"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)

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A common reason for putting off varicose vein treatment

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

We hear it often, and it can lead people to put off even the consultation and assessment they need.

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.)

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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 further treatment can be considered.

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 both were seen in 17%. In 35% the cause was uncertain or unknown. Counted separately, by site rather than by cause, reflux had developed at a new site in 32% of limbs — so that figure overlaps with the others.

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 less effective than the data suggest.

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2. The data: what vein closure rates actually look like after treatment

① Two years: over 90% closure in all three arms of a randomised trial

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). In this trial, about nine out of ten treated veins were still closed at two years. Time to return to work was 1.04 days after adhesive in that trial, with 95% of that group back on day one.

② Five years and beyond: closure by method, and no significant difference from 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 three and five years, closure rates were significantly higher with radiofrequency than with laser, and adhesive and radiofrequency were similar. Pain scores and complication rates were higher, and return to daily activities took longer, after laser 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 (pooled risk ratio 1.35, 95% CI 0.76–2.37, P = .3 — a pooled estimate across trials, not the ratio of the two percentages): 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 there was no significant difference between endovenous treatment and surgery, not that either fails.

③ Cochrane: technical success and recurrence up to five years

The 2021 Cochrane review (Whing et al.) compared every treatment for great saphenous reflux. Technical success may be 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.

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3. Why recurrence happens — and what knowing the causes allows

Understanding the three causes turns "they always come back" into "they can come back under certain conditions, some 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 further treatment can be considered. 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, there was no recurrence in the 40 limbs in which the duplex scan and the other predictive measures were normal at three weeks, 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 may help, since they 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.

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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 recurrence percentage says little unless it is clear which of the two it refers to.

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5. If varicose veins do recur, retreatment can be considered

Even with genuine recurrence, retreatment can be considered, often 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. Have the treatment that is needed, manage the risk factors, and keep the follow-up scans.

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6. What happens if varicose veins are left untreated

A vague fear of recurrence is not, on its own, a reason to put off a consultation. Some symptomatic varicose veins progress over time toward pigmentation, lipodermatosclerosis and ulceration. For patients who already have a venous ulcer there is trial evidence: 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. If you have symptoms, have them assessed with ultrasound at a consultation; whether and when to treat is decided from the findings and the symptoms.

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Key points: not "always recurs" — a manageable chronic condition

• In the randomised trial cited, endovenous treatment kept the vein closed in over 90% of cases at two years, and in the meta-analysis five-year recurrence did not differ significantly from surgery.
• 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; in the trials cited, severity scores stayed improved at two years and quality of life was comparable between methods at fourteen years.
• When recurrence happens, retreatment can be considered, often as an outpatient.
• Some symptomatic disease progresses if left alone, so symptoms are worth having assessed.

Declining treatment because "they'll just come back" is like declining dental treatment because you might get another cavity. The sensible course is to deal with the problem that is there now, manage the risk factors to reduce the chance of recurrence, and keep the follow-up.

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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;72(3):533-540. (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)