Quality-of-life outcomes after varicose vein surgery: A 12-month prospective study of 605 patients identifying key prognostic factors

Abstract

Objective

To evaluate quality-of-life (QoL) outcomes after varicose vein (VV) surgery and identify predictors of postoperative QoL to inform patient counselling and clinical management.

Methods

This prospective single-center study enrolled a cohort of consecutive patients who underwent surgical treatment for primary lower extremity VVs between September 2021 and December 2024. QoL was assessed using the Chronic Venous Insufficiency Questionnaire-20 at 1, 6, and 12 months postoperatively. Clinical severity was evaluated using the Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification and Venous Clinical Severity Score (VCSS), and psychological status was assessed with the Self-Rating Anxiety Scale. Multivariate linear regression identified independent predictors of QoL at each time point.

Results

The cohort comprised 605 patients (370 females, 61.2%) with a mean age of 55.6 ± 12.6 years. CEAP classifications included C2 (10.1%), C3 (19.0%), C4 (66.9%), C5 (2.3%), and C6 (1.7%). Mean Chronic Venous Insufficiency Questionnaire-20 scores improved significantly from 81.15 ± 8.62 at 1 month to 89.11 ± 8.54 at 6 months (P < .001) and 95.59 ± 6.07 at 12 months (P < .001). Multivariate analysis revealed that advanced age, higher CEAP classification, greater VCSS, and elevated anxiety scores were consistent independent predictors of poorer QoL across all time points. At 12 months, age ≥60 years (P = .007), C5 or C6 classification (P < .001 and P = .01), higher VCSS (P < .001), and higher Self-Rating Anxiety Scale scores (P = .001) significantly predicted reduced QoL. Patients with C2 or C3 disease demonstrated superior QoL compared with those with C4 to C6 disease (P < .001). Additional factors influencing early postoperative QoL included gender, surgical technique, patient's occupation, and complications.

Conclusions

VV surgery yields sustained and progressive QoL improvements through 12 months postoperatively. Advanced age, greater disease severity, higher VCSS scores, and elevated anxiety independently predict poorer QoL outcomes. These findings support risk-stratified preoperative counseling, targeted postoperative follow-up, and integration of psychological assessment into comprehensive VV care.

Article Highlights.

• •Type of Research: Prospective cohort study evaluating quality-of-life (QoL) outcomes after varicose vein (VV) surgery
• •Key Findings: VV surgery resulted in sustained quality-of-life improvements through 12 months postoperatively, with mean Chronic Venous Insufficiency Questionnaire-20 scores increasing significantly from 81.15 ± 8.62 at 1 month to 95.59 ± 6.07 at 12 months (P < .001). Advanced age (≥60 years), higher Clinical, Etiological, Anatomical, and Pathophysiological classification (C5-C6), greater Venous Clinical Severity Scores, and elevated anxiety levels independently predicted poorer postoperative QoL outcomes across all time points. Patients with early stage disease (C2-C3) demonstrated significantly superior QoL at 12 months compared with those with advanced disease (C4-C6), highlighting the value of early intervention.
• •Take Home Message: Surgical treatment of VVs provides progressive and sustained improvements in patient QoL. However, outcomes vary significantly based on patient characteristics and disease severity. Clinicians should provide risk-stratified preoperative counselling for older patients and those with advanced venous disease, implement targeted postoperative follow-up protocols, and integrate psychological assessment into routine care since anxiety is a significant independent predictor of poorer outcomes. These findings support a comprehensive, patient-centered approach to VV management that addresses both physical and psychological aspects of recovery.

