# Subclinical varicose vein recurrence: modern approaches in aesthetic phlebology

## TL;DR

This study explores a two-step treatment approach for subclinical varicose vein recurrence, focusing on hemodynamic correction followed by aesthetic care to improve outcomes.

## Contribution

A novel two-stage treatment protocol combining ultrasound-guided interventions and cryo-laser therapy is proposed for subclinical varicose recurrence.

## Key findings

- Subclinical recurrence is primarily hemodynamic, with 78% of patients having multiple reflux sources.
- The two-stage treatment achieved 83.1% good/excellent aesthetic outcomes at 6 months.
- Minor adverse effects were limited to transient pigmentation or matting.

## Abstract

Recurrence after varicose vein treatment is usually framed as varices on a previously treated limb, potentially overlooking patients with cosmetic C0–C1 concerns who still experience duplex Doppler ultrasound-verified reflux.

To characterize patterns of subclinical (C1-dominant) recurrences in duplex Doppler ultrasound and evaluate a 2-stage pathway prioritizing hemodynamic correction before aesthetic care.

This retrospective single-center cohort study (2018-2024) was conducted with patients from a vascular clinic. The participants were 354 women with unaesthetic telangiectasias/reticular veins without C2 varices on the index limb after prior varicose treatment. The interventions (exposures) were: (Stage 1) ultrasound-guided 3% polidocanol foam for segments ≤ 3 mm and endovenous laser ablation ≥ 3 mm (anterior accessory saphenous vein/ greater saphenous vein /small saphenous vein/perforators); (Stage 2) 2 sessions of cryo-laser and cryo-sclerotherapy at a 1-month interval, guided by near-infrared augmented-reality. The main outcomes were duplex-verified occlusion of Stage-1 targets at 1 month and aesthetic outcome at 6 months (rated on a 5-point Likert scale). Safety measures included symptomatic venous thromboembolism and minor adverse effects.

At 1 month, all targets were occluded and no symptomatic venous thromboembolisms had occurred. Mapping frequently showed multilevel reflux (anterior accessory saphenous vein, angiomatosis in the vein stump or strip tract, junctional complexes, perforators), with 78% of patients having ≥ 2 sources. At 6 months, good/excellent aesthetic outcomes (Likert scale score 4-5) were achieved in 83.1% of patients (mean score: 4.22). The scoring distribution was: 1 point: 7 (2.0%); 2 points: 11 (3.1%); 3 points: 42 (11.9%); 4 points: 131 (37.0%); and 5 points: 163 (46.0%). Minor events were limited to transient pigmentation/matting.

Subclinical recurrence is chiefly hemodynamic. An etiology-first strategy using duplex Doppler ultrasound followed by cryo-laser and cryo-sclerotherapy yields high early satisfaction and could mitigate early cosmetic recurrence.