Perth's Leading Specialist in the Treatment of Varicose Veins
Dr Luke Matar | MBBS, FRANZCR, FACP
Glue Treatment For Varicose Veins
The Vein Clinic
6/28 Subiaco Square Rd, Subiaco
Considering glue treatment? What you should know
If a surgeon or clinic has recommended glue (VenaSeal™) for your varicose veins, this page is written for you. Dr Matar has performed both glue and laser treatment at volume — more than 200 glue treatments and more than 2,400 laser treatments. He was an early adopter of glue and co-authored the Australasian national consensus document on its use (Phlebology, 2020) — and he no longer offers it. His first-line treatment for saphenous vein reflux is endovenous laser ablation (EVLA).
What is Glue Treatment For Veins?
The most well known and used glue treatment for veins in Australia is the VenaSeal™ closure system. It was developed to improve the patient experience in the treatment of varicose veins and aims to replace the need for surgery, Endovenous Laser Ablation or Radiofrequency Ablation in many cases of saphenous insufficiency, by using a cyanoacrylate adhesive or “medical superglue” to seal the abnormal vein.
How Does Glue Treatment Work?
The VenaSeal™ procedure involves the placement of a very small amount of cyanoacrylate adhesive (medical superglue) into the abnormal vein through a catheter delivery system.
Whilst the initial studies suggested this to be equally effective as laser and a “painless procedure” without the need for the wearing stockings, this was not consistently borne out in practice.
How Long Has Glue Treatment Been Around For?
CE mark approval (Europe) occurred in September 2011, Australian TGA approval in January 2012 and US Food and Drug Administration (FDA) approval in February 2015. MBS (Medicare) funding for this procedure was introduced in May 2018.
Why do some surgeons favour glue?
If glue has been recommended to you, it helps to understand who it suits, and why. Some of the appeal is genuine and patient-facing: no tumescent anaesthetic injections, a quick procedure, a fast return to activity. But glue also has practical attractions on the practitioner’s side of the table:
No laser safety infrastructure. Laser requires a compliant laser-safe treatment room, protective eyewear and laser safety procedures. Glue requires none of this.
Lower equipment barrier. Laser involves a significant capital investment in the laser generator plus single-use fibres. Glue needs only the delivery kit.
No tumescent anaesthesia. Delivering ultrasound-guided tumescent anaesthetic (and nerve blocks) is one of the most skill-dependent parts of endovenous laser treatment. Glue removes that requirement entirely.
A shorter learning curve. Glue is technically simpler to deliver, which makes it attractive where vein treatment is one part of a broader surgical practice rather than a dedicated focus.
None of these are improper reasons — they are practical realities of running different kinds of practice. But they are conveniences for the provider, not outcomes for the patient. When you weigh a recommendation, it helps to separate the two — and to ask your surgeon the questions listed further down this page.
Advertised benefits vs real-world experience
Glue marketing lists an appealing set of benefits. Several of them are true — but equally true of modern laser treatment: no general anaesthetic, treatment in under an hour, a walk-in walk-out procedure, and a quick return to normal activity. EVLA offers every one of these, so they are not points of difference.
Glue does have one genuine technical advantage: it uses no thermal energy, so heat-related risks (skin burns, thermal nerve irritation) do not apply. Context matters, though: across more than 2,400 laser treatments in our practice, no skin burn has occurred, and nerve irritation is uncommon, mainly relevant below the knee, and usually temporary. In exchange, glue introduces risks that cannot be engineered away, because they belong to the implant itself: allergy, foreign-body reaction, and glue extension toward the deep veins.