Lower extremity varicose veins (VVs) represent a highly prevalent chronic venous disorder affecting 10% to 30% of the global population,¹ with notable disparities by sex (46.7% in women vs 27.8% in men).² In China alone, approximately 8.9% of the population, >100 million individuals, suffer from this condition.³ Beyond the visible manifestations of dilated superficial veins, patients experience a spectrum of symptoms including pain, heaviness, swelling, and skin changes that substantially impair physical function and daily activities.⁴ As the global population ages, the prevalence and severity of VVs continue to escalate, imposing significant economic burdens on healthcare systems and diminishing quality of life (QoL) for affected individuals.^5,6

Surgical intervention remains the most effective treatment modality for symptomatic VVs.⁷ The therapeutic landscape has evolved substantially over the past two decades,⁸ with minimally invasive endovenous techniques such as radiofrequency ablation (RFA) and laser increasingly being used and recommended as first-line treatment in international guidelines.9, 10, 11 Although considerable research has compared the technical efficacy and complication rates of various surgical approaches, patient-centered outcomes, particularly QoL, have received less systematic attention.^12,13 Understanding how QoL evolves postoperatively and which factors predict recovery is essential for patient counselling, shared decision-making, and optimizing therapeutic outcomes in contemporary patient-centered care models.¹⁴

Despite the recognized importance of QoL as a key outcome measure, comprehensive longitudinal data examining QoL trajectories and their determinants after VV surgery remain limited.^15,16 Most existing studies have focused on comparing surgical techniques rather than systematically identifying modifiable and nonmodifiable factors that influence patient-reported outcomes.¹⁷ Furthermore, there is insufficient evidence regarding how QoL evolves over the first postoperative year and which patient subgroups may experience suboptimal recovery. Therefore, this prospective study aimed to evaluate QoL after surgical treatment for lower extremity VVs and to identify independent factors associated with postoperative QoL outcomes.

Methods

Study design

This prospective, single-center cohort study was conducted at the University of Hong Kong-Shenzhen Hospital, between September 2021 and December 2024. Patients who underwent surgical treatment for primary lower extremity VVs were enrolled and followed longitudinally at 1, 6, and 12 months postoperatively. The study protocol was approved by the Medical Ethics Committee of the University of Hong Kong-Shenzhen Hospital (Ref: [2022]225). All participants provided written informed consent after receiving detailed information about the study objectives, procedures, and follow-up requirements. The study was conducted in accordance with the STROBE guidelines.¹⁸

Eligibility criteria

Patients were eligible for inclusion if they were aged ≥18 years, had a confirmed diagnosis of primary lower extremity VVs according to established diagnostic criteria, underwent surgical treatment for VVs, and had a Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) clinical classification of C2 to C6.¹⁹ Additional inclusion criteria required that participants have clear consciousness, normal communication and comprehension abilities to participate in telephone follow-up interviews, and willingness to participate in the study with signed informed consent. Patients were excluded if they had cognitive or mental disorders that would impair their ability to complete questionnaires; severe primary diseases of the heart, liver, or kidneys; active serious infections; or malignancy.

Data collection

Baseline demographic and clinical data were systematically collected from all participants before surgery. Demographic variables included age, sex, marital status, educational level, place of residence, occupation type, and medical payment method. Clinical characteristics documented included CEAP classification, disease duration, family history of VVs, presence of comorbidities, surgical technique performed, history of previous VV surgery, and occurrence of postoperative complications. Follow-up assessments were conducted via structured telephone interviews by trained research team members at 1, 6, and 12 months after surgery. All completed questionnaires were independently reviewed by a second researcher for accuracy and completeness before data entry into Excel 2010 for subsequent analysis.

Assessment instruments

QoL was assessed using the Chronic Venous Insufficiency Questionnaire (CIVIQ-20),²⁰ a disease-specific instrument developed by Launois et al specifically for patients with chronic venous disease. The CIVIQ-20 comprises 20 items across 4 domains: physical, psychological, social, and pain, with a total possible score of 100 points. Higher scores indicate better QoL.

Venous disease severity was evaluated using the Venous Clinical Severity Score (VCSS),²¹ a validated instrument proposed by Vasquez et al as a refinement of the CEAP classification system. The VCSS assesses 10 clinical parameters: pain, edema, venous claudication, pigmentation, lipodermatosclerosis, ulcer size, ulcer duration, ulcer recurrence, number of ulcers, and use of compression therapy. Each parameter is scored from 0 (absent) to 3 (severe), yielding a total score ranging from 0 to 30 points, with higher scores reflecting greater disease severity.

