Varicose veins: diagnosis and management – NICE guideline

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This National Institute for Health and Care Excellence (NICE) guideline covers diagnosing and managing varicose veins in people aged 18 and over. It aims to ensure that people understand the options for treating varicose veins and that healthcare professionals know when to refer people for specialist assessment and treatment.

Key recommendations

Referral to a vascular service

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

  • symptomatic primary or symptomatic recurrent varicose veins
  • lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
  • 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)
  • a healed venous leg ulcer.

Assessment and treatment in a vascular service

Assessment

  • Use duplex ultrasound to confirm the diagnosis of varicose veins and the extent of truncal reflux, and to plan treatment for people with suspected primary or recurrent varicose veins.

Interventional treatment

  • For people with confirmed varicose veins and truncal reflux, offer endothermal ablation and endovenous laser treatment of the long saphenous vein.
  • If endothermal ablation is unsuitable, offer ultrasound‑guided foam sclerotherapy.
  • If ultrasound‑guided foam sclerotherapy is unsuitable, offer surgery.
  • If incompetent varicose tributaries are to be treated, consider treating them at the same time.

Non-interventional treatment

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

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
  • 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 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.

You can read the guideline on NICE's website.