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Cardiovascular

Varicose veins

Last revised in September 2024

Varicose veins are tortuous, dilated, superficial leg veins.

Varicose veins: Summary

  • Varicose veins are dilated, tortuous, superficial veins which most commonly affect the lower limb. They are often visible and palpable, and are an indication of superficial lower extremity venous insufficiency.
  • Varicose veins are thought to be caused by incompetent valves in the affected vein, which result in reflux of blood and increased pressure in the vein distally. 
  • Risk factors for developing varicose veins include increasing age, family history of varicose veins, female sex, pregnancy, obesity, prolonged standing or sitting, and a history of deep vein thrombosis (DVT). 
  • For most people, varicose veins are mainly a cosmetic concern; however, in some people they can cause lower limb symptoms, typically pain, aching, discomfort, swelling, heaviness, and itching, and can have a significant impact on their quality of life.
  • Varicose veins may become more severe over time and can lead to complications, such as bleeding, changes in skin pigmentation, superficial vein thrombosis, DVT, and venous ulceration.
  • When assessing a person with varicose veins, it is necessary to:
    • Ask about symptoms that might be caused by the varicose veins.
    • Ask about red flag symptoms such as weight loss, rectal or vaginal bleeding, changes in bowel habits, urinary symptoms, pelvic pain, or night sweats.
    • Ask about previous interventions on the veins (including varicose vein surgery) as well as a history of trauma, DVT, ulcerations, or bleeding from varicose veins.
    • Identify risk factors for varicose veins.
    • Identify why the person is concerned about their varicose veins.
    • Check for complications, such as changes in skin pigmentation and leg ulceration.
  • If varicose veins are bleeding, first aid should be offered and admission arranged to a vascular service.
  • If varicose veins are not bleeding, management includes:
    • Providing appropriate information and advice to the person. This should include explaining what varicose veins are and reassuring that it is unlikely they will lead to complications. 
    • Giving self-care advice, including weight loss (if applicable), avoidance of sitting or standing for long periods of time, and elevating the legs where possible. 
    • Considering referral to a vascular service for consideration of interventional treatments (endothermal ablation, foam sclerotherapy, or surgery).
    • Offering compression stockings (after excluding arterial insufficiency).  
  • If a pregnant woman has varicose veins, she should be advised that they are common and will usually improve considerably after pregnancy. Interventional treatments are unlikely to be an option in pregnant women, except in exceptional circumstances.
  • Management includes:
    • Offering compression stockings (where appropriate).
    • Providing self-care advice, including avoiding standing for long periods of time and sitting with crossed legs, avoiding excessive weight gain, elevating the legs when sitting and sleeping, undertaking light exercise and performing simple foot stretching exercises.

Have I got the right topic?

From age 18 years onwards.

This CKS topic covers the primary care management of varicose veins of the leg.

This CKS topic does not give detailed information on the interventional treatments for varicose veins, although indications for referral are considered. This CKS topic does not cover the primary care management of complications of varicose veins, but links to other CKS topics where appropriate. It also does not cover the management of telangiectases (spider veins), reticular veins, venous malformations, or varicose veins not located in the leg.

There are separate CKS topics on Compression stockings, Leg ulcer - venous, Thrombophlebitis - superficial, and Venous eczema and lipodermatosclerosis.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

August 2024 — reviewed. A literature search was conducted in August 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Based on expert opinion in a review article, three new recommendations were added regarding the assessment of people with varicose veins. These included asking about red flag symptoms which may be indicative of rare but severe causes of varicose veins, examining the varicose veins for the presence of superficial vein thrombosis, and performing an abdominal examination to assess for an abdominal or pelvic mass. There have also been minor structural changes to the topic, updating the basis for recommendation sections in line with the updated literature.

Previous changes

February 2024 — minor update. A link has been to the NHS England Decision support tool: making a decision about treatment for varicose veins.

February 2020 — minor update. Links updated.

January 2020 — minor update. The sections on Complications and Management have been updated.

August 2019 — reviewed. A literature search was conducted in July 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to clinical recommendations have been made, but the topic has been restructured. 

February 2020 — minor update. Links updated.

January 2020 — minor update. The sections on Complications and Management have been updated.

