Effectiveness and Limitations of Endovenous Laser Ablation for Anterior Saphenous Vein Insufficiency: A Single-Center Retrospective Study

<b>Background</b>: Anterior saphenous vein (ASV) incompetence represents the third most common form of truncal varicose veins, and evidence for endovenous laser ablation (EVLA) in this setting remains limited. <b>Methods</b>: We evaluated outcomes of EVLA in cases with dominant ASV insufficiency. All EVLA procedures performed by a single surgeon between April 2019 and December 2023 for primary ASV reflux (ASV-R) were compared with a cohort containing all EVLA treatments for great saphenous vein (GSV) insufficiency without ASV reflux from April to December 2019 (GSV-R). We used a 1470-nm diode laser with radially emitting fibers for the interventions. <b>Results</b>: We included 378 patients (mean age 49.5 years): 208 and 256 treated limbs in the ASV-R and GSV-R cohorts, respectively. Female patients were more frequent in the ASV-R cohort than in the GSV-R cohort (80.5% vs. 62.9%, <i>p</i> < 0.001). ASV-R cases exhibited concomitant GSV insufficiency in 54.3% of cases. Redo procedures due to initial treatment failure were more frequent in ASV-R (1.9% vs. 0%, <i>p</i> = 0.04). Over a mean follow-up period of 332 days, 16 recurrences occurred in the ASV-R cohort compared with 4 in the GSV-R cohort, corresponding to a significantly increased hazard of recurrence in ASV-R (HR 8.41, 95% CI 2.78-25.4). Rates of subsequent foam sclerotherapy (16.8% vs. 10.5%) and minor complications (5.3% vs. 4.3%) did not differ significantly between ASV-R and GSV-R, respectively. ASV-R cases without concomitant GSV reflux demonstrated a higher need for secondary sclerotherapy, compared to ASV-R cases with additional GSV insufficiency. <b>Conclusions</b>: Our findings suggest that EVLA for ASV insufficiency is technically more challenging and yields inferior outcomes than EVLA for GSV incompetence. These considerations should be taken into account during preoperative planning and patient counseling. Further prospective and comparative analyses are needed to better define the effectiveness of thermal ablation strategies in ASV insufficiency and to support patient-centered, individualized treatment decisions.