Varicose vein interventions

There are various interventional procedures for treating varicose veins. These include endothermal ablation, ultrasound guided foam sclerotherapy and traditional surgery (this is a surgical procedure that involves ligation and stripping of varicose veins) all of which have been shown to be clinically and cost effective compared to no treatment or treatment with compression hosiery. Varicose veins are common and can markedly affect patients quality of life, can be associated with complications such as eczema, skin changes, thrombophlebitis, bleeding, leg ulceration, deep vein thrombosis and pulmonary embolism that can be life threatening.

1.1 Intervention in terms of, endovenous thermal (laser ablation, and radiofrequency ablation), ultrasound guided foam sclerotherapy, open surgery (ligation and stripping) are all cost effective treatments for managing symptomatic varicose veins compared to no treatment or the use of compression hosiery. For truncal ablation there is a treatment hierarchy based on the cost effectiveness and suitability, which is endothermal ablation then ultrasound guided foam, then conventional surgery.

1.2 Refer people to a vascular service if they have any of the following:

1. Symptomatic* primary or recurrent varicose veins
2. Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency.
3. Superficial vein thrombophlebitis (characterised by the appearance of hard, painful veins) and suspected venous incompetence.
4. A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks).
5. A healed venous leg ulcer.

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

For patients whose veins are purely cosmetic and are not associated with any symptoms do not refer for NHS treatment

1.3 Refer people with bleeding varicose veins to a vascular service

1.4 Do not offer compression hosiery to treat varicose veins unless interventional treatment is unsuitable.

For further information, please see:

NICE Varicose veins in the legs [QS67]

NICE Varicose veins: diagnosis and management [CG168]

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.

Open surgery is a traditional treatment that involves surgical removal by ‘stripping’ out the vein or ligation (tying off the vein), this is still a valuable technique, it is still a clinically and cost-effective treatment technique for some patients but has been mainly superseded by endothermal ablation and ultrasound guided foam sclerotherapy.

Recurrence of symptoms can occur due to the development of further venous disease, that will benefit from further intervention (see above). NICE guidance states that a review of the data from the trials of interventional procedures indicates that the rate of clinical recurrence of varicose veins at 3 years after treatment is likely to be between 10–30%.

For people with confirmed varicose veins and truncal reflux NICE recommends:

• Offer endothermal ablation of the truncal vein
• If endothermal ablation is unsuitable, offer ultrasound‑guided foamsclerotherapy.
• If ultrasound‑guided foam sclerotherapy is unsuitable, offer surgery
• Consider treatment of tributaries at the same time
• Do not offer compression hosiery to treat varicose veins unless interventional treatment is unsuitable.

Complications of intervention include recurrence of varicose veins, infection, pain, bleeding, and more rarely blood clot in the leg. Complications of non-intervention include decreasing quality of life for patients, increased symptomatology, disease progression potentially to skin changes and eventual leg ulceration, deep vein thrombosis and pulmonary embolism.

Information for Patients

Surgery to remove varicose veins, should only be carried out when specific criteria are met. This is because the medical evidence tells us that there are alternative treatments which can be just as effective and as with all surgical procedures there are risks attached.

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 tiny 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).

It is important that if you have symptomatic veins or complications that your doctor refers you to a vascular specialist. It is important that your vascular specialist then explains 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?

The first treatment option is endothermal ablation, which uses radio waves or laser to burn and close the affected veins from inside the vein. The second, known as ultrasound guided foam sclerotherapy, involves injecting a foam medication into the affected vein to scar and block the vein. Open surgery (also known as ‘stripping’) remains an option for some patients, but should only be carried out if other alternatives are not suitable.

What are the RISKS?

The risks of intervention are very low but include deep vein thrombosis (DVT), nerve damage, infection and pain. The procedure is 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 you are not suitable for intervention. Regular exercise, avoiding standing for long periods of time or elevating the affected area when resting may relieve some symptoms.

What if you do NOTHING?

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

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.
5. 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. Gloviczki P1, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, Lohr JM, McLafferty RB, Meissner MH, Murad MH, Padberg FT, Pappas PJ, Passman MA, Raffetto JD, Vasquez MA, Wakefield TW; Society for Vascular Surgery; American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S-48S. doi: 10.1016/j.jvs.2011.01.079.
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.

Last revised December 2023