August 2019 — reviewed. A literature search was conducted in July 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to clinical recommendations have been made, but the topic has been restructured. 

May 2014 — reviewed. A literature search was conducted in March 2014 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. Structural changes have been made to the topic, and management and referral recommendations now reflect the guideline Varicose veins in the legs: the diagnosis and management of varicose veins from the National Institute for Health and Care Excellence.  

July to October 2008 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 August 2024.

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2024.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2024.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 August 2024.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 August 2024.

New policies

No new national policies or guidelines since 1 August 2024.

New safety alerts

No new safety alerts since 1 August 2024.

Changes in product availability

No changes in product availability since 1 August 2024.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of varicose veins.
  • Provide appropriate information and advice to a person with varicose veins.
  • Provide appropriate treatment in primary care.
  • Refer appropriately to a vascular service or other specialist service.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Varicose veins in the legs

  • People with varicose veins that are causing symptoms or complications (including ulceration) are referred to a vascular service. 
  • People with varicose veins who are seen by a vascular service are assessed with duplex ultrasound.
  • 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.

[NICE, 2015] 

Background information

What is it?

  • Varicose veins are dilated, tortuous, superficial veins which most commonly affect the lower limb. They are often visible and palpable and are an indication of superficial lower extremity venous insufficiency. 
    • For most people, varicose veins are mainly a cosmetic concern; however, they can cause symptoms in some people.
    • Varicose veins may become more severe over time, can lead to complications, and may have a negative impact on physical, psychological and social components of quality of life.

[NICE, 2013a; DePopas, 2018; Gawas, 2022; BMJ Best Practice, 2023; Gloviczki, 2024]

What are the causes and risk factors?

  • Varicose veins are an indication of superficial lower extremity venous insufficiency [DePopas, 2018; Gawas, 2022; BMJ Best Practice, 2023]
    • In the normal venous system, blood from superficial venous capillaries is directed upward via one-way valves into superficial veins. These in turn drain via the perforator veins, which pass through a muscular fascial layer, into the deep veins.
    • Varicose veins are thought to be caused by incompetent valves in the affected vein, which result in reflux of blood and increased pressure in the vein distally. Unlike deep veins, which have thick walls and are confined by fascia, superficial veins are unable to withstand the high pressure and eventually become dilated and tortuous.
    • Other pathological factors, such as weakness or degeneration of the vein wall, may also be involved in the development of varicose veins.
    • The increase in venous pressure in the leg is usually particularly marked if there is also incompetence in deep veins.
  • Risk factors for developing varicose veins include:
    • Increasing age — the prevalence of varicose veins increases with age [NICE, 2013a; BMJ Best Practice, 2023]. In a study in which participants were divided into three age cohorts of 40, 50, and 60 year olds, the prevalence of varicose veins overall was 22%, 35%, and 41%, respectively [Laurikka, 2002]. 
    • Family history of varicose veins — there is likely a significant hereditary component to the development of varicose veins [Fan, 2003]. A case-control study found that the risk of developing varicose veins is 90% if both parents are affected, 25% in males and 62% in females if one parent is affected, and 20% if no parent is affected [Cornu-Thenard, 1994]. 
    • Female sex — many studies have shown a greater prevalence of varicose veins in females than males. An analysis of 21 epidemiological studies showed that the overall prevalence of visible varicose veins in the Western population older than 15 years of age was 10–15% in males and 20–25% in females [Callam, 1994]. The higher prevalence in women is thought to be due to the effects of the female hormones on the veins: progesterone is thought to lead to passive venous dilation, which may then lead to valvular dysfunction; oestrogen produces collagen fibre changes and smooth muscle relaxation, both of which lead to venous dilation [BMJ Best Practice, 2023].
    • Pregnancy — this is thought to be a major contributory factor in the increased incidence of varicose veins in women [RCS/Vascular Society, 2013; Smyth, 2015; Ismail, 2016]. A study reported the prevalence of varicose veins in women with one, two, three, and four or more pregnancies as 38%, 43%, 48%, and 59%, respectively. Pregnancy increases total body fluid and intra-abdominal pressure, both of which may cause venous distension. Hormonal changes during pregnancy also increase venous relaxation which may play a role in the development of varicose veins [BMJ Best Practice, 2023] .
    • Obesity — being overweight or obese can increase the risk of developing varicose veins. The impact of body weight on the development of varicose veins appears to be more significant in women than in men [DePopas, 2018; Gawas, 2022; BMJ Best Practice, 2023]
    • Prolonged standing or sitting — studies have shown that prolonged standing and sitting are risk factors for venous symptoms, including varicose veins [Laurikka, 2002; Carpentier, 2004]. A large longitudinal study also associated low physical function with an increased risk of incident varicose veins [Mok, 2022].
    • History of deep vein thrombosis (DVT) — DVT may cause valvular damage and dysfunction in the deep veins, leading to increased pressure with subsequent distension and varicose vein formation [BMJ Best Practice, 2023].