The remaining advertised claims deserve a closer look. The comparison below reflects Dr Matar’s experience across more than 200 glue treatments and more than 2,400 laser treatments — a clinical observation, not a randomised trial:
| Advertised benefit | Real-world experience (>200 glue / >2,400 laser cases) |
|---|---|
| “A low-risk, minimally invasive procedure” | Minimally invasive, yes — but glue carries risks no other vein treatment has: allergy to the adhesive, foreign-body reaction (one of our patients required surgical excision of a glued vein for this reason), and glue extension toward the deep veins, reported in up to 21% of patients in early trial data. |
| “Virtually pain-free — only minor discomfort” | Not always. The glue system is delivered through a 7 French introducer sheath (per the manufacturer’s instructions for use) — considerably larger than a fine laser fibre. In smaller veins this can trigger venospasm and significant pain. Some patients we treated with glue on one leg and laser on the other told us they preferred the laser experience. |
| “Success rates of up to 96.8%” | Look closely at how “closure” is defined — a vein with multiple residual open segments can still be counted as “closed” (explained below). In our experience across more than 200 glue cases, a number of saphenous veins required retreatment for incomplete closure; one patient required rescue surgery after the vein could not be closed despite repeated attempts, and one required surgical excision of the glued vein for a foreign-body reaction. Across more than 2,400 laser cases, roughly 1 in 1,000 veins has needed re-treatment with laser — and none has needed rescue surgery. |
| “No compression stockings required” | True for closure — trial data show veins close without compression. But glue commonly causes a phlebitis-type reaction (reported in around 16% of patients in early trial data), and evidence across endovenous treatments consistently shows short-term compression reduces pain in the first week. Many specialists still recommend short-term compression after glue for exactly this reason. |
| Specifically designed for saphenous vein closure | The system is designed for the straight main saphenous trunks (GSV/SSV). Real-world reflux is rarely that tidy: accessory veins, tributaries, perforators and recurrent veins are often part of the pattern. A fine, flexible laser fibre can treat many of these (extended EVLA); a glue catheter cannot reach most of them. |
How safe is glue — and why Dr Matar stopped offering it
Cyanoacrylate-based medical glue, a time-tested adhesive employed in medical practices such as brain surgery and wound closure for over 50 years, boasts an impressive safety record. Initial studies involving cyanoacrylate for vein treatment suggested that severe adverse events were comparatively rare.
However, new perspectives have been brought to light by a pivotal presentation by Professor Parsi, Head of UIP, at the 2023 Adelaide ACP (Australiasian College of Phlebology) conference. His research highlights potential complications linked with glue treatment for veins, pinpointing risks tied to potential allergies to the glue’s components and subsequent foreign body reactions. This revelation underscores the significance of ongoing research and a comprehensive understanding of vein treatment options.
Dr Matar’s own view is grounded in direct experience, not distance: he adopted glue early, performed more than 200 glue treatments, and co-authored the Australasian consensus document on its use (Phlebology, 2020). Two things ultimately changed his assessment. First, the safety signal — hypersensitivity and foreign-body reactions to the permanently implanted adhesive, sometimes delayed, occasionally needing steroids or surgical removal of the glued vein. Unlike laser, which closes the vein and leaves nothing behind, glue stays in the body as a foreign material, and a reaction can be difficult to manage. Second, his own results — the pattern set out in the comparison table above.
As a result of this evidence and his personal experience, Dr Matar has stopped offering glue treatment altogether and uses laser as his first-line method for treating saphenous veins. This reflects his philosophy of only offering treatments he would be comfortable having himself, or offering to friends and family.
Reasonable specialists weigh these factors differently, and glue remains an approved treatment in Australia — but that is the judgement Dr Matar has reached.
Why EVLA instead?
Moving away from glue is only half the picture — the other half is what laser offers in its place. Beyond avoiding an implanted adhesive, three things stand out:
Versatility across the whole reflux pattern. A laser fibre is fine and flexible — in selected patients it can treat not just the main saphenous trunks but accessory veins, tributaries, perforators and recurrent veins (an approach Dr Matar terms extended EVLA), whereas glue delivery mainly suits straighter truncal segments. Real-world reflux rarely follows the textbook.
Nothing left behind. The laser-treated vein is sealed and gradually reabsorbed — no permanent implant, and so no possibility of a delayed reaction to one.
A comfortable recovery. Modern higher-wavelength lasers with single-use radial fibres — the equipment Dr Matar uses — are associated in published comparisons with less post-procedure pain than older equipment, and EVLA is a walk-in, walk-out procedure under local anaesthetic.
EVLA also carries the strongest first-line recommendations for truncal veins in the major guidelines (ESVS, NICE, SVS), with published closure rates above 94%. You can read how the procedure works, what to expect, and the full evidence on our Endovenous Laser Ablation (EVLA) page.
