Told You Don't Need Surgery for Varicose Veins — But Your Legs Still Ache? How the Need for Treatment Is Judged

"I was told I don't need surgery — that I can live with it. But my legs ache and feel uncomfortable."

This is a concern we hear often in the varicose vein clinic. Patients are reassured to learn that nothing is urgently wrong, yet they are unsure what to make of discomfort that returns every day. Some worry that having treatment would amount to overtreatment.

There is a distinction worth drawing here. Whether you need surgery right now and whether treatment could help you are two different questions. The fact that emergency surgery is not required does not mean the need for treatment disappears.

This column sets out, from international guidelines and published studies, the criteria by which the need for treatment is judged when varicose veins are causing symptoms.

1. "You don't need surgery" has a context

Having varicose veins does not mean everyone needs surgery. When symptoms are absent or mild and the examination and ultrasound findings allow it, watchful waiting can be appropriate. Conservative management is also chosen on the basis of a patient's health or preference.

The 2023 guidelines of the Society for Vascular Surgery (SVS), American Venous Forum (AVF) and American Vein and Lymphatic Society (AVLS) make this explicit. Even in a patient with symptoms and confirmed reflux, compression therapy can be suggested as primary treatment if the patient's ambulatory status or underlying medical conditions warrant a conservative approach, or if the patient prefers conservative treatment for a trial period or as definitive management (2.1.1).

Other patients, however, have pain, heaviness, swelling or itching that interferes with daily life. The severity of symptoms, and their effect on quality of life, vary from person to person.

So a single sentence from an earlier consultation cannot be judged right or wrong on its own. What matters is which symptoms were described at the time, what the ultrasound showed, and why observation was advised. If symptoms have since changed or the discomfort persists, that is reason enough to be reassessed.

2. Relieving pain and restoring daily life are also goals of treatment

Medicine includes treatment that saves lives, but also treatment that reduces pain, preserves function and improves day-to-day comfort.

If standing at work has become difficult, if heaviness in the legs makes you cut back on activity, or if recurring discomfort restricts your life, those symptoms deserve serious attention in the consultation.

The UK NICE guideline (CG168) lists varicose veins accompanied by troublesome lower-limb symptoms — typically pain, aching, discomfort, swelling, heaviness and itching — as a reason for referral to a vascular service (1.2.2). Skin pigmentation or eczema thought to be caused by chronic venous insufficiency, superficial vein thrombosis and venous leg ulcers are referral criteria too.

This does not mean that symptoms alone call for immediate surgery. It means that the patient's discomfort should be medically evaluated and the treatment options explained.

Whether such treatment actually helps patients has been studied. In a randomised trial at two UK hospitals (REACTIV), 246 patients with uncomplicated varicose veins were assigned to surgery or to conservative management (lifestyle advice). Over two years, the surgical group showed meaningful improvement in quality-of-life scores, in symptoms and in anatomical findings. The trial dates from the era when stripping was the standard operation, and its patients had been referred to secondary care in the UK — limitations worth noting — but it shows that "symptom improvement" is a measurable goal of treatment.

3. Not all leg pain is caused by varicose veins

There is something that must be checked before any decision on treatment. Leg pain, swelling, tingling and cramps are not symptoms exclusive to venous disease.

The Edinburgh Vein Study examined the relationship between leg symptoms and varicose veins found on examination in 1,566 adults from the general population. In women, heaviness or tension, aching and itching were statistically associated with trunk varices, but the agreement between having symptoms and having varices was too low to be of clinical value. The authors concluded that even in the presence of varices, many leg symptoms probably have a non-venous cause.

The European Society for Vascular Surgery (ESVS) 2022 guidelines likewise note that similar symptoms occur in other conditions of the lower limb and that symptom severity does not always match the severity of venous disease. In patients with swelling in particular, non-venous causes must be considered.

So surgery should not be decided on the basis of "my leg hurts" alone — and finding reflux on ultrasound is not, by itself, a reason to attribute every complaint to that vein.

When the symptoms worsen, where the discomfort is felt, and whether the examination and ultrasound findings can account for it all need to be reviewed together. Only then can you be given a realistic picture of what is likely to improve after treatment and what may remain.

4. With symptoms and a clear target, a procedure is an evidence-based choice

The 2023 SVS/AVF/AVLS guidelines recommend, for patients with symptomatic varicose veins and axial reflux in the great or small saphenous vein who are candidates for intervention, superficial venous intervention over long-term compression stockings (2.1.2, strong recommendation, moderate-quality evidence). As noted above, compression therapy remains an option when a conservative approach suits the patient's health or is what the patient prefers (2.1.1).

In other words, treatment carried out after confirming the patient's symptoms, the test findings and suitability for intervention is a choice the guidelines themselves endorse. Treatment aimed at relieving symptoms cannot be called overtreatment simply because "surgery is not needed to stay alive."