How common is it?

What are the complications?

  • Possible complications of varicose veins include:
    • Bleeding, especially when the varicose veins are large, traumatized, or located over bony prominences. 
    • Superficial vein thrombosis (characterized by the appearance of hard, painful veins). 
    • Deep vein thrombosis. 
    • Changes in skin pigmentation (occurs in up to 7% of people with varicose veins annually) — including, hyperpigmentation (brown-red discolouration caused by haemosiderin deposition), venous eczema (itchy, red, scaly, and/or flaky skin which may have blisters and crusts on the surface), lipodermatosclerosis (painful, hardened, tight skin), or atrophie blanche (star-shaped, ivory-white, depressed, atrophic scars with surrounding pigmentation).
    • Skin ulceration (occurs in 3–6% of people with varicose veins). 
    • Depression (due to cosmetic skin changes).
    • Decreased quality of life.

[NICE, 2013a]  [Chang, 2018; Abelyan, 2018; Atkins, 2020; Gawas, 2022; BMJ Best Practice, 2023; Gloviczki, 2024]

What is the prognosis?

  • Without appropriate management, varicose veins may progress in severity and extent and complications, such as skin changes and ulceration, may occur [Piazza, 2014].
  • Although a resolution of symptoms is expected for over 95% of people, new varicose veins may occur over time [BMJ Best Practice, 2023].

Diagnosis

How should I assess a person with varicose veins?

  • ​​​​​​Take a history. 
    • Ask about symptoms experienced, if any. 
      • Pain, aching, itching, and swelling of the affected leg are commonly reported but may be due to other causes. Discomfort after prolonged standing, relief with leg elevation, and discomfort over the affected veins suggest that the symptoms are due to varicose veins.
      • Restless legs and leg cramps (usually nocturnal) may also be present.
    • If relevant, ask whether symptoms are worse during menstruation or during any previous pregnancies.
    • Ask about the extent to which their symptoms affect their daily activities.
    • Ask about red flag symptoms such as weight loss, rectal or vaginal bleeding, changes in bowel habits, urinary symptoms, pelvic pain, or night sweats.
    • Ask about previous interventions on the veins (including varicose vein surgery) as well as a history of trauma, deep vein thrombosis, ulcerations, or bleeding from varicose veins.
    • Identify risk factors for varicose veins, such as prolonged standing or a family history of varicose veins.
    • Identify why the person is concerned about their varicose veins. For many people, it is because of the cosmetic appearance, or worries that they will get worse or cause complications.
  • Examine the legs.
    • Examine the skin visually and by palpation (with the person standing and lying) for irregularities and bulges consistent with varicose veins. Note the extent, size, and location of the dilated veins to help exclude telangiectasias and reticular veins.
      • Varicose veins are 3 mm or more in diameter in the upright position. 
      • Telangiectasias (also known as spider or thread veins) are intradermal veins that are less than 1 mm in diameter.
      • Reticular veins are permanently dilated intradermal veins that range between 1–3 mm in diameter. They may be tortuous but are usually asymptomatic.
      • Superficial vein thrombosis may be present if there is a hard, tender lump at the site of a varicose vein which causes extreme pain when touched.
    • Assess for any complications, including:
      • Skin changes — look for hyperpigmentation (brown-red discolouration caused by haemosiderin deposition), venous eczema (itchy, red, scaly, and/or flaky skin which may have blisters and crusts on the surface), lipodermatosclerosis (painful, hardened, tight skin), and atrophie blanche (star-shaped, ivory-white, depressed, atrophic scars with surrounding pigmentation). See the CKS topic on  Venous eczema and lipodermatosclerosis  for more information.
      • Areas of active or healed ulceration — venous leg ulcers typically occur in the gaiter area of the leg (from the ankle to mid-calf). See the CKS topic on Leg ulcer - venous for more information.
      • Superficial vein thrombosis — characterized by the appearance of hard, painful veins. See the CKS topic on Superficial vein thrombosis (superficial thrombophlebitis) for more information.
      • Bleeding — erosion of varices can lead to bleeding that may require surgical intervention.
  • Perform an abdominal examination to assess for an abdominal or pelvic mass.
    • Varicose veins caused by an abdominal or pelvic mass may be more likely if there is unilateral varicose veins or leg swelling.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Varicose veins in the legs: The diagnosis and management of varicose veins [NICE, 2013b] and Varicose veins: diagnosis and management [NICE, 2013a], a joint Royal College of Surgeons (RCS) and Vascular Society for Great Britain and Ireland publication Commissioning guide: Varicose veins [RCS/Vascular Society, 2013], discussions in a randomized controlled trial and observational study [Michaels, 2006] and population-based studies [Bradbury, 1999; Carpentier, 2004], and on expert opinion in narrative review articles Varicose Veins [Piazza, 2014], Varicose Veins and Lower Extremity Venous Insufficiency [DePopas, 2018], Varicose veins in primary care [Atkins, 2020] and Varicose veins [BMJ Best Practice, 2023].

