. Reviews in Vascular Medicine 2016:6-7:20-8. DOI: https://doi.org/10.1016/j.rvm.2016.08.002

39. Cappelli M, Molino Lova R, Pinelli M, Franceschi C. Are saphenous sparing treatments beneficial to the hemodynamics of the venous system? JTAVR 2023;08:33-7. DOI: https://doi.org/10.24019/jtavr.149

40. Ricci S. Chiva for “dummies”. Phlebology 2024;39:238-44. DOI: https://doi.org/10.1177/02683555231225788

41. Mendoza E. “Saphenous sparing strategy in the CHIVA context, 4.1 CHIVA in two steps or ‘CHIVA 2’ “. In: “Saphenous vein-sparing strategies in chronic venous disease”, Zamboni P, Mendoza E, Gianesini S (eds.). Springer Nature; Berlin, Germany; 2018. DOI: https://doi.org/10.1007/978-3-319-70638-2_6

42. Franceschi C Venous Hemodynamics for GSV sparing graft and improved varicose treatment JTAVR 2023;8:13-5. DOI: https://doi.org/10.24019/jtavr.165

43 Richards T, Anwar M, Beshr M, et al. Systematic review of ambulatory selective variceal ablation under local anesthetic technique for the treatment of symptomatic varicose veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2020;9:525-35. DOI: https://doi.org/10.1016/j.jvsv.2020.10.014

44. Melliere D. Why and when to preserve the saphenous veins ofvaricose patients to serve as an arterial bypass? J Mal Vasc 1994;19:216-21.

45. Fligelstone LJ, Salaman RA, Oshodi TO, et al. Flush saphenofemoral ligation and multiple stab phlebectomy preserve a useful greater saphenous vein four years after surgery. J Vasc Surg 1995;22:588-92. DOI: https://doi.org/10.1016/S0741-5214(95)70044-7

46. Cappelli M, Lova RM, Ermini S, et al. Ambulatory conservative hemodynamic management of varicose veins: critical analysis of results at 3 years. Ann Vasc Surg 2000;14:376-84. DOI: https://doi.org/10.1007/s100169910064

47. Skoog J, Nelzen O. Zachrisson H. Venous compliance in great saphenous vein incompetence: pre- and postinterventional changes. EJVES 2020;47:78-82. DOI: https://doi.org/10.1016/j.ejvssr.2019.11.006