NICE has recommended that some people with varicose veins, such as those causing pain and ulcers, should be offered alternatives to surgery, known as endothermal ablationⁱ, heat energy treatment of the wall of the vein (radiofrequency or laser treatmentⁱⁱ), which are less invasive than surgery with a much speedier recovery time. The recommendations are part of new NICE guidance that sets out treatment options to match the severity of a patient's symptoms so that no matter where they live, they get the care that's right for them. Varicose veins develop when blood vessels, commonly in the legs, become enlarged as the small valves inside them stop working properly. This prevents blood flowing back to the heart efficiently and results in blood flowing in the wrong direction.

Up to a third of the UK adult population are affected by varicose veins - they become more common as people get older and women are more likely to develop them than men. Many people have no symptoms, but for those that do, they can include heaviness, aching, throbbing, itching, cramps, or tiredness in the legsⁱⁱⁱ. Varicose veins can worsen over time and some people will go on to develop leg ulcers, which can be difficult to heal and significantly affect quality of life.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE said: “Although varicose veins are a common health complaint, there was no established framework for diagnosis and treatment in the NHS until now. For some people they present few problems, while others can suffer painful and distressing symptoms. This guidance sets out the options for patients and their physicians to treat the individual symptoms of each patient so that no matter where they live, they have access to the therapy that's right for them.”

The guidance:

The new NICE guidance recommends that people should be referred to a vascular service^iv if they have symptomatic primary^v or recurrent varicose veins; lower limb skin changes such as pigmentation or eczema, hard painful veins (superficial vein thrombosis), or leg ulcers below the knee. Duplex ultrasound^vi should be used to confirm the diagnosis of varicose veins and plan the course of treatment. It also states that endothermal ablation (radiofrequency or laser) should be offered to treat confirmed varicose veins. Ultrasound-guided foam sclerotherapy^vii should be offered to patients if endothermal ablation is not suitable. NICE recommends that only if neither treatment is suitable, surgery should be considered. Compression hosiery (e.g. tights and stockings) should be offered only if any of these treatments are unsuitable. Interventional treatments such as endothermal ablation, ultrasound guided foam sclerotherapy or surgery, should not be carried out during pregnancy.

Professor Alun Davies, Professor of Vascular Surgery & Honorary Consultant Surgeon, Imperial College & Imperial College NHS Trust, Charing Cross and St Mary's Hospitals, London, and chair of the group which developed the guideline said: “Varicose veins are a common problem, with around 35% of the UK population being affected. Treatment offered however, varies on where you live. This guideline shows quite clearly that interventional treatment for some patients who are suffering from symptomatic varicose veins is a better alternative to surgery, and is both clinically and cost effective. It will help standardise care for all those with this condition.”

Joyce Calam, patient member of group which developed the guideline said:“I've had problems with varicose veins for over twenty years - in that time I have had a number of procedures, but my veins always returned. They were very painful and caused aching and swelling. I was eventually successfully treated with endothermal ablation as well as foam sclerotherapy. These new NICE guidelines outline clear, effective ways to treat varicose veins, for both patients and healthcare professionals alike.”

Ends

Notes to Editors

References

i. Endothermal ablation involves heating the wall of the varicose vein using radiofrequency energy. The vein is accessed through a small cut made just above or below the knee. A narrow tube, called a catheter, is guided into the vein using an ultrasound scan. A probe is inserted into the catheter that sends out radiofrequency energy. This heats the vein until its walls collapse, closing it and sealing it shut. Once the vein has been sealed shut, blood will naturally be redirected to one of the healthy veins. Endothermal ablation is carried out under local anaesthetic. The procedure may cause some short-term side effects, such as pins and needles (paraesthesia). See the NICE website for interventional procedures guidance on radiofrequency ablation of varicose veins.

ii. Endovenous laser treatment involves having a catheter inserted into the vein and using an ultrasound scan to guide it into the correct position. A tiny laser is passed through the catheter and positioned at the top of the varicose vein. The laser delivers short bursts of energy that heat up the vein and seal it closed. The laser is slowly pulled along the vein using the ultrasound scan to guide it and allowing the entire length of the vein to be closed. Endovenous laser treatment is carried out under local anaesthetic. See the NICE website for interventional procedures guidance on endovenous laser treatment of the long saphenous vein.

iii. NHS Choices

iv. A team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and provide a full range of treatment.

v. Veins found in association with problematic lower limb symptoms (typically pain, aching, discomfort, swelling, heaviness and itching).

vi. A duplex ultrasound is a test to see how blood moves through arteries and veins.

vii. Ultrasound guided foam sclerotherapy works by injecting a foam substance into a vein using ultrasound to guide the injection. The foam causes an inflammatory reaction in the vein wall, blocking the vein. Compression bandages are applied after the procedure and are typically worn for between a week and a month. See the NICE website for interventional procedures guidance on ultrasound foam guided sclerotherapy.

About the guideline

1. The new NICE clinical guideline will be available from 00.01hrs on Wednesday 24 July 2013.

Embargoed copies are available on request from the NICE press office.

2. In 2009/10 there were 35,659 varicose veins procedures carried out in the NHS. Source: NICE guideline on the diagnosis and management of varicose veins in the legs.

Related published NICE guidance

General

3. Patient experience in adult NHS services. NICE clinical guidance 138 (2012).

Condition-specific

4. Ultrasound-guided foam sclerotherapy for varicose veins.NICE interventional procedure guidance 440 (2013).

5. Promoting physical activity in the workplace. NICE public health guidance 13 (2008).

6. Physical activity and the environment. NICE public health guidance 8 (2008).

7. Obesity. NICE clinical guideline 43 (2006).

8. Four commonly used methods to increase physical activity. NICE public health guidance 2 (2006).

9. Endovenous laser treatment of the long saphenous vein. NICE interventional procedure guidance 52 (2004).

10. Transilluminated powered phlebectomy for varicose veins. NICE interventional procedure guidance 37 (2004).

11. Radiofrequency ablation of varicose veins NICE interventional procedure guidance 8 (2003).

About NICE

12. The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Formerly the National Institute for Health and Clinical Excellence, our name changed on 1 April 2013 to reflect our new and additional responsibility to develop guidance and set quality standards for social care, as outlined in the Health and Social Care Act (2012).

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

Our products and resources are produced for the NHS, local authorities, care providers, charities, and anyone who has a responsibility for commissioning or providing healthcare, public health or social care services.

To find out more about what we do, visit our website: www.nice.org.uk and follow us on Twitter: @NICEcomms.