5. Avoiding overtreatment means the reasons for treatment must be specific

That does not make every varicose vein treatment justified. Whether a treatment is appropriate depends on how specifically these questions can be answered:

• What symptoms and daily limitations is the patient actually experiencing?
• Which finding on testing is judged to be related to those symptoms?
• What benefit is expected from treatment compared with observation or conservative management?
• Which veins should be treated, and how far?
• Have the risks of complications, recurrence and residual symptoms been fully explained?

Explaining the need for treatment means covering both the benefit the patient can expect and the burden they must accept. NICE likewise advises that, when discussing treatment, patients are told what options are available, the expected benefits and risks of each, that new varicose veins may develop after treatment, and that more than one session may be needed (1.1.2). The same guideline asks clinicians to address misconceptions patients may hold about the likelihood of progression and complications (1.1.1).

6. Patients who can be observed and patients whose treatment should be discussed are different groups

There is not enough evidence to recommend routine preventive procedures for patients without symptoms on the grounds of averting future deterioration. The SVS/AVF/AVLS guidelines state that in asymptomatic C2 disease, prophylactic intervention does not prevent progression, and that weight control, compression stockings and avoiding prolonged standing may be beneficial (consensus statement 5.2.1).

On the other hand, persistent symptoms or skin changes should be evaluated and the direction of treatment discussed. Not every patient progresses to advanced disease, but in some, skin damage, bleeding or ulceration can develop. In the 13-year follow-up of the Edinburgh Vein Study, disease progressed in 57.8% of the 334 participants who had varicose veins or chronic venous insufficiency at baseline, and 31.9% of the 270 who had varicose veins alone went on to develop signs of chronic venous insufficiency such as skin change. Put the other way, two thirds were still free of skin change 13 years later. Because progression cannot be predicted for an individual in advance, anyone who chooses observation should know which changes mean it is time to come back.

What patients need is neither a vague instruction to put up with it nor a blanket statement that treatment is essential. They need an explanation they can understand of why observation is reasonable in their current state — or why treatment should be considered.

If your legs ache, you are entitled to find out why

"Nothing is urgently wrong" is reassuring information. At the same time, patients are entitled to have the pain and discomfort they live with every day evaluated, and to discuss how it might be improved.

What da Re-Fit Clinic cares about is the process by which treatment is decided. We listen to the discomfort the patient describes, connect it to the test findings, and look together at the benefits and limits of both treatment and observation.

If you decide on treatment, you should understand why it is needed. If you decide to wait, you should know which changes mean you should come back.

Improving a painful, uncomfortable daily life is a legitimate goal of treatment. The criteria for judging whether a given treatment serves that goal are the patient's symptoms, objective test findings, and the expected benefits and risks.

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References and scope of the evidence

The recommendations above are drawn from international clinical guidelines and published studies. They do not represent the reimbursement criteria of any national or private insurer. Individual diagnosis and treatment are decided after examination and ultrasound.

• NICE. Varicose veins: diagnosis and management. Clinical guideline CG168. 2013. https://www.nice.org.uk/guidance/cg168 — referral criteria (1.2.2: varicose veins with troublesome symptoms, skin changes, superficial vein thrombosis, venous ulcer); information for patients (1.1.1 likelihood of progression and complications, addressing misconceptions; 1.1.2 options, benefits and risks, new veins may develop, more than one session may be needed).
• 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) — 2.1.1 compression as primary treatment when a conservative approach is warranted or preferred; 2.1.2 intervention over long-term compression for symptomatic GSV/SSV axial reflux in candidates for intervention (strong recommendation, moderate-quality evidence); consensus statement 5.2.1, no prophylactic intervention in asymptomatic C2 disease.
• Gloviczki P, Lawrence PF, Wasan SM, et al. The 2022 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 I. Duplex Scanning and Treatment of Superficial Truncal Reflux. J Vasc Surg Venous Lymphat Disord. 2023;11(2):231-261.e6. (PMID: 36326210) — duplex evaluation and treatment of truncal reflux.
• De Maeseneer MG, Kakkos SK, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022;63(2):184-267. (PMID: 35027279) — non-specific symptoms, mismatch between symptom severity and disease severity, non-venous causes of oedema.
• Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ. 1999;318(7180):353-356. (PMID: 9933194) — 1,566 adults from the general population; agreement between symptoms and trunk varices too low for clinical use; many symptoms probably non-venous.
• Michaels JA, Brazier JE, Campbell WB, MacIntyre JB, Palfreyman SJ, Ratcliffe J. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg. 2006;93(2):175-181. (PMID: 16432825) — REACTIV trial, 246 patients; quality of life (SF-6D, EQ-5D), symptoms and anatomical findings improved with surgery over two years.
• Lee AJ, Robertson LA, Boghossian SM, et al. Progression of varicose veins and chronic venous insufficiency in the general population in the Edinburgh Vein Study. J Vasc Surg Venous Lymphat Disord. 2015;3(1):18-26. (PMID: 26993676) — 13.4-year follow-up; progression in 57.8% of 334 (4.3% per year); chronic venous insufficiency developed in 31.9% of 270 with varicose veins alone.

※ This article is general medical information. Whether and how to treat is decided for each patient after examination and ultrasound.