Is the Newest Treatment Always the Better One? Phlebectomy and the Question of Evidence

A request that comes up often in consultation:

"I'd like the newest method, if possible."

The instinct is understandable. In most fields, newer is generally better. In varicose vein treatment, however, that intuition does not reliably hold. There are several randomised trials in which a newer technique went head to head with an older one and lost.

This article looks at one of the oldest techniques still in routine use: ambulatory phlebectomy, the removal of bulging tributary veins through micro-incisions.

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Why a seventy-year-old technique is still here

The modern form of the procedure was standardised in 1956 by the Swiss dermatologist Robert Muller. Under local anaesthetic, incisions of roughly one to three millimetres are made and the bulging tributary veins are hooked out directly. The openings are small enough not to require sutures, and patients walk out the same day.

The principle is simple: the problem vein is physically removed.

That simplicity is the defining feature. Other methods close the vein rather than remove it — with heat (laser, radiofrequency), with a sclerosant that hardens it (sclerotherapy), or with adhesive (cyanoacrylate). Every closure method carries some possibility of the vein reopening. A vein that has been removed has nothing left to reopen.

Whether that difference shows up in outcome data is the question worth asking.

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Evidence 1 — Removed versus hardened, at two years

One randomised controlled trial addressed this directly. De Roos and colleagues in the Netherlands, publishing in Dermatologic Surgery in 2003, randomised 98 legs to either ambulatory phlebectomy or compression sclerotherapy.

Recurrence at one year

• Phlebectomy: 1 of 48 (2%)
• Compression sclerotherapy: 12 of 48 (25%)
• p < 0.001

By two years, six further recurrences had appeared — all of them in the sclerotherapy arm (p < 0.001).

At least in this trial, physically removing a vein and chemically hardening it are not equally durable.

The same study also recorded what phlebectomy costs. Blistering, telangiectatic matting (fine new spider veins appearing around the treated area), scar formation and bruising from bandaging were all significantly more common in the phlebectomy arm. The durability was not free.

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Evidence 2 — Adding phlebectomy to truncal ablation

Phlebectomy is more often used alongside closure of the saphenous trunk than on its own, and the trials of that combination point consistently in one direction.

In a randomised trial of 50 patients published by Carradice and colleagues from the Hull academic vascular unit in the British Journal of Surgery in 2009, the arm receiving laser ablation with concomitant phlebectomy did clearly better: VCSS at three months 0 versus 2 (p < 0.001), AVVQ at six weeks 7.9 versus 13.5 (p < 0.001). In the five-year follow-up of the same cohort, 16 of 24 patients (67%) in the deferred arm eventually returned for a further procedure.

A meta-analysis by Xie and colleagues, published in Phlebology in April 2026, pooled randomised trials only — six trials, 432 patients.

• Reintervention: relative risk 0.33 (95% CI 0.18–0.62)
• AVVQ at six weeks: mean difference 5.24 (95% CI 2.53–7.94)
• VCSS at twelve months: mean difference 0.86 (95% CI 0.40–1.31)
• Superficial thrombophlebitis, nerve-related events, postoperative pain, serious adverse events: no difference

That the reduction in reintervention holds up using randomised evidence alone, without observational studies in the pool, matters. (An earlier 2020 meta-analysis by Aherne and colleagues found no difference within its randomised subgroup; as more trials accumulated, the picture changed.)

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So why did "newest" keep failing to win?

This is the heart of the matter. Three randomised trials in which a newer technique challenged an established one and came off worse.

Case 1 — Powered phlebectomy: fewer incisions, worse recovery

In the 2000s a device called transilluminated powered phlebectomy (TIPP) appeared. It illuminates the tissue from beneath the skin and removes veins with a powered suction resector. Its selling point was a substantial reduction in the number of incisions compared with hooking veins out one at a time.

Chetter and colleagues tested it in a randomised trial of 62 patients, published in the British Journal of Surgery in 2006.

• Number of incisions: significantly fewer with TIPP — as promised
• Bruising at one and six weeks: significantly greater with TIPP (p < 0.01)
• Pain at six weeks: significantly higher with TIPP (p = 0.019)
• Generic quality of life: worse with TIPP, with more prolonged recovery

Operating time did not differ. The device won on the metric it was designed around, and lost on what patients actually experience.

Case 2 — MOCA: tumescent anaesthesia removed, pain unchanged

Mechanochemical ablation (MOCA, ClariVein) uses no heat and therefore requires no tumescent anaesthesia. Since infiltrating tumescent anaesthetic is the step patients find most painful during thermal ablation, pain should in theory be lower.

The LAMA randomised trial from the Hull group — 150 patients, published in Annals of Surgery in 2021 — compared the two directly.

• Intraprocedural pain (100 mm visual analogue scale): laser 22 mm versus MOCA 15 mm, p = 0.210 — not significant
• Occlusion at one year: laser 91% (63/69) versus MOCA 77% (53/69), p = 0.020

The pain it set out to reduce was not significantly reduced, and the occlusion rate was lower. Both groups improved substantially and comparably in symptoms and quality of life.

Case 3 — Newest against newest, and still no difference

The MOCCA trial by Belramman and colleagues — 167 patients, published in JAMA Surgery in 2022 — compared the two non-thermal, non-tumescent techniques directly: MOCA versus cyanoacrylate adhesive. Both are marketed on being less painful.

There was no significant difference in pain immediately after treatment (VAS 24 mm for MOCA versus 20 mm for adhesive, p = 0.23). Occlusion rates, clinical severity and quality of life were comparable. Four patients in the adhesive arm developed minor complications — superficial thrombophlebitis and thrombus extension.

