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Varicose veins in the legs

About

What is covered

This pathway covers the diagnosis and management of varicose veins in the legs in adults aged 18 years and over.
Varicose veins are dilated, often palpable, subcutaneous veins with reverse blood flow. They are most commonly found in the legs. Estimates of the prevalence of varicose veins vary. Visible varicose veins in the lower limbs are estimated to affect at least a third of the population. Risk factors for developing varicose veins are unclear, although prevalence rises with age and they often develop during pregnancy.
In some people varicose veins are asymptomatic or cause only mild symptoms, but in others they cause pain, aching or itching and can have a significant effect on their quality of life. Varicose veins may become more severe over time and can lead to complications such as changes in skin pigmentation, bleeding or venous ulceration. It is not known which people will develop more severe disease but it is estimated that 3–6% of people who have varicose veins in their lifetime will develop venous ulcers.
There are several options for the management of varicose veins, including:
  • advice and reassurance
  • interventional treatments (endothermal ablation, foam sclerotherapy and surgery)
  • compression hosiery.
In 2009/10 there were 35,659 varicose veins procedures carried out in the NHS. There is no definitive system for identifying which people will benefit the most from interventional treatment and no established framework within the NHS for the diagnosis and management of varicose veins. This has resulted in wide regional variations in the management of varicose veins in the UK. This guideline was developed with the aim of giving healthcare professionals guidance on the diagnosis and management of varicose veins in the legs, in order to improve patient care and minimise disparities in care across the UK.

Updates

Updates to this pathway

24 May 2016 The following were added to assessment and treatment:
  • endovenous mechanochemical ablation for varicose veins (NICE interventional procedure guidance 557)
  • lower limb deep vein valve reconstruction for chronic deep venous incompetence (NICE interventional procedure guidance 219)
  • subfascial endoscopic perforator vein surgery (NICE interventional procedure guidance 59)
23 June 2015 Cyanoacrylate glue occlusion for varicose veins (NICE interventional procedure guidance 526) added to assessment and treatment.
13 August 2014 Varicose veins in the legs (NICE quality standard 67) added.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on diagnosing and managing varicose veins in the legs in an interactive flowchart.

What is covered

This pathway covers the diagnosis and management of varicose veins in the legs in adults aged 18 years and over.
Varicose veins are dilated, often palpable, subcutaneous veins with reverse blood flow. They are most commonly found in the legs. Estimates of the prevalence of varicose veins vary. Visible varicose veins in the lower limbs are estimated to affect at least a third of the population. Risk factors for developing varicose veins are unclear, although prevalence rises with age and they often develop during pregnancy.
In some people varicose veins are asymptomatic or cause only mild symptoms, but in others they cause pain, aching or itching and can have a significant effect on their quality of life. Varicose veins may become more severe over time and can lead to complications such as changes in skin pigmentation, bleeding or venous ulceration. It is not known which people will develop more severe disease but it is estimated that 3–6% of people who have varicose veins in their lifetime will develop venous ulcers.
There are several options for the management of varicose veins, including:
  • advice and reassurance
  • interventional treatments (endothermal ablation, foam sclerotherapy and surgery)
  • compression hosiery.
In 2009/10 there were 35,659 varicose veins procedures carried out in the NHS. There is no definitive system for identifying which people will benefit the most from interventional treatment and no established framework within the NHS for the diagnosis and management of varicose veins. This has resulted in wide regional variations in the management of varicose veins in the UK. This guideline was developed with the aim of giving healthcare professionals guidance on the diagnosis and management of varicose veins in the legs, in order to improve patient care and minimise disparities in care across the UK.

Updates

Updates to this pathway

24 May 2016 The following were added to assessment and treatment:
  • endovenous mechanochemical ablation for varicose veins (NICE interventional procedure guidance 557)
  • lower limb deep vein valve reconstruction for chronic deep venous incompetence (NICE interventional procedure guidance 219)
  • subfascial endoscopic perforator vein surgery (NICE interventional procedure guidance 59)
23 June 2015 Cyanoacrylate glue occlusion for varicose veins (NICE interventional procedure guidance 526) added to assessment and treatment.
13 August 2014 Varicose veins in the legs (NICE quality standard 67) added.

