Over-intervention in varicose veins: A call for long-term evidence and conservative-first strategies

As a dermatologist and dermatopathologist in India, I seek to alert the dermatology community to the routine use of surgical or endovenous interventions in clinically stable patients with varicose veins, classified as clinical-etiological-anatomical-pathophysiological (CEAP) C2-C3, i.e., varicose veins without skin changes or ulceration. Ablating superficial veins may increase pressure on deep veins, risking delayed valvular incompetence across all ages, with complications potentially emerging later in life. A 50-year-old woman with minimal symptoms (CEAP C2) underwent endovenous laser treatment (ELT), a minimally invasive ablation method. This was performed by a vascular surgeon after a routine consultation following her diagnosis of varicose veins. Three years post-procedure, she presented with sclerotic hyperpigmentation and telangiectatic matting, with histopathology showing dermal fibrosis, potentially iatrogenic changes that may have been avoidable with conservative care. I observe several such cases annually in patients aged 50-70 years, prompting urgent re-evaluation of over-intervention. This viewpoint critiques the routine use of all interventional modalities, ELT, sclerotherapy, and surgical stripping, in CEAP C2-C3 patients, given the absence of long-term (>10 yr) comparative trials versus conservative therapy.

Varicose veins cause venous hypertension due to incompetent valves, leading to inflammation, hemosiderin deposition, and skin changes like stasis dermatitis or ulceration. Interventions like stripping or ELT aim to eliminate reflux by removing or sealing superficial veins, preventing blood pooling, and reducing localised venous pressure. However, their benefits are unproven in CEAP C2-C3 and poorly evidenced in C5-C6 beyond short-term outcomes. The early venous reflux ablation (EVRA) trial showed faster ulcer healing in CEAP C5-C6 patients (healed or active ulcers) at 1 year.¹ The effect of surgery and compression on healing and recurrence (ESCHAR) trial reported reduced ulcer recurrence over 4 years.² However, no trials compare interventions to optimised medical therapy [e.g., Micronized purified flavonoid fraction (MPFF; Daflon), exercise, weight loss] beyond 10 years for any CEAP stage. For C2-C3, the randomised clinical trial, observational study, and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV) trial found only short-term symptom relief.³ Recent international guidelines endorse intervention in symptomatic uncomplicated varicose veins (C2S) with documented reflux, but these recommendations are grounded in short- to mid-term outcomes, and no data confirm durable benefit beyond 10 years.⁴ While early intervention may theoretically improve quality of life or prevent progression to advanced stages (C4-C6), no long-term studies confirm these benefits. To date, no long-term (> 10-year) randomised controlled trials have evaluated recurrence, symptom relief, or adverse events in surgically versus conservatively managed CEAP C2-C3 patients. A retrospective cohort in Int J Vasc Med (2024) reported a 33.8% recurrence rate over a median follow-up of ∼9 years (range 5-12), yet lacked comparison to medical management, highlighting the absence of prospective, controlled, long-term data.⁵

Over time, progressive deep venous degeneration, driven by valvular wear-and-tear, can negate intervention benefits and worsen outcomes by eliminating collateral veins. Conservative treatments, including Daflon to improve venous tone, weight loss, and calf muscle exercises to enhance venous return, are effective yet underused. Recent guidelines reaffirm the central role of conservative strategies, particularly compression, but acknowledge challenges with adherence.⁴ Compression therapy, despite only ∼30% adherence in India’s tropical climate, remains a cornerstone. Low adherence does not justify irreversible interventions without long-term evidence.

Aesthetic concerns and inter-specialty overlaps drive over-intervention, risking harm. In India, this is compounded by fee-for-procedure models, cultural preferences for quick fixes, and low compliance adherence due to tropical climates. In the absence of standardised conservative protocols, treatment remains fragmented. Dermatologists, as primary observers of venous skin complications, must lead evidence-based restraint. Invasive procedures should be reserved for:

• Active ulceration (CEAP C5-C6).

• Persistent symptoms despite a 3-month conservative trial (MPFF, compression, exercise, weight loss).

• Severe symptoms with duplex-confirmed reflux and deep vein competence, pending robust evidence for broader use.

Robust randomised trials comparing intervention with optimised medical therapy across CEAP stages are urgently needed to quantify long-term benefit and harm. Restraint must guide our approach.

In my opinion

• No long-term (>10 yr) comparative trials support surgical intervention over medical therapy for any CEAP stage. Post-procedural fibrosis/pigmentation is underreported.

• Daflon, weight loss, exercise, and compression are effective conservative options.

• In India’s tropical climate, <30% compression adherence should not justify irreversible procedures.

• Restraint is essential until robust evidence emerges.

Although conservative management is the formal first-line recommendation in international guidelines, in practice, it is frequently bypassed, especially in early CEAP stages, necessitating reiteration of its primacy and proper sequencing.