Chronic Venous Disease (CVD) affects approximately 38% of the Brazilian population, requiring interventions ranging from clinical management to invasive approaches. Historically, conventional surgery (“high ligation and stripping”) has dominated the therapeutic landscape, but it imposes logistical limitations and operative risks.

• Sclerotherapy

• Varicose Veins

• Venous Insufficiency

Borges WR (2026) The Comparison of Records of Varicose Vein Surgery and Ultrasound-Guided Densed Foam Sclerotherapy: is this the End of Conventional Surgical Treatment for Varicose Veins of the Lower Limbs? Ann Vasc Med Res 13(1): 1198.

Chronic Venous Disease (CVD) affects approximately 38% of the Brazilian population, requiring interventions ranging from clinical management to invasive approaches. Historically, conventional surgery (“high ligation and stripping”) has dominated the therapeutic landscape, but it imposes logistical limitations and operative risks. In contrast, foam sclerotherapy has emerged as the predominant technique due to its low cost and outpatient nature. Although it presents higher recanalization rates, the safety of the method drives a therapeutic transition in the public health system, which aims to optimize resources in the face of a chronic and progressive disease.

Varicose veins are dilated, tortuous veins that primarily affect the lower extremities [1]. They are the most common manifestation of chronic venous disease (CVD), a disorder of the circulatory system of unknown etiology, but with multifactorial influences such as genetic predisposition, hormones, endothelial dysfunction, and disturbances in the balance of matrix molecules. They present clinically in various forms, without necessarily indicating severity, with symptoms such as changes in skin appearance, a sensation of heaviness, muscle cramps, and edema [2,3].

The formation of microvessels involves venous return dysfunction in the lower limbs, which may result from reflux due to incompetence of venous microvalves or from obstruction caused by a partial or total blockage of veins, leading to local blood accumulation and, in the long term, hypertension and chronic venous insufficiency [4,5]. Blood stasis associated with endothelial damage promotes the spread of blood into the skin’s microvascular networks, potentially progressing to venous ulcers in the most advanced stage of CVI [6].

Epidemiological data show that the average prevalence in the Brazilian population is approximately 38% [7]. Brazilian and international studies show that women are more affected by primary varicose veins and that pregnancy is one of the contributing factors to this statistic [8,13]. Given the marked physiological changes, including increased blood volume, weight gain, elevated intra abdominal pressure, and reduced venous return¹?. Other risk factors are associated with age, body mass index, family and personal history of vascular diseases, prolonged standing during work, Caucasian race, overweight, and a sedentary lifestyle [14,16].

The mean age in randomized clinical trials ranged from 40 to 56 years, with evidence showing that the number of insufficient venous segments is directly proportional to age, as is the frequency of reflux in superficial and perforating veins [10,17].

The choice of treatment method depends on characteristics such as clinical signs—including the presence of telangiectasias, varicose veins, or varicosities— the anatomical location of the affected vessel (superficial, deep, or perforating), and the pathophysiology involved in lesion formation (due to reflux or obstruction)[2].

The treatment of varicose veins can be medical, involving the use of medications, elastic compression, lifestyle and dietary measures, and physical exercise, or surgical, with a combined approach being the most common. Due to the multiple clinical presentations, there is a variety of both conventional and minimally invasive techniques for treating the vessels [18].

Varicose veins have been documented since ancient times, and Hippocrates (460–377 BCE), the Greek physician considered the father of medicine, was the first to note the association between varicose veins and leg ulcers and to treat them by cauterizing the vessels with a red-hot iron [19]. The millennia-old nature of this disease, however, has not altered the essence of treatment, which still consists of using various techniques for vessel occlusion, through ligation or the use of thermal or chemical agents, with less painful and more effective alternatives in the medium and long term.

Open varicose vein surgery known as “high ligation and stripping” (HL&S) is a widely performed method in vascular surgery and is the primary form of intervention for varicose veins of the lower extremities20. However, this procedure carries risks inherent to surgery and anesthesia and has been associated with complications such as postoperative pain, surgical wound infection, hematomas, nerve and lymphatic damage, prolonged bed rest, development of deep vein thrombosis (DVT), and long recovery periods [20]. Furthermore, open surgery alone without follow-up rarely provides complete control of varicose vein disease in a single stage [10].