Sources

NICE guidance and other sources used to create this pathway.
Varicose veins: diagnosis and management (2013) NICE guideline CG168
Endovenous mechanochemical ablation for varicose veins (2016) NICE interventional procedure guidance 557
Cyanoacrylate glue occlusion for varicose veins (2015) NICE interventional procedure guidance 526
Ultrasound-guided foam sclerotherapy for varicose veins (2013) NICE interventional procedure guidance 440
Subfascial endoscopic perforator vein surgery (2004) NICE interventional procedure guidance 59
Endovenous laser treatment of the long saphenous vein (2004) NICE interventional procedure guidance 52
Transilluminated powered phlebectomy for varicose veins (2004) NICE interventional procedure guidance 37
Radiofrequency ablation of varicose veins (2003) NICE interventional procedure guidance 8
Varicose veins in the legs (2014) NICE quality standard 67

Quality standards

Varicose veins in the legs

These quality statements are taken from the varicose veins in the legs quality standard. The quality standard defines clinical best practice for varicose veins in the legs care and should be read in full.

Quality statements

Referral to a vascular service

This quality statement is taken from the varicose veins in the legs quality standard. The quality standard defines clinical best practice in varicose veins in the legs care and should be read in full.

Quality statement

People with varicose veins that are causing symptoms or complications (including ulceration) are referred to a vascular service.

Rationale

If left untreated, varicose veins will continue to cause symptoms that affect quality of life, and may progress to bleeding, skin damage and ulceration. Referral to a vascular service is a first step to interventional treatment for varicose veins that can relieve symptoms, and slow disease progression and improve people’s quality of life.

Quality measures

Structure
Evidence of local arrangements and written referral criteria to ensure that people with varicose veins that are causing symptoms or complications (including ulceration) are referred to a vascular service.
Data source: Local data collection.
Process
Proportion of people with varicose veins that are causing symptoms or complications (including ulceration) who are referred to a vascular service.
Numerator – the number in the denominator who are referred to a vascular service.
Denominator – the number of people who present with varicose veins that are causing symptoms or complications (including ulceration).
Data source: Local data collection.
Outcome
a) Progression of venous leg disease.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and vascular services) ensure that local referral pathways into vascular services are consistent with the evidence-based referral criteria in NICE clinical guideline 168, which include varicose veins that are causing symptoms or complications (including ulceration).
Healthcare professionals (such as GPs) follow local referral pathways into vascular services to ensure that people with varicose veins that are causing symptoms or complications (including ulceration) are referred to a vascular service.
Commissioners (CCGs and NHS England) monitor activity across local referral pathways to ensure that the evidence-based referral criteria in NICE clinical guideline 168 are being followed.

What the quality statement means for patients and carers

People with varicose veins that are causing symptoms (for example pain, aching, discomfort, swelling, heaviness and itching) or problems such as bleeding, eczema or leg ulcers are referred to a specialist vascular service (a team of healthcare professionals who have training and experience in diagnosing and treating varicose veins).

Source guidance

Definitions of terms used in this quality statement

Symptoms of varicose veins
Symptoms of varicose veins include troublesome lower limb symptoms (typically pain, aching, discomfort, swelling, heaviness and itching). The symptoms may be associated with primary or recurrent varicose veins. [Adapted from NICE clinical guideline 168, recommendation 1.2.2]
Complications of varicose veins
Complications of varicose veins are:
  • lower-limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
  • bleeding varicose veins
  • superficial vein thrombosis (characterised by the appearance of hard, painful veins) and suspected venous incompetence
  • a venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks) or a healed venous leg ulcer.
[Adapted from NICE clinical guideline 168, recommendation 1.2.2]
Vascular service
A vascular service is a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and provide a full range of treatment. [NICE clinical guideline 168, recommendation 1.2.1]

Duplex ultrasound

This quality statement is taken from the varicose veins in the legs quality standard. The quality standard defines clinical best practice in varicose veins in the legs care and should be read in full.