Psychological status was measured using the Zung Self-Rating Anxiety Scale (SAS),²² a widely used 20-item instrument developed by Zung in 1971 to assess anxiety symptoms. Each item is rated on a 4-point Likert scale based on symptom frequency: 1 (none or very rarely), 2 (some of the time), 3 (a considerable amount of time), and 4 (most or all of the time). Items 5, 9, 13, 17, and 19 are reverse scored. The raw total score is multiplied by 1.25 to obtain a standardized score ranging from 25 to 100. Scores >50 indicate the presence of anxiety, with 50 to 59 representing mild anxiety, 60 to 69 moderate anxiety, and ≥70 severe anxiety.

The CIVIQ-20 and SAS were administered at each of these three postoperative follow-up time points. No preoperative SAS baseline was collected.

Primary end point

The primary end point was QoL as measured by CIVIQ-20 total scores at 1, 6, and 12 months postoperatively.

Statistical analysis

Continuous variables were expressed as mean ± standard deviation and compared using independent t tests for two groups or one-way analysis of variance for multiple groups. Categorical variables were presented as frequencies and percentages. Correlations between assessment scale scores and QoL were evaluated using Pearson or Spearman correlation analysis depending on whether data met normality assumptions. Univariate analyses were performed to examine associations between patient characteristics and QoL scores at each time point. Variables demonstrating statistical significance in univariate analysis were subsequently entered into stepwise multiple linear regression models to identify independent predictors of QoL at 1, 6, and 12 months postoperatively. The entry and removal criteria for stepwise regression were set at an alpha of 0.05 and a beta of 0.10, respectively. Model fit was evaluated using R² and adjusted R² values, and overall model significance was assessed using F statistics. Further comparison of QoL outcomes between patients with early stage disease (CEAP C2-C3) and advanced stage disease (CEAP C4-C6) at 12 months was performed. All statistical tests were two-tailed, and a P value of <.05 was considered statistically significant. All analyses were performed using SPSS version 26.0 statistical software (IBM Corporation).

Results

Patient characteristics

Between September 2021 and December 2024, a total of 659 patients were enrolled, with 605 completing the 12-month follow-up (91.8% response rate). The cohort included 235 males (38.8%) and 370 females (61.2%), with a mean age of 55.6 ± 12.6 years. Most patients (66.9%) presented with C4 disease, while C2, C3, C5, and C6 represented 10.1%, 19.0%, 2.3%, and 1.7%, respectively. RFA was performed in 54.0% of cases, traditional high ligation and stripping in 14.7%, and a combination of two procedures for bilateral legs in 31.2%. Detailed baseline characteristics are shown in Table I.

Table I.

Baseline demographics and clinical characteristics of study participants (n = 605)

Variable	No.	Percent
Gender
Male	235	38.8
Female	370	61.2
Age, years
18-44	140	23.1
45-59	204	33.7
≥60	261	43.2
BMI, kg/m2
<18.5	15	2.4
18.5-23.9	249	41.2
24-27.9	263	43.5
≥28	78	12.9
Smoking
Yes	74	12.2
No	531	87.8
Alcohol consumption
Yes	123	20.3
No	482	79.7
Marital status
Married	517	85.5
Single/divorced/widowed	88	14.5
Education level
Primary school or below	121	20.0
Secondary school	284	46.9
College or above	200	33.1
Occupation type
Office worker/civil servant	122	20.2
Farmer/worker	146	24.1
Professional/technical	77	12.7
Others	260	43.0
Long-term residence
Urban	539	89.1
Rural	66	10.9
Living status
Living alone	42	6.9
Living with others	563	93.1
Medical payment type
Medical insurance	539	89.1
Commercial insurance	6	1.0
Self-paid	60	9.9
Household per capita income, ¥/month
<3000	78	12.9
3000-4999	116	19.2
5000-9999	199	32.9
≥10,000	211	35.0
Family history
Yes	159	26.3
No	446	73.7
Comorbidity
Yes	188	31.1
No	417	68.9
Disease duration, years
<5	151	25.0
5-9	54	8.9
≥10	400	66.1
CEAP classification
C2	61	10.1
C3	115	19.0
C4	405	66.9
C5	14	2.3
C6	10	1.7
Surgical procedure
RFA	327	54.0
HLS	89	14.7
No. of operations
1	566	93.6
≥2	39	6.4
Postoperative complications
Yes	83	13.7
No	522	86.3

BMI, Body mass index; CEAP, Clinical-Etiological-Anatomical-Pathophysiological; HLS, high ligation and stripping; RFA, radiofrequency ablation.