Ultrasound-guided dense foam sclerotherapy (UGDFS) is another common method and currently the most widely used, although it is less effective [21], and consists of a chemical ablation procedure involving the injection of sclerosing agents at specific sites, causing venous fibrosis—an effective technique for treating reflux varicose veins. The most frequent complications are transient hyperpigmentation, telangiectatic matting, venous thrombosis, and neurological events [22].

EEED has become increasingly common over the years due to the ease of treatment, the fact that general anesthesia is not required, the possibility of repeated use, and a faster return to normal activities compared to surgery. However,in addition to the higher need for recanalization and lower long-term quality of life, the use of elastic compression for days or weeks is not a reasonable option in areas with hot climates; yet the ease of reintervention makes it the most widely used technique [2,25].

These long-term results and the lower cost effectiveness indicate that caution is warranted when recommending foam sclerotherapy as the standard of care for the treatment of primary varicose veins. Despite this, it may be an advantageous alternative in the elderly since, even though recanalization rates reach 42% within 10 years, the priority is to prevent complications such as ulcers, bleeding, and thrombosis, which can be achieved with a simple, complication-free, low-cost outpatient injection procedure [10].

The chronic nature of the disease, with a high probability of new varicose veins developing over time, may raise questions about the actual effectiveness of treatment, especially in public health systems where resources are limited [23]. Thus, although the Brazilian guideline is well-established regarding the indications for each type of treatment, in Brazilian clinical practice, sclerotherapy is used indiscriminately, including by non medical professionals, without considering the indications for each type of patient [26].

Diseases of the circulatory system are closely linked to diseases of the cardiovascular system; however, this correlation can lead to underdiagnosis of other conditions, such as chronic venous disease—the most common disorder of the circulatory system, with varicose veins of the lower limbs as its most frequent manifestation [27].

One of the factors influencing the choice of treatment method is the classification of chronic venous disease. However, in Brazil, there is no consensus on classifications involving chronic venous disease; the recommendation is to use the CEAP classification, which addresses all forms of CVD. The CEAP classification is defined by the clinical, etiological, anatomical, and pathophysiological aspects corresponding to each letter [2].

The clinical classification ranges from C0 to C6, from the absence of visible or palpable signs (C0) to active venous ulcers (C6), including telangiectasias or reticular veins (C1), varicose veins (C2) (distinguished from reticular veins by a diameter of 3 mm or more), edema (C3), cutaneous and subcutaneous changes (C4—C4a hyperpigmentation/eczema, C4b lipodermatosclerosis/ white atrophy), and healed venous ulcers (C5). Each class is further designated with an A (asymptomatic) or S (symptomatic), for example, C 2A or C 5S [28].

As for etiology (E), it can be congenital (Ec), primary of undetermined cause (Ep), or secondary of known cause (Es), and may be caused by post-thrombotic, post traumatic, and other events [29]. In terms of anatomy (A), “As” refers to superficial veins, “Ad” to deep veins, and “Ap” to perforating veins28. As for pathophysiology (P), it may be due to reflux (Pr), obstruction (Po), or both (Po,r) [28].

Due to the multiple clinical presentations of chronic venous disease, there is a variety of treatment techniques, ranging from conventional surgical procedures (such as total/partial saphenectomy, ligation, and varicose vein resection) to minimally invasive techniques, such as laser or radiofrequency phlebocauterization, endoscopic surgery for subfascial ligation, and the use of foam [18].

Brazilian guidelines consider that the conventional “stripping” procedure and laser or radiofrequency thermal ablation yield similar long-term results for the treatment of saphenous veins, with the minimally invasive technique offering a reduced risk of short-term complications; these should be prioritized for patients with symptomatic varicose veins who prioritize long-term outcomes, thereby improving long-term quality of life and reducing the likelihood of recurrence [2].