Quality statement

People with varicose veins who are seen by a vascular service are assessed with duplex ultrasound.

Rationale

Duplex ultrasound is a non-invasive scan used to image the blood vessels of the body. It provides detailed information that helps to confirm the diagnosis and pattern of venous disease and determine the most appropriate treatment option. The handheld doppler is still used in some services, but it is outdated and does not provide the detailed, accurate information produced by duplex ultrasound.

Quality measures

Structure
Evidence of local arrangements to ensure that people with varicose veins seen by a vascular service are assessed with duplex ultrasound.
Data source: Local data collection.
Process
Proportion of people with varicose veins seen by a vascular service who are assessed with duplex ultrasound.
Numerator – the number in the denominator who are assessed with duplex ultrasound.
Denominator – the number of people with varicose veins seen by a vascular service.
Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 1.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care) ensure that vascular services have adequate numbers of duplex ultrasound machines and that staff have undergone appropriate training, so that all people with varicose veins referred to a vascular service are assessed with duplex ultrasound.
Healthcare professionals working in a vascular service ensure that people with varicose veins are assessed with duplex ultrasound.
Commissioners (CCGs) ensure that they commission vascular services that have sufficient capacity, equipment and skilled staff to assess varicose veins using duplex ultrasound.

What the quality statement means for patients, service users and carers

People with varicose veins who have been referred to a vascular service have a duplex ultrasound scan (a scan that uses high-frequency sound waves to produce a picture of the veins). The scan shows the blood flow and helps the vascular service team locate any damaged valves that might be causing the varicose veins.

Source guidance

Definitions of terms used in this quality statement

Vascular service
A vascular service is a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and provide a full range of treatment. [NICE clinical guideline 168, recommendation 1.2.1]
Duplex ultrasound
A device utilising doppler ultrasound that permits colour-coded visualisation of blood flow in the superficial, perforating and deep veins, as well as grey-scale imaging of the veins and surrounding tissue. It can also be used to image blood flow in arteries. [Full guideline on varicose veins in the legs, glossary]

Treatment of varicose veins

This quality statement is taken from the varicose veins in the legs quality standard. The quality standard defines clinical best practice in varicose veins in the legs care and should be read in full.

Quality statement

People with confirmed varicose veins and truncal reflux are offered a suitable treatment in this order: endothermal ablation, ultrasound-guided foam sclerotherapy, surgery, compression hosiery.

Rationale

Historically surgery and compression therapy were the only treatments available to people with varicose veins, but in recent years other treatments including endothermal ablation and ultrasound-guided foam sclerotherapy have been developed. These newer therapies are less invasive than surgery, promote faster recovery and need shorter hospital stays. Not all treatments are suitable for all people and therefore it is important that the person’s needs and preferences are also considered when deciding which is the most suitable treatment.

Quality measures

Structure
Evidence of local arrangements that the full range of treatments for varicose veins is commissioned in accordance with NICE clinical guideline 168.
Data source: Local data collection.
Process
a) Proportion of people with confirmed varicose veins and truncal reflux suitable for endothermal ablation who are offered endothermal ablation.
Numerator – Number in the denominator offered endothermal ablation.
Denominator – Number of people with confirmed varicose veins and truncal reflux suitable for endothermal ablation.
Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 2.
b) Proportion of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation who are offered ultrasound-guided foam sclerotherapy.
Numerator – Number in the denominator offered ultrasound-guided foam sclerotherapy.
Denominator – Number of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation, but suitable for ultrasound-guided foam sclerotherapy.
Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 3.
c) Proportion of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation and ultrasound-guided foam sclerotherapy who are offered surgery.
Numerator – Number in the denominator offered surgery.
Denominator – Number of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation and ultrasound-guided foam sclerotherapy, but suitable for surgery.
Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 4.
d) Proportion of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation, ultrasound-guided foam sclerotherapy and surgery who are offered compression hosiery.
Numerator – Number in the denominator offered compression hosiery.
Denominator – Number of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation, ultrasound-guided foam sclerotherapy and surgery.
Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 6.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care) ensure that the local treatment pathway is consistent with the evidence-based treatment order in NICE clinical guideline 168.
Healthcare professionals ensure that they follow the local treatment pathway to offer people a treatment that is consistent with the evidence-based treatment order in NICE clinical guideline 168.
Commissioners (CCGs) ensure that the full range of treatments for varicose veins is commissioned in accordance with NICE clinical guideline 168.

