Varicose veinsBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e667 (Published 09 February 2012) Cite this as: BMJ 2012;344:e667
All rapid responses
We enjoyed reading the advice about varicose veins by Nogaro et al. We wondered if their 55 year old woman might also ask if she has any increased risk of developing other circulatory diseases 1. We have considered the risk of other circulatory diseases in people with varicose veins (and also in people with haemorrhoids).
Using the epidemiological database of the Oxford Record Linkage Study, we compared the risk of developing subsequent circulatory diseases in patients with varicose veins (or haemorrhoids) with a control cohort 2. We found that varicose veins predisposes to a very modestly increased risk of deep vein thrombosis (rate ratio 1.20; 95% CI: 1.08-1.33), as others have reported, but no other circulatory diseases showed any elevated risk, including pulmonary embolism, or coronary heart disease. If patients with varicose veins ask their doctor whether they have an elevated risk of other circulatory diseases, the summary answer is that, with the exception of a very slight increase in risk of deep vein thrombosis, they do not.
1. Nogaro M-C, Pournaras DJ, Prasannan C, Chaudhuri A. 10 Minute Consultation: Varicose Veins. BMJ 2012;344:e667
2. Rahman F, Wotton CJ, Goldacre MJ. Varicose veins, haemorrhoids and the risk of circulatory diseases: record-linkage study. Br J Cardiol 2011;18:124-129.n
Competing interests: No competing interests
We read with interest interest your cover article “10-Minute Consultation Varicose veins”, by M-C Nogaro and colleagues (1). The paper is timely, but misleading in parts and does not include significant advances in the medical literature which may be of benefit to many patients (2-4).
The paper suggests that simple varicose vein disease will not progress to skin complications. This notion is not supported by large studies including the Bonn Vein Study, which clearly highlighted that a substantial proportion of patients with varicose veins develop skin problems and ultimately to venous ulcers. (5,6).
Significant evidence from the ESCHAR study indicated that whilst venous ulcer healing rate is not increased, recurrence is reduced, and as venous ulcer disease requires extremely expensive dressing management surely this is a beneficial aim (7,8).
It is important not to confuse different skin problems such as classifying telangectasia and thread veins with skin changes. Venous skin changes, such as lipodermatosclerosis, are a significant risk factor for impending ulceration and should not be ignored (6). Thread veins are cosmetic and consequently not covered under the NHS (9).
Treatment of varicose veins has changed significantly with extensive work showing cost-effectiveness for all form of treatment from traditional surgery to radiofrequency or laser ablation (10). Treatment with compression hosiery incurs significant cost as the stockings must be regularly replaced on prescription.
Treatment with endovenous ablation or foam sclerotherapy requires minimal time off work.
Evidence-based guidelines for the management of varicose veins are available from the Royal Society of Medicine Venous Forum and the Society for Vascular Surgery and the American Venous Forum (11-13).
Tristan RA Lane (a), J Rosalind Herbert (b), Ian J Franklin (a) and Alun H Davies (a)
(a) - Academic Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF
(b) - Department of Primary Care and Public Health Faculty of Medicine, Imperial College London
1. Nogaro MC, Pournaras DJ, Prasannan C, et al. Varicose veins. BMJ. 2012;344:e667.
2. Kelleher D, Lane TRA, Franklin IJ, et al. Treatment options, clinical outcome (quality of life) and cost benefit (quality-adjusted life year) in varicose vein treatment. Phlebology. 2012;27(Suppl 1):16–22.
3. Rasmussen LH, Lawaetz M, Bjoern L, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. BJS. 2011 Aug.;98(8):1079–1087.
4. Nesbitt C, Eifell RK, Coyne P, et al. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2011;(10):CD005624.
5. Rabe E, Pannier-Fischer F, Bromen K, et al. Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie. Phlebologie. 2003;
6. Rabe E, Pannier F. Clinical, aetiological, anatomical and pathological classification (CEAP): gold standard and limits. Phlebology. 2012 Feb. 6;27(Supplement 1):114–118.
7. Gohel MS, Barwell JR, Earnshaw JJ, et al. Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)--haemodynamic and anatomical changes. BJS. 2005 Mar. 1;92(3):291–297.
8. Rabe E, Pannier F. Societal costs of chronic venous disease in CEAP C4, C5, C6 disease. Phlebology. 2010 Oct. 1;25 Suppl 1:64–67.
9. Audit Commission. Reducing Spending on Low Clinical Value Treatments [Internet]. London: Audit Commission; 2011. Available from: http://www.audit-commission.gov.uk/sitecollectiondocuments/downloads/201...
10. Gohel MS, Epstein DM, Davies AH. Cost-effectiveness of traditional and endovenous treatments for varicose veins. BJS. 2010 Dec. 1;97(12):1815–23; discussion 1823–4.
11. Venous Forum of the Royal Society of Medicine, Berridge DC, Bradbury AW, et al. Recommendations for the referral and treatment of patients with lower limb chronic venous insufficiency (including varicose veins). Phlebology. 2011;26(3):91–93.
12. Gloviczki P, Gloviczki ML. Guidelines for the management of varicose veins. Phlebology. 2012 Feb. 6;27(Supplement 1):2–9.
13. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S–48S.
Competing interests: Professor Alun Davies is the Chairman of the National Clinical Guidance Group for Varicose Veins (NICE).
We thank Mr Carradice for his interest in our article. We agree there is a “post-code lottery” on the treatment of varicose veins across the UK; however, the scope of this article focuses on practical advice to GPs on managing patients presenting with varicose veins as opposed to tackling the wider challenge of NHS resources allocation. The reality of health care provision currently is that intervention for uncomplicated/asymptomatic varicose veins falls into the low priority treatment category that some Primary Care Trusts fund in only exceptional circumstances.
