Varicose veinsBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e667 (Published 09 February 2012) Cite this as: BMJ 2012;344:e667
- M-C Nogaro, core surgical trainee,
- D J Pournaras, specialist registrar general surgery,
- C Prasannan, general practitioner,
- A Chaudhuri, consultant vascular surgeon
- Correspondence to: M-C Nogaro
- Accepted 3 October 2011
A 55 year old woman presents with a history of tortuous veins on both legs and a related ache towards the end of the day. She finds these veins unsightly and would like to know whether she can have them treated.
What you should cover
Varicose veins are very common: 40% of men and 32% of women aged 18-64 years have this condition.1
Document risk factors such as increasing age, family history, obesity, and occupational history associated with prolonged standing.3 Varicose veins may first become apparent during pregnancy and the risk increases with parity.1 3
Ask about red flag symptoms such as weight loss and rectal bleeding where varicose veins may be due to a pelvic or abdominal mass.
Ask about previous treatment of varicose veins and outcome. Document a history of deep vein thrombosis or thrombophlebitis, where varicose veins could be acting as collaterals in the presence of deep vein obstruction.3 Document symptoms of arterial insufficiency in patients with ulcers, as this situation is a contraindication to compression.
What you should do
Document skin changes, including pigmentation and lipodermatosclerosis, and complications such as ulceration, thrombophlebitis, or haemorrhage, and refer patients with these features to a specialist.4 Clinical examination to determine the site of venous incompetence is unreliable. The gold standard for determining this site is duplex scanning, which should be done in secondary care.1 3
Reassure patients with uncomplicated varicose veins that no treatment is needed.1 4 Because most people will not develop complications, treatment is usually not provided on the NHS. Surgery does not prevent long term complications, particularly leg ulceration, in patients with no history of ulcers. Varicose veins rarely “burst” spontaneously but are at risk of bleeding from direct trauma. Bleeding will stop with firm pressure.
Emphasise to patients with venous ulcers that the mainstay of treatment for ulcers is compression bandaging. Varicose vein surgery will not improve healing, but will reduce the risk of recurrence.5
Conservative measures include weight loss, regular exercise, prevention of constipation, elevation of limbs, and support hosiery. Compression classes vary between each country. We recommend below knee European class 2 or British class 3 stockings depending on local availability. These stockings should be worn all day and must be fitted correctly.
Interventional options range from open surgery, such as high tie and stripping with avulsions, to less invasive procedures, such as radiofrequency ablation, endovenous laser therapy, and foam sclerotherapy. All these interventions are effective with similar recurrence rates (13-30% at five years) and are routinely performed as day cases. Treatment options will depend on local availability. Patients undergoing surgery will usually attend a pre-operative assessment clinic. On the day of surgery, the surgeon will outline the varicosities with a marker pen. Although varicose vein surgery is safe, patients need to be aware of the risks of scarring, pain, bruising, sensory symptoms, infection, deep vein thrombosis, and recurrence. Inform patients that surgery will not alter skin changes (such as thread veins) and may not improve symptoms such as aching.
Open surgery is usually done under general or regional anaesthetic, such as spinal anaesthesia. Patients can go home the same day, and they may be advised to wear bandages or compression stockings postoperatively. They are advised to walk, but time off work may be needed depending on occupation. Instructions on driving are similar to those for other operative procedures.
Radiofrequency ablation and laser therapy do not remove the vein, but seal it off by use of localised high thermal energy. They are usually done under ultrasound guidance. Similar postoperative instructions apply here, but these procedures can be done under local anaesthetic and usually result in quicker recovery.
Foam sclerotherapy can be done in the outpatient setting and several cycles of injection may be required.
There is no nationally agreed policy on NHS treatment of varicose veins and primary care trust policy for funding is variable. Some healthcare providers judge that uncomplicated varicose veins are of low priority and are treated in primary care, whereas others still fund surgical treatment. Surgery is funded if the varicose veins are associated with the complications mentioned above.
Checklist: what to include in referral letter to vascular surgeon
Background information—symptoms, duration, risk factors including occupation, thromboembolic disease, other relevant medical history
Any treatment received so far and outcome (for example, trial of support hosiery, previous surgery)
Details of any complications
Most recent examination findings, how findings have evolved over time
Patient’s concerns and expectations
Circulation Foundation (www.circulationfoundation.org.uk/vascular_disease/varicose_veins)
For healthcare professionals
Tisi P. Varicose veins. Clinical Evidence 2007;10:212 (http://clinicalevidence.bmj.com/ceweb/conditions/cvd/0212/0212-2007-10.pdf)
Medscape: Pathogenesis of varicose veins and implications for clinical management (www.medscape.com/viewarticle/567029)
NHS Clinical Knowledge Summaries (www.cks.nhs.uk/varicose_veins#-341100)
Cite this as: BMJ 2012;344:e667
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
We thank Dr Emma Holland (GP trainee) and the general practitioners at School Lane Surgery in Thetford for advice and guidance during the preparation of the manuscript.
Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.