How Often Do Varicose Veins Come Back? Recurrence Rates by Procedure, at 10 and 14 Years

The question comes up before treatment and again afterwards:

"Will they come back?"

Some possibility of recurrence exists with every method. What has changed recently is that we can now answer with long-term randomised data — trials reporting at ten and fourteen years, rather than the one- and two-year figures that dominated the literature for a long time.

Those two trials appear at first to contradict each other. They do not, and understanding why is the most useful thing in this article.

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The methods being compared

• High ligation and stripping (HL/S) — the traditional operation; the vein is tied off and physically removed
• Endovenous laser ablation (EVLA) — a fibre inside the vein closes it with heat
• Radiofrequency ablation (RFA) — the same idea using radiofrequency energy
• Ultrasound-guided foam sclerotherapy (UGFS) — a foamed sclerosant injected to close the vein
• Cyanoacrylate closure (CAC) — medical adhesive; no tumescent anaesthesia, no compression stockings required

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Fourteen years — the longest randomised follow-up

Published in the European Journal of Vascular and Endovascular Surgery in 2026, Rahman and colleagues at Helsinki University Hospital randomised 233 patients with symptomatic great saphenous reflux 1:1:1 to HL/S, EVLA or UGFS, and followed 214 of them to fourteen years.

Recurrent above-knee GSV reflux on duplex

	Recurrence
HL/S	2.6% (1 of 38)
EVLA	6.1% (3 of 49)
UGFS	30.8% (12 of 39)

Overall p < .001. UGFS versus HL/S: RR 11.7 (95% CI 1.6–85.6). UGFS versus EVLA: RR 5.0 (95% CI 1.5–16.6).

Note that first confidence interval. It spans 1.6 to 85.6 because the comparison rests on a single recurrence event in the stripping arm. The direction is clear; the magnitude is not precisely known.

Re-intervention on the GSV — HL/S 13.2%, EVLA 8.2%, UGFS 56.4% (overall p < .001).

Two findings that complicate the picture

Neovascularisation did not differ: 29.0% after HL/S, 22.5% after EVLA, 23.1% after UGFS (p = .76). New vessels grow back at similar rates whatever was done.

Quality of life was comparable across all three arms. Aberdeen Varicose Vein Questionnaire scores were 8.9 (HL/S), 6.1 (EVLA) and 8.8 (UGFS), overall p = .21 — including the UGFS group with its 30.8% recurrence and 56.4% re-intervention rate.

That last point deserves emphasis. Anatomical recurrence and how a patient feels fourteen years later are not the same variable. A duplex finding of reflux is not automatically a bad outcome for the person carrying it.

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Ten years — and an apparent contradiction

Mohamed and colleagues at Hull published ten-year outcomes in the British Journal of Surgery in 2024, comparing conventional surgery against EVLA in patients randomised for unilateral GSV reflux. Data were obtained for 206 of 280 patients (73.6%).

Clinical recurrence: EVLA 37% versus surgery 59% (p = 0.005). The number needed to treat with EVLA to avoid one clinical recurrence over ten years was five.

EVLA also scored better on quality of life — SF-36 bodily pain 84 versus 62 (p = 0.009), general health 77 versus 67 (p = 0.017), AVVQ 3.1 versus 6.3 (p = 0.029). Both groups retained significant improvement over baseline, and disease progression from baseline occurred in only 10.7%.

So: Helsinki finds stripping and laser comparable, with stripping numerically ahead. Hull finds laser clearly superior to surgery. Both are randomised trials with long follow-up.

Why the two trials disagree — they measure different things

The reconciliation is in the outcome definitions.

Helsinki's primary outcome was above-knee GSV reflux on duplex ultrasound — an anatomical finding, detected by scanning, whether or not the patient has visible veins.

Hull's outcome was clinical recurrence — visible, symptomatic varicose veins the patient actually presents with.

These diverge. A treated vein can show reflux on ultrasound without producing visible varicosities, and visible varicosities can arise from vessels other than the one that was treated. Stripping physically removes the trunk, so there is less of it left to reflux — which favours it on the anatomical measure. Neovascularisation after groin dissection, which stripping involves and endovenous methods avoid, plausibly feeds clinical recurrence — which disfavours it on the clinical measure.

Neither trial is wrong. They answer different questions, and the second one is closer to what a patient cares about.