Ultrasound-guided foam sclerotherapy (UGFS) stands out for its ability to treat collateral veins that are difficult to access using other methods. It is considered a positive approach in terms of cost-effectiveness and aesthetic outcome, establishing itself as a valuable therapy, especially for patients with surgical contraindications or for the treatment of smaller vessels, such as telangiectasias and reticular veins [20,30]. Although the reintervention rate within one year can reach 20%, the technique remains the first choice for treating perforating veins due to its lower invasiveness and ease of reintervention [2].

Despite its benefits, sclerotherapy has limitations and is not the first-line technique recommended for larger diameter veins, distal venous reflux, or saphenous veins. Studies indicate that ultrasound-guided sclerotherapy has shown inferior results compared to surgery and thermal ablation in long-term treatment. To optimize efficacy, studies have explored the use of foam administered via long catheters or combined with mechanical injury devices, taking advantage of the fact that microfoam displaces blood, promoting more homogeneous and prolonged contact with the endothelium [2].

In contrast to the Brazilian consensus on techniques, the European guidelines (ECLAP), in their most stringent recommendation, indicate surgery (High Ligation and Stripping - HLS) for saphenous vein insufficiencies only in the absence of alternative sclerotherapy methods, prioritizing endovenous thermal ablation [22].

Although performed in an outpatient setting— which significantly reduces hospitalizations and facilitates logistics within the public health system— the sclerotherapy technique has a high patient dropout rate. This discontinuation of treatment is due to multiple factors, such as the slow, time-consuming, and painful nature of the treatment—which requires periodic visits to the clinic over weeks or months—and complications inherent to the procedure, such as the potential for skin pigmentation, which causes aesthetic dissatisfaction and deters the patient from follow-up, compromising the long term efficacy of sclerotherapy [31].

Thus, this study aims to analyze the two main methods of treating chronic venous disease in Brazil, seeking patterns of therapeutic substitution over time and analyzing the relationships between the two approaches and epidemiological characteristics.

To analyze the trend of replacing varicose vein surgery with ultrasound-guided foam sclerotherapy in the Brazilian Unified Health System (SUS). Furthermore, it investigates the relationship between the techniques and the sociodemographic profile (sex, age, and type of care), compares the financial impact, and identifies regional disparities in the adoption of these technologies in Brazil.

To assess whether there is a trend toward a reduction in surgical treatment of varicose veins associated with an increase in sclerotherapy in the management of patients with lower limb varicose veins treated in the SUS between 2017 and 2024 in Brazil.

Descriptive ecological study, based on the analysis of secondary data from DATASUS. This research compares surgical and ultrasound-guided sclerotherapy treatment of varicose veins in unilateral and bilateral modalities across all regions of Brazil between 2008 and 2024. The variables analyzed include the volume of procedures, patient profiles, and average costs.

An observational, cross-sectional, retrospective, and descriptive study using aggregated human data from secondary sources, involving a comparison of surgical treatment with non-cosmetic sclerotherapy in Brazilian regions.

Data were analyzed on individuals who underwent non-aesthetic sclerotherapy for unilateral or bilateral varicose veins of the lower limbs in an outpatient setting, as well as patients who underwent surgical treatment for unilateral or bilateral varicose veins treated in a hospital setting in Brazil.

Records were included from January 2017 to December 2024, covering outpatient procedures classified by place of residence according to the following codes: 0309070015 Non-Cosmetic Sclerotherapy for Varicose Veins of the Lower Limbs (Unilateral) and 0309070023 Non-Cosmetic Sclerotherapy for Varicose Veins of the Lower Limbs (Bilateral). In addition, the in-hospital procedures analyzed were records from January 2008 to December 2024 according to procedures 0406020566 Surgical Treatment of Varicose Veins (Bilateral) and 0406020574 Surgical Treatment of Varicose Veins (Unilateral), classified by consolidated AIH (RD) data, by place of residence, starting in 2008.

Records with inconsistencies or incomplete or missing data in the analyzed variables were excluded.