Been offered glue? Get an independent opinion first
Before committing to any vein procedure, a duplex ultrasound assessment establishes exactly which veins are refluxing and what the full treatment plan should look like — glue and laser alike are rarely stand-alone solutions, and branch veins often need foam sclerotherapy or phlebectomy regardless of how the trunk is treated. Dr Matar has performed both procedures at volume and can give you an evidence-based view of your options, with no obligation.
Glue Treatment for Varicose Veins
Before & Afters
Treatment Method
These before/after images demonstrate a case study of glue treatment for veins. A 59-year-old patient presented with large varicose veins after 20 years of discomfort and heavy legs toward the end of the day, as well as symptoms of itchy legs. As a cabinet maker, he wanted a tailored “walk-in walk-out” treatment approach that would allow him to go back to work ASAP with minimal downtime.
The first stage of treatment involved VenaSeal glue treatment to the malfunctioning saphenous veins. The second stage included sclerotherapy and ultrasound-guided phlebectomy removal of branch vessels.
This treatment was performed during the period when The Vein Clinic offered glue closure; glue treatment is no longer offered at the clinic.
The Procedure
A fine catheter is inserted into the vein under ultrasound guidance.
Glue is then deposited into the vein in small increments.
Compression is immediately placed on the vein to allow the vein walls to seal together.
Over time fibrous tissue forms around the glue causing a permanent seal.
Stages of Vein Treatment
Stage 1
Treatment of large malfunctioning veins (trunk)
Endovenous Laser Treatment (EVLA) to great, small, and/or anterior accessory saphenous veins. 60 minutes
Stage 2
Treatment of large varicose veins (branches)
Phlebectomy removal of larger bulging varicose veins 90-120 minutescombined with
Ultrasound-Guided Foam Sclerotherapy (UGFS) on smaller veins. 30 minutes
Stage 2
Treatment of small varicose veins (branches) if required
Extra sessions of UGFS to close smaller veins if identified as required at post-treatment follow-up scan 30 minutes
You may not require this stage.
Stage 3
Optional treatment surface veins (leaves)
Usually done by Microsclerotherapy 30 minutes
Most patients require multiple treatment sessions to remove spider veins.
Stage 4
Follow up and maintenance to ensure best results
Is Glue Treatment The Right Option For You?
Should you be considering glue treatment for varicose veins, it’s crucial to familiarise yourself with the recognised risks and benefits of this procedure. As this method is relatively recent, our understanding continues to evolve. Certain risks we are aware of today were not known when cyanoacrylate glue was initially licensed for use both in Australia and internationally.
Reflecting on the perspectives of phlebology professionals, a significant shift is apparent. Most phlebologists in Australia and New Zealand no longer employ glue for saphenous vein closures.
Read MoreWhy Choose The Vein Clinic Perth?
Dr Luke Matar’s journey in the specialised field of phlebology began in 2011 with UK-based EVLA expert Professor Mark Whiteley, renowned as the inventor of laser perforator vein ablation. Following this, Dr Matar honed his expertise under the guidance of numerous renowned international vein specialists, including Professor Kurosh Parsi, Professor Ken Myers, Dr Mark Malouf, Dr Andrew Stirling, Dr Loius Loizou, Dr Chris Lekich, Dr Chris Ragg (Berlin) Dr David West (UK) and Dr Ron Bush (USA).
Dr Matar established the Vein Clinic in 2014, driven by the desire to offer optimally effective, carefully individualised vein treatments to his patients. His practice philosophy is deeply personal: providing the kind of treatment he would wish for himself or a family member. This means recommending what is genuinely best for the patient, even if it requires referring them elsewhere for particular vein issues.
Having personally undergone three laser treatments, multiple phlebectomies and several foam sclerotherapy sessions, Dr Matar empathises deeply with his patients’ experiences. His passion and commitment lie in offering individualised treatment plans, uniquely customised to address each patient’s specific vein issues and personal preferences. The unique insight gained from the other side of the treatment table also led him to refine and pioneer a number of advanced treatments including UGFP (Ultrasound-Guided Foam Phlebectomy) and extended endovenous laser ablation extending what can be achieved with laser treatment.