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What the pooled evidence says

A 2026 meta-analysis in Scientific Reports (Sayarer and colleagues, 27 randomised trials) found anatomic success statistically indistinguishable across the thermal and surgical options:

• EVLA versus surgery: RR 0.98 (95% CI 0.90–1.06), p = .63
• EVLA versus RFA: RR 1.01 (95% CI 0.95–1.07), p = .80
• RFA versus surgery: RR 1.00 (95% CI 0.89–1.13), p = .94
• EVLA reduced nerve injury versus surgery: RR 0.47 (95% CI 0.29–0.76), p < .01
• UGFS showed inferior long-term anatomic durability

The systematic review underpinning the SVS/AVF/AVLS guidelines (Farah and colleagues, 73 studies including 45 RCTs) reached partly different conclusions and is worth reading carefully:

• HL/S showed higher anatomic closure at 30 days and 5 years than both RFA and UGFS (moderate certainty)
• No significant difference between HL/S and EVLA at 5 years
• UGFS carried increased recurrence risk versus HL/S
• EVLA had lower closure at 30 days than cyanoacrylate, and higher rates than UGFS at 1 and 5 years
• Thermal interventions scored lower on generic quality of life and carried more adverse events than cyanoacrylate (low certainty)
• Thermal interventions had lower recurrence risk than UGFS, but higher recurrence risk than cyanoacrylate

Note the disagreement: Farah found stripping outperforming RFA on closure, while Sayarer's RCT-only pooling found them equivalent. Reviews differ in what they include and how they weight it. That is normal, and it is a reason to be sceptical of any clinic presenting one figure as settled.

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Why recurrence happens at all

Neovascularisation. New vessels grow around the treated area and reflux resumes. As the fourteen-year data show, this occurs at similar rates across methods — roughly a quarter of patients.

Disease progression. Varicose veins are a manifestation of chronic venous disease. New varicosities can form in vessels that were healthy at the time of treatment. At ten years this accounted for about 10.7% of patients.

Obesity, pregnancy, prolonged standing at work and family history all raise the risk. These continue to operate after treatment, which is why what happens afterwards matters as much as which method was used.

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What this means in practice

EVLA and RFA deliver long-term results comparable to stripping, with faster recovery and — for EVLA versus surgery — roughly half the risk of nerve injury.

UGFS has substantially higher long-term recurrence: 30.8% anatomical recurrence and 56.4% re-intervention at fourteen years. It has a role in smaller vessels and in patients for whom other options carry more risk, but not as a first-line treatment for a refluxing trunk.

Cyanoacrylate performs well at one to five years and may carry lower recurrence than thermal methods, but the ten-year-plus data do not yet exist. Its evidence is graded low certainty.

Quality of life improved and stayed improved in every group. In the fourteen-year trial it was statistically indistinguishable between arms.

That final point is the one most often lost. "Recurrence" measured on a duplex scan and "the treatment worked for me" are different things, and a clinic quoting a single recurrence percentage without saying which of the two it measured is not telling you enough to decide with.

Ask which outcome the number refers to, over what period, and from which study. At da Re-Fit we go through the ultrasound findings with each patient and explain why a given method suits their anatomy — our source vein treatment page sets out the options in more detail.

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References

• 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 Feb 1. (PMID: 41633433)
• Mohamed AH et al. Ten-year outcomes of a randomized clinical trial of endothermal ablation versus conventional surgery for great saphenous varicose veins. Br J Surg. 2024 Aug 2;111(8):znae195. (PMID: 39162334)
• Sayarer C, Arayici ME, Gencpinar T, Bayrak S. Effectiveness of endovenous ablation techniques and surgery for great saphenous vein incompetence: a comprehensive meta-analysis of randomized controlled trials. Sci Rep. 2026;16(1). (PMID: 41764322)
• Farah MH et al. A systematic review supporting the Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society guidelines on the management of varicose veins. J Vasc Surg Venous Lymphat Disord. 2022;10(5):1155-1171. (PMID: 34450355)
• Fayyaz F et al. Advancements in Varicose Vein Treatment: Anatomy, Pathophysiology, Minimally Invasive Techniques, Sclerotherapy, Patient Satisfaction, and Future Directions. Cureus. 2024;16(1):e51990. (PMID: 38344644)
• Mao Y, Chen G, Zhou S. Global research trends and clinical trial progress in varicose vein treatment: A decade of advancements (2014-2024). Medicine (Baltimore). 2026;105(6):e47592. (PMID: 41650092)