The study was conducted using data provided by the Ministry of Health and obtained from the DATASUS database, based on health care data from the Outpatient Information System (SIA/SUS) and the Hospital Information System (SIH/SUS) of the Unified Health System, accessible via the website http://www2.datasus. gov.br/.

The data analyzed covered the period from January 2008 to December 2024.

The variables analyzed regarding hospital procedures were the number of hospitalizations, age group, male and female patients, average cost per hospitalization in dollars, and type of care. Outpatient procedures were analyzed in terms of the number of cases, age group, male and female gender, average cost in dollars, and type of care.

For the analysis of average values, all amounts in Brazilian reais were converted to dollars using the exchange rate from May 26, 2025 (R$ 5.71). The source used was: Central Bank of Brazil. This information can be verified at the link: https://www.bcb.gov.br/. The calculation of the average cost for outpatient procedures involving non-cosmetic sclerotherapy of unilateral and bilateral varicose veins was performed by dividing the total cost by the number of procedures performed each year.

To maximize statistical power in the assessment of long-term trends, sclerotherapy and surgical treatments were analyzed according to distinct time periods. For the surgical treatment of unilateral and bilateral lower limb varicose veins, the complete historical series available in DATASUS was used, covering the period from January 2008 to December 2024. Unilateral and bilateral non cosmetic sclerotherapy was analyzed for the period from January 2017 to 2024, which corresponds to when records of these procedures first became available in DATASUS.

To ensure comparability of patient characteristics and costs (demographic, clinical, and economic profiles), the secondary variables (sex, age, type of care, and average cost) for both treatment groups were analyzed within a common and coinciding time frame. This analysis period was defined as the only one with available data for non aesthetic sclerosing treatment of lower limb varicose veins in the system (January 2017 to December 2024), avoiding biases and allowing for a valid comparison between the populations.

Thus, methodological rigor is ensured by using distinct time frames for specific purposes: for the analysis of the long-term trend of treatments, the longest available historical series for each therapeutic method analyzed was used, maximizing statistical power to detect the actual trend of treatment types for lower limb varicose veins.

The data were stored in Microsoft Office Excel 2010 and presented in absolute numbers. To summarize the results, they were presented in tables and graphs.

The statistical analysis of the temporal trend was conducted using StatsKingdom software, applying Pearson’s correlation test to assess the strength and significance of the linear relationship between the year of care and the number of procedures. This method was chosen because it is the most appropriate for short time series, allowing for the rejection of the null hypothesis of zero correlation and the determination of the 95% confidence interval to infer the population trend of sclerosing and surgical treatments during the analyzed period.

Since this study involves the collection of secondary data from online databases, which are therefore in the public domain, it does not require approval by the Research Ethics Committee (CEP). However, in accordance with the recommendations of Resolution 466/12 of the National Health Council, this study ensures the rights and duties of research participants, as well as bioethical principles, such as the recognition and affirmation of dignity, autonomy, beneficence, and justice.

This study analyzed the trends in the treatment of chronic venous disease within the Brazilian Unified Health System (SUS) between 2008 and 2024, comparing the conventional surgical modality of high ligation and stripping (HL&S) with the emerging ultrasound-guided dense foam sclerotherapy (UGDFS), seeking to identify patterns of therapeutic substitution, regional disparities, and the economic impact of these interventions on the Brazilian public health landscape.

The data reveal an increase ranging from 3 to 10 thousand percentage points in the number of sclerotherapy procedures associated with a decline in bilateral surgical treatment, with statistically significant trends; these findings corroborate the literature, which highlights sclerotherapy as a modality experiencing global growth due to its technical ease and safety, lack of need for sedation, and rapid return to normal activities [32].

Although unilateral surgery shows a pattern of historical stability with a recovery in growth in the post-pandemic period compared to the pandemic period, this increase is considered modest and statistically insignificant when compared to the explosion in sclerotherapy modalities.

