Network meta-analysis of randomized controlled trials evaluating long-term outcomes of interventional approaches for great saphenous vein insufficiency.

OBJECTIVE

Great saphenous vein (GSV) insufficiency is a major contributor to chronic venous disease, associated with substantial morbidity and reduced health status. Although various surgical and minimally invasive interventions are available, their long-term efficacy, safety, and recovery profiles remain uncertain. Therefore, this study aims to provide comprehensive evidence to guide clinical decision-making and optimize interventional strategies for GSV insufficiency.

METHODS

This network meta-analysis (NMA) was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-NMA checklist of items. Comprehensive searches were conducted on PubMed, Scopus, Cochrane Central Register of Controlled Trials, ProQuest, and Web of Science from inception to July 11, 2025. Data analyses were performed using RStudio version 4.5.1 (Posit Software). Kaplan-Meier (KM) and log-rank test were applied to evaluate freedom from failure, with individual patient data reconstructed from published KM curves. Clinical outcomes were synthesized using a Frequentist NMA with DerSimonian-Laird random-effects model. Complications were analyzed using meta-proportions with a generalized linear mixed model at the latest follow-up.

RESULTS

A total of 7913 cases of GSV insufficiency from 47 reports from 33 randomized controlled trials were included. KM and log-rank analyses revealed that high ligation and stripping (HL&S) had a significantly higher long-term freedom from failure compared with cyanoacrylate closure [hazard ratio (HR), 1.98; 95% confidence interval (CI), 1.24-3.16; P < .001], endovenous laser ablation (EVLA)-1470 nm (HR, 2.37; 95% CI, 1.38-4.06; P < .001), and radiofrequency ablation (HR, 2.64; 95% CI, 1.69-4.12; P = .002) among patients with Clinical-Etiology-Anatomy-Pathophysiology C2-C5 Classification. Regarding clinical outcomes, electrocoagulation (mean difference, -0.59; 95% CI, -1.11 to -0.06; P = .03) showed lowest Venous Clinical Severity Score at 6 months among interventions. Minimally invasive interventions (EVLA-1470, P < .001; EVLA-810, P = .02; electrocoagulation, P = .006) demonstrated a faster return to normal activities compared with HL&S. In terms of complications, HL&S showed higher proportion of ecchymosis (76.37%) and infection (2.35%), whereas ablation procedures demonstrated higher proportion of skin pigmentation (4.34%-11.41%) across interventions.

CONCLUSIONS

In individuals with Clinical-Etiology-Anatomy-Pathophysiology stages C2 to C5 disease, HL&S offer higher long-term freedom from failure and Venous Clinical Severity Score improvement, whereas minimally invasive interventions offer faster short-term recovery. These findings provide evidence to ensuring recommendations address both long-term efficacy and patient-centered short-term outcomes.