History

  • Evidence indicates that people with varicose veins are more likely to complain of leg discomfort, itching, and swelling, but these symptoms are also common in people without varicose veins [Bradbury, 1999]. Other symptoms and signs of varicose veins are based on the NICE guideline [NICE, 2013a], the joint RCS and Vascular Society publication [RCS/Vascular Society, 2013], and review articles [Piazza, 2014; BMJ Best Practice, 2023].
  • The recommendation to ask about previous interventions on the veins, as well as a history of trauma, deep vein thrombosis (DVT), ulcerations, or bleeding from varicose veins, is based on expert opinion in a review article [BMJ Best Practice, 2023].
  • The most common complaint that people have about their varicose veins is their unsightliness. In addition, many people with varicose veins are worried about the possibility of complications, such as bleeding, ulcers, and DVT, although often these fears are unfounded [Michaels, 2006]. The recommendation to identify the person's concerns is extrapolated from the NICE guideline, which states that any misconceptions the person may have about the risks of developing complications should be addressed [NICE, 2013a].
  • The recommendation to ask about the extent to which a person's symptoms affect their daily activities, and red flag symptoms such as weight loss, rectal or vaginal bleeding, changes in bowel habits, urinary symptoms, pelvic pain, or night sweats, is based on expert opinion in a review article [Atkins, 2020].

Examination

  • Although most varicose veins do not progress to complications [BMJ Best Practice, 2023], CKS pragmatically suggests assessing for any complications. 
  • The information on telangiectasias and reticular veins is taken from the NICE guideline [NICE, 2013b] and review articles [Piazza, 2014; BMJ Best Practice, 2023].
  • The recommendation to examine varicose veins for the presence of superficial vein thrombosis (thrombophlebitis), and to perform an abdominal examination to assess for an abdominal or pelvic mass is based on expert opinion in a review article [Atkins, 2020].

Management

Scenario: Varicose veins

From age 18 years onwards.

How should I manage a person with varicose veins?