This shift in practice is justified by the greater operational efficiency of ultrasound-guided dense foam sclerotherapy, which is based on safety and convenience, as it is the first-line treatment for perforating veins and allows for the treatment of both limbs in an outpatient setting, eliminating the need for hospitalization, spinal anesthesia, and the use of operating rooms, and is documented in the literature as having a low cost [2,23], information that corroborates data showing an average cost approximately 50% lower than that of surgery.

In 2020, the volume of conventional surgeries (HL&S) recorded a sharp 60% decline, a phenomenon that this study attributes to the impact of the COVID-19 pandemic and the resulting shutdown of operating rooms for elective procedures. In contrast, unilateral sclerotherapy showed significantly smaller declines, while the bilateral modality maintained its continuous growth, demonstrating greater resilience of the outpatient model during periods of health crises. The findings corroborate data in the literature, which describe a greater reduction in bed-dependent inpatient procedures compared to outpatient interventions [33]; in the latter, the volume exceeded pre-pandemic levels, unlike surgical interventions.

The increase in sclerotherapy suggests that the method has become the primary management tool for addressing demand, aligning with trends of decreasing inpatient surgical procedures and increasing outpatient treatments, with this shift intensifying during the pandemic—possibly due to patient turnover and a level of care reach that the conventional model cannot sustain financially or logistically [34,35].

Thus, the stability of conventional surgery suggests that it remains reserved for specific cases or centers with idle infrastructure, remaining a complementary approach, while sclerotherapy takes center stage as a strategy for expanding access and ensuring the financial sustainability of the public system. This reservation of the surgical method for specific scenarios aligns with the DVC Guideline of the Brazilian Society of Angiology and Vascular Surgery (SBACV), which emphasizes that surgery still has better indications than sclerotherapy in cases of great saphenous vein and small saphenous vein insufficiency [2].

Geographic analysis reveals that the replacement of the surgical model with sclerotherapy does not occur uniformly, being influenced by disparities in infrastructure and regional management strategies. The Northeast was the leading region in this transition, showing accelerated growth in sclerotherapy, peaking in 2024 with a strong dominance of bilateral sclerotherapy. This phenomenon may suggest an institutional adoption of the foam technique as a priority public policy aimed at reducing waiting lists for the treatment of perforating and tributary veins, as recommended by the Brazilian guidelines [2], while the abrupt surge observed in the South starting in 2023 in unilateral sclerotherapy indicates a delayed but vigorous adoption.

On the other hand, the Midwest region demonstrates resilience of the conventional bilateral model, which has the highest percentage (41.3%) when the values of each therapeutic modality are analyzed individually. Nevertheless, the region does not diverge from the national trend, since the sum of sclerotherapy treatments (51.3%) is, in percentage terms, higher than the sum of surgical treatments (48.7%). The scarcity of detailed data on clinical indication criteria prevents an in-depth analysis of these patients’ profiles. However, the persistence of this pattern may reflect a technical preference based on the population profile and treatment durability, in which the long-term efficacy of surgical treatment outweighs the immediate benefits of the outpatient approach [23], justifying the preservation of this classic technique in settings where lower recurrence rates are prioritized over the speed of the procedure.

The Southeast stands out for having the most balanced distribution among therapeutic modalities in the national context, reflecting the complexity of its healthcare network. Although the region maintains a significant absolute volume of surgeries—ranking as the second largest hub in percentage terms for surgery—there is a strategic coexistence between inpatient treatment, often reserved for referral centers and more complex cases, and the expansion of sclerotherapy, which is gaining ground as a flexible and efficient alternative for managing the large volume of patients [2,35].

The unique profile of the Northern Region, characterized by an almost exclusive focus on unilateral sclerosing procedures, raises the hypothesis that this technique is being used as a strategy for the decentralization of the SUS. Although the nature of the secondary data limits the analysis’s ability to establish causality, it is possible to hypothesize that sclerotherapy serves as an alternative for overcoming critical geographical challenges. From this perspective, the method would be implemented through mobile units and teams, potentially facilitating care in riverside communities and hard-to-reach areas. Thus, the idea emerges that this modality could function as a mobile healthcare tool, serving as a pathway for vascular treatment in locations where conventional hospital infrastructure is scarce [36].

