Reviewed on : 9 Sep 2021

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

Expires : 9 Sep 2023

Varicose Vein Intervention

Referral Criteria

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.

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

Refer people with bleeding varicose veins to a vascular service immediately.

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

Please refer to the locally agreed protocol for referral of varicose veins and the five classifications.

Classifications 3 to 6 varicose veins are funded for intervention. Classifications 1 and 2 are not funded.

1. Please confirm that your patient meets the criteria for ONE of the following sections:

Section a

The patient has Class 3 varicose veins representing varicose veins with skin changes at the ankle with the additional possibility of further complications (bleeding, superficial thrombophlebitis, oedema)

Section b

The patient has Class 4 varicose veins representing skin changes ascribed to venous disease pigmentation, venous eczema, lipodermatosclerosis

Section c

The patient has had a full vascular assessment and has Class 5 and/or 6 varicose veins representing severe skin changes and/or active ulceration. Late stage venous disease

Classification of Varicose Veins

Refer to the locally agreed protocol for referral of varicose veins and the five classifications:

• Class 1 – thread veins or reticular veins with cosmetic symptoms                                   NOT FUNDED
• Class 2 – varicose veins with no complications                                                                NOT FUNDED
• Class 3 – represents varicose veins with skin changes at the ankle with the additional possibility of further complications (bleeding, superficial thrombophlebitis, oedema).                          Funded
• Class 4 – represents skin changes ascribed to venous disease pigmentation, venous eczema, lipodermatosclerosis.                                                                                                         Funded
• Class 5 and 6 – represents severe skin changes and/or active ulceration. Late stage venous disease.                                                                                         Funded subject to full vascular assessment

Referral Guidelines

Prior approval from the CCG will be required before any treatment proceeds in secondary care.

Refer to Secondary Care provider via RSS using the appropriate Prior Approval Referral Form.

Refer to a vascular service any of the following (Class 3 to 6) :

• 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.
• Venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks).
• Healed venous leg ulcer.

Refer immediately:

Bleeding varicose veins to a vascular service / A&E.

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.