Varicose vein interventions

Published January 2019 | Last reviewed September 2024

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Varicose veins are a common problem affecting up to 40% of adults. In some these are asymptomatic, but many people are affected by significant pain and complications including irreversible skin damage, venous eczema, venous thrombosis, ulceration and bleeding. Overall, varicose veins have a significant impact upon Health Related Quality of Life (HRQoL). Ulcer disease particularly has a severe impact upon HRQoL and is very expensive to treat.

NICE guidance identifies interventional treatment as being highly clinically effective, cost-effective and recommends access for all patients with symptoms or complications. These treatments are almost all delivered as day case local anaesthetic procedures using endothermal ablation or non-thermal methods such as ultrasound guided foam sclerotherapy.

NHS treatment should not be offered to patients with asymptomatic varicose veins who wish to have treatment for purely cosmetic reasons.

1. It is recommended not to offer patients definitive treatment with compression hosiery unless they are not suitable for any other interventions. Compression hosiery can be an option for treatment whilst awaiting intervention, or for the indication of VTE prophylaxis when clinically appropriate.

2. Patients should have an urgent referral (within 2 weeks) to a vascular service for the following:

• Bleeding varicose veins requiring treatment.
• A venous leg ulcer (a break in the skin below the knee that has not healed within two weeks).
• Superficial vein thrombosis (thrombophlebitis) (characterised by the appearance of hard, painful veins) and suspected venous incompetence.

Patients should have a routine referral to a vascular service for the following:

• Symptomatic* primary or recurrent varicose veins.
• Lower limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency.
• A healed venous leg ulcer.

*  Symptomatic: “Veins found in association with troublesome lower limb symptoms (typically pain, aching, discomfort, swelling, heaviness and itching).”

Venous Disease – Assessment and Referral Form

3. Assessment should include clinical examination and Duplex ultrasound.

4. For people with confirmed varicose veins and truncal reflux (as per NICE CG168):

• Offer endothermal ablation.
• If endothermal ablation is unsuitable, offer ultrasound-guided foam sclerotherapy.
• If ultrasound-guided foam sclerotherapy is unsuitable, offer surgery.

If incompetent varicose tributaries are to be treated, consider treating them at the same time.

5. A validated decision support tool should be used when consenting patients for possible intervention taking into account factors such as severity, patient choice and patient health status. An example of decision aid tool can be found on the NHS website.

International guidelines, NICE guidance and NICE Quality standards provide clear evidence of the clinical and cost-effectiveness that patients with symptomatic varicose veins should be referred to a vascular service for assessment, including duplex ultrasound.

These criteria remain up to date taking into account current literature and should be applied in full by NHS services. The current guidance reflects this position, with a number of slight modifications in line with newer evidence and guidance.

The EVRA trial and subsequent Cochrane review has established that early intervention in patients with a venous leg ulcer is highly clinically effective and cost saving. This adds to the ongoing HRQoL deficit and high healthcare costs as a rationale for urgent referral for assessment and intervention in this group.

NICE CG168 covers the diagnosis and management of patients with varicose veins. NICE guidance makes reference to patients with bleeding ulcers who should be referred to vascular services immediately.

There is evidence outlined in more recent guidelines that associate superficial vein thrombosis (SVT, thrombophlebitis) with deep vein thrombosis (DVT) (including in the contralateral limb). DVT is a significant health concern which can acutely lead to the potentially life-threatening condition of pulmonary embolus. Chronically it can lead to a post-thrombotic syndrome in around half of patients, which in turn is challenging to treat and leads to significant symptoms, tissue damage and ulceration.

Patients with SVT should be evaluated urgently and assessed for the need of a short course anticoagulation if they are found to have extensive SVT. This role may be fulfilled by a VTE service rather than directly by the vascular service, however patients with underlying varicose veins as the cause should be assessed and if appropriate, offered intervention by the vascular service to reduce the risk of recurrence.

About the condition

Varicose veins are swollen and enlarged veins that can occur in your legs. They develop when the small valves inside the veins stop working properly. In a healthy vein, blood is prevented from flowing down the leg by a series of valves that open and close to let blood through. If the valves weaken or are damaged, the blood can flow backwards and collect in the vein, eventually causing it to become swollen and enlarged (varicose).

This may cause symptoms such as pain, throbbing, aching or itching and can damage the skin of your leg which may be permanent. If you have any of these symptoms or other complications your doctor will refer you to a vascular specialist. This should be done urgently in the following circumstances:

• Ulcer (a wound on your leg which has not healed within 2 weeks).
• Bleeding.
• Hard, red and painful segment of a vein (superficial vein thrombosis or thrombophlebitis).