These regional variations demonstrate that, although sclerotherapy is a national trend, its application is adaptive. While in wealthier regions with dense hospital infrastructure, conventional surgery still holds its ground, in regions with greater access issues and pressure for cost efficiency, the ultrasound-guided foam technique has established itself as an indispensable tool for the universalization of varicose vein treatment through the SUS.

The sociodemographic analysis of treatment methods reveals a classic epidemiological profile of chronic venous disease, but with fundamental differences in the choice of therapeutic modality. The predominance of women, who underwent 83% of the procedures analyzed, reinforces the current literature pointing to the influence of hormonal factors, pregnancies, and increased contraceptive use as aggravating factors for venous reflux 8–13. However, male participation, although lower, is more pronounced in unilateral surgical treatment. This finding, when considered alongside the nature of care, suggests that men tend to neglect initial symptoms, seeking medical help at more advanced or complicated stages of the disease, which requires hospital-based interventions and explains why men consistently have emergency treatment rates equal to or higher than those of women.

Regarding age group, the study identifies a higher frequency of multiple varicose vein treatments starting at age 40, corroborating data available in the literature and showing a direct proportional relationship between the number of insufficient venous segments and age. Furthermore, there is a critical transition in the care model across decades of life: while surgical procedures reach their peak percentage earlier, sclerotherapy establishes itself as the dominant modality starting at age 55, a trend that becomes significantly more pronounced in older age groups.

This shift in preference has a direct clinical rationale: elderly patients often present with a higher number of comorbidities and greater anesthetic-surgical risk, and when combined with the risks inherent to surgery— such as prolonged recovery time and the development of deep vein thrombosis22— ESD emerges as a highly safe alternative, allowing the treatment of patients who, in past decades, would have been excluded from the therapeutic process due to clinical frailty or the high risk of postoperative complications.

It is important to note that, as this is a study based on secondary data, the available information is limited, making it impossible to identify, within the volume of procedures analyzed, which clinical criteria were used to perform the procedures and whether reinterventions— frequently described in the literature10,24—are included, which may inflate the absolute volume of sclerotherapy procedures without necessarily representing the number of new patients treated.

Furthermore, this study design precludes an analysis of treatment effectiveness due to a lack of information such as venous recanalization rates, post-sclerotherapy bruise index sclerotherapy, the number of sessions required to achieve the therapeutic outcome, and the pain scale during treatment—factors that lead to patient dissatisfaction, deter them from follow-up, and result in high dropout rates and failure to resolve the varicose condition, thereby compromising the long-term efficacy of sclerotherapy [31].

The predominantly elective nature of care underscores that the treatment of varicose veins within the SUS is, at its core, a preventive and rehabilitative health strategy aimed at avoiding serious complications such as venous ulcers. However, the higher incidence of emergencies in surgical procedures compared to sclerotherapy confirms that, in acute cases such as varicose bleeding with veins larger than 1 mm, conventional HL&S surgery retains its technical relevance [37]. However, it is essential to consider that the expansion of sclerotherapy in Brazil has, at times, occurred indiscriminately, without due observance of precise clinical indications. This scenario, coupled with treatment difficulties such as the time-consuming and painful nature of the procedure—which requires periodic office visits over weeks or months—may compromise long-term therapeutic efficacy and the sustainability of the clinical results obtained [31].

Brazil is undergoing a technological transition marked by the progressive replacement of surgery with ultrasound guided dense foam sclerotherapy, although surgery remains relevant in complex cases and emergencies. The change is heterogeneous, influenced by the available regional infrastructure and consolidated by its high cost benefit ratio and safety, used as a priority strategy to universalize access and ensure the financial sustainability of the system.

Although conventional surgery retains its role in more complex or urgent scenarios, sclerotherapy has established itself as a priority strategy for universal access and the sustainability of the Brazilian public health system.