  • If varicose veins are bleeding, offer first aid and admit to a vascular service.
    • If there is doubt about whether admission is required, seek immediate specialist advice from a vascular surgeon.
  • If varicose veins are not bleeding:
    • Give verbal and written information on varicose veins.
    • Give self-care advice to relieve symptoms and reduce the risk of complications. Advise the person to:
      • Lose weight (if overweight or obese). See the CKS topic on Obesity for more information.
      • Engage in light to moderate physical activity.
      • Avoid factors that exacerbate symptoms, such as sitting or standing for long periods of time.
      • Elevate the legs when possible.
    • The National Institute for Health and Care Excellence (NICE) recommends referral to a vascular service in the following cases for consideration of interventional treatments:
      • Primary or recurrent varicose veins associated with lower limb symptoms, typically pain, aching, discomfort, swelling, heaviness, and itching.
      • Lower-limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency. See the CKS topic on Venous eczema and lipodermatosclerosis for more information.
      • Superficial vein thrombosis (characterized by the appearance of hard, painful veins) and suspected venous incompetence. See the CKS topic on Superficial vein thrombosis (superficial thrombophlebitis) for more information.
      • An active venous leg ulcer (break in the skin below the knee that has not healed within 2 weeks). See the CKS topic on Leg ulcer - venous for more information.
      • A healed venous leg ulcer.
    • If referral is not indicated, offer compression stockings (after excluding arterial insufficiency).
      • Class 2 stockings may be more effective than class 1 stockings, but they are generally less well tolerated. The choice will, therefore, depend on the severity of the varicose veins, the tolerability of stockings, and patient preference.
      • See the CKS topic on Compression stockings for detailed information on the use of compression stockings.
    • If the person is a pregnant woman: 
      • Reassure her that varicose veins are common in pregnancy, are not harmful to the baby, and often improve considerably after pregnancy.
      • Offer treatment with compression stockings after excluding arterial insufficiency and where appropriate. Advise that these may improve the symptoms but will not prevent varicose veins from emerging.
      • Be aware that interventional treatments are unlikely to be an option in pregnant women, except in exceptional circumstances.
      • Provide self care advice including avoiding standing for long periods of time and sitting with crossed legs, avoiding excessive weight gain, elevating the legs when sitting and sleeping, undertaking light exercise and performing simple foot stretching exercises.
    • Advise the person to seek further medical help if:
      • Their varicose veins become hard or painful.
      • They develop skin changes (such as pigmentation, venous eczema, lipodermatosclerosis, and atrophie blanche).  
      • They develop a venous ulcer (break in the skin below the knee that has not healed within 2 weeks).
      • There is bleeding from the varicose veins.

Interventional treatments for varicose veins

  • Duplex ultrasound provides both anatomical and haemodynamic data on the functioning of the superficial and deep venous systems.
    • People with varicose veins who are seen by a vascular service should be assessed with duplex ultrasound to confirm the diagnosis of varicose veins and the extent of truncal reflux, and to plan treatment for suspected primary or recurrent varicose veins.
  • Interventional treatments can be done under local or general anaesthesia, including:
    • Surgical approaches — involves ligation (tying off) and stripping (removal) of the affected vein.
    • Endothermal ablation — using energy either from high-frequency radio waves (radiofrequency ablation) or lasers (endovenous laser treatment) to seal the affected veins.
    • Foam sclerotherapy — injection of an irritant foam into the vein, resulting in an inflammatory response that causes closure of the vein. 
    • Cyanoacrylate glue bioadhesive occlusion — closes the veins by adherence and fibrosis of the lumen. 

Excluding arterial insufficiency

  • It is important to exclude arterial insufficiency before prescribing compression stockings. If arterial circulation is impaired, compression may further impair the arterial supply and result in pressure damage, limb ischaemia, and amputation. For more information see the CKS topic Peripheral arterial disease. 

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Varicose veins in the legs: The diagnosis and management of varicose veins [NICE, 2013b] and Varicose veins: diagnosis and management [NICE, 2013a], guidance from the Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society Clinical practice Guidelines for the management of varicose veins of the lower extremities (Part II) [Gloviczki, 2024], joint Royal College of Surgeons (RCS) and Vascular Society for Great Britain and Ireland publication Commissioning guide: Varicose veins [RCS/Vascular Society, 2013], evidence from a Cochrane systematic review [Knight Nee Shingler, 2021], and on expert opinion in narrative review articles Varicose veins - natural history, assessment and management [Wright, 2013], Varicose veins [Piazza, 2014], Varicose Veins and Lower Extremity Venous Insufficiency [DePopas, 2018], Varicose veins in primary care [Atkins, 2020], Comprehensive Review on Varicose Veins: Preventive Measures and Different Treatments [Gawas, 2022], and Varicose veins [BMJ Best Practice, 2023].

