Key messages

We are uncertain about which treatments are best for varicose veins because we found only a small number of studies that compared the different types of treatment, and because studies differed in how they measured results.

- All currently available varicose vein treatments are similar in terms of whether the treatment fully destroys the vein, or stops blood from pooling in the legs, or both (technical success).

- We need studies that provide more evidence on all the available treatments.

What are varicose veins?

Varicose veins are bulging, twisty veins close to the skin’s surface that usually occur in the legs. They are caused by chronic venous insufficiency, which is when your veins do not manage to help blood to flow back up to your heart efficiently, and blood pools in your legs. About one-third of adults are thought to have chronic venous insufficiency. Women are more likely than men to have varicose veins.

Varicose veins can be painful, itchy and unsightly, especially when standing and walking. Occasionally, they may result in skin changes or sores (ulcers) on the leg that take more than two weeks to heal.

How are varicose veins treated?

Varicose veins can be treated using a variety of procedures.

Traditionally, surgery was used to remove the main surface vein (called the ‘great saphenous vein’, which runs from the groin to the ankle) and any connected varicose veins through small openings in the leg. People having this procedure (known as ‘high ligation and stripping’) need to have a general anaesthetic to make them unconscious and stop them from feeling pain or moving while the surgery is done.

More recently, several treatments have emerged where the procedure is done inside the vein (endovenous), using a very fine tube. These treatments involve sealing the main vein in the thigh by deliberately damaging the vein wall. There are two main types of treatment:

- heat-based, where heat energy from lasers, radio waves or steam, is used to damage the vein wall;

- chemical-based, where chemicals (including foam or glue) are used to damage and consequently seal the vein.

These newer treatments are done using a local anaesthetic, meaning you do not feel pain in your legs during the procedure but you remain awake.

What did we want to find out?

We wanted to compare all the currently available treatments for varicose veins to find out which is best in terms of:

- short- and long-term technical success (whether the treatment fully destroys the vein, or stops blood from pooling in the legs, or both);

- stopping varicose veins from returning (recurrence);

- avoiding unwanted effects; and

- improving people’s well-being.

What did we do?

We searched for studies that compared treatments for varicose veins in men and women of any age.

We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found 24 studies that involved 5135 people with mild to severe varicose veins. The studies followed people for between 5 weeks to 8 years after their treatment. The majority of the people in the studies were women.

The studies took place in private and public clinics and hospitals in 10 different countries: Austria, Denmark, Egypt, Finland, France, Germany, the Netherlands, Turkey, the United Kingdom and the USA.

The studies we found did not investigate all possible treatments for varicose veins, especially newer treatments.

Main results

Technical success

Most treatments are equally likely to fully destroy the vein or prevent blood pooling in the legs, or both. However:

- heat-based endovenous treatment with a laser may be more successful than traditional surgery;

- both heat-based laser treatment and surgery may be more successful than chemical-based endovenous treatment with a foam chemical.

Recurrence rates

Most treatments were similarly successful at stopping varicose veins from recurring.

Heat-based radio wave endovenous treatment may be better than both laser endovenous treatment and surgery at preventing varicose veins from recurring in the longer term.

Unwanted effects

Unwanted effects were generally low for all treatments. The studies reported very few serious unwanted effects requiring treatment, both in the short and long term.

Well-being

People in the studies said they had improved well-being regardless of the treatment they received.

What are the limitations of the evidence?

Our confidence in the evidence ranges from moderate to very low because of:

- concerns over how the studies were carried out (people in most of the studies were aware of which treatment they were getting, as were the researchers assessing treatment data, which could affect the studies’ results);

- similar studies did not get the same results; and

- only a small number of studies contributed data to each result.

We were not able to reach firm conclusions about which of the treatments compared is best.

How up to date is this evidence?

This Cochrane Review updates our previous review. The evidence is current to November 2020