The analysis of 1,806,147 procedures between 2017 and 2024 reveals a drastic change in the profile of varicose vein treatment in Brazil. Unilateral sclerotherapy consolidated itself as the most common method, with a growth of 3,824%, while the bilateral modality increased by 10,753%. Simultaneously, bilateral surgery showed a statistically significant decrease, while unilateral surgery maintained historical stability, with recovery after the Covid-19 pandemic. Regionally, the Northeast has led in sclerotherapy volume since 2021, surpassing the Southeast, which, along with the South, exhibits more diversified networks. The North focuses on unilateral sclerotherapy techniques, while the Central-West region is the one that most preserves the hospital model. Economically, sclerotherapy has an average cost 50% lower than surgery. The female population is dominant, and elective surgery is the majority nationwide, although men represent a higher relative proportion in emergency surgeries (6%). HL&S is the predominant choice in younger patients (up to 54 years old), while sclerotherapy becomes the dominant modality from age 55 onwards, a trend that intensifies with increasing age and clinical frailty.

This study comparatively analyzed 1,806,147 treatment procedures for lower limb varicose veins between 2017 and 2024 and revealed distinct treatment patterns across Brazilian regions. Overall, non-aesthetic sclerotherapy for unilateral varicose veins is the most common standalone procedure in Brazil, accounting for 43.2% of the total.

However, the treatment pattern is strongly influenced by region, with the North Region demonstrating an almost exclusive focus on unilateral sclerotherapy procedures, while the other regions exhibit greater diversity and variability in therapeutic choice depending on the specific regional context, since bilateral sclerotherapy prevails in the Northeast, whereas in the Midwest, the bilateral surgical approach accounts for the highest percentage (41.3%) of treatments in that region during the analyzed period.

The Southeast and South regions show a more diverse distribution of treatment modalities, reflecting more complex healthcare networks. In the Southeast, unilateral sclerotherapy predominates; however, it remains the region with the second-highest percentage of surgical approaches. In the South, although unilateral sclerotherapy also accounts for the largest volume, there is a significant dispersion among bilateral sclerotherapy and unilateral surgery (Table 1).

Table 1: Number of hospitalizations by region of residence according to treatment for varicose veins of the lower limbs in Brazil between 2017 and 2024.

Source: Ministry of Health – SUS Outpatient Information System (SIA/SUS) and SUS Hospital Information System

The national volume of sclerotherapy procedures has grown exponentially, with unilateral sclerotherapy rising from just 7,814 procedures in 2017 to 306,687 in 2024, representing a 3,824% increase. This growth trend statistically revealed a strong and significant positive correlation between the year of treatment and the number of procedures (r = 0.885; 95% CI 0.477–0.979; p = 0.004). This expansion demonstrated distinct regional dynamics: the Southeast region led in absolute volume of hospitalizations during the first four years, but the Northeast region showed accelerated and significant growth, surpassing the Southeast in 2021 and reaching its highest number in 2024. The North and South regions started with lower volumes but recorded a sharp and delayed surge beginning in 2023. The Midwest, despite the lower absolute volume, maintained a stable and progressive annual growth trend 

Showing even more dramatic growth, bilateral sclerotherapy saw an impressive 10,753% increase during the period analyzed. The data suggest a strong linear growth trend, revealing a strong and significant positive correlation between the year of treatment and the number of procedures (r = 0.855; 95% CI 0.377–0.973; p = 0.007). The growth in volume was continuous, even during the peak of the COVID-19 pandemic, and reached its highest volume in 2024.

Growth has been heavily driven by the Northeast region, which has led the way since 2023. In contrast,the Southeast, South, and Midwest regions showed more linear and gradual growth over time. The North region, in turn, diverged drastically from the others, maintaining negligible volumes of bilateral sclerotherapy, which contrasts with the late surge observed in the unilateral modality in the same region.

