Recurrent varicose veins after surgery: A new appraisal of a common and complex problem in vascular surgery

Objective. To assess the true incidence, the reflux patterns and the mechanisms responsible for recurrent varicose vein disease according to-current definitions and guidelines. Patients and methods. Ninety-three patients (69 female, 24 male, mean age: 48 years) were prospectively evaluated pre- and postoperatively (1 month and 5 years), using clinical and colour duplex examination of both lower limbs. The CEAP score and its modification for recurrence (REVAS) were used for classification. Results. In 113 operated lower limbs, 28 (25%) were found to have a recurrence, 20 of which were symptomatic (20128, 72%). However, in this group, the mean severity score decreased significantly from 6.5 (SD 3.1) to 5.2 (SD 2.8) (p < 0.001, paired t-test). The correlation between the type and cause of recurrence revealed: (1) true recurrent varices in eight limbs (8/28, 29%), primarily caused by neovascularisation, (2) new varicose veins as a consequence of disease progression in seven limbs (7128, 25%), (3) residual veins in three limbs (3/28, 11%) mainly due to tactical errors (e.g. failure to strip the GSV), (4) complex patterns in 10 limbs (10/28, 36%). In the limbs with recurrence, 42 sources of venous reflux were identified: (1) 19 new sites of venous reflux were due to disease progression (15% of the operated limbs), (2) 13 were caused by neovascularisation (11.5% of the operated limbs), (3) six resulted from tactical failures (5.3% of the operated limbs) and (4) four were due to technical failures (3.5% of the operated limbs). Conclusions. This study shows that the recurrence of varicose veins after surgery is not uncommon. However, the clinical condition of most affected limbs remains improved. Progression of the disease and neovascularisation are responsible for more than half of the recurrences. Rigorous evaluation of patients and assiduous surgical technique might reduce recurrence due to technical and tactical failures.