What the quality statement means for patients, service users and carers

People with varicose veins caused by problems with the blood flow in the leg are offered treatment with:
  • endothermal ablation (in which the veins are closed off using heat)
  • or, if endothermal ablation is unsuitable, a treatment called ultrasound-guided foam sclerotherapy (in which the veins are closed off using a chemical foam)
  • or, if both endothermal ablation and ultrasound-guided foam sclerotherapy are unsuitable, surgery to remove the varicose veins.
They should only be offered compression hosiery (stockings designed to improve blood flow by squeezing the legs) as a permanent treatment if none of the other treatments are suitable for them.

Source guidance

Definitions of terms used in this quality statement

Suitable treatment order
NICE clinical guideline 168 recommends that endothermal ablation, ultrasound-guided foam sclerotherapy or surgery may be offered in that order, according to suitability. It recommends compression hosiery only if those 3 interventions are unsuitable for the person. The suitability of each option will depend on the person’s clinical circumstances and their preferences.
Truncal reflux
Truncal reflux is the failure of competence of valves in 1 or more of the 3 truncal veins – the great saphenous vein, the small saphenous vein and the anterior accessory saphenous vein. [Adapted from Full guideline on varicose veins in the legs, page 122 and glossary definition of reflux]
Endothermal ablation
There are 2 types of endothermal ablation in common use: radiofrequency ablation (see Radiofrequency ablation of varicose veins [NICE interventional procedure guidance 8]) and laser ablation (see Endovenous laser treatment of the long saphenous vein [NICE interventional procedure guidance 52]). Radiofrequency ablation uses radio wave electromagnetic energy to cause venous ablation and closure by raising the temperature of the inner lumen of the vein. Laser ablation uses laser energy to cause venous ablation and closure by raising the temperature of the inner lumen of the vein. [Adapted from Full guideline on varicose veins in the legs, glossary definitions of radiofrequency ablation and laser ablation]
Ultrasound-guided foam sclerotherapy
The injection of a sclerosing agent into a vein for chemical ablation guided by real time ultrasound imaging (see Ultrasound-guided foam sclerotherapy for varicose veins [NICE interventional procedure guidance 440]). [Full guideline on varicose veins in the legs, glossary definition of ultrasound guided foam sclerotherapy]
Surgery
A surgical technique of truncal or tributary vein removal, in which the vein is physically stripped from surrounding tissues and removed. [Full guideline on varicose veins in the legs, glossary definition of stripping]
Compression hosiery
Graduated elastic stockings work by compressing the varicose veins, so emptying them of blood and by increasing the venous return, both of which reduce venous pressure. They can be bought ‘off the shelf’ in different sizes or they can be made to measure and are available in different pressures. [Adapted from Full guideline on varicose veins in the legs, glossary definition of compression hosiery]
Reflux
Reflux is the backflow of blood through a venous valve. [Full guideline on varicose veins in the legs, glossary definition of stripping]

Effective interventions library

Effective interventions library

Successful effective interventions library details

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Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

veins found in association with troublesome lower limb symptoms (typically pain, aching, discomfort, swelling, heaviness, and itching)
a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and provide a full range of treatment

Paths in this pathway

Pathway created: July 2013 Last updated: May 2016

© NICE 2016

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