Summary of intervention

There are various interventional procedures for treating varicose veins. These include endothermal ablation, ultrasound guided foam sclerotherapy and traditional surgery (this is a surgical procedure that involves ligation and stripping of varicose veins) all of which have been shown to be clinically and cost effective compared to no treatment or treatment with compression hosiery. Varicose veins are common and can markedly affect patients quality of life, can be associated with complications such as eczema, skin changes, thrombophlebitis, bleeding, leg ulceration, deep vein thrombosis and pulmonary embolism that can be life threatening.

 

Number of CCG intervention 201718

28,846

 

Recommendation

1.1 Intervention in terms of, endovenous thermal (laser ablation, and radiofrequency ablation), ultrasound guided foam sclerotherapy, open surgery (ligation and stripping) are all cost effective treatments for managing symptomatic varicose veins compared to no treatment or the use of compression hosiery. For truncal ablation there is a treatment hierarchy based on the cost effectiveness and suitability, which is endothermal ablation then ultrasound guided foam, then conventional surgery.

 

1.2 Refer people to a vascular service if they have any of the following:

    1. Symptomatic * primary or recurrent varicose veins
    2. Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency.
    3. Superficial vein thrombophlebitis (characterised by the appearance of hard, painful veins) and suspected venous incompetence.
    4. A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks).
    5. A healed venous leg ulcer.

 

*  Symptomatic: “Veins found in association with troublesome lower limb symptoms (typically pain, aching, discomfort, swelling, heaviness and itching).”

 

For patients whose veins are purely cosmetic and are not associated with any symptoms do not refer for NHS treatment

 

1.3 Refer people with bleeding varicose veins to a vascular service

1.4 Do not offer compression hosiery to treat varicose veins unless interventional treatment is unsuitable.

For further information, please see:

NICE Varicose veins in the legs [QS67]

NICE Varicose veins: diagnosis and management [CG168]

 

Rationale for recommendation

International guidelines, NICE guidance and NICE Quality standards provide clear evidence of the clinical and cost-effectiveness that patients with symptomatic varicose veins should be referred to a vascular service for assessment including duplex ultrasound.

 

Open surgery is a traditional treatment that involves surgical removal by ‘stripping’ out the vein or ligation (tying off the vein), this is still a valuable technique, it is still a clinically and cost-effective treatment technique for some patients but has been mainly superseded by endothermal ablation and ultrasound guided foam sclerotherapy.

 

Recurrence of symptoms can occur due to the development of further venous disease, that will benefit from further intervention (see above). NICE guidance states that a review of the data from the trials of interventional procedures indicates that the rate of clinical recurrence of varicose veins at 3 years after treatment is likely to be between 10–30%.

 

For people with confirmed varicose veins and truncal reflux NICE recommends:

  • Offer endothermal ablation of the truncal vein
  • If endothermal ablation is unsuitable, offer ultrasound‑guided foamsclerotherapy.
  • If ultrasound‑guided foam sclerotherapy is unsuitable, offer surgery
  • Consider treatment of tributaries at the same time
  • Do not offer compression hosiery to treat varicose veins unless interventional treatment is unsuitable.

 

Complications of intervention include recurrence of varicose veins, infection, pain, bleeding, and more rarely blood clot in the leg. Complications of non-intervention include decreasing quality of life for patients, increased symptomatology, disease progression potentially to skin changes and eventual leg ulceration, deep vein thrombosis and pulmonary embolism.

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