What EVLA is and when to use it?

EVLA is a minimally invasive, office/outpatient procedure that thermally ablates refluxing superficial trunk veins (most commonly the great and small saphenous veins) under tumescent local anesthesia using a laser fiber introduced percutaneously under ultrasound guidance. Patients typically ambulate immediately and return to normal activity within days, with no surgical incisions or stripping scars [1,38].
- Contemporary guidelines and evidence reviews consider duplex ultrasound the diagnostic gold standard and endorse endothermal ablation (EVLA or radiofrequency ablation, RFA) as first‑line therapy for symptomatic saphenous reflux (CEAP C2–C6), with EVLA achieving long-term closure rates comparable to high ligation/stripping (HL/S) and superior anatomic success to ultrasound‑guided foam sclerotherapy (UGFS) in most comparisons

Effectiveness vs other modalities (mid- to long-term)

- EVLA vs surgery (HL/S). Long-term anatomic success is similar to HL/S at 5 years in systematic reviews; EVLA yields fewer wound infections/hematomas and faster return to work [2,6]. A 10‑year randomized trial found endothermal ablation (predominantly EVLA) had lower clinical recurrence and better quality-of-life (QoL) domains than conventional surgery (number needed to treat = 5 to prevent one recurrence) [4]. Meta-analyses show HL/S may have slightly lower SFJ recurrent reflux than EVLA, but clinical scores (VCSS) are similar [8].
- EVLA vs RFA. Technical success and recurrence are generally comparable in pooled RCTs up to 5 years; some reviews suggest a possible long-term recurrence benefit with RFA in selected analyses, whereas others show similar or slightly better reflux-prevention with EVLA depending on context and timeframe [3,5,6,7,10].
- EVLA vs UGFS. EVLA provides higher anatomic closure and lower reintervention than UGFS across RCTs and meta-analyses, with similar patient-reported outcomes when tributary management is optimized [3,8,9,44].
- EVLA vs nonthermal nontumescent techniques (MOCA, cyanoacrylate). Mid-term network meta-analyses show MOCA has lower great saphenous vein (GSV) closure and smaller VCSS improvement than EVLA; cyanoacrylate closure (CAC) demonstrates similar anatomic efficacy to EVLA/RFA with less periprocedural pain but higher device cost and different adverse event profile

Durability and special anatomies

- Large-diameter GSVs. EVLA and RFA remain highly effective for diameters ≥12 mm (≈94–96% occlusion at 1–2 years); however, increasing vein diameter correlates with slightly lower occlusion and technical success and a modest rise in EHIT risk, arguing for diameter‑tailored parameter adjustments [59].
- Small saphenous vein (SSV). EVLA achieves pooled anatomic success ≈98.5% and is preferred over UGFS or surgery for SSV incompetence; thermal techniques do carry a small risk of sural nerve injury, mitigated by technique (e.g., careful below-knee dosing, sheath position) . Contemporary series report ≈95–96% 1‑year occlusion with EVLA
- Recurrent varicose veins (RVVs). EVLA can safely and effectively treat groin recurrences (including short stumps and neovascular tissue) using direct puncture or distal cannulation approaches with high technical success and low morbidity . Targeting anterior accessory GSV (AAGSV) reflux with EVLA can restore SFJ competence while preserving the native GSV in selected anatomies . .