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Varicose Veins

My varicose veins don't hurt. Can I just leave them alone?

The argument for treating rests on symptoms, so having none is the weakest case for a procedure. The mortality figure sometimes quoted against that is real, observational, and not Korean.

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Answer

Largely yes. In a Korean national survey of chronic venous disease about 60 percent of patients said physical symptoms rather than appearance were what harmed their quality of life, so the main driver of harm is absent in someone without symptoms — and while a Taiwanese nationwide cohort of 4,644 patients found 1.37 times the mortality (95% CI 1.19 to 1.57) and 2.05 times the rate of major adverse cardiovascular events against matched controls, that is an observational association in administrative data, not evidence that veins cause either outcome or that treating them prevents anything.

Key takeaways

  • In a Korean survey, about 60 percent of patients with chronic venous disease said physical symptoms, not appearance, were what damaged their quality of life.
  • A Taiwanese nationwide cohort of 4,644 newly diagnosed patients found 1.37 times the mortality of propensity-matched controls (95% CI 1.19 to 1.57).
  • The same cohort found 2.05 times the rate of major adverse cardiovascular events, and 1.83 times the mortality in the most severe grade.
  • These are observational associations; varicose veins and cardiovascular disease share risk factors that administrative matching cannot fully balance.
  • No equivalent Korean cohort analysis has been published, so the mortality figure is imported from a different health system.
  • A separate case-control study found primary valvular reflux 4.7 times more prevalent in patients with confirmed deep vein thrombosis than in symptomatic controls (65.5 against 29.0 percent).
  • No trial has tested whether treating asymptomatic varicose veins changes mortality or cardiovascular outcomes.

This question usually arrives after someone has been told that varicose veins are not merely cosmetic. That statement is defensible. What it does not establish is that a leg with no symptoms needs a procedure.

Why symptoms are the argument

In a national survey of chronic venous disease in Korea, roughly 60 percent of patients said the physical symptoms — heaviness, aching, swelling — were what harmed their quality of life, ahead of appearance or the emotional effect. That is the clearest evidence available on what this condition actually costs the people who have it, and it is a finding about symptoms.

A leg without symptoms is missing the thing that most patients report as the harm. It does not follow that nothing is happening inside it, but it does follow that the strongest reason to intervene is not present.

The number quoted on the other side

A study using Taiwan's National Health Insurance Database identified 4,644 patients newly diagnosed with varicose veins between 1999 and 2013 and matched them against controls on age, sex and chronic cardiovascular risk factors. Mortality was 1.37 times higher (95% CI 1.19 to 1.57) and major adverse cardiovascular events 2.05 times more frequent, with the most severe grade carrying 1.83 times the mortality risk.

The one association with a plausible mechanism

A case-control study of outpatients presenting with signs of deep vein thrombosis found primary valvular reflux in 65.5 percent of those with a confirmed clot against 29.0 percent of symptomatic controls — a 4.7-fold difference. Slow, refluxing venous flow is a mechanism by which a leg vein problem could plausibly contribute to a clot, which is more than can be said for the route from varicose veins to a stroke.

Its controls were people who came to a vascular laboratory worried about a clot, not the general population, so it describes who among the worried turns out to have one. It does not give an absolute risk for someone with painless varicose veins.

What can honestly be said

Watching painless varicose veins is a reasonable choice, and the thing to watch for is the arrival of symptoms or of skin changes around the ankle, which is where the disease does its visible damage. What does not follow from the evidence is treating an asymptomatic leg on the strength of a hazard ratio of 1.37 from a matched observational cohort in another country.

Sources

  1. 1

    Wu NC, Chen ZC, Feng IJ, Ho CH, Chiang CY, Wang JJ, Chang WT

    Severe varicose veins and the risk of mortality: a nationwide population-based cohort study

    BMJ Open 2020;10(6):e034245

    doi:10.1136/bmjopen-2019-034245 · PMID:32565451

    https://doi.org/10.1136/bmjopen-2019-034245
  2. 2

    Shaydakov ME, Comerota AJ, Lurie F

    Primary venous insufficiency increases risk of deep vein thrombosis

    Journal of Vascular Surgery: Venous and Lymphatic Disorders 2016;4(2):161-166

    doi:10.1016/j.jvsv.2015.09.008 · PMID:26993861

    https://doi.org/10.1016/j.jvsv.2015.09.008
  3. 3

    Kim H, Lee SH, Park JK, Kang JM, Hong KP, Yu YS, Choi HZ, Joh JH

    Public awareness of chronic venous disease in Korea

    Journal of Vascular Surgery: Venous and Lymphatic Disorders 2023;11(3):477-482

    doi:10.1016/j.jvsv.2022.12.005 · PMID:36580999

    https://doi.org/10.1016/j.jvsv.2022.12.005