Truncal Ablation and Phlebectomy: Together in One Session, or in Stages? The Evidence Reviewed

Patients being talked through a surgical plan almost always arrive at the same question.

"So will I need two operations?"

It is a reasonable thing to ask. Varicose vein surgery usually involves two distinct tasks. One is closing the saphenous trunk — the vein whose valve failure is driving the reflux. The other is dealing with the tributary varicosities, the visibly bulging veins running under the skin.

The open question is whether those two tasks should happen on the same day or on separate days. In the literature the first approach is called concomitant treatment and the second staged treatment. This is not a matter of surgical preference: several randomised controlled trials have been run specifically to compare them.

This article reviews what those trials found.

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First, why would anyone argue for staging?

The case for staged treatment is more persuasive than it first appears. The argument is that once the cause of the reflux is removed, the tributaries shrink on their own.

And they do. Closing the saphenous trunk removes the reflux load that was distending the veins below it, and a substantial proportion of dilated tributaries regress over the following weeks. In a 2025 evidence review, Xu and colleagues report that many tributaries undergo partial or complete regression between six weeks and six months after truncal ablation.

If that is so, why add incisions at the outset? Waiting means fewer incisions, less tumescent anaesthetic, and less bruising. The same review also sets out a haemodynamic argument: preserving tributaries maintains their drainage function, which may help prevent oedema in the territory they drain.

The reasoning is sound. That is precisely why it needed testing.

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Evidence 1 — A meta-analysis of 15 studies and 6,915 limbs

The largest synthesis on this question is the systematic review and meta-analysis by Aherne and colleagues, published in the European Journal of Vascular and Endovascular Surgery in 2020. It pooled 15 studies covering 6,915 limbs.

Reintervention rate

• Concomitant: 6.3%
• Staged: 36.1%
• Relative risk 0.21 (95% CI 0.07–0.62), p = 0.004

Clinical severity (VCSS) — lower in the concomitant group (mean difference −1.16, 95% CI −1.97 to −0.35, p = 0.005)

Quality of life (AVVQ) — favoured concomitant treatment both under three months and between three and twelve months

Complications — comparable between groups (RR 1.14, not statistically significant)

Deep vein thrombosis — comparable between groups (RR 1.41, not statistically significant)

A gap between 6.3% and 36.1% is substantial. But the authors themselves attach an important qualification: when the randomised trials were analysed as a subgroup on their own, there was no difference in reintervention rates. The overall gap comes from the observational studies, where bias cannot be excluded.

Quoting "6.3% versus 36.1%" without that qualification would misrepresent the finding.

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Evidence 2 — A randomised trial followed for five years

So what did the randomised evidence show? The most informative single trial is the five-year follow-up published by El-Sheikha and colleagues from the Hull academic vascular unit in the British Journal of Surgery in 2014.

Fifty patients with great saphenous vein incompetence were randomised into two arms. One received endovenous laser ablation with phlebectomy in the same session (EVLTAP). The other received laser ablation alone, with phlebectomy deferred by at least six weeks and performed only if still required.

Early results clearly favoured the concomitant arm.

• VCSS at 12 weeks: 0 (IQR 0–1) versus 2 (0–2), p < 0.001
• AVVQ at 6 weeks: 7.9 (4.1–10.7) versus 13.5 (10.9–18.1), p < 0.001
• AVVQ at 12 weeks: 2.0 (0.4–7.7) versus 9.6 (2.2–13.8), p = 0.015

By one year the two arms had converged. Read in isolation, that looks like a null result. What matters is how they converged.

In the staged arm, 16 of 24 patients (67%) had undergone a secondary procedure. In the concomitant arm it was 1 of 25 (4%), p < 0.001.

In other words, the equivalence at one year was purchased by returning two-thirds of the staged group to the treatment room. From one to five years the two arms remained equivalent.

The authors' conclusion is appropriately balanced: both strategies are acceptable and both achieve excellent five-year results, with concomitant treatment offering the optimal improvement in clinical severity and quality of life along the way.

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Evidence 3 — Does the same hold for non-thermal treatment?

The trials above centred on thermal ablation. Does the pattern persist with non-thermal methods such as mechanochemical ablation (MOCA)?

A team at Helsinki University Hospital published three-year follow-up data in the Journal of Vascular Surgery: Venous and Lymphatic Disorders in 2025. Eighty-five patients with CEAP C2–C4 disease were randomised, after MOCA of the great saphenous vein, to either staged foam sclerotherapy at three months if required or concomitant phlebectomy.

Over three years, additional treatment was needed in 11.4% (5/44) of the staged group and 4.9% (2/41) of the concomitant group. The odds ratio was 2.5 (95% CI 0.46–13.67), p = 0.435 — not statistically significant. There were no significant differences in reflux, quality of life, symptoms or patient satisfaction either.

Two details stand out. First, the non-inferiority analysis suggested the staged approach may be inferior to the concomitant one. Second, the staged group had more visible varicosities at three years — though this did not translate into any difference in symptoms or satisfaction.

The authors are again cautious: staged treatment delivers acceptable midterm outcomes, but its potential inferiority should be weighed when durable long-term results are the priority.

