Comment on: A randomized clinical trial of isolated ambulatory phlebectomy versus saphenous thermal ablation with concomitant phlebectomy (SAPTAP trial)

Dear Editor

We read with interest the article by Scheerders et al.¹ published on 5 December 2022. The authors, in a multicentre randomized study, compared two treatments for varicose veins, simple ambulatory phlebectomy (SAP) versus endothermal ablation of the great saphenous vein (GSV) and/or anterior accessory saphenous vein with concomitant phlebectomy (TAP), at 1-year follow-up.

The primary outcome was quality of life, and the trial did not show any difference between the two arms. The authors also evaluated a variety of secondary outcomes. Among the latter, duplex assessment of saphenofemoral reflux is certainly the most interesting measure. In the SAP arm, reflux disappeared in 99 per cent of patients, with no significant differences versus the TAP arm. Such a phenomenal finding is not surprising and was already described at 1-year follow-up (https://doi.org/10.1053/ejvs.2001.1338).

Moreover, a predictive duplex finding of SAP durability over years has been described just only in BJS (https://doi.org/10.1002/bjs.7022). It is mandatory to assess the competence of the GSV terminal valve with the Duplex sample placed at the femoral side. Reflux has to be elicited either by squeezing or by Valsalva manoeuvre. It has been demonstrated that approximately half of patients with varicose veins exhibit a competent terminal valve. When at least one of the two duplex manoeuvres above was negative for reflux, SAP recurred in 14 per cent of patients by 3-year follow-up, which is quite competitive and cost-effective compared with any other technique. On the contrary, SAP performed in presence of an incompetent terminal valve leads to disastrous results at 3 years (https://doi.org/10.1002/bjs.7022).