Reviewed on : 11 Sep 2024

Reviewed by : Lucy Dyde Coventry & Warwickshire ICB IFR and Gateway Editor

Expires : 11 Sep 2026

Varicose Vein Intervention

1. Category: Prior Approval

Prior approval from the Integrated Care Board (ICB) will be required before any treatment proceeds in secondary care unless an alternative contract arrangement has been agreed with the ICB that does not necessitate the requirement of prior approval before treatment

2. Background

This policy is based on NHS England’s Evidence-Based Interventions (EBI) recommendations see link to programme below – accurate at the point of publication: Varicose vein interventions – EBI (aomrc.org.uk)

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.

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

3. Indication

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technique, it is still a clinically and cost-effective treatment technique for some patients but has been mainly superseded by endothermal ablation and ultrasound guided foam sclerotherapy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 foam sclerotherapy
• 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

4. Eligibility Criteria/ Commissioning position

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

• Symptomatic* primary or recurrent varicose veins
• Lower limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
• Superficial vein thrombophlebitis (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)
• A healed venous leg ulcer
• Refer people with bleeding varicose veins to a vascular service

* 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

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

5. Guidance/References

Varicose vein interventions – EBI (aomrc.org.uk)

NICE Varicose veins in the legs [QS67] https://www.nice.org.uk/guidance/qs67

NICE Varicose veins: diagnosis and management [CG168] https://www.nice.org.uk/guidance/cg168

NICE Guidance. referral advice varicose-veins

Compression Hosiery:

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

Compression hosiery exerts a resting pressure. The daily build-up of pressure is controlled by the limited ability of the hosiery to stretch, so incompetent venous valves are approximated, venous return is accelerated, the fibrinolytic activity of the venous wall is increased and the risk of thrombosis reduced

Limited evidence from a systematic review of randomized controlled trials indicates that wearing compression stockings reduces symptoms of varicose veins in men and non-pregnant women. Compression stockings which exert an ankle pressure of 10–20 mmHg seem to be as effective as stockings which exert an ankle pressure greater than 20 mmHg

Therefore, for most people, class 1 light compression stockings (14–17 mmHg) or class 2 medium compression stockings (18–24 mmHg) will be suitable