Endovenous laser ablation versus radiofrequency ablation in chronic venous insufficiency: a comparative meta-analysis of efficacy and safety.

Background: Chronic venous insufficiency (CVI) is a common vascular disorder that substantially impairs quality of life. Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) have largely replaced conventional surgery; however, their comparative efficacy and safety-particularly across follow-up time points and EVLA wavelengths-remain debated. Methods: We conducted a systematic review and meta-analysis of PubMed, Scopus, Web of Science, the Cochrane Library, and Google Scholar from inception to September 2024. Thirty-three comparative studies (9 randomized controlled trials and 24 non-randomized studies) involving 22,814 patients (8,144 EVLA and 14,670 RFA) were included. Analyses were performed at the patient level. The single primary outcome was complete occlusion of the treated vein; all other endpoints were secondary. Secondary outcomes included procedural success, recanalization, partial occlusion, reflux-free rate, postoperative pain, recurrence, return to work or daily activities, patient satisfaction, and complications, with stratified analyses by follow-up time and EVLA wavelength. Results: RFA was associated with significantly lower postoperative pain at 6 weeks (mean difference [MD] = -3.00; 95% CI: -3.42 to -2.58) and 6 months (MD = -1.00; 95% CI: -1.85 to -0.14), and a reduced risk of paresthesia at 1 month (odds ratio [OR] = 0.52; 95% CI: 0.28-0.95). Non-randomized studies suggested lower recurrence rates with RFA compared with EVLA (OR = 0.42; 95% CI: 0.29-0.62), although randomized trials showed no significant difference. Complete occlusion rates were lower with RFA than with EVLA in pooled analyses (OR = 0.07; 95% CI: 0.04-0.14), particularly at early follow-up (1 day: OR = 0.01; 95% CI: 0.00-0.11), with differences diminishing over time. Variation in outcome definitions and imaging timing likely contributed to these early effects. Reflux-free rates and patient-reported outcomes, including Aberdeen Varicose Vein Questionnaire scores, did not differ significantly between groups. Conclusion: Both EVLA and RFA are effective and safe treatments for CVI. RFA provides advantages in short-term postoperative comfort and selected complications, whereas EVLA-particularly with 1,470-nm wavelengths-achieves more consistent early technical occlusion. However, these differences do not translate into clear differences in reflux-free status or patient-reported quality-of-life outcomes, supporting individualized treatment selection. When performed competently, neither modality offers a clinically meaningful advantage for patient-centered outcomes.