The Ultrasound Found Reflux. Does Every Vein Need Treatment?

"The scan showed reflux in several veins. Do they all need treatment?"

This is a natural question after a varicose vein ultrasound. Hearing that more than one vein needs attention can raise two opposite worries: that the treatment is too extensive, or that treating only part of it will leave a problem behind.

Finding reflux is important diagnostic information. But deciding how much to treat requires looking at where the reflux starts and how far it extends, together with your symptoms and the condition of the leg. Explaining what the scan found and building a treatment plan are connected, but they are two different steps.

1. The scan goes a step beyond "is there reflux?"

Leg veins are connected in many branches. Ultrasound checks not only whether blood is flowing backwards, but where that reflux begins, how far it continues, and how it connects to the bulging veins you can see.

So a good explanation of the results gives more than "the reflux lasts so many seconds". It should say which vein, and which segment of it, has the problem. The UK guideline from the National Institute for Health and Care Excellence (NICE) recommends using duplex ultrasound to confirm the diagnosis and the extent of truncal reflux, and to plan treatment (recommendation 1.3.1). How the reflux time threshold is used is covered in our column on the 0.5-second standard, and what the scan looks for in why we map the veins before treatment.

Alongside "is there reflux?", it helps to ask "which vein, and which part of it, has the problem?"

2. Finding reflux does not mean the normal segments are treated too

Reflux in part of a vein does not mean the whole vein has to be treated.

The 2023 joint guidelines of the Society for Vascular Surgery, the American Venous Forum and the American Vein and Lymphatic Society (Part II) state in a consensus statement that ablating an isolated refluxing segment of the great saphenous vein, when the segments above and below it are competent, is rarely indicated. Conversely, in patients with symptoms, ablation of the great saphenous vein may be appropriate even when the reflux does not run the full length of the vein or the junction at the groin is competent. In both situations the guideline calls for shared decision-making with the patient.

The point is that the length of reflux alone does not decide treatment. The connections between the veins and the clinical picture are judged together.

3. When veins are treated together, each part needs its own reason

When a refluxing main vein and bulging tributary varicosities are both found, treating both in the same session can be considered: closure of the main vein combined with phlebectomy or ultrasound-guided foam sclerotherapy of the tributaries.

The NICE guideline says that if incompetent varicose tributaries are to be treated, treating them at the same time should be considered (recommendation 1.3.2). The US guidelines suggest that for symptomatic great or small saphenous reflux, staging the tributary treatment after the truncal ablation should be done only when there are anatomical or medical reasons, and that the timing should be decided together with the patient (recommendation 8.1.3, a weak recommendation with low-certainty evidence). The studies comparing the two approaches are summarised in our column on concomitant phlebectomy.

The same combination does not apply to every patient. And the explanation you receive should not stop at "we will do several things together". You should be able to understand which vein each treatment is aimed at, and why it is needed.

4. Veins that will be observed need a follow-up plan

If some veins are not being treated this time, the reason and the follow-up plan should be explained as well.

Ask: "Why are we observing this for now?", "What changes should bring me back?", and "What will the next scan check?"

Understanding the areas that will be watched matters as much as understanding the areas that will be treated.

5. Three questions to ask before you decide

Before agreeing to a procedure, we suggest asking:

1. Which veins do you consider related to my symptoms?
2. What is the extent of treatment this time, and why is each part needed?
3. For the parts you are not treating, when and how will they be checked again?

At da Re-Fit Clinic we look at the ultrasound findings and your symptoms together, separate the veins to treat from the veins to observe, and plan combined treatment when it is needed. When discussing the extent and timing, we also consider the recovery burden and how easily you can return for follow-up. For international patients, consultations are supported through our interpretation system, and if you have a scan report from home, bring it. Why treatment differs between patients with the same diagnosis is explained in Same Diagnosis, Different Treatment.

Helping you understand which vein is treated, why, and how is where our consultation starts.

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References

• National Institute for Health and Care Excellence (NICE). Varicose veins: diagnosis and management. Clinical guideline CG168, 24 July 2013. Recommendation 1.3.1 (duplex ultrasound to confirm the diagnosis and extent of truncal reflux and plan treatment); 1.3.2 (if incompetent varicose tributaries are to be treated, consider treating them at the same time). https://www.nice.org.uk/guidance/cg168
• Gloviczki P, Lawrence PF, Wasan SM, et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II. J Vasc Surg Venous Lymphat Disord. 2024;12(1):101670. (PMID: 37652254) — Consensus statement 5.2.4 (ablation of isolated refluxing GSV segments with competent segments proximally and distally is rarely indicated; ablation may be indicated in symptomatic patients even if axial reflux is incomplete; shared decision-making); guideline 8.1.3 (staged tributary treatment only for anatomical or medical reasons; timing decided with the patient).

This article provides general health information. Whether and how much to treat depends on the examination and ultrasound findings and needs to be confirmed in consultation.