Patterns of recurrent varicose veins after surgery (REVAS): A systematic review and network meta-analysis of randomized trials

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Background Recurrence of superficial venous incompetence is common following interventional treatment and a classification system (Recurrent Varices After Surgery, REVAS) has been developed. However, it is not known whether specific, predictable patterns of reflux occur following treatment nor how these may vary by treatment modality. This study aimed to explore varicose vein recurrence patterns according to procedural technique. Methods Following PRISMA guidelines and a registered protocol (CRD42023455512), MEDLINE, Embase, and ClinTrials.gov were searched for randomized control trials (RCTs) on surgical or endovenous treatment of primary saphenous vein insufficiency with at least 1-year follow-up, and assessment of recurrence patterns. The primary outcome was reflux recurrence as per the REVAS classification. A random-effects network meta-analysis was conducted in R, calculating risk ratios and 95% confidence intervals (CIs). Results The 3467 records identified yielded 23 unique RCTs, investigating 8 different modalities. Recurrence rates varied by anatomical section: saphenofemoral junction (SFJ) showed 23.6% cumulative recurrence, thigh perforators 7.6%, and lower leg perforators 4.7% recurrence. Endovenous laser ablation (EVLA) and foam sclerotherapy (FS) had higher risk of SFJ recurrence compared to HLS with a risk ratio of 2.29 (1.40–3.76) and 2.09 (1.20–3.62) (I 2 = 47.7%). EVLA was associated with a reduced risk of thigh perforator recurrence compared to HLS (0.45, (0.21–0.93)) (I 2 = 0%). FS was associated with higher risk of recanalization compared to HLS (4.05 (2.23–7.35)), and EVLA (3.14 (1.82–5.41)), Both EVLA and FS were associated with lower risk of neovascularization, compared to HLS; 0.28 (0.18–0.43) and 0.18 (0.08–0.40), respectively (I 2 = 0%). Conclusion Recurrence patterns varied by treatment modality, with HLS showing lower SFJ and ASV recurrence, while endovenous methods had less neovascularization and thigh perforator recurrence. Concerningly, only 13% of RCTs reported recurrence using REVAS. Improved reporting of varicose vein recurrence to delineate reflux sources will allow better technical outcome assessment and enhanced patient care.

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