QoL trajectories over time

Mean CIVIQ-20 scores improved progressively from 81.15 ± 8.62 at 1 month to 89.11 ± 8.54 at 6 months (P < .001) and 95.59 ± 6.07 at 12 months postoperatively (P < .001).

Factors associated with QoL

Univariate analysis identified multiple demographic and clinical variables associated with QoL at different time points (Table II). At 1 month, significant associations included gender, age, education, occupation, income, comorbidity, disease duration, CEAP classification, surgical procedure, and postoperative complications (all P ≤ .041). By 6 months, associations with disease duration, surgical procedure, and complications were not statistically significant. At 12 months, gender, age, education, occupation, family history, comorbidity, and CEAP classification remained significant predictors.

Table II.

Univariate analysis of quality of life (QoL) at 1, 6, and 12 months of follow-up

Variable	QoL score
	1 Month	6 Months	12 Months
Gender
Male	79.81 ± 9.75a	88.08 ± 9.60b	94.91 ± 7.06b
Female	82.00 ± 7.72	89.76 ± 7.74	96.03 ± 5.31
Age, years
18-44	84.24 ± 7.94c	91.73 ± 7.89c	97.14 ± 5.32c
45-59	81.82 ± 8.03	89.88 ± 7.91	96.14 ± 5.38
≥60	78.96 ± 8.85	87.10 ± 8.90	94.34 ± 6.69
Education level
Primary	79.87 ± 8.60a	87.80 ± 8.34c	94.92 ± 6.19a
Secondary	80.73 ± 8.72	88.32 ± 8.67	95.06 ± 6.38
Tertiary	82.82 ± 8.24	91.03 ± 8.19	96.76 ± 5.36
Occupation type
Office worker/civil servant	82.02 ± 7.49b	90.88 ± 7.74c	96.80 ± 4.76b
Farmer/worker	79.21 ± 8.70	86.73 ± 8.69	94.48 ± 6.40
Professional/technical	82.46 ± 9.21	90.26 ± 8.79	95.75 ± 6.35
Others	81.44 ± 8.76	89.28 ± 8.50	95.61 ± 6.26
Household per capita income, ¥/month
<3000	79.87 ± 8.60a	87.87 ± 8.62b	94.73 ± 6.68
3000-4999	78.71 ± 8.91	87.50 ± 8.83	94.58 ± 6.22
5000-9999	82.30 ± 7.75	89.60 ± 7.99	95.88 ± 6.12
≥10,000	81.87 ± 8.98	89.98 ± 8.75	96.20 ± 6.12
Family history
Yes	81.93 ± 7.55	90.01 ± 7.26	86.35 ± 5.06b
No	80.87 ± 8.97	88.79 ± 8.94	95.33 ± 6.38
Comorbidity
Yes	79.44 ± 9.27a	87.38 ± 9.05	94.71 ± 6.48b
No	81.92 ± 8.21	89.89 ± 8.20	95.99 ± 5.84
Disease duration, years
<5	82.62 ± 7.39b	90.01 ± 7.82	96.33 ± 5.72
5-9	81.46 ± 8.84	89.72 ± 8.64	96.63 ± 5.31
≥10	80.55 ± 8.97	88.68 ± 8.78	95.17 ± 6.26
CEAP classification
C2	84.68 ± 7.15c	91.39 ± 7.78c	97.31 ± 4.18c
C3	83.89 ± 6.53	91.81 ± 6.74	97.34 ± 4.22
C4	80.95 ± 7.86	89.09 ± 7.76	95.72 ± 5.49
C5	65.14 ± 9.63	72.79 ± 8.23	83.07 ± 7.48
C6	58.50 ± 7.23	67.60 ± 7.70	77.60 ± 5.71
Surgical procedure
RFA	82.04 ± 8.55a	89.48 ± 8.51	95.61 ± 6.19
HLS	78.42 ± 8.89	87.75 ± 8.89	95.28 ± 6.28
Postoperative complications
Yes	77.90 ± 6.93c	89.81 ± 7.95	95.49 ± 5.82
No	81.67 ± 8.76	89.00 ± 8.64	95.61 ± 6.12