Our Real World Experience
At The Vein Clinic Perth, we’ve tracked our outcomes closely.
Among patients treated with cyanoacrylate glue, approximately 1 in 10 (10%) required some form of retreatment—whether for persistent reflux, residual veins, or related symptoms.
By comparison in > 2400 cases, < 0.1% of saphenous vein treated with endovenous laser have required retreatment with laser.
This reflects the superior reliability and consistency we’ve observed with laser therapy over time.
Do I Need Treatment for Varicose Veins?
You could benefit from treatment for varicose veins if you experience any of the following vein problems.
Other Minimally Invasive
Varicose Veins Treatments
Frequently Asked Questions
Does The Vein Clinic still offer glue treatment?
No. Dr Matar was an early adopter of glue closure — performing more than 200 glue treatments — and co-authored the Australasian national consensus document on its use, but he no longer offers glue treatment. Based on published safety evidence and the outcomes observed in his own practice, his first-line treatment for saphenous vein reflux is endovenous laser ablation (EVLA), combined where needed with foam sclerotherapy or phlebectomy. If you have specific questions about glue — including symptoms after previous glue treatment elsewhere — book an appointment to see Dr Matar.
Is glue treatment a complete solution for varicose veins on its own?
No, glue treatment, like other vein treatments, is rarely a standalone solution. It typically addresses the main saphenous veins, but follow-up procedures such as foam sclerotherapy or phlebectomy are often necessary to treat associated branch vessels for comprehensive results.
What are the advertised benefits of glue treatment compared to laser or radiofrequency ablation?
Vein glue is commonly marketed on six main claims. It is useful to separate the genuine differences from laser treatment from claims that also apply to modern EVLA.
Genuine Differences From Laser
1/ No tumescent anaesthesia
This is a genuine difference. Glue avoids the ultrasound-guided local anaesthetic injections used during laser treatment.
However, in our experience, tumescent anaesthesia is generally well tolerated when performed by an experienced operator, particularly with the addition of ultrasound-guided nerve blocks where appropriate.
2/ No thermal energy
This is also a genuine difference. Because glue does not use heat, heat-related risks such as skin burns and thermal nerve irritation do not apply.
In context, however:
• We have performed more than 2,400 EVLA treatments without a skin burn.
• Nerve irritation is uncommon.
• When it does occur, it is mainly relevant to treatment below the knee and is usually temporary.
Claimed Advantages That Also Apply to Modern Laser
3/ Quick outpatient procedure
Glue is promoted as a quick, walk-in, walk-out procedure.
Modern EVLA is also performed under local anaesthetic, usually takes less than an hour, and patients walk out immediately afterwards.
4/ Fast return to normal activity
This is also not unique to glue. Most patients return quickly to normal daily activity after EVLA.
Claims That Are Not Consistently Borne Out
5/ Less pain
Glue is often promoted as being less painful than laser, but this is not always our experience.
The glue system is delivered through a 7 French introducer sheath, which is considerably larger than the fine fibre used for EVLA. In smaller veins, introducing this larger sheath can cause venospasm and significant discomfort.
Some patients treated at this clinic with glue in one leg and laser in the other have actually preferred the laser experience.
6/No compression stockings required
Veins can close successfully after glue without compression stockings.
However, glue commonly causes a phlebitis-type inflammatory reaction. Evidence across endovenous treatments also suggests that short-term compression can reduce discomfort during the first week.
For this reason, many vein specialists still recommend compression after glue treatment.
So What Are the Real Differences?
When the marketing claims are separated out, glue has two clear differences from EVLA:
• No tumescent anaesthetic injections
• No thermal energy
These need to be weighed against an important difference in the other direction: glue leaves a permanent synthetic implant inside the treated vein.
That introduces risks that do not occur with laser treatment, including:
• Allergic or hypersensitivity reactions
• Foreign-body inflammatory reactions
• Extension of glue toward the deep venous system
After performing more than 200 glue treatments and more than 2,400 EVLA treatments, Dr Matar concluded that the balance of advantages, risks and patient experience favoured EVLA.
For this reason, The Vein Clinic no longer offers vein glue and uses EVLA as its first-line treatment for suitable patients.
The comparison table above sets out each of these claims in more detail
What are the potential downsides of glue treatment compared to laser or radiofrequency ablation?