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The evidence on the other side

Read this far and the balance appears to tip toward concomitant treatment. It does not tip cleanly, and leaving out the counter-evidence would distort the picture.

First, the guidelines disagree with one another. The 2025 review by Xu and colleagues cited earlier notes substantial divergence among major venous disease guidelines. The Japanese Society of Phlebology's 2019 guidelines advise against concomitant procedures; the European Society for Vascular Surgery's 2022 guidelines and Chinese frameworks support individualised decision-making; the American Vein and Lymphatic Society's 2023 guidelines prioritise concomitant treatment. This is not a settled question internationally.

Second, concomitant treatment carries its own costs. The same review argues that concomitant procedures do not consistently translate into lower reintervention rates or better early VCSS, while complication risk and postoperative pain tend to be higher. Staged strategies, on this reading, are better tolerated. That sits somewhat uneasily against the Aherne meta-analysis, which found no significant difference in complications — which is itself a signal that this particular question remains unresolved.

Third, one trial reversed the sequence entirely. The Dutch SAPTAP randomised trial, published in the British Journal of Surgery in 2023, enrolled 464 patients and found that treating the tributary first and the trunk only if needed (single ambulatory phlebectomy) was non-inferior on quality of life at twelve months compared with truncal ablation plus concomitant phlebectomy — and was less costly. That said, 25.6% of the phlebectomy-first group went on to require truncal ablation anyway.

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So what actually drives the decision?

Summarising:

• The strength of concomitant treatment is a clearly better early recovery window — roughly six weeks to three months — and a much lower likelihood of returning for a second procedure. This holds up in the randomised evidence.
• The strength of staged treatment is fewer incisions and less anaesthetic, and not intervening on tributaries that would have regressed anyway. Its five-year results match those of concomitant treatment.
• Neither can be called the better operation, because the five-year outcomes are equivalent. What differs is the path taken to get there.

Which is why the decision is made patient by patient. The factors that weigh on it are usually these.

Size and distribution of the tributaries. Large, widely distributed tributaries are less likely to regress on their own after the trunk is closed. Fine, localised ones leave more room to wait and see.

Severity of symptoms. Where pain, heaviness or swelling is pronounced, the difference in the early recovery window is something the patient actually feels.

The patient's circumstances. For someone travelling from another region or another country, or working to a fixed period of leave, the number of visits is itself a decisive variable.

Tolerance for incisions and anaesthetic. Where there are comorbidities, or particular concern about bruising and pigmentation, adding incisions is a real cost.

CEAP class and skin changes. In advanced disease with dermatitis or ulceration, the calculus changes again.

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In closing

"One session and you're done" makes for an appealing sentence, but it is not what the evidence says. At five years the two strategies produce the same result.

A more accurate statement would be this: concomitant treatment is an option that shortens the early recovery window and reduces the likelihood of a second procedure. It is not a default applied to everyone, but a decision made by looking at the tributaries and at the patient.

At da Re-Fit, we map the extent of truncal reflux and the distribution of the tributaries on duplex ultrasound, then discuss with the patient whether to treat them together or separately. Whichever is chosen, we explain the reasoning while looking at the ultrasound images together. The relevant treatment stage is described in more detail on our source vein treatment page.

When a surgical plan is explained to you, it is worth asking why it was planned that way. Whether the answer comes with reasons attached is a good indication of whether the plan was built around you.

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References

• Aherne TM et al. Concomitant vs. Staged Treatment of Varicose Tributaries as an Adjunct to Endovenous Ablation: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2020 Sep;60(3):430-442. (PMID: 32771286)
• El-Sheikha J et al. Clinical outcomes and quality of life 5 years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins. Br J Surg. 2014 Aug;101(9):1093-7. (PMID: 24916467)
• Rahman T et al. Three-year follow-up of a randomized controlled trial comparing concomitant and staged treatment of varicose veins following mechanochemical ablation of the great saphenous vein. J Vasc Surg Venous Lymphat Disord. 2025 May;13(5):102255. (PMID: 40335021)
• Hager ES et al. Evidence summary of combined saphenous ablation and treatment of varicosities versus staged phlebectomy. J Vasc Surg Venous Lymphat Disord. 2017 Jan;5(1):134-137. (PMID: 27987603)
• Scheerders ERY et al. A randomized clinical trial of isolated ambulatory phlebectomy versus saphenous thermal ablation with concomitant phlebectomy (SAPTAP Trial). Br J Surg. 2023 Feb 15;110(3):333-342. (PMID: 36464887)
• Xu MJ et al. Concomitant versus staged tributary management during endovenous truncal ablation for varicose veins: an evidence-based progress review. Zhonghua Wai Ke Za Zhi. 2025 Sep 1;63(9):854-858. (PMID: 40734419)
• Gloviczki P et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II. J Vasc Surg Venous Lymphat Disord. 2024 Jan;12(1):101670. (PMID: 37652254)
• De Maeseneer MG et al. Editor's Choice — European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022 Feb;63(2):184-267. (PMID: 35027279)