CEAP, Clinical-Etiological-Anatomical-Pathophysiological; HLS, high ligation and stripping; RFA, radiofrequency ablation.

Data are mean ± standard deviation.

^aP < .01.

^bP < .05.

^cP < .001.

Multivariate regression analysis identified independent predictors at each time point (Table III). At 1 month, nine factors were independently associated with QoL, explaining 51.0% of the variance (R² = 0.518). These included VCSS score (β = −1.13), SAS score (β = −0.10), female gender (β = 1.30), older age, C4 and C5 classification, RFA procedure (β = 1.49), and presence of complications (β = −3.88) (all P ≤ .011). At 6 months, five independent predictors remained, accounting for 42.0% of variance (R² = 0.437). By 12 months, four consistent predictors emerged: age ≥60 years (β = −1.62, P = .007), C5 classification (β = −6.72, P < .001), C6 classification (β = −5.10, P = .01), VCSS score (β = −1.19, P < .001), and SAS score (β = −0.12, P = .001), explaining 45.3% of variance (R² = 0.467).

Table III.

Multivariate analysis of independent predictors of quality of life (QoL) at 1, 6, and 12 months of follow-up

Independent variable	B	SE	β	t	P value
1 Month (R2 = 0.518, adjusted R2 = 0.51), F = 63.886, P < .001
Constant	93.34	1.24	–	75.61	<.001
VCSS score	−1.13	0.08	−0.525	−13.50	<.001
SAS score	−0.10	0.03	−0.137	−3.13	.002
Female (vs. male)	1.30	0.51	0.073	2.55	.011
Age 45-59 (vs. 18-44)	−1.52	0.68	−0.083	−2.26	.014
Age ≥60 (vs. 18-44)	−3.10	0.66	−0.178	−4.72	<.001
C4 (vs. C2)	2.66	0.61	0.145	4.35	<.001
C5 (vs. C2)	−5.93	1.89	−0.103	−3.14	.002
RFAA (vs. HLS)	1.49	0.50	0.086	2.98	.003
Complications present	−3.88	0.72	0.155	−5.39	<.001
6 Months (R2 = 0.437, adjusted R2 = 0.42), F = 25.319, P < .001
Constant	99.72	2.08	–	47.87	<.001
VCSS score	−1.02	0.10	−0.414	−9.82	<.001
SAS score	−0.14	0.05	−0.144	−3.16	.002
Age ≥60 (vs. 18-44)	−2.48	0.87	−0.144	−2.84	.005
C5 (vs. C2)	−7.32	2.21	−0.129	−3.32	.001
Farmer/Worker (vs. Office)	−2.14	0.91	−0.107	−2.35	.019
12 Months (R2 = 0.467, adjusted R2 = 0.453), F = 32.212, P < .001
Constant	102.19	1.35	–	75.48	<.001
VCSS score	−1.19	0.10	−0.440	−11.98	<.001
SAS score	−0.12	0.04	−0.140	−3.31	.001
Age ≥60 (vs. 18-44)	−1.62	0.60	−0.132	−2.70	.007
C5 (vs. C2)	−6.72	1.55	−0.166	−4.33	<.001
C6 (vs. C2)	−5.10	1.96	−0.107	−2.60	.010

B, Unstandardized regression coefficient; β, standardized regression coefficient; HLS, high ligation and stripping; RFA, radiofrequency ablation; SAS, Self-Rating Anxiety Scale; SE, standard error; VCSS, Venous Clinical Severity Score.