The national volume of hospitalizations for surgical treatment of unilateral lower limb varicose veins showed a pattern of stability in the 17-year temporal analysis (2008 to 2024). From 2008 to 2016, the volume of surgeries showed a slight increase of 7.3%; in 2020, the annual volume suffered a sharp drop of about 60%, returning in 2024 to levels equivalent to those of 2017–2019, with a 14% increase compared to the period preceding the drop. Statistical analysis of the entire series indicated a very small and non-significant negative correlation between the year of care and the total number of hospitalizations (r = -0.054; 95% CI -0.521 to -0.438; p = 0.837)

Regionally, the analysis of unilateral surgical procedures shows that the Southeast and South, which historically accounted for the highest volume of procedures, began to recover starting in 2022. In contrast, the Northeast region demonstrated a more robust recovery, surpassing previous levels and reaching its peak volume in 2024, as did the North and Midwest regions

An analysis of bilateral surgical treatment over 17 years reveals a statistically significant downward trend in the volume of procedures. The number of hospitalizations peaked in 2011 and declined over the following years, suffering a sharp drop of about 60% in 2020. By 2023, the volume had recovered to the levels seen before the decline but remained below the historical peak. This downward trend is statistically validated with a Pearson correlation coefficient of r = -0.599 (95% CI -0.8381, -0.1657; p = 0.011), revealing a strong negative correlation between the year of care and the number of procedures. The Southeast region dominated the volume and was primarily responsible for sustaining national figures. In contrast, the Northeast and South regions showed stable or slightly declining volumes over the long term.

An analysis of the average cost of procedures shows that the national average cost of surgical treatments (ranging from $108.91 for unilateral to $127.98 for bilateral) is approximately double the cost of sclerotherapy procedures (which range from $53.62 for unilateral to $68.90 for bilateral). In general, the costs of sclerotherapy showed high consistency across regions. However, the regions exhibited more marked differences in surgical costs, with the North region recording the highest costs for both surgical modalities, while the Midwest had the lowest average cost for unilateral surgery and the Northeast for bilateral surgery (Table 2).

Table 2: Average cost in dollars by type of treatment in each region of residence in Brazil between 2017 and 2024.

Source: Ministry of Health – SUS Outpatient Information System (SIA/SUS) and SUS Hospital Information System (SIH/SUS).

Analysis by sex showed a predominance of females in all treatment modalities evaluated, accounting for 83% of the recorded procedures. Although males accounted for only 17% of the total, their participation varied significantly across treatment modalities: the lowest proportion of men was observed in bilateral sclerotherapy, at 13%. In contrast, the highest proportion of men was 25% in unilateral surgical treatment (Table 3).

Table 3: Number of procedures by sex according to type of treatment for varicose veins of the lower limbs from 2017 to 2024 in Brazil.

Source: Ministry of Health – SUS Outpatient Information System (SIA/SUS) and SUS Hospital Information System (SIH/SUS).

The nature of care provided for lower limb varicose vein treatments in Brazil is predominantly elective, accounting for 97% of the total. However, an analysis of the volume of emergency cases, although low (3% of the total), reveals important differences: surgical procedures accounted for the highest proportions of emergency admissions, ranging from 4% to 6%, as opposed to a range of 1% to 3% for sclerotherapy. In addition, males consistently recorded slightly higher or equal proportions of emergency cases compared to females across all treatments, particularly in unilateral surgery, where emergency cases represent the highest observed rate, corresponding to 6% of the volume of this procedure (Table 4).

Table 4: Number of procedures for lower limb varicose vein treatment by sex and type of care in Brazil between 2017 and 2024.

Source: Ministry of Health – SUS Outpatient Information System (SIA/SUS) and SUS Hospital Information System (SIH/SUS).

The distribution of procedures by age group shows that treatment for varicose veins of the lower extremities is concentrated among patients aged 40 to 69, with the peak in procedures occurring in the 50–54 and 55–59 age groups. Although all modalities focus on adult and elderly patients, there is a notable difference: surgical procedures (unilateral and bilateral) reach their peak percentage slightly earlier (50–54 years), while sclerotherapy treatment peaks between 55 and 59 years. Furthermore, surgical approaches account for a higher percentage of the total volume in the age group up to 54 years. However, starting at age 55, sclerotherapy establishes itself as the proportionally dominant modality, a trend that becomes significantly more pronounced in older age groups.

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