"You're Going to Close a Vein?" What Closing a Refluxing Vein Does to Circulation

A worry that starts with the word "close"

It comes up in almost every consultation:

"If you get rid of the vein, doesn't the blood lose its route back? Won't the circulation get worse?"

It is a perfectly reasonable question. Described as "closing a vein," treatment sounds like blocking a perfectly good road. Once you understand what a varicose vein is actually doing, though, it becomes clear that the procedure is meant to help venous circulation rather than impede it.

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What a varicose vein is — a vein flowing the wrong way

Varicose veins are a condition in which the valves in the leg veins have failed and blood flows backwards (refluxes). As blood falls back down through the failed valves, the vein stretches and becomes tortuous.

A varicose vein is already not doing its job. Instead of carrying blood up toward the heart, it is sending blood back down and creating pooling — the opposite of what a vein is for.

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The leg has two venous systems

Leg veins belong to one of two systems.

• Deep veins run inside the muscle compartments and are generally described as carrying roughly 85–90% of the blood returning from the leg.
• Superficial veins run just beneath the skin and carry the remaining 10–15%. The great saphenous vein is the main one.

Varicose vein treatment removes or closes the superficial vein that has failed and is refluxing. The deep veins — the main route home — are not what is being treated.

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What happens when a refluxing vein is closed

When a failed superficial vein is closed:

1. The reflux pathway is shut, and the blood stops circulating uselessly downward.
2. The load on the deep veins, which were receiving that refluxed blood, falls.
3. Overall venous return can improve.

Removing a refluxing vein does not obstruct circulation. It shuts a wrong-way route to help the right-way route work properly.

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The evidence on closing a refluxing vein

Study 1: haemodynamic measures improved after closing the saphenous vein — even with deep vein reflux present

Marston and colleagues (Journal of Vascular Surgery, 2008) looked at a demanding group: 75 limbs with both superficial and deep venous reflux. In the 35 limbs where deep reflux was confined to the common femoral vein, laser ablation of the saphenous vein reduced the venous filling index from 6.54 to 2.2 cc/sec (P < .001) and improved the venous clinical severity score from 7.0 to 1.3 (P < .001).

Two things follow. In this study, closing the superficial vein alone was followed by an improvement in the haemodynamic measure. And that was so even in limbs where the deep system was also refluxing — though the same study found that when deep vein reflux was fast (over 10 cm/sec in the femoral or popliteal vein), symptoms were more likely to persist. That is a reason to assess the deep veins carefully before treatment, not a reason to doubt the principle.

Study 2: laser and surgery — similar improvement

The RELACS trial (Rass et al., Archives of Dermatology, 2012) randomised 400 patients with great saphenous vein incompetence to endovenous laser or high ligation and stripping. At two years, both treatments improved clinical severity scores and disease-related quality of life equally; on the haemodynamic measure — venous refilling time — laser showed an advantage. With either method, treating the refluxing trunk was followed by improvement.

Study 3: long-term follow-up

A systematic review and meta-analysis by Kheirelseid and colleagues (Journal of Vascular Surgery: Venous and Lymphatic Disorders, 2018) pooled nine randomised trials — 2,185 legs — with at least five years' follow-up. Endovenous laser and radiofrequency ablation showed no significant difference in recurrence compared with conventional surgery (36.6% vs 33.3% for laser vs surgery, P = .3). The authors noted that only 1,352 legs (61.9%) were actually followed for the full five years, which limits how firm the conclusion can be.

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How each method closes the vein

• Endovenous laser ablation (EVLA): an optical fibre is threaded into the vein and heats the inner wall until the vein seals.
• Radiofrequency ablation (RFA): a catheter delivers radiofrequency heat to the same effect.
• Sclerotherapy: a sclerosant is injected to harden and close the vein.
• Non-thermal methods (medical adhesive, mechanochemical ablation) close the vein without heat.

A closed vein is gradually absorbed by the body over the following months. Blood returns through the deep veins and other remaining veins.

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Key points: varicose vein treatment and vein closure

Think of a motorway with one lane running against the traffic. Closing that lane does not slow the motorway — it lets the correct lanes flow. Varicose vein treatment works on the same idea, because a refluxing vein is already not helping circulation. Whether treatment is needed, though, depends on the symptoms and the examination findings.

If you suspect varicose veins, the first step is a duplex ultrasound and a consultation to establish what your own veins are doing — including the deep system, since the state of the deep veins is part of what the assessment has to establish.

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References

• Marston WA, Brabham VW, Mendes R, Berndt D, Weiner M, Keagy B. The importance of deep venous reflux velocity as a determinant of outcome in patients with combined superficial and deep venous reflux treated with endovenous saphenous ablation. J Vasc Surg. 2008;48(2):400-5. (PMID: 18644484)
• Rass K, Frings N, Glowacki P, et al. Comparable effectiveness of endovenous laser ablation and high ligation with stripping of the great saphenous vein: two-year results of a randomized clinical trial (RELACS study). Arch Dermatol. 2012;148(1):49-58. (PMID: 21931012)
• 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)