Four factors consistently predicted QoL across all time points: age, CEAP classification, VCSS, and SAS scores, all showing negative associations with QoL outcomes.

QoL by disease severity

At 12 months, patients with early stage disease (C2-C3, n = 176) demonstrated significantly superior QoL compared with those with advanced-stage disease (C4-C6, n = 429): 97.33 ± 4.19 vs 94.88 ± 6.56 (t = 5.465, P < .001) (Table IV).

Table IV.

Comparison of quality of life (QoL) at 12 months by Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification (n = 605)

Group	No. (%)	QoL score	T value	P value
C2-C3	176 (29.1)	97.33 ± 4.19	5.465	<.001
C4-C6	429 (70.9)	94.88 ± 6.56

Data are mean ± standard deviation.

Discussion

This prospective study demonstrates sustained improvement in disease-specific QoL after surgical treatment of lower extremity VVs, with CIVIQ-20 scores increasing progressively from 81.15 at 1 month to 95.59 at 12 months postoperatively. This temporal pattern reflects early relief of venous symptoms followed by gradual restoration of physical function and social participation.

The findings of this study are consistent with previously published literature. The RELIEF validation study reported an 18-point Global Index improvement over six months with pharmacological treatment.²³ MacKenzie et al²⁴ reported significant and sustained disease-specific health-related QoL improvement up to 2 years after open VV surgery. Biemans et al²⁵ demonstrated that CIVIQ scores improved in 76% of patients after VV treatment with a clinically meaningful medium effect size. Thao Cuong et al²⁶ reported VCSS improvement from 5.9 ± 2.4 to 2.7 ± 1.6 at 1 month after endovascular laser ablation, consistent with the VCSS changes observed in our cohort. Direct numeric CIVIQ-20 comparison across studies is limited by differences in scoring conventions. Our study uses the 0 to 100 Global Index (higher = better), whereas some contemporary studies report the raw summed score.

The VCSS emerged as the strongest predictor of QoL across all time points, with each 1-point increase in VCSS associated with approximately 1.0- to 1.2-point decrease in the CIVIQ-20 score, consistent with the strong VCSS-CIVIQ-20 correlation (r = 0.63, P < .001) reported by Thao Cuong et al.²⁶ This persistent association suggests that advanced venous disease creates tissue-level pathology, including chronic inflammation, microcirculatory dysfunction, and fibrosis, that is not fully reversible with hemodynamic correction alone.²⁷ The independent effect of CEAP classification reinforces this finding, with C5 or C6 disease showing substantially reduced QoL at all time points, consistent with the approximately 16-point Global Index difference observed between adjacent CEAP severity groups in the RELIEF study.²³ Patients with early-stage disease (C2-C3) achieved superior 12-month outcomes, supporting intervention before development of advanced skin changes, although our observational design precludes causal inference.

Advanced age (≥60 years) consistently predicted lower QoL throughout follow-up. Beyond diminished physiological reserve and comorbidity burden, functional factors may play a substantial independent role. Fukaya and Kolluri²⁸ have outlined how calf muscle pump dysfunction, compounded by diabetes, peripheral neuropathy, arthritis, and foot deformities, sustains venous hypertension even after technically successful intervention. Obesity, present in 55% of our cohort, may increase intra-abdominal pressure and obstruct venous return, constituting an independent risk factor for disease progression.²⁹ Sedentary behavior and limited ankle range of motion further impair calf pump activation, and addressing these factors through structured exercise is noted as underappreciated in the elderly.³⁰ These observations are consistent with previous studies. Ahmadi et al³¹ identified physical performance and functional dependence as the strongest independent predictors of QoL in elderly patients. Brinson et al³² demonstrated that preoperative frailty predicts postoperative functional limitations and prehabilitation improves recovery in older surgical patients. This persistent effect supports age-stratified counseling and prospective evaluation of adjunctive prehabilitation programs in older patients undergoing VV surgery.

