Can varicose veins recur after treatment?

Varicose Veins Can and Do Recur After Treatment

Yes, varicose veins frequently recur after treatment, with recurrence rates ranging from 20-28% at 5 years even with appropriate surgical intervention, and higher rates (up to 47-66%) when measured by clinical and physiologic criteria. 1, 2, 3

Understanding Recurrence Rates by Treatment Type

Surgical Treatment Recurrence

• Traditional surgical stripping has a 5-year recurrence rate of 20-28%, even when performed correctly 1
• At the saphenofemoral junction, recurrence occurs in 1% at 1 year but increases to 23% by 3 years 3
• At the saphenopopliteal junction, recurrence is higher: 25% at 1 year, escalating to 52% by 3 years 3
• Clinical recurrence reaches 47.1% at 5 years, with physiologic recurrence (measured by venous filling index) occurring in 66% of limbs 3

Endovenous Thermal Ablation Recurrence

• Radiofrequency ablation achieves 91-100% occlusion rates at 1 year, representing superior short-term outcomes compared to surgery 1, 4
• However, long-term recurrence still occurs at rates of 15-35% by 2 years post-intervention 5, 1

Foam Sclerotherapy Recurrence

• Foam sclerotherapy demonstrates 72-89% occlusion rates at 1 year 1, 6
• Chemical sclerotherapy alone has significantly worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation, with higher rates of recurrent GSV reflux and saphenofemoral junction failure 1, 6

Primary Mechanisms of Recurrence

1. Incomplete Initial Treatment

• Inadequate surgery at major junctions contributes to recurrence in 7.2% of limbs 3
• Failure to treat saphenofemoral junction reflux is a critical factor, as untreated junctional reflux causes persistent downstream pressure leading to tributary vein recurrence 1, 6
• Failure to ligate perforating veins is identified as a major contributor, with 92.7% of recurrent cases showing perforating vein insufficiency 7

2. Neovascularization

• Neovascular reconnection at the saphenofemoral junction is a major contributor to late recurrence, occurring even after technically adequate initial surgery 3
• This represents new vessel formation connecting the superficial and deep venous systems 8, 9

3. Disease Progression

• Persistent abnormal venous function predicts recurrence, with 29 of 53 limbs that had normal venous filling index post-operatively deteriorating by 3 years 3
• Incompetent perforator vessels increase progressively in number over time 3
• 78.9% of recurrent cases show reflux of the superficial femoral vein of varying severity 7

4. Residual Untreated Disease

• 75.2% of recurrent cases had residual saphenous vein that was not adequately treated initially 7
• 17.4% had blocked iliac veins due to post-thrombotic syndrome, representing upstream obstruction 7

Predictors of Recurrence

Limbs with the following characteristics at 3 weeks post-treatment are at highest risk:

• Multiple sites of reflux preoperatively 3
• Venous filling index >2 mL/s 3
• Persistent abnormality at duplex scanning 3

Notably, 40 limbs with normal findings at 3 weeks had zero recurrence, demonstrating the importance of complete initial treatment 3

Critical Treatment Principles to Minimize Recurrence

Mandatory Pre-Treatment Assessment

• Comprehensive duplex ultrasound within 6 months is essential, documenting reflux duration ≥500ms, exact vein diameters, and all sites of incompetence 1, 4, 6
• Preoperative imaging must identify all perforating vein insufficiency to guide complete surgical intervention 7

Treatment Sequencing Matters

• Endovenous thermal ablation must be performed first for saphenofemoral or saphenopopliteal junction reflux (veins ≥4.5mm diameter) 1, 4
• Sclerotherapy should be reserved for tributary veins (2.5-4.5mm diameter) as adjunctive treatment, not primary therapy 1, 6
• Treating tributary veins alone without addressing junctional reflux results in 20-28% recurrence at 5 years 1

Anatomic Considerations

• Careful dissection of the saphenofemoral junction combined with stripping to just below the knee is the best approach to prevent recurrence from the great saphenous vein 8
• Preoperative location of the exact level of the saphenopopliteal junction is critical, as this junction has higher recurrence rates 8, 3

Common Pitfalls Leading to Recurrence

1. Treating only visible varicose veins without addressing underlying junctional reflux 1, 6
2. Using sclerotherapy as monotherapy for veins that require thermal ablation (diameter ≥4.5mm) 1
3. Inadequate preoperative duplex assessment failing to identify all sources of reflux 7
4. Failure to treat perforating vein insufficiency when present 7, 3
5. Insufficient follow-up imaging at 3 weeks to identify incomplete treatment before clinical recurrence develops 3

Post-Treatment Surveillance

Early postoperative duplex scans at 2-7 days are mandatory to detect endovenous heat-induced thrombosis and assess treatment adequacy 1, 4

Follow-up at 3 weeks identifies patients at risk for recurrence, allowing for early intervention before clinical deterioration 3