Closed randomized comparative study of great saphenous vein crossectomy laser ablation versus standard laser technique to minimize recurrence in the treatment of primary varicose veins
Authors: Nagib S , Mahmoud Abdel Bary Mostafa Soliman , Elsayed Eldieb Khaled Abdel Sattar , Kamel Amr Nabil 
Published: October 2023

Background
Incompetence at the saphenofemoral junction (SF) is the most common cause (70%) of varicose veins. Endovenous laser ablation (EVLA) uses laser energy to ablate incompetent axial veins selectively and was originally described for the treatment of GSV reflux and its related varicosities. The venous system is a network of interconnected vessels; any preserved inflow of the saphenous-femoral mouth can cause postoperative recurrence. However, according to the literature, the greatest risk of recurrence is associated with the stump of the GSV of venous tributaries, including great venous trunks parallel to the GSV in the thigh.

Aim of the work
Comparison of the standard endovenous laser ablation technique (1.5–2 cm from SFJ) versus crossectomy ablation for the treatment of varicose veins regarding recurrence of reflux and incidence of endovenous heat-induced thrombus (EHIT) in the first week.

Patients and methods
In all, 80 patients admitted to Ain Shams University Hospitals and Alexandria Armed Forces Hospital from Jan. 1st, 2021 to Jan. 30th, 2023 participated in the study. The patients were divided evenly into two groups:
Participants were randomly assigned to one of the trial groups using the sealed envelope method.Group A was treated by ablation of the great saphenous vein at the saphenofemoral junction (0 cm from SFJ) using 1470 nm radial double-ring diode laser fibers (ELVeS Radial 2ring™ fiber) and Biolitec Ceralas E1470/15 W laser machine. Group B was treated by ablation of the great saphenous vein at 1.5–2 cm from the saphenofemoral junction using the same laser fiber and machine. Ablation was done after putting an appropriate amount of tumescent anesthesia (500 mg lidocaine, 1 mg of epinephrine, and 12.5 mEq sodium bicarbonate added to a 1-liter solution of 0.9% normal saline). The ultrasound machine was used for the accurate placement of the laser fiber. Postoperative duplex was done on day 1, 1 week, and at 6, 12, and 18 months.

Results
Mean age: 39.28+/– 12.27 years in both groups; M/F: 23/17 in the first group, 20/20 in the second group. Postoperative duplex showed the absence of reflux in both groups after 1 day, after 6 months. One patient (2.5%) in group A and four patients (10%) in group B showed recurrent reflux, while recurrent refluxes were observed in one case (2.5%) in group A and five cases (12.5%) in the other group after 12 and 18 months of follow-up. One patient (2.5%) developed superficial thrombophlebitis along the course of the ablated great saphenous vein in both groups while extension to the deep veins was not detected in both groups.

Conclusion
Crossectomy (ablation at 0 cm at SFJ) ablation of varicose veins with 1470 radial double rings and nm diode laser with an appropriate amount of tumescent showed better results with less recurrence rate due to neovascularization or tributaries left than the standard technique of endovenous laser ablation of varicose veins (1.5–2 CM from SFJ). Along with showing a lesser incidence of thermal propagation into the deep system (EHIT) both crossectomy and standard techniques showed the same complication rate regarding venous thrombosis.