Our paper was intended to provide simple guidance for GPs within the current economic constraints pertaining to varicose vein treatment. Patients with symptomatic varicose veins, including those whose quality of life is severely affected, should routinely be referred to specialists according to NICE guidance . GPs in some of our nearby towns actually need PCT approval to even refer patients. However, the expectations of patients who have no associated skin changes, as in our case presentation, who may not qualify for NHS treatment based on local policy, need to be managed appropriately. These patients should be reassured that the risk of complication is low and that treatment is not essential .
In the REACTIV trial, patients in group 1 (minor varicose veins with no reflux) showed no significant difference in quality of life between conservative and interventional treatment . With regards to cost effectiveness of surgery in the same trial, the figures quoted are based in calculations for group 3 only, which included patients with skin changes . We agree that uncomplicated varicose veins may be associated with a low quality of life, however, further high quality comparative trials in this population are needed to guide treatment and resource allocation. Whilst we would be delighted to treat all the varicose veins that come our way, we are sure that Mr Carradice would agree that in the current NHS that is simply impossible.
1. National Institute for Health and Clinical Excellence. Referral advice for varicose veins. NICE, 2001.
2. Campbell B. Varicose veins and their management. BMJ 2006; 333:287-92.
3. Michaels JA et al. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess 2006;10(13).
Competing interests: No competing interests
M-C Nogaro and colleagues have very good practical advice for patients presenting with varicose veins to primary care. However, despite agreeing with the authors statement that compression is the mainstay of treatment for these patients, I disagree with their assertion that varicose surgery will not improve healing(1).
The long term results of the ESCHAR study(2) were published in 2007 but, despite the authors' analysis on an intention to treat basis, almost a quarter of their trial patients refused surgical treatment. The authors hinted that novel treatment modalities such as foam sclerotherapy, radio frequency ablation and laser treatment may be used in future, should they demonstrate their efficacy and durability. It would interested to see if a similar trial using those newer treatments would still yield the same results. Further to the ESCHAR study there have been a published number of studies that support the addition of incompetent superficial and perforator vein ablation(3) to heal recalcitrant venous ulcers that fail to improve with compression alone(4). These techniques usually involve radio frequency or laser ablation under local anaesthetic, rendering them suitable for some of these elderly patients with a number of co-morbidities.
1- Nogaro M-C, Pournaras DJ, Prasanna C, Chaudhuri. Varicose veins. BMJ 2012:344:45-46.
2- Gohel MS, Barwell J, Taylor M, Chant T, Foy C, Earnshaw JJ, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR) : randomised controlled trial. BMJ 2007;335:83.
3- Harlander-Locke M, Lawrence PF, Alktaifi A, Jimenez JC, Rigberd D, DeRubertis B. The impact of ablation of incompetent superficial and perforator veins on ulcer healing rates. J Vasc Surg 2012;55:458-464.
4- P.F. Lawrence, A. Alktaifi, D. Rigberg, B. DeRubertis, H. Gelabert, J.C. Jimenez. Endovenous ablation of incompetent perforating veins is effective treatment for recalcitrant venous ulcers
J Vasc Surg 2011;54:737–742.
Competing interests: No competing interests
I read with interest your cover article entitled “10-Minute Consultation Varicose veins”.
There has been significant changes in our understanding of the spectrum of disease associated with superficial venous insufficiency in recent years and this has been accompanied by a revolution in management concepts and modalities. Furthermore the comissioning of treatment has become a contraversial issue, resulting in a “post-code lottery” across the UK and Europe.
Unfortunately this article confirms that the widely held misperceptions regarding this disease persist; and it is unsurprising that this area has become a soft target for rationing and budgetary constraint.
Of particular concern is that the authors recommend that patients suffering with uncomplicated varicose veins should be reassured that no treatment is needed. This advice goes against current level 1 evidence and indeed the NICE guidelines which are quoted by this article. The NICE recommendation is that patients with symptomatic varicose veins should be routinely referred to a specialist. This position was supported by the HTA sponsored REACTIV trial1; which demonstrated significant benefits in quality of life following surgical treatment when compared to the conservative measures recommended by this article, and went on to demonstrate that surgery for symptomatic varicose veins was highly cost effective (less than £2000 per QALY). Several RCTs have since replicated the QALY gain reported, demonstrating the validity of these conclusions. A recent Markov model analysis comparing conservative management with all of the current modalities of treatment; has similarly confirmed that conservative measures are not cost-effective (particularly when compared to some of the newer techniques)2. Quality of life analysis has demonstrated the significant impairment of those suffering symptoms, even in the absence of skin changes. In fact there is no difference in the magnitude of impairment between those with and without complications in the absence of ulcer disease3. Rationing treatment on the basis of complications alone is therefore nonsensical.
In the light of this evidence and the new role of primary care as a commissioning body; perhaps this article should focus on which healthcare programmes should have their NHS funding withdrawn, for it to be invested in this highly efficacious and cost-effective treatment for a common disease.
Mr Dan Carradice
MBChB MRCS (Eng) PGC Med US (Distn) PGD Health Econ MD (Hons)
NIHR Clinical Lecturer in Vascular Surgery
1) Michaels JA et al. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess 2006;10(13).
2) Gohel MS et al. Cost-effectiveness of traditional and endovenous treatments for varicose veins. Br J Surg 2010; 97(12):1815-1823.
3) Carradice D et al. Modelling the effect of venous disease on quality of life. Br J Surg 2011; 98(8):1089-1098.
Competing interests: I am the first author of some of the evidence quoted. My institution has in the past received unconditional funding of the research nurse to facilitate the performance of RCTs into the management of SVI. I own 2 legs and as such have a 30 to 50% chance of suffering from this disease in the future.