Cyanoacrylate glue treatment (e.g., VenaSeal) is often marketed as a convenient, non-thermal option. However, unlike thermal methods such as endovenous laser ablation (EVLA) or radiofrequency ablation (RFA), glue remains in the vein permanently as a foreign body. This can introduce long-term risks such as inflammation, hypersensitivity, and immune reactions. Laser and RFA treatments seal the vein without leaving any material behind, offering more consistent and durable results with fewer complications.
What are the documented risks of glue treatment?
Risks associated with glue treatment include:
• Phlebitis (inflammation of the vein)
• Hypersensitivity or allergic reactions (sometimes severe or delayed)
• Foreign body granulomas (in 0.7% to 1.6% of cases)
• Thrombosis in the treated vein
A major study by Dr. Kurosh Parsi (Phlebology, October 2023) reported 899 serious adverse events globally, including 13 deaths, 7 strokes, and 211 thromboembolic events. Dr. Eri Fukaya (Endovascular Today, 2025) found that up to 13% of patients developed immune or allergic responses, with some requiring oral steroids or surgical vein removal.
Is glue treatment as versatile as laser treatment?
No. This is one of the clearest practical differences between the two, and it is rarely mentioned in glue marketing.
The VenaSeal system is designed for the straight main saphenous trunks — the great saphenous vein and small saphenous vein. Within that specific role it works as intended. The limitation is that real-world venous reflux is rarely confined to a single straight trunk.
Most patients have a pattern involving several of the following:
Accessory saphenous veins. The anterior accessory saphenous vein is a frequent source of reflux, either alongside the main trunk or in isolation, and is a common cause of recurrence when missed. It often runs a short, angled course close to the skin and may be difficult or impossible to treat using the venaseal catheter delivery system.
Tributary and branch veins. The visible bulging varicose veins patients present with are usually tributaries rather than the trunk itself. These are tortuous and superficial.
Perforator veins. These connect the superficial and deep systems and are short, angled and often refluxing in patients with skin changes or ulceration. They are a recognised contributor to venous ulcer non-healing. The venaseal catheter delivery system is unable to treat these veins, they can in many cases be treated with laser by a skilled operator.
Recurrent veins. After previous surgery or ablation, recurrent reflux typically runs through irregular, neovascular channels rather than a clean trunk.
A laser fibre is fine and flexible, and it delivers energy along the length of the vein through a catheter that can be advanced into small, curved and short segments. In selected patients this allows treatment of accessory veins, tributaries, perforators and recurrent veins in the same session as the main trunk — an approach Dr Matar terms extended EVLA.
The glue delivery catheter is stiffer and requires a 7 French introducer sheath. It is difficult or impossible to navigate into most of these vessels, and glue is not designed or approved for them.
The practical consequence is that glue treats one part of the problem. Whatever is not treated still needs addressing, usually with foam sclerotherapy or phlebectomy, and anything left untreated is a potential source of persisting symptoms or early recurrence. Laser is not a stand-alone solution either — branch veins commonly need foam sclerotherapy or phlebectomy after EVLA as well — but it can address a wider range of the underlying reflux pattern before those steps are needed.
This is why a duplex ultrasound assessment before treatment matters. It maps which veins are actually refluxing, and that map determines whether the treatment being proposed can reach all of them.
Is glue treatment as successful as laser treatment?
Glue is often marketed as highly successful, but it's important to look at how “success” is defined. In clinical studies, a treated vein is considered successfully closed as long as no single open segment exceeds 5 cm. This means a vein can have multiple shorter open sections and still be labelled “closed.” These residual open segments can continue to cause symptoms such as varicose veins or venous reflux and may require additional treatment.
Can incomplete closure with glue be considered “successful”?
Yes, incomplete closure may still be counted as success, even if parts of the vein remain open and continue to cause symptoms. These residual patent (open) segments can lead to persistent varicose veins, ongoing reflux, or the need for further treatment. Laser treatments, by contrast, aim for complete and continuous closure of the entire vein length—offering a more consistent and durable outcome.
Why are many experts now cautious about glue treatment?