Several factors showed time-dependent effects. Surgical technique influenced QoL only at 1 month, with RFA conferring early advantages that disappeared by 6 months, consistent with literature showing procedural differences primarily affect perioperative recovery rather than long-term outcomes.³³ Postoperative complications demonstrated the greatest effect at 1 month, but did not persist, indicating that complication-related deficits typically resolve while emphasizing the importance of prevention. Female gender showed protective effects only at 1 month, and farmer/worker occupation was associated with lower QoL at 6 months, possibly reflecting occupational demands during return to work.

Anxiety symptoms showed modest but consistent associations with QoL at all time points. Because the SAS was assessed concurrently with the CIVIQ-20 at each postoperative follow-up time point and no preoperative baseline was collected, the observed association is cross-sectional at each time point. The clinical impact is nonetheless meaningful: a patient with moderate anxiety (SAS 60) scored approximately 6 points lower on CIVIQ-20 than one without anxiety (SAS 40), independent of clinical severity. Whether the anxiety observed was preexisting, related to the surgical experience, or emerged during recovery cannot be established from these data. The consistent co-occurrence across all three time points, however, suggests a stable relationship between anxiety and reduced QoL throughout the postoperative period. Matei et al³⁴ demonstrated significant Generalized Anxiety Disorder 7 improvement alongside QoL recovery following open VV surgery, consistent with a relationship in which symptom burden and anxiety are mutually reinforcing.^35,36 These findings support routine anxiety screening at postoperative follow-up to identify patients who may benefit from psychological support. Future studies should incorporate preoperative and repeated postoperative anxiety measures to disentangle causal mechanisms.

Our models explained 42% to 51% of QoL variance, indicating that unmeasured factors, including social support, health literacy, patient expectations, detailed comorbidity profiles, and physical activity patterns, contribute substantially to outcomes.³⁷ This result highlights the complexity of recovery and the limitations of prediction based solely on demographic and clinical variables.

This study has several limitations. The single-center design may limit generalizability. Telephone follow-up captured patient experience efficiently, but did not allow imaging assessment or evaluation of recurrence. We assessed only anxiety, not depression or other psychological dimensions. The SAS was not assessed preoperatively. The causal direction of its association with QoL cannot be established. Limited representation of C5 and C6 disease (4% of the cohort) constrains precision for advanced disease subgroups. The CIVIQ-20 may not optimally capture ulcer burden in this subgroup, for which the Charing Cross Venous Ulcer Questionnaire (ie, the only patient-reported outcome measure to meet all three validation phases for C5-C6 disease) might be more appropriate.¹⁵ A formally validated minimal clinically important difference for the CIVIQ-20 has not been established in the VV literature. Biemans et al²⁵ applied Norman's rule of thumb (ie, a change exceeding half a standard deviation) as a proxy for clinical meaningfulness. The approximately 16-point Global Index difference between adjacent CEAP severity groups in the RELIEF study provides the closest available benchmark in our scoring convention.²³ Formal minimal clinically important difference derivation using anchor-based or distribution-based methods is recommended as a priority for future studies. Given the heterogeneity in treatment approaches, multicenter prospective registries would be particularly valuable for advancing evidence-based care.

Conclusions

Surgical treatment of lower extremity VVs produces sustained QoL improvement through 12 months, with outcomes shaped by clinical and psychological factors. VCSS is the dominant predictor across all time points, whereas surgical technique and complications affect only early recovery. These findings support risk-stratified patient counselling, with recognition that older patients and those with advanced disease may experience more modest improvement despite technically successful intervention. Future research should evaluate whether targeted interventions, such as enhanced postoperative support for high-risk subgroups or integration of psychological assessment into perioperative care can further optimize patient-centered outcomes.

Author Contributions

Conception and design: XX, HL

Analysis and interpretation: XX, LL, YG, KK, HL

Data collection: LL, YG, DC, ZH

Writing the article: XX, LL, YG, KK, HL

Critical revision of the article: XX, DC, ZH, KK, HL

Final approval of the article: XX, LL, YG, DC, ZH, KK, HL

Statistical analysis: XX, LL, YG, KK, HL

Obtained funding: XX

Overall responsibility: HL

Funding

This study was supported by the Guangdong Health Economics Association Project (2025-WJMZ-105).

Disclosures

None.