"Varicose Veins Always Come Back After Treatment" — Taking the Claim Apart With the Data

Key sources Kheirelseid EAH et al. J Vasc Surg Venous Lymphat Disord. 2018 (PMID: 29292115) · Eroglu E, Yasim A. Eur J Vasc Endovasc Surg. 2018 (PMID: 30042039) · Whing J et al. Cochrane Database Syst Rev. 2021 (PMID: 34378180) · Perrin MR et al. REVAS, J Vasc Surg. 2006 (PMID: 16476610)

---

The most common reason for putting off treatment

"A friend had it done and a few years later they were back. Don't they always come back?"

We hear it constantly, and it does real harm: it delays a decision at the point when treatment is simplest, and in some people it lets the condition progress to skin damage and ulceration before anything is done.

To be direct: "varicose veins always recur after treatment" is not true. What follows is the evidence, and — just as important — an explanation of what the recurrence figures actually count, because that is where most of the confusion comes from.

(This article addresses the myth. For a method-by-method comparison of the recurrence figures at ten and fourteen years, see our companion article.)

---

1. First, what "recurrence" means

The word is used for three different things, and the international REVAS consensus (Recurrent Varices After Surgery) was written precisely to separate them.

Residual or technical failure. The vein was never fully closed in the first place. Strictly this is not recurrence at all — it is an incomplete procedure, detectable on the follow-up scan and correctable.

Neovascularisation. New small vessels grow around the treated site and reconnect the deep and superficial systems.

True recurrence, or disease progression. Reflux develops in a different vein that was normal at the time of treatment. Varicose veins are a chronic condition of the venous system, not a single faulty vessel; treating one refluxing trunk does not change the tendency of others to fail.

When the REVAS investigators examined 199 limbs with recurrence after surgery across eight countries, neovascularisation and technical failure were equally common (20% and 19%), and in 32% of limbs the recurrence was at a new site altogether. In 35% the cause could not be determined.

So when a friend says their veins "came back," it may have been an incomplete first procedure, a new vein in a different place, or genuine neovascularisation. Bundling all three together as "it came back" makes treatment look far less effective than it is.

---

2. The data: what closure rates actually look like

① Two years: over 90% closure with every modern method

Eroglu and Yasim randomised 525 patients to cyanoacrylate adhesive, radiofrequency or laser (European Journal of Vascular and Endovascular Surgery, 2018), with 456 followed for two years. Closure at two years was 92.6%, 90.9% and 91.5% respectively — no difference between methods (P = .89). Nine out of ten treated veins were still closed at two years. Return to work was quickest after adhesive (1.04 days), with 95% back on day one.

② Five years and beyond: equivalent to surgery

A retrospective series from Istanbul (El Kilic et al., 2022) followed 232 patients for a mean of 67.5 months after laser, adhesive or radiofrequency. Closure was comparable across all three at one day, six months, one year and two years; at longer follow-up, radiofrequency held up better than laser. Laser had the highest pain scores, most complications and slowest return to activity in that series.

The Dublin meta-analysis (Kheirelseid et al., 2018) pooled nine randomised trials with at least five years of follow-up — 2,185 legs. Recurrence after laser was 36.6% versus 33.3% after conventional surgery (risk ratio 1.35, 95% CI 0.76–2.37, P = .3): no significant difference, and the same for radiofrequency versus surgery.

Read that figure carefully, because it is the one that fuels the myth. "A third recur at five years" sounds alarming. But this is recurrence in the broadest definition — technical failure, neovascularisation and new-site disease all combined, on duplex ultrasound, whether or not the patient noticed anything. And the finding is that endovenous treatment matches surgery, not that either fails.

③ Cochrane: laser ahead of surgery for closure up to five years

The 2021 Cochrane review (Whing et al.) compared every treatment for great saphenous reflux. Technical success was better with laser than with high ligation and stripping up to five years (OR 2.31, 95% CI 1.27–4.23; 6 trials, 1,051 participants) — graded low-certainty evidence — with no clear difference at five years and beyond, and comparable recurrence at both time points. The authors' overall conclusion: technical success was comparable between most modalities, with a possible long-term recurrence benefit for radiofrequency.

---

3. Why recurrence happens — and what that means for prevention

Understanding the three causes turns "they always come back" into "they can come back under certain conditions, most of which can be addressed."

Cause 1: incomplete treatment

Treating without ultrasound guidance, with inadequate energy settings, or with insufficient experience can leave part of the vein open. This is treatment failure, not recurrence. It shows on the early follow-up scan and can be corrected. It is the reason accurate ultrasound and an experienced operator matter — and the reason the early scan matters: in van Rij's five-year study of 127 limbs after surgery, not one of the 40 limbs with a normal duplex scan at three weeks went on to recur, while inadequate treatment at the junctions was already identifiable at that visit in 7.2%.