Managing bleeding varicose veins
  • NICE recommends immediate referral to a vascular service because of the potential for serious or life-threatening bleeding [NICE, 2013b; NICE, 2013a].
  • CKS has pragmatically suggested discussing with a vascular surgeon if unsure whether immediate referral is required, for example if bleeding is minor, to avoid unnecessary admissions.
Giving information and reassurance
  • The NICE guideline development group (GDG) found little evidence on how to give information to people with varicose veins but felt that providing people with information was likely to improve quality of life [NICE, 2013b].
  • Evidence discussed in the NICE guideline suggests that people with varicose veins have a poor understanding of the risk factors for varicose veins and pessimistic ideas of the likelihood of developing complications. There was some concern within the GDG that in-depth discussions of possible complications of varicose veins may cause anxiety. It was felt, therefore, that although misconceptions should be explored, it was not necessary to introduce new factors that may cause anxiety and that information should be tailored to the person and their needs [NICE, 2013b].
Self-care advice
  • Evidence reviewed by NICE identified a high body mass index (BMI) as a risk factor for progression to more serious varicose veins and also a factor predicting worse outcome after treatment compared with a normal BMI [NICE, 2013b].
  • The NICE GDG felt that light to moderate physical activity (for example walking or swimming) may help but that strenuous exercise may aggravate varicose veins. The available evidence suggested that exercise was not an independent factor for increasing or reducing varicose veins progression, but the GDG felt it was important to tell people that light to moderate physical activity is safe, as the positive overall health effects of health promotion outweigh any small risks (from which there is no evidence) [NICE, 2013b; NICE, 2013a].
  • The NICE GDG noted that aggravating factors are individual to the person with varicose veins. The experience of the primary care members of the GDG was that people with varicose veins had often worked out the factors that exacerbated their symptoms (for example hot baths and prolonged standing) and they should be advised to avoid these factors where possible [NICE, 2013b; NICE, 2013a].
  • Guidance from the Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society recommends that people with varicose veins or venous ulcerations should be counseled on the possibility of venous bleeding, and should receive education regarding leg elevation and simple compression techniques to control severe bleeding [Gloviczki, 2024].
  • This guidance is supported by expert opinion provided in review article which recommends to apply pressure to the affected vein and elevate the leg If there is external bleeding. This article also highlights that a large amount of blood can be lost from the high pressure varicose veins, which may require emergency treatment [Atkins, 2020].
Referral to a vascular service
  • The NICE referral criteria are based on evidence from two prognostic reviews, although the evidence was limited in terms of quality and consistency. They are also based on the expert opinion of the NICE GDG [NICE, 2013b]. 
    • Referral is usually recommended for symptom control and to prevent disease progression. 
      • Symptomatic varicose veins — NICE found evidence showing that interventional treatment is cost effective in this case. The NICE GDG also considered that evaluation by a vascular surgeon was necessary to make the decision that compression stockings should be offered (only recommended if the person is unsuitable or declines interventional therapy). 
      • Lower limb skin changes — if a person has skin changes due to venous hypertension, they are at increased risk of developing venous leg ulcers. Therefore, the GDG felt referral was appropriate to plan prophylactic treatment.
      • Superficial vein thrombosis (characterized by the appearance of hard, painful veins) and suspected venous incompetence — the GDG made this recommendation based on evidence that deep vein thrombosis is present in 20% of legs with superficial vein thrombosis.
      • Venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks) — the GDG recommends early referral (within 2 weeks) as ulcers of longer duration are more difficult to heal.
      • A healed venous leg ulcer — NICE recommends referral as these people may benefit from interventional treatment.
  • NICE recommends referral to a vascular service, where a full clinical and duplex Doppler ultrasound assessment as well as a full range of treatments can be provided.
    • The GDG highlighted that the location of this service can be decided locally, with some of the service being delivered in primary care where skills and equipment are available.
    • The GDG acknowledged that people referred would not necessarily receive interventional treatment but could still benefit from the expertise available from vascular specialists.
  • Guidance from the Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society recommends [Gloviczki, 2024]:
    • People with bleeding varicose veins should be promptly referred to a venous specialist.
