As a sign of progressive disease, varicose veins can require ongoing medical attention.
The recurrence of varicose veins remains a challenge to managing chronic venous disease (also known as vein disease). Despite the advancements in diagnosis and minimally invasive therapies, recurrence after treatment for varicose veins has been reported in more than 20-30 percent of patients, which can be frustrating.
What are varicose veins, and how do they occur?
Varicose veins, most often found in the legs, are enlarged, ropy, blue blood vessels. They occur when the valves in the veins become weak or diseased and no longer provide adequate support. The loss of structural integrity causes blood to pool in the legs, ankles, and feet, forming twisted, enlarged vessels that you know as varicose veins.
In their early stages, varicose veins are often asymptomatic and maybe not even visible to the naked eye. Later, they can progress and become more enlarged and noticeable. At this point, they may start causing throbbing or aching pain, itching, leg swelling, and irreversible skin changes around the ankle. Two percent of patients will end up with leg ulcers/wounds.
When the patient presents with symptomatic varicose veins, typically, a full venous duplex (a vein mapping ultrasound) is performed to assess all veins of the legs and pelvis, looking for potential pathology (disease) that led to the development of the varicose veins. Possible disorders include:
After a thorough evaluation, a comprehensive and detailed treatment plan is customized for each individual and followed carefully.
How are varicose veins treated?
Commonly treatment will consist of superficial vein ablation using minimally invasive techniques such as radiofrequency ablation, laser ablation, chemical sclerotherapy, and micro-phlebectomy, where the goal of treatment is to close the vein that is refluxing (i.e., leaking). However, in very rare cases (usually in patients with accompanying pelvic pain), patients may also require venous ballooning or stenting.
Modern treatment for recurrent varicose veins includes the following options:
What are the chances of varicose veins returning after treatment?
Most patients who are considering having their varicose veins treated ask this question. But before answering this question, first, we have to understand that there are three different types of recurrence:
(1) Residual varicose veins, which are veins that remain leaky and that have not been entirely successfully treated in a procedure performed.
(2) True recurrent varicose veins, which are veins that have recanalized “reopened” after a previously or regenerated “neovascularization” after a previously successful treatment.
(3) New refluxing veins are new varicose veins developing in a different anatomic region (different parts of the leg) where there were previously no vessels.2
So, the exact answer to this question will depend on the type of recurrence that could occur and whether it was a true recurrence, a residual vein, or a new vein that has developed.
To make it easier to understand; developing varicose veins is dependent on a number of causes. It combines venous disease progression, inadequate diagnosis and treatment, and venous neovascularization treatment-related and patient-related risk factors.
In the following section, I will summarize these risk factors and explain how we can eliminate them.
Factors in varicose vein reoccurrence can include (but are not limited to):
Inadequate diagnosis: It is rare for any two patients with varicose veins to have the same disease pattern. As such, to treat all the veins correctly, it is essential to have a thorough duplex ultrasound scan performed by a specialist trained to look for all these different veins. Such a scan should take at least 45 minutes and should be performed in a standing position. Suboptimal venous duplex scanning during the initial consultation can lead to overlooking refluxing segments of the vein, especially accessory veins, perforator veins, deep veins, and pelvic veins, leading to ineffective treatment planning.
Inadequate procedure techniques: Procedures performed by inexperienced providers who left residual varicosities untreated or missed treating the refluxing entry point at the junction, accessory vein, or perforator veins, that eventually lead to recanalization or neovascularization (i.e., small branches that have been left at the first operation can enlarge and branch).
Inadequate choice of procedure modality: Different surgical modalities can be used. However, not all modalities are equally successful for all patients. Every patient should have a personalized and customized treatment plan based on their unique venous anatomy, daily lifestyle routine, and associated medical history.
Venous obstruction: Recurrent varicose veins are more common in patients with a history of DVT and post-thrombotic syndrome, which makes the possibility of deep venous obstruction a possible cause of the recurrent varicosities, especially with more advanced symptoms. Therefore, patients with recurrent varicose veins and advanced disease should be considered for venography and intravascular ultrasound. This could show proximal occlusive disease that could cause increased venous pressures leading to recurrent reflux, varicose veins, and more advanced symptoms. This could be treated with venous angioplasty and stent(s) with good long-term results.
Failure to follow-up: Venous insufficiency that leads to varicose veins is a chronic condition, and venous disease progression in other health veins is unpredictable and can occur at any time, and they can only be treated asthey arise. All doctors must establish a close follow-up plan for those patients who are at higher risk of disease progression.
Patients at higher risk include patients with a strong family history of varicose veins, patients with a history of DVTs, patients who have a lifestyle that requires them to sit or stand for long hours, patients with elevated BMI (i.e., overweight), patients with a history of multiple pregnancies, patient and of course patient that failed initial varicose vein treatment.
Patient-related risk factors: Once you have had your veins treated by your vein doctor, you can play a part in helping prevent your varicose veins from coming back. Certain lifestyle factors contribute to the likelihood of developing varicose veins. These include being overweight, maintaining a sedentary lifestyle, standing or sitting for many hours at a time, and smoking. Based on your medical and family history, your vein doctor should work with you to develop strategies that work for you.
Prevention is the key to avoiding varicose vein reoccurrence
In conclusion, recurrent varicose veins are an inevitable part of treating venous disease. As with any disease, prevention goes a long way toward reducing the incidence of recurrence. Prevention can be achieved with a thorough duplex evaluation and treatment of all refluxing escape points from the deep venous system to the superficial venous system.
Despite proper diagnosis and treatment, recurrence is still a problem. The most common sources of recurrence are accessory and perforator veins, neovascularization, and deep venous disease from refluxing abdominal pelvic veins and obstruction. Treatment of these patients can be challenging and requires careful follow-up with duplex ultrasound evaluation and occasionally other imaging modalities.
Nowadays, we are fortunate to offer our patients a wide range of minimally invasive procedures which can successfully treat difficult and complex varicose veins. Modern endovascular techniques are the preferred method of treating any recurrent varicose veins. This allows us to treat any vein that can be seen with a duplex ultrasound scan under local anesthesia to achieve the best therapeutic outcome.
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