Cause 2: the underlying tendency persists

The main risk factors — family history, obesity, occupations involving prolonged standing, pregnancy, female hormones — do not go away when a vein is closed. New reflux can develop in other veins. The comparison patients find most useful is blood pressure: medication controls it, but salt and weight still matter. This is a property of the disease, not a failure of the procedure.

Weight control, compression when standing for long periods, and avoiding prolonged immobility all act on the same venous pressure that drives new disease.

Cause 3: neovascularisation

New vessels growing around the treated site. Historically most associated with open surgery at the groin, and one of the arguments for endovenous methods, which avoid groin dissection. The fourteen-year Helsinki trial, however, found neovascularisation at similar rates after stripping, laser and foam (29%, 22.5% and 23.1%, P = .76) — so the advantage may be smaller than once thought. It remains the least controllable of the three causes.

---

4. Ultrasound recurrence is not symptom recurrence

The recurrence figures in trials are mostly duplex ultrasound findings. A refluxing segment on a scan is not the same as heavy, aching, swollen legs. What matters clinically is whether the patient has symptoms.

In the Eroglu trial, the venous clinical severity score fell significantly by six months and stayed down at two years in every group. In the fourteen-year Helsinki data, quality of life was statistically indistinguishable between arms — including the foam group with 30.8% anatomical recurrence. Anatomical recurrence and how a patient feels are different variables, and a clinic quoting a recurrence percentage without saying which one it refers to is not telling you enough.

---

5. If it does recur, it can be treated

Even genuine recurrence is treatable, usually as an outpatient: ultrasound-guided foam sclerotherapy, phlebectomy, or a further ablation, depending on what the scan shows. The expectation that one procedure should settle the matter for life is not realistic for a chronic condition — any more than it is for blood pressure or dental decay. Treat what is there now, manage the risk factors, and keep the follow-up scans.

---

6. Waiting is the costly option

Putting off treatment out of a vague fear of recurrence has a cost. Untreated reflux progresses toward pigmentation, lipodermatosclerosis and ulceration. The evidence here is strong and specific: in the ESCHAR trial (500 patients with venous ulcers), adding surgical correction of superficial reflux to compression cut four-year ulcer recurrence from 56% to 31%; and in the EVRA trial (450 patients, 20 UK centres), ablating the reflux early rather than waiting for the ulcer to heal shortened healing time from 82 days to 56 days. Treating the vein is what changes the course of the disease.

---

In summary: not "always recurs" — a manageable chronic condition

• Modern endovenous treatment closes the vein in over 90% of cases at two years, and matches surgery at five years and beyond.
• Much of what is called "recurrence" is either an incomplete first procedure or new disease in a different vein — the persistence of risk factors, not the failure of treatment.
• Ultrasound recurrence and symptom recurrence are different things; quality of life stays improved in every long-term trial.
• Recurrence, when it happens, is treatable as an outpatient.
• Delaying treatment carries its own, well-documented cost.

Declining treatment because "they'll just come back" is like declining dental treatment because you might get another cavity. The sensible course is to treat what is there, address the risk factors, and keep the follow-up.

---

References

1. Perrin MR, Labropoulos N, Leon LR Jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg. 2006;43(2):327-34. (PMID: 16476610)
2. Eroglu E, Yasim A. A Randomised Clinical Trial Comparing N-Butyl Cyanoacrylate, Radiofrequency Ablation and Endovenous Laser Ablation for the Treatment of Superficial Venous Incompetence: Two Year Follow up Results. Eur J Vasc Endovasc Surg. 2018;56(4):553-560. (PMID: 30042039)
3. El Kilic H, Bektas N, Bitargil M, et al. Long-term outcomes of endovenous laser ablation, n-butyl cyanoacrylate, and radiofrequency ablation for treatment of chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2022;10(4):865-871. (PMID: 34688972)
4. Kheirelseid EAH, Crowe G, Sehgal R, et al. Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins. J Vasc Surg Venous Lymphat Disord. 2018;6(2):256-270. (PMID: 29292115)
5. Whing J, Nandhra S, Nesbitt C, Stansby G. Interventions for great saphenous vein incompetence. Cochrane Database Syst Rev. 2021;8(8):CD005624. (PMID: 34378180)
6. Rahman T, Noronen K, Vähäaho S, Halmesmäki K, Venermo M. Fourteen Year Outcomes of a Randomised Controlled Trial Comparing Endovenous Laser Ablation, High Ligation and Stripping, and Ultrasound Guided Foam Sclerotherapy for Great Saphenous Varicose Veins. Eur J Vasc Endovasc Surg. 2026. (PMID: 41633433)
7. van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg. 2003;38(5):935-43. (PMID: 14603197)
8. Gohel MS, Barwell JR, Taylor M, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ. 2007;335(7610):83. (PMID: 17545185)
9. Gohel MS, Heatley F, Liu X, et al. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med. 2018;378(22):2105-2114. (PMID: 29688123)