Your vascular specialist will explain the treatment options to you, including the benefits and risks of intervention and what will happen if you do nothing.

What are the BENEFITS of the intervention?

There is strong evidence to suggest that treatment of varicose veins can help to improve your quality of life, improve ulcer healing and other symptoms, and prevent further complications. Treatment now almost always involves a simple walk-in walk-out procedure of either:

• Endothermal ablation. Radiofrequency or laser energy is used to heat and close the affected veins.
• Ultrasound guided foam sclerotherapy. Foam medication is injected into the affected vein to close it.
• Ultrasound guided medical glue (cyanoacrylate). A special type of medical ‘superglue’ is injected into the affected vein to close it.

Open surgery to remove the veins from the leg (also known as ‘high tie and stripping’) is an option for some patients but should only be carried out if other treatments are not suitable.

What are the RISKS?

The risks from the treatment are low but include deep vein thrombosis (DVT), pulmonary embolus (PE), nerve damage, bleeding, bruising, infection and pain.

Varicose veins can also recur even after an initially successful treatment.

Endothermal ablation, foam sclerotherapy and cyanoacrylate procedures are usually carried out under local anaesthetic. Most people can return to normal activities including work within 24 hours.

What are the ALTERNATIVES?

Compression stockings can be helpful but are only recommended if suitable treatments are not possible for you. Regular exercise, avoiding standing for long periods of time or elevating the affected area when resting may relieve some symptoms. Varicose veins may be more common in people who have gained weight. Maintaining a healthy weight through diet and exercise is beneficial.

What if you do NOTHING?

Varicose veins don’t always need treatment. But if the veins are causing you pain, discomfort, swelling or are leading to other complications such as bleeding, skin discolouration, thrombosis or ulceration you should seek treatment.

1. NICE Guidance. referral advice varicose-veins 
2. NICE Guidance (2013) Varicose veins: diagnosis and management [CG168] 
3. NICE Quality Standard (2014) Varicose veins in the legs [QS67] 
4. Editor’s Choice -Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, de Wolf M, Eggen C, Giannoukas A, Gohel M, Kakkos S, Lawson J, Noppeney T, Onida S, Pittaluga P, Thomis S, Toonder I, Vuylsteke M, Esvs Guidelines Committee, Kolh P, de Borst GJ, Chakfé N, Debus S, Hinchliffe R, Koncar I, Lindholt J, de Ceniga MV, Vermassen F, Verzini F, Document Reviewers, De Maeseneer MG, Blomgren L, Hartung O, Kalodiki E, Korten E, Lugli M, Naylor R, Nicolini P, Rosales A Eur J Vasc Endovasc Surg. 2015 Jun;49(6):678-737. doi: 10.1016/j.ejvs.2015.02.007. Epub 2015 Apr 25. 
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6. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration.Gohel MS1, Heatley F1, Liu X1, Bradbury A1, Bulbulia R1, Cullum N1, Epstein DM1, Nyamekye I1, Poskitt KR1, Renton S1, Warwick J1, Davies AH1; EVRA Trial Investigators. N Engl J Med. 2018 May 31;378(22):2105-2114. doi: 10.1056/NEJMoa1801214. Epub 2018 Apr 24. 
7. Kakkos, S.K., Gohel, M., Baekgaard, N., Bauersachs, R., Bellmunt-Montoya, S., Black, S.A., ten Cate-Hoek, A.J., Elalamy, I., Enzmann, F.K., Geroulakos, G., Gottsäter, A., Hunt, B.J., Mansilha, A., Nicolaides, A.N., Sandset, P.M., Stansby, G., ESVS Guidelines Committee, de Borst, G.J., Bastos Gonçalves, F. and Chakfé, N. (2021). Editor’s Choice – European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. European Journal of Vascular and Endovascular Surgery, 61(1), pp.9–82. doi:https://doi.org/10.1016/j.ejvs.2020.09.023. 
8. Cai PL, Hitchman LH, Mohamed AH, Smith GE, Chetter I, Carradice D. Endovenous ablation for venous leg ulcers. Cochrane Database of Systematic Reviews 2023, Issue 7. Art. No.: CD009494. DOI: 10.1002/14651858.CD009494.pub3. 
9. ‌ National Wound Care Strategy Programme (2020). Lower Limb | National Wound Care Strategy Programme. [online] NWCSP.