Trunk choice by CLASS, ulcer healing versus recurrence, and tributary timing with nerve honesty

Model answer

(A) The 34-year-old choosing a trunk — laser or surgery first, foam priced honestly (4 marks). Quote CLASS (798 patients): foam gains less disease-specific quality of life than surgery at 6 months (effect size −1.74) but matches laser, while procedural complications run 1% laser against 7% foam and 8% surgery, truncal ablation favours surgery and laser equally over foam, and foam/laser return patients to behaviours faster.^[15] Confirm with the Dutch 3-arm (240 patients): 1-year anatomic success 88.5% laser, 88.2% surgery, 72.2% foam, with complications low and equal.^[17] Add Cochrane (13 trials, 3081 patients): laser-versus-surgery recurrence tied, with laser halving neovascularisation (OR 0.05) and technical failure (OR 0.29).^[19] Close with the decade: the same Pronk cohort shows 10-year duplex groin-recurrence freedom of 73 versus 44% favouring stripping with reinterventions at 17 versus 36%, and the 14-year cohort shows foam reinterventions at 56.4 versus 13.2 versus 8.2% — so offer laser or stripping first and foam for convenience with repeat-procedure consent.^[23][29]

(B) The healed ulcer wanting freedom — recurrence is the enemy, stockings the cover (3 marks). Separate healing from recurrence with ESCHAR (500 legs): 24-week healing tied 65 versus 65%, but 12-month recurrence more than halved at 12 versus 28% with minimal equal harm — and at 4 years healing still tied (89 vs 93%) while recurrence runs 56 versus 31% with ulcer-free time at 78 versus 71%.^[9][10] Refuse the stocking holiday with Cochrane (8 trials, 1995 participants): European class-3 stockings halve reulceration against none (RR 0.46), and UK class-2 carries 1.55-fold the reulceration of class-3 — higher pressure prevents more ulcers while fewer legs tolerate it.^[34]

(C) The active ulcer with tributaries and small saphenous reflux — ablate early, combine tributaries, respect the nerve (3 marks). Time ablation by EVRA (450 patients, 20 centres): ablation within 2 weeks of randomisation versus deferred — healing hazard 1.38, median 56 against 82 days, 24-week healing 85.6 against 76.3%, ulcer-free 306 against 278 days.^[12] Combine tributaries by default: 6 randomised trials with 432 patients show immediate phlebectomy-or-foam with truncal ablation cuts reintervention to one-third (RR 0.33) with better 6-week AVVQ and 12-month VCSS and no safety penalty — staging only where the elimination test promises trunk rescue (50% reflux-free at 1 year, >65% when positive).^[26][25] Treat the small saphenous trunk nerve-first: the sural nerve lies within 5 mm in 70% of proximal and 90% of distal legs with fascia shielding in 95% proximally but 15% distally, so favour the proximal third; quote flush-laser heat-thrombosis at 2.5% class-3 plus 0.2% class-4 with zero embolism/thrombosis observed, and cover high-thrombosis-risk legs with 1–2 weeks of low-molecular-weight heparin by consensus.^[38][36][37]