Ambulatory Selective Variceal Ablation under Local anaesthetic (ASVAL) technique for the treatment of symptomatic varicose veins - a systematic review.

OBJECTIVES The ambulatory selective variceal ablation under local anaesthesia (ASVAL) technique subscribes to the "ascending" theory of varicose vein aetiology, which recommends primary ambulatory phlebectomy as a treatment for tributary varicosities and truncal vein incompetence. This systematic review explores the efficacy and safety of the ASVAL technique for the treatment of symptomatic varicose veins. METHODS A comprehensive search of the Medline and Embase databases and the Cochrane Register of Controlled Trials in May 2019 revealed 11 original articles that were qualitatively reviewed. The primary outcome was absence from recurrent varicose veins at one-year follow-up. Secondary outcomes were resolution of great saphenous vein (GSV) reflux on duplex ultrasound, change in GSV diameter, objective and subjective clinical improvement in chronic venous disease (CVD) and patient-reported outcome measures. RESULTS 2106 limbs underwent intervention in 1734 patients reported in two randomized controlled trials (RCTs), one case control study, three cohort studies and five case series. Varicosity recurrence at one year ranged from 0.5% to 13.5% in patients. Of 1622 limbs with diagnosed GSV incompetence prior to intervention, 1114 were competent at one year (mean 68.2% [+/- 12.62%]). All studies measuring GSV diameter reported statistically significant reductions in vein size. CONCLUSION ASVAL may be considered as a minimally-invasive treatment for early stages of CVD in the presence of truncal reflux. The evidence base should be strengthened by prospective RCTs that follow standardised procedures and report according to recognised measures of quality of life alongside clinical and haemodynamic data.