What the three trials share: the advantage a newer technique was built around either did not appear under randomised comparison, or appeared only at the expense of some other outcome.

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How to read the level of evidence

One point has to be made plainly here. The conclusions above do not rest on phlebectomy having an abundant evidence base.

The numbers give a sense of the scale:

Study	Size
de Roos 2003 (phlebectomy vs sclerotherapy)	98 legs, single centre
Chetter 2006 (conventional phlebectomy vs TIPP)	62 patients, single centre
Carradice 2009 (concomitant phlebectomy)	50 patients, single centre
Xie 2026 meta-analysis	6 randomised trials, 432 patients

Set against drug licensing trials enrolling thousands, these are all small. The randomised trial directly comparing phlebectomy with sclerotherapy dates from 2003, and a comparably sized repetition is hard to find. A team at Imperial College registered a randomised trial of phlebectomy versus foam sclerotherapy (target 160 patients) in 2018 and published the protocol in 2019, but we were unable to locate a published results paper.

This is where a common misreading arises.

"Less evidence" and "less effective" are not the same statement.

An older technique has no patent and no manufacturer. There is nobody with a commercial reason to design and fund a large trial. A new device, by contrast, generates studies because approval and marketing require them — but a substantial share of those studies are single-arm, without a comparator, and short in follow-up.

Count papers, and newer techniques look overwhelmingly better supported. Narrow the count to studies that randomised the new method against the established one and won, and the picture changes. The three cases above are exactly that.

Which is why what matters is not the number of studies but their design.

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Phlebectomy has clear disadvantages too

For balance, the other side of the ledger. Phlebectomy is not a universal answer.

It requires incisions. However small, the skin is opened, and more openings mean more discomfort during recovery.

Bruising and pigmentation can follow. The de Roos trial, where blistering, matting, scarring and bruising were all significantly more frequent after phlebectomy, makes this concrete.

Results vary with the operator. This is handwork, not machine work; where and how each vein is hooked and withdrawn changes the outcome, which also makes it harder to standardise.

It does not suit every vessel. Fine vessels sitting very close to the skin surface, and spider veins, are not treated this way. That territory belongs to sclerotherapy and surface laser.

The evidence cited above has limits of its own, too. As set out in our article on concomitant and staged treatment, whether adding phlebectomy is always the better course is a point on which the major guidelines still disagree.

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What should actually guide the choice?

To summarise: "newest" is not a selection criterion. The criterion is which vessel the method suits.

• Large, deep trunks such as the saphenous vein → thermal closure (laser, radiofrequency) or non-thermal closure (cyanoacrylate, MOCA)
• Tributary veins bulging under the skin → phlebectomy or sclerotherapy
• Spider veins visible through the skin → sclerotherapy, surface laser

Each layer calls for a different tool, and more than one layer is commonly present in the same leg. Real treatment plans are therefore usually combinations.

None of this means newer techniques lack genuine value. Cyanoacrylate closure reduces the compression stocking burden; MOCA widens the options below the knee, where nerve injury is a concern. The point is that those advantages apply in defined situations.

That is why da Re-Fit maintains second-generation thermal treatment, third-generation non-thermal treatment and phlebectomy side by side. With only one tool available, every vein ends up being explained in terms of that tool. Our source vein treatment page sets out how the stages fit together.

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In closing

New technology generally arrives intending to improve something. Whether it actually did can only be answered by studies that randomised it against the established method. Look at those studies, and sometimes the improvement is confirmed and sometimes it is not.

Phlebectomy has survived seventy years not through inertia. A removed vein cannot reopen — a simple fact confirmed repeatedly across randomised trials. The same trials also recorded the price: incisions and bruising.

When choosing a clinic, it is more useful to ask whether they can explain why they chose a given method than whether they have the newest equipment. Only a clinic with several tools can match the tool to the vein — and only then is there a reason to explain.

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References

• de Roos KP, Nieman FH, Neumann HA. Ambulatory phlebectomy versus compression sclerotherapy: results of a randomized controlled trial. Dermatol Surg. 2003 Mar;29(3):221-6. (PMID: 12614412)
• Chetter IC, Mylankal KJ, Hughes H, Fitridge R. Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins. Br J Surg. 2006 Feb;93(2):169-74. (PMID: 16432820)
• Carradice D, Mekako AI, Hatfield J, Chetter IC. Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins. Br J Surg. 2009 Apr;96(4):369-75. (PMID: 19283745)
• 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)
• Xie Y et al. Combined endovenous ablation with phlebectomy or foam sclerotherapy versus endovenous ablation alone for lower limb varicose veins: A systematic review and meta-analysis. Phlebology. 2026 Apr 16. (PMID: 41990331)
• 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)
• Mohamed AH et al. A Randomized Controlled Trial of Endovenous Laser Ablation Versus Mechanochemical Ablation With ClariVein in the Management of Superficial Venous Incompetence (LAMA Trial). Ann Surg. 2021 Jun 1;273(6):e188-e195. (PMID: 31977509)
• Belramman A et al. Pain Outcomes Following Mechanochemical Ablation vs Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Vein Incompetence: The MOCCA Randomized Clinical Trial. JAMA Surg. 2022 May 1;157(5):395-404. (PMID: 35385061)
• Belramman A, Bootun R, Lane TRA, Davies AH. Foam sclerotherapy versus ambulatory phlebectomy for the treatment of varicose vein tributaries: study protocol for a randomised controlled trial. Trials. 2019 Jul 3;20(1):392. (PMID: 31269978)
• 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)