Same Diagnosis, Different Treatment — How da Re-Fit Clinic Decides What to Treat

Search for varicose veins and a list of treatment names comes back. Laser, radiofrequency, VenaSeal, non-thermal closure such as Flebogrif and ClariVein, phlebectomy, sclerotherapy. Reading the explanations can make it harder, not easier, to tell which one fits your leg.

"It's the same varicose veins. Why does one person get laser and another has the vein removed?"

To answer that, one thing has to be established first. Even with the same diagnosis, where the reflux begins, how the veins are shaped, and what the symptoms and skin look like are not the same from one patient to the next.

da Re-Fit Clinic maps the veins with ultrasound and reads the result alongside the patient's symptoms before planning treatment. This article explains what we weigh at each step.

1. First, what troubles the patient most

For some people it is the visible, bulging vein. For others the veins hardly show, but the legs are heavy and swollen every evening. Some have already been treated elsewhere and come back because discomfort remains.

The explanation and the goal of treatment cannot be the same for all of them.

In the consultation we ask where and when the discomfort occurs, how it changes with prolonged standing or walking, and whether the skin has changed. At the same time, we ask whether venous disease actually explains those symptoms.

Not every leg pain, tingling or swelling comes from varicose veins. Musculoskeletal or nerve problems and other conditions can coexist. In patients with oedema in particular, the European Society for Vascular Surgery (ESVS) 2022 guideline recommends considering non-venous causes before planning treatment.

That an abnormality was found on testing, and how much of the present discomfort it explains, are two things that have to be reviewed together. Only then can the change to expect from treatment be described realistically. When treatment should be actively discussed is covered in a separate column.

2. Ultrasound looks not only for reflux but for where it is and how far it goes

Varicose vein ultrasound establishes whether reflux is present. Planning treatment requires more than that.

Which vein does the reflux start in, how far does it extend, and how does it connect to the bulging tributaries? Vein diameter, course and the state of the deep veins also shape the decision.

So "the reflux lasts this many seconds, therefore you need this operation" does not describe a treatment plan. Reflux time is one part of the assessment; the actual extent of treatment is decided from the anatomy and the clinical picture together. That is why the 2022 joint guideline of the Society for Vascular Surgery (SVS), American Venous Forum (AVF) and American Vein and Lymphatic Society (AVLS), Part I, asks for anatomical detail to be recorded alongside reflux on the duplex scan. Part II of the same guideline suggests against using truncal vein diameter alone to decide who needs ablation in symptomatic C2 patients (weak recommendation, moderate evidence). Why the 0.5-second reflux cut-off is a threshold rather than a severity score is explained in the reflux time column.

At da Re-Fit Clinic we go through the ultrasound images with the patient and decide first whether treatment is needed at all.

What a patient needs to grasp is not a list of vein names. It is which part is the problem, and why that part is the one we propose to treat.

3. The source vein and the bulging veins can play different roles in treatment

One distinction helps in understanding varicose vein treatment.

Treating reflux in a truncal vein such as the great or small saphenous vein, and treating the tortuous tributary varicosities that bulge under the skin, can be two different targets.

Target	Options that may be considered	Role of the treatment
Refluxing truncal vein	Laser or radiofrequency ablation, non-thermal closure (VenaSeal, Flebogrif)	Stops reflux in that vein
Bulging tributary varicosities	Miniphlebectomy, ultrasound-guided foam sclerotherapy	Treats the problem tributaries directly

For symptomatic tributary varicosities, the SVS/AVF/AVLS 2023 guideline (Part II) recommends miniphlebectomy or ultrasound-guided sclerotherapy (recommendation 7.2.1, strong recommendation, moderate evidence). Its consensus statement adds that symptomatic tributaries should be treated even when the truncal veins are competent (7.2.3).

Where truncal reflux and bulging tributaries coexist, treatments can be combined to match each. Conversely, not every patient needs both truncal closure and tributary treatment.

This is why da Re-Fit Clinic combines methods according to vein size, location and symptoms. Each treatment has a defined role, and the extent needed is decided from that. The methods themselves are compared in the treatment overview.

4. Together or in stages is a decision too

Once the target veins are set, the next question follows.

"Is it better to treat everything at once?"

After truncal reflux is treated, some tributaries shrink over time. In other cases it is more appropriate to treat the bulging veins at the same session.

The SVS/AVF/AVLS 2023 guideline (Part II) recommends, for patients with symptomatic great or small saphenous reflux and associated varicosities, ablation of the trunk with concomitant phlebectomy or sclerotherapy of the varicosities (8.1.1, strong recommendation). It notes that the evidence is low to very low (C), that staged treatment may be chosen for anatomical or medical reasons, and that timing should be decided with the patient through shared decision-making (8.1.3).

At da Re-Fit Clinic we confirm the extent of truncal reflux and the distribution of tributaries, then discuss whether to treat together or in stages while observing the response. Procedure burden, recovery schedule and the likelihood of a return visit are weighed alongside symptoms.

Choosing concomitant treatment does not guarantee that no further treatment will ever be needed. If a staged approach is chosen, it matters to explain what will be observed and what would prompt additional treatment.

The trials behind this question, and their limits, are set out in the column comparing concomitant and staged treatment.

5. With oedema, the plan after treatment is explained in advance

For patients with swelling there is something as important as the choice of procedure.

"Treating the reflux may not make all of the swelling disappear straight away."

In the CEAP classification of chronic venous disease, oedema is class C3. A C3 label alone does not establish that all of the swelling is venous.

Raised venous pressure, microvascular change and lymphatic load can all contribute, and activity level or general health may overlap. If swelling persists after reflux is corrected, the cause is reassessed and the management plan set accordingly. The ESVS 2022 guideline, which recommends compression in C3, also asks that non-venous causes be considered first, for the same reason.

This is why da Re-Fit Clinic explains the need for follow-up care before treatment. Separating what can be expected to change from what will take time helps the patient understand their own recovery.

The topic continues in Why your leg can still swell after varicose vein treatment.

6. Expected benefit and burden are explained together

To choose treatment, a patient needs to understand not only "what improves" but "what it costs in recovery and risk".

These are the questions da Re-Fit Clinic considers essential when explaining a treatment plan.

• Which problem is this treatment meant to improve?
• Why this method and this extent?
• What are the alternatives, and how do they differ?
• What should you know about recovery and side effects?
• If symptoms remain after treatment, how will they be assessed?

These questions are not there to complicate treatment. They are what a patient needs in order to take part in decisions about their own care. For patients travelling from abroad, the practical path is described in Your treatment journey in Korea.

What matters to da Re-Fit Clinic is the reason for the choice

The same diagnosis can lead to different treatment. The difference should reflect the patient's veins, symptoms and goals.

da Re-Fit Clinic decides what needs treatment from the ultrasound findings, combines methods where needed, and connects the plan to what happens after treatment.

If treatment has been recommended to you, it is reasonable to ask:

"Why is this method the right one for my leg?"

Explaining that reason in a way the patient can follow, from the test results and their own circumstances, is the standard da Re-Fit Clinic sets for itself when planning treatment.

---

References

• 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-venous causes of oedema in C3; compression.
• 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 scanning and treatment of truncal reflux.
• 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) — against diameter-based selection (5.1.1), tributary treatment (7.2.1, 7.2.3), concomitant versus staged treatment (8.1.1, 8.1.3).

This article is general medical information. The method and extent of an individual's treatment are decided after examination and duplex ultrasound.