Hybrid Varicose Vein Treatment: Why Use Two Methods on the Same Vein?

Stripping with endovenous ablation, or two endovenous methods, applied segment by segment

"It is one vein. Why do you need two methods to treat it?"

In a varicose vein consultation you hear about laser, radiofrequency, medical adhesive, stripping and more. It is easy to think of them only as alternatives to one another.

But a single vein is not the same from top to bottom. One segment may run fairly straight, another may be sharply tortuous or pass close to the skin. The diameter also changes along its length.

Taking these differences into account, two or more methods can be combined on different segments of the same vein. In this article we call that approach hybrid treatment.

1. What makes hybrid treatment different

In the literature, "hybrid" is used in more than one sense. It often means closing the main trunk and removing the bulging tributaries around it in the same session. That approach is covered in our column on concomitant phlebectomy.

What we describe here is more specific: choosing different methods for different segments of the same truncal vein.

For example, part of the great saphenous vein may be closed with laser while another part is removed by partial stripping. Or the above-knee segment may be closed endovenously while the below-knee segment is treated with foam sclerotherapy.

This is not the same as stacking treatments on one spot. It is a plan that assigns the right method to each segment.

2. Stripping and endovenous ablation have been combined in studies

Stripping physically removes the target vein. Endovenous laser delivers heat inside the vein to close it.

A Japanese series published in 2019 combined the two in 42 patients (51 limbs) whose great saphenous vein measured more than 15 mm at its widest point. Laser was used for the thigh segment nearest the trunk, and the segment below was removed by partial stripping through small incisions. Symptom scores were reported to improve over the following three months.

The series shows that the two methods are not necessarily an either-or choice. But it had no comparison group, was small, and involved a specific situation: very large veins. It cannot be read as showing that combined treatment is better, or recurs less, for every patient.

3. Two different endovenous methods can also be combined

Endovenous methods divide into thermal and non-thermal. So even within one vein, different approaches can be considered for different segments.

A UK randomised trial in 2008 assigned 65 patients (68 limbs) with reflux both above and below the knee to three groups: laser above the knee only, laser extended to mid-calf, or laser above the knee combined with foam sclerotherapy below the knee. The proportion who later needed sclerotherapy for residual varicosities was 61%, 17% and 36% respectively. Symptom scores improved in all three groups, and satisfaction was highest in the extended-laser group.

The point is that the combined approach was not the best on every measure in this trial. The appropriate choice depends on the extent of reflux and the course of the vein.

The Korean SOVAECS trial published in 2023 also combined treatments: laser, radiofrequency or adhesive above the knee, with foam sclerotherapy below the knee, in 42 patients (84 limbs). But that trial was designed to compare compression methods after treatment, so it should not be taken as evidence that combined treatment beats a single method. It shows that such combinations are used in practice.

4. Before the method, check where the vein runs

Planning treatment means looking not only at whether reflux is present but at where the vein travels. What the scan looks for is explained in why we map the veins before treatment.

Where a vein lies very close to the skin, thermal skin injury has to be considered. In the lower calf, the relationship to nearby nerves matters.

The 2023 joint guidelines of the Society for Vascular Surgery, the American Venous Forum and the American Vein and Lymphatic Society (Part II) put it this way in their consensus statements. When the saphenous vein lies within 0.5 cm of the skin, thermal ablation can cause burns or pigmentation, and miniphlebectomy or limited stripping is a safe and effective option (statement 5.2.6). For reflux in the distal calf, non-thermal techniques are preferred to avoid thermal nerve injury (5.2.5).

Conversely, a large vein does not automatically mean stripping. The same guidelines state that for non-aneurysmal saphenous veins larger than 10 mm, thermal ablation with laser or radiofrequency should be performed rather than non-thermal techniques (5.2.7). No single feature decides the method. Diameter, depth, course and nearby nerves are weighed segment by segment. How the role of stripping has changed is covered in our column on stripping.

5. Using two methods is not automatically better treatment

The aim of hybrid treatment is not to increase the number of procedures.

If one method treats the vein properly, there is no reason to add another. Combining two methods requires being able to explain which segment each is for, why, what benefit is expected, and what additional burden it adds.

Nor does the word "hybrid" remove pain, complications or the possibility of recurrence. You should be told the risks, recovery and follow-up plan for each of the treatments being combined.

Questions worth asking in consultation:

• Which segment of my vein will each method treat?
• Why does that segment need a different method?
• How does this differ from treating with one method?
• What extra wounds, recovery burden or precautions does it add?

6. The right treatment is explained by the plan, not the name

Choosing varicose vein treatment by "which device is used" is difficult. The same method means something different depending on which vein, and which segment, it is applied to.

When da Re-Fit Clinic explains hybrid treatment, what matters is not the number of methods but the reason for the choice. Why treatment differs between patients with the same diagnosis is explained in Same Diagnosis, Different Treatment. For international patients, consultations are supported through our interpretation system.

Different segments of the same vein can call for different methods. But adding a method needs a reason.

Planning the treatment that is needed, based on the vein structure and extent of reflux seen on ultrasound and on your symptoms: that is where understanding hybrid treatment starts.

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References

• Nakashima M, Kobayashi M. Endovenous Laser Ablation Combined with Stripping Technique for Large Saphenous Varicose Veins: The Selection of Operation Technique. Ann Vasc Dis. 2019;12(4):514-518. (PMID: 31942210) — 42 patients, 51 limbs, GSV over 15 mm; proximal laser plus distal partial stripping; no comparison group.
• Theivacumar NS, Dellagrammaticas D, Mavor AI, Gough MJ. Endovenous laser ablation: does standard above-knee great saphenous vein ablation provide optimum results in patients with both above- and below-knee reflux? A randomized controlled trial. J Vasc Surg. 2008;48(1):173-178. (PMID: 18440756) — 65 patients, 68 limbs; above-knee laser vs extended laser vs above-knee laser plus below-knee foam; sclerotherapy required in 61%, 17% and 36%.
• Yie K, Jeong EH, Hwang EJ, Shin AR. Stocking-only versus additional eccentric compression after below-the-knee truncal vein sclerotherapy: A SOVAECS prospective randomized within-person trial. J Vasc Surg Venous Lymphat Disord. 2023;11(6):1122-1129. (PMID: 37536560) — 42 patients, 84 limbs; above-knee laser, radiofrequency or adhesive plus below-knee foam; compared compression methods.
• Gloviczki P, Lawrence PF, Wasan SM, 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;12(1):101670. (PMID: 37652254) — consensus statements 5.2.5 (distal calf: non-thermal preferred), 5.2.6 (vein within 0.5 cm of skin: miniphlebectomy or limited stripping), 5.2.7 (non-aneurysmal vein over 10 mm: thermal ablation).

This article provides general treatment information. The actual method and extent of treatment depend on the examination and ultrasound findings.