    • Doppler ultrasound scanning (DUS) as the diagnostic test of choice to evaluate for venous reflux. This recommendation is provided inclusive of people with bleeding varicose veins, and those with severe symptoms of pain or burning. The guidance also recommends DUS evaluation to exclude associated venous incompetence in people with symptomatic varicose veins, and that the deep venous system should be routinely evaluated for infrainguinal obstruction or valvular incompetence.
Compression stockings
  • An evidence review commissioned by NICE compared compression stockings with no treatment or lifestyle advice for varicose veins. Evidence from three randomized controlled trials (RCTs) and five observational studies were of poor quality, and it was difficult to draw conclusions on a number of outcomes. However, a clinical benefit was demonstrated with compression stockings for the symptoms of heavy or tired legs, and overall complaints of symptoms [NICE, 2013b].
  • A Cochrane systematic review (search date: May 2020) aimed to assess the effectiveness of compression stockings as the only initial treatment of varicose veins in people without healed or active venous ulceration. Thirteen studies were identified, but the authors were unable to pool the results due to heterogenous outcomes and analysis approaches. The evidence quality was therefore assessed as low to very low.  The authors concluded that there was insufficient evidence to determine whether or not compression stockings were effective as the sole and initial treatment of varicose veins, or whether any type of stocking type was superior to any other [Knight Nee Shingler, 2021].
  • NICE made no definite recommendation on how to manage people in primary care for whom referral is not indicated. CKS has extrapolated the recommendations from the NICE recommendation that compression hosiery should not be offered for the treatment of varicose veins unless interventional treatment is unsuitable [NICE, 2013a]. This recommendation is also consistent with:
    • Expert opinion in a review article, which states that compression stockings alone may be appropriate for people who are too unfit for intervention and for people who do not wish to have any form of surgical intervention [Wright, 2013].
    • Guidance from the Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society which recommends superficial venous intervention over long-term compression stockings for people with symptomatic varicose veins and axial reflux in the great saphenous vein or small saphenous vein who are candidates for intervention [Gloviczki, 2024].
  • The NICE GDG reported a variation in practice in terms of types of stockings used but found insufficient evidence to make a recommendation on the type of compression stockings to be offered. The GDG was of the opinion that although class 3 stockings may be more effective than class 1 or 2, they are more difficult to put on. The GDG noted that compliance is very important as treatment will not be effective if stockings are not worn [NICE, 2013b]. 
Managing pregnant women
  • Varicose veins can develop during, or be exacerbated by, pregnancy [NICE, 2013b; RCS/Vascular Society, 2013; Smyth, 2015; Ismail, 2016].
  • The recommendations on treating varicose veins in pregnancy are based on expert opinion in the NICE guidelines on varicose veins [NICE, 2013b; NICE, 2013a], the joint RCS and Vascular Society publication [RCS/Vascular Society, 2013], and a HSCNI Public Health Agency publication The Pregnancy Book [HSCNI, 2024].
    • The GDG of the NICE varicose veins guideline recommends considering compression stockings for the symptom relief of leg swelling associated with varicose veins in pregnancy. The GDG considered the benefits to outweigh the potential harms to the woman and her child and felt that the extra cost of compression stockings was justified, given the potential improvement in quality of life and the fact that interventional treatments are unlikely to be an option during pregnancy (except in exceptional circumstances) [NICE, 2013b].
  • The recommendation to carefully consider the need for referral in pregnant women is pragmatic, based on what CKS considers to be good clinical practice and the opinion of the NICE GDG that the clinical benefits of interventional treatment of varicose veins during pregnancy did not outweigh the possible harms to the woman and her baby [NICE, 2013b].
  • CKS has not made specific recommendations on lifestyle advice to give pregnant women, based on the opinion of the NICE GDG that advice given to pregnant women is no different to advice given to anyone else with varicose veins [NICE, 2013b].
    • Guidance from the HSCNI advises pregnant women to avoid standing for long periods of time, sitting with their legs crossed, and gaining too much weight. It also recommends that to ease discomfort pregnant women should sit with their legs up as often as possible, consider the use of support tights, try sleeping with their legs elevated, to do foot exercises (bending and stretching each foot up and down [30 times per foot], and rotating in both directions [80 times per foot]) and participate in antenatal exercise (such as walking and swimming) [HSCNI, 2024].
When to seek further medical help
  • This recommendation is based on the NICE varicose veins guideline [NICE, 2013b].
Interventional treatments for varicose veins
  • Duplex ultrasound