Varicose Veins

Scope

  • Varicose veins are very common and most people with varicose veins do not need referral or treatment.
  • People with varicose veins and eczema or lipodermatosclerosis (colour changes in the skin and hardness of the subcutaneous tissues of the lower leg) should be referred because they are at risk of ulcers.
  • People with varicose veins often have leg pains from other causes (e.g. arthritis). Varicose veins do not cause groin pain, pain on activity, or restriction of movement.
  • The Commissioning Policy for Devon and Cornwall does not allow referral of people with symptomatic varicose veins in the absence of skin changes, ulcers, bleeding or recurrent phlebitis. This policy differs from the recommendations of NICE Clinical Guideline 168 (July 2013) on Varicose Veins. Patients with symptoms can only be referred within the NHS if they are designated as exceptional cases.

A recent audit in Western locality has revealed that varicose vein surgery is being performed on a significant number of Grade 2 varicose veins.

DRSS has been asked by NEW Devon CCG and secondary care to tighten implementation of the current Varicose Veins Policy.

The majority of GP referrals will be unaffected, but there is going to be stricter implementation of the policy wording on " skin change".

It is considered that mild skin changes, for example haemosiderin deposition, thread veins and non varicose eczema are in keeping with Grade 2 veins and will therefore not be suitable for onward referral.

Recurrent thrombophlebitis, significant bleeding from varicosities, lipodermatosclerosis, varicose eczema and active or healed ulceration imply grade 3 or higher and can be referred into secondary care.

There will be a proforma (see referral section) for use by GP practices and further information on these changes in Planned Care News.

Assessment

Signs and Symptoms

  • Varicose veins are usually asymptomatic
  • Symptoms include aching, heaviness, throbbing and itching – typically after prolonged standing or walking
  • Skin changes (see below)
  • Occasionally thrombophlebitis ("phlebitis") – hard, red, tender veins persisting typically for 1-3 weeks
  • Bleeding – typically from a thin-walled "bleb" or a little crusted area (not from varicose veins covered by healthy skin)

History and Examination

History
  • Ask about details of symptoms to differentiate from other cause of leg pain
  • Ask about fears and concerns: family history may be relevant
  • Any previous treatments for varicose veins
  • Any history of DVT or leg ulcers?
Examination
  • General size, extent and distribution of varicose veins
  • Differentiate from thread veins and small reticular veins
  • Note any leg swelling
  • Examine ankle area for:
    • Dark/brown/purple/red discoloration of the skin in the gaiter area of the leg (lipodermatosclerosis) - or eczema anywhere on the leg
    • Hardness of the subcutaneous tissues ("liposclerosis"). The subcutaneous fat may shrink, to produce a contracted, indrawn area
    • The whole area may become red, hard, inflamed and sometimes very painful. This is "inflammatory liposclerosis" (not phlebitis)
    • Small areas of pearly, white discoloration called "atrophie blanche" may develop and represent an advanced stage of lipodermatosclerosis
  • If a leg ulcer is present, check foot pulses and/or Doppler pressure (ABPI)

Differential Diagnoses

  • Many other causes of leg pain. Varicose veins are very common and pains are often wrongly attributed to them because they are the only visible abnormality on the leg

Red Flags

  • Bleeding – emergency control is by elevation and pressure, followed by bandaging. Refer urgently

Investigations

  • No special investigations required before referral

Management

Grade 0: Telangectasia and reticular veins: Cosmetic significance only. People may seek treatment outside the NHS.

Picture of Grade 0

Grade I and II: Varicose veins without symptoms or with symptoms such as aching, heaviness or swelling:

  • Reassurance that varicose veins are not harmful unless they start to cause skin damage. They may or may not worsen. Just because varicose veins are large or extensive is not a reason to be worried about them or to treat them. DVT risk is not significantly increased by uncomplicated varicose veins but precautions for long haul flights seem sensible, including compression stockings, avoiding dehydration and exercising the legs.
  • Lifestyle advice includes advice to lose weight if obese and to elevate the leg/s on resting to relieve symptoms.
  • Graduated compression stockings can control many symptoms of varicose veins, including aching and ankle swelling (in addition to reducing the risk of ulceration in people with skin changes). Stockings are available on FP10 or can be purchased from pharmacists. Class 1 stockings or support tights for mild symptoms. Class 2 stockings for severe symptoms or significant ankle oedema. Below-knee stockings are usually effective. For symptomatic varicose veins above the knee, thigh-length stockings may require a suspender belt or a "stay-up" design to remain in place. Note that NICE CG 168 recommends (section 1.3.4) "Do not offer compression hosiery to treat varicose veins unless interventional treatment is unsuitable". However, in the context of patients with symptomatic varicose veins not meeting the criteria of the Peninsula policy for referral, it is reasonable to offer compression hosiery for relief of symptoms.

Picture of Grade I

Picture of Grade II

Grade III. Varicose veins with complications, including bleeding, recurrent phlebitis or eczema.

  • Varicose eczema. Advice to moisturise regularly. Steroid cream to settle inflammatory eczema – but for use for a few days only until the eczema has settled.
  • Recurrent thrombophlebitis. Advice on leg elevation, topical or systemic NSAID's and stockings. Antibiotics are not required. Sometimes thrombophlebitis causes veins to thrombose permanently and to pose no further problems or risks. When, very rarely, thrombophlebitis affects the long saphenous vein above the knee and extends towards the groin, emergency referral is appropriate.
  • Bleeding. Emergency control is by elevation and pressure. Urgent referral.

Picture of Grade III

Grade IV: Signs of severe venous insufficiency – lipodermatosclerosis or healed ulceration.

  • Advice to moisturise the skin and prescription of Class 2 below knee compression stockings.
  • Inflammatory lipodermatosclerosis should be treated by anti-inflammatory drugs and analgesics, not antibiotics.

Picture of Grade IV

Referral

Referral Criteria

  • Bleeding associated with varicose veins: as an emergency if necessary or (better) urgently after effective control.
  • A venous leg ulcer (defined as a break in the skin below the knee that has not healed within two weeks) or a healed venous leg ulcer.
  • Skin changes - eczema or lipodermatosclerosis thought to be caused by chronic venous insufficiency.
  • Thrombophlebitis - if recurrent

New Devon CCG Commissioning Policy "Referral for Varicose Veins"

Referral Instructions

Routine referral to vascular specialist
  • e-Referral service selection:
    • Specialty: Surgery - Vascular
    • Clinic Type: Varicose Veins
    • Service: DRSS-Western-Vascular- Devon CCG-15N

Referral Forms

Varicose Vein Interventions referral form - No merge fields

Varicose Vein referral form - Emis WEB

Varicose Vein referral form - Microtest

Varicose Vein referral form - Systmone

Supporting Information

Patient Information

MyHealth patient information - Varicose veins

Evidence

National Institute for Health and Care Excellence. Clinical guideline 168. Varicose veins in the legs. Issued July 2013

National Institute for Health and Care Excellence. Clinical guideline 168. Varicose veins in the legs. Methods, evidence and recommendations. Issued July 2013.

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.

Publication date: December 2016

 

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