Due to growing evidence of long-term risks and complications, many Phlebologists in Australia and New Zealand now favour EVLA as the preferred treatment for saphenous veins. Glue is generally reserved for select cases where its specific advantages clearly outweigh the risks.
An interesting paradox is that in Perth, glue usage is rising rapidly — largely driven by surgeons — while interstate the increase is stable or much smaller. Yet at interstate professional meetings, experienced vein specialists increasingly report scaling back or discontinuing glue use altogether due to safety concerns.
What should I ask my doctor before choosing glue therapy?
If you're considering glue treatment, it's essential to ensure you receive thorough and honest informed consent. Ask your provider about:
• Long-term data on glue safety
• Their personal complication rates
• Whether alternatives like EVLA might offer similar or better outcomes with fewer risks
• The likelihood of needing additional treatments (e.g., foam sclerotherapy or phlebectomy for branch veins)
Remember: Glue is rarely a stand-alone solution. Like all vein treatments, follow-up care is often needed to achieve optimal results.
I have already had glue treatment — should I be worried?
Most patients who have had glue treatment do well and need no special action. Serious reactions are uncommon. However, if you have developed persistent redness, itching, lumpiness, swelling or discomfort along a glue-treated vein — particularly if symptoms appeared weeks or months after treatment — it is reasonable to have this assessed. A duplex ultrasound can establish whether the vein has closed properly and whether any reaction around the implanted adhesive may be contributing to your symptoms.
References
- Parsi K, Roberts S, Kang M, et al. Cyanoacrylate closure for peripheral veins: Consensus document of the Australasian College of Phlebology. Phlebology. 2020;35(3):153–175. doi:10.1177/0268355519864755. (Co-authored by Dr Luke Matar.)
- Gibson K, Minjarez R, Rinehardt E, Ferris B. Frequency and severity of hypersensitivity reactions in patients after VenaSeal™ cyanoacrylate treatment of superficial venous insufficiency. Phlebology. 2020;35(5):337–344. doi:10.1177/0268355519878618.
- Parsi K, Zhang L, Whiteley MS, et al. 899 serious adverse events including 13 deaths, 7 strokes, 211 thromboembolic events, and 482 immune reactions: The untold story of cyanoacrylate adhesive closure. Phlebology. 2024;39(2):80–95. doi:10.1177/02683555231211086.
- Fukaya E, O’Banion LA, Shao MY, et al. Hypersensitivity reaction with cyanoacrylate glue: Patient selection, technical considerations, and management. Endovascular Today. 2025;24:52–56.
- Almeida JI, Javier JJ, Mackay EG, Bautista C, Proebstle TM. First human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord. 2013;1(2):174–180. doi:10.1016/j.jvsv.2012.09.010.
- Gibson K, Ferris B. Cyanoacrylate closure of incompetent great, small and accessory saphenous veins without the use of post-procedure compression: Initial outcomes of a post-market evaluation of the VenaSeal System (the WAVES Study). Vascular. 2017;25(2):149–156. doi:10.1177/1708538116651014.
- Medtronic. VenaSeal™ Closure System. Product information and instructions for use. Medtronic; accessed August 2026.
- De Maeseneer MG, Kakkos SK, Aherne T, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022;63(2):184–267. doi:10.1016/j.ejvs.2021.12.024.
- National Institute for Health and Care Excellence (NICE). Varicose veins: diagnosis and management. Clinical guideline CG168. Published 24 July 2013.
- 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: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. J Vasc Surg Venous Lymphat Disord. 2024;12(1):101670. doi:10.1016/j.jvsv.2023.08.011.
- Palombi L, et al. TOTal Endovenous Laser Ablation Multicenter Trial (TOTEM): Early Results. J Vasc Surg Venous Lymphat Disord. Published online June 13, 2026:102554. doi:10.1016/j.jvsv.2026.102554.
- Belramman A, Bootun R, Lane TRA, Davies AH. COmpressioN following endovenous TreatmenT of Incompetent varicose veins by sclerotherapy (CONFETTI). J Vasc Surg Venous Lymphat Disord. 2024;12(2):101729. doi:10.1016/j.jvsv.2023.101729.
This page provides general information only and is not a substitute for a medical consultation. A duplex ultrasound assessment is required before any treatment recommendation can be made.
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