Quality statement 3: Treatment of varicose veins

Quality statement

People with confirmed varicose veins and truncal reflux are offered a suitable treatment in this order: endothermal ablation, ultrasound-guided foam sclerotherapy, surgery, compression hosiery.

Rationale

Historically surgery and compression therapy were the only treatments available to people with varicose veins, but in recent years other treatments including endothermal ablation and ultrasound-guided foam sclerotherapy have been developed. These newer therapies are less invasive than surgery, promote faster recovery and need shorter hospital stays. Not all treatments are suitable for all people and therefore it is important that the person's needs and preferences are also considered when deciding which is the most suitable treatment.

Quality measures

Structure

Evidence of local arrangements that the full range of treatments for varicose veins is commissioned in accordance with NICE clinical guideline 168.

Data source: Local data collection.

Process

a) Proportion of people with confirmed varicose veins and truncal reflux suitable for endothermal ablation who are offered endothermal ablation.

Numerator – Number in the denominator offered endothermal ablation.

Denominator – Number of people with confirmed varicose veins and truncal reflux suitable for endothermal ablation.

Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 2.

b) Proportion of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation who are offered ultrasound-guided foam sclerotherapy.

Numerator – Number in the denominator offered ultrasound-guided foam sclerotherapy.

Denominator – Number of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation, but suitable for ultrasound-guided foam sclerotherapy.

Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 3.

c) Proportion of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation and ultrasound-guided foam sclerotherapy who are offered surgery.

Numerator – Number in the denominator offered surgery.

Denominator – Number of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation and ultrasound-guided foam sclerotherapy, but suitable for surgery.

Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 4.

d) Proportion of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation, ultrasound-guided foam sclerotherapy and surgery who are offered compression hosiery.

Numerator – Number in the denominator offered compression hosiery.

Denominator – Number of people with confirmed varicose veins and truncal reflux unsuitable for endothermal ablation, ultrasound-guided foam sclerotherapy and surgery.

Data source: Local data collection. NICE clinical guideline 168 clinical audit tool, standard 6.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care) ensure that the local treatment pathway is consistent with the evidence-based treatment order in NICE clinical guideline 168.

Healthcare professionals ensure that they follow the local treatment pathway to offer people a treatment that is consistent with the evidence-based treatment order in NICE clinical guideline 168.

Commissioners (CCGs) ensure that the full range of treatments for varicose veins is commissioned in accordance with NICE clinical guideline 168.

What the quality statement means for patients, service users and carers

People with varicose veins caused by problems with the blood flow in the leg are offered treatment with:

  • endothermal ablation (in which the veins are closed off using heat)

  • or, if endothermal ablation is unsuitable, a treatment called ultrasound-guided foam sclerotherapy (in which the veins are closed off using a chemical foam)

  • or, if both endothermal ablation and ultrasound-guided foam sclerotherapy are unsuitable, surgery to remove the varicose veins.

They should only be offered compression hosiery (stockings designed to improve blood flow by squeezing the legs) as a permanent treatment if none of the other treatments are suitable for them.

Source guidance

Definitions of terms used in this quality statement

Suitable treatment order

NICE clinical guideline 168 recommends that endothermal ablation, ultrasound-guided foam sclerotherapy or surgery may be offered in that order, according to suitability. It recommends compression hosiery only if those 3 interventions are unsuitable for the person. The suitability of each option will depend on the person's clinical circumstances and their preferences.

Truncal reflux

Truncal reflux is the failure of competence of valves in 1 or more of the 3 truncal veins – the great saphenous vein, the small saphenous vein and the anterior accessory saphenous vein. [Adapted from Full guideline on varicose veins in the legs, page 122 and glossary definition of reflux]

Endothermal ablation

There are 2 types of endothermal ablation in common use: radiofrequency ablation (see Radiofrequency ablation of varicose veins [NICE interventional procedure guidance 8]) and laser ablation (see Endovenous laser treatment of the long saphenous vein [NICE interventional procedure guidance 52]). Radiofrequency ablation uses radio wave electromagnetic energy to cause venous ablation and closure by raising the temperature of the inner lumen of the vein. Laser ablation uses laser energy to cause venous ablation and closure by raising the temperature of the inner lumen of the vein. [Adapted from Full guideline on varicose veins in the legs, glossary definitions of radiofrequency ablation and laser ablation]

Ultrasound-guided foam sclerotherapy

The injection of a sclerosing agent into a vein for chemical ablation guided by real‑time ultrasound imaging (see Ultrasound-guided foam sclerotherapy for varicose veins [NICE interventional procedure guidance 440]). [Full guideline on varicose veins in the legs, glossary definition of ultrasound guided foam sclerotherapy]

Surgery

A surgical technique of truncal or tributary vein removal, in which the vein is physically stripped from surrounding tissues and removed. [Full guideline on varicose veins in the legs, glossary definition of stripping]

Compression hosiery

Graduated elastic stockings work by compressing the varicose veins, so emptying them of blood and by increasing the venous return, both of which reduce venous pressure. They can be bought 'off the shelf' in different sizes or they can be made to measure and are available in different pressures. [Adapted from Full guideline on varicose veins in the legs, glossary definition of compression hosiery]

Reflux

Reflux is the backflow of blood through a venous valve. [Full guideline on varicose veins in the legs, glossary definition of stripping]