Why Vein Stripping Is No Longer the First Choice — and Why It Has Not Disappeared

Anyone researching varicose vein treatment soon comes across this remark.

"I heard nobody pulls the vein out any more these days."

As endovenous methods such as laser and radiofrequency ablation have become widespread, the operation known as stripping has moved to a different place than it once held.

Does that mean stripping is an operation that stopped working and fell out of use? Is every treatment that physically removes a vein an outdated one?

To answer that, stripping and miniphlebectomy first have to be told apart. Then the effectiveness, the recovery and the role each holds in current guidelines can be looked at together.

First: stripping and miniphlebectomy are different operations

Both remove a vein physically. But they target different veins and remove them in different ways.

	Stripping	Miniphlebectomy
Main target	Truncal veins such as the great or small saphenous vein	Tributary varicosities bulging under the skin
Method	A segment of the target vein is removed with an instrument	Tributaries are removed through tiny skin incisions
Role in the treatment plan	One option for treating truncal reflux	One option for treating the problem tributaries

Stripping removes a segment of the refluxing truncal vein. It has usually been combined with high ligation.

Miniphlebectomy removes the tortuous tributaries under the skin through small incisions. It can be combined with laser or radiofrequency treatment of the trunk.

So "pulling the vein out" does not describe one operation, and treating the two as the same leads to misunderstanding the plan. The 2023 joint guideline of the Society for Vascular Surgery (SVS), American Venous Forum (AVF) and American Vein and Lymphatic Society (AVLS), Part II, recommends miniphlebectomy or ultrasound-guided sclerotherapy for symptomatic tributary varicosities (recommendation 7.2.1, strong recommendation, moderate evidence).

That stripping has slipped down the order does not mean the role of miniphlebectomy has shrunk with it. The evidence for miniphlebectomy is covered in a separate column.

1. Was stripping pushed aside because it does not work?

That explanation does not fit the trial data.

Stripping is an effective treatment that physically removes the refluxing vein. Long-term results give no reason to say its effect has faded.

The clearest example is the five-year follow-up of the CLASS trial, published in the NEJM in 2019. At 11 UK centres, 798 patients with primary varicose veins were randomised to laser ablation, foam sclerotherapy or surgery. At five years, 595 (75%) completed quality-of-life questionnaires.

Both laser and surgery gave better disease-specific quality of life (AVVQ) than foam sclerotherapy. In generic health-related quality of life, no difference between groups was found (Brittenden et al., 2019).

The trial shows that surgery also delivers a meaningful long-term benefit. At the same time, it does not show that laser is superior to surgery in every respect, nor that every outcome of the two is identical.

What matters to a patient, alongside abolishing the reflux, is what the recovery involves and what burden is taken on.

2. So why is endovenous treatment considered first?

Laser and radiofrequency treat from inside the vein through a catheter. The reflux is stopped without physically extracting the vein segment, which is a different kind of intervention.

Choosing treatment means comparing that difference in invasiveness together with pain, return to daily life and long-term results.

The 2011 randomised trial by Rasmussen and colleagues compared laser, radiofrequency, foam sclerotherapy and stripping in 500 patients (580 legs) with great saphenous reflux.

Median time to return to normal function was as follows.

Treatment	Median return to normal function
Laser	2 days
Radiofrequency	1 day
Foam sclerotherapy	1 day
Stripping	4 days

Radiofrequency and foam gave faster recovery and less post-procedure pain than laser and stripping. Foam, however, had the highest technical failure at one year: the great saphenous vein was open and refluxing in 16.3%, against 5.8% after laser, 4.8% after radiofrequency and 4.8% after stripping. Speed of recovery and durability of the vein treatment have to be judged separately (Rasmussen et al., 2011).

These figures should not be applied as today's recovery time for every patient. They reflect the equipment and technique of the time, and miniphlebectomy was performed in every group.

Note too that stripping in this trial was done under tumescent local anaesthesia with light sedation. The simple contrast "stripping always needs a general anaesthetic" is not accurate either.

This is how the order of preference has shifted: through weighing effectiveness, recovery burden and the conditions of the procedure together. Recovery times by method are set out in more detail in the recovery column.

3. Stripping has not vanished from the US guideline

The SVS/AVF/AVLS 2023 guideline (Part II) recommends endovenous ablation over high ligation and stripping for symptomatic axial reflux in the great or small saphenous vein in patients who are candidates for intervention (4.1.1 for the great saphenous vein, strong recommendation, moderate evidence; 4.1.2 for the small saphenous vein, strong recommendation, low evidence).

The same guideline, however, recommends high ligation and stripping when the technology or expertise for endovenous ablation is not available, or when the venous anatomy precludes endovenous treatment (4.1.4, strong recommendation).

What changed in the guideline, then, is which treatment is considered first. Stripping itself has not been classed as an inappropriate operation.

Guideline and actual usage also need separating. That endovenous treatment is preferred does not tell us how far stripping has declined in the United States, or whether it is rarely performed.

That is why, in describing stripping, "an operation for selected situations" is more accurate than "an obsolete operation".

4. Why it was chosen matters more than how old it is

The easiest yardstick for a patient is often the word "latest". But when a treatment first appeared says nothing about whether it suits your leg.

If stripping is recommended, you are entitled to hear why it was judged more appropriate than endovenous treatment. Equally, if laser or radiofrequency is recommended, you should understand which vein is to be treated and over what extent.

The questions are the same in either case.

• Is the vein to be treated a trunk or a tributary?
• Why was this method chosen for my veins?
• How do the expected benefit and burden compare with the alternatives?
• How will recovery and follow-up be handled?

Only when these can be answered does the plan become clear beyond the name of the procedure. Why the same diagnosis can lead to different treatment is explained in How da Re-Fit Clinic decides what to treat.

da Re-Fit Clinic explains the target and the reason for the choice

da Re-Fit Clinic maps the location and extent of reflux, the course of the veins and the distribution of tributaries with ultrasound, and reads them alongside the patient's symptoms.

Treatment of truncal reflux and treatment of bulging tributaries are distinguished and, where needed, combined. Whether to treat together or in stages while observing the response is discussed with the patient.

Understanding how the role of stripping has changed clarifies how to think about varicose vein treatment as a whole. An effective treatment can drop in priority when other options advance. Conversely, a long-established method retains a role for the right patients.

What da Re-Fit Clinic considers important is choosing the treatment that fits the patient's veins, and explaining the reason in a way the patient can follow.

The evidence for miniphlebectomy continues in Is the newest procedure always better?, and the question of treating together or in stages in the concomitant versus staged treatment column.

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References

• Brittenden J, Cooper D, Dimitrova M, et al. Five-Year Outcomes of a Randomized Trial of Treatments for Varicose Veins. N Engl J Med. 2019;381(10):912-922. (PMID: 31483962) — CLASS trial, five-year results; 798 randomised, 595 responded.
• Rasmussen LH, Lawaetz M, Bjoern L, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1079-87. (PMID: 21725957) — 500 patients, 580 legs, one-year follow-up; miniphlebectomy in all groups.
• 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) — endovenous ablation preferred (4.1.1, 4.1.2), conditions for high ligation and stripping (4.1.4), tributary treatment (7.2.1).

This article is general medical information. The method of an individual's treatment is decided after examination and duplex ultrasound.