Advances in Endovenous Ablation Techniques

Abstract Chronic venous insufficiency affects tens of millions of adults in the United States and imposes a substantial economic burden, driven largely by venous leg ulceration. Over the past two decades, endovenous ablation has displaced open ligation and stripping as the primary intervention for symptomatic superficial venous reflux, and the number of available thermal and nonthermal modalities has expanded rapidly. The objective of this study is to describe the currently available endovenous ablation techniques, compare their reported outcomes, and identify gaps in the evidence base that should inform future research. We performed a narrative review of the literature on endovenous ablation of the superficial truncal veins, prioritizing randomized controlled trials, systematic reviews and meta-analyses, and current clinical practice guidelines. Endovenous laser ablation, radiofrequency ablation, and cyanoacrylate adhesive closure achieve comparable short-term occlusion exceeding 90%, with durable 5-year results. Mechanochemical ablation and ultrasound-guided foam sclerotherapy demonstrate lower anatomical durability, and foam sclerotherapy carries the highest recanalization and reintervention rates. Serious thrombotic complications are uncommon across all modalities. Nonthermal techniques avoid tumescent infiltration and thermal nerve injury but have not consistently demonstrated superior periprocedural pain outcomes. Quality-of-life improvement is broadly similar across modalities. Guidelines diverge: the European Society for Vascular Surgery designates thermal ablation as the first-choice treatment, whereas the Society for Vascular Surgery treats thermal and nonthermal ablation as equivalent options. Thermal ablation and cyanoacrylate closure currently offer the most durable outcomes. Long-term comparative data for mechanochemical and steam ablation remain limited, and contemporary cost-effectiveness analyses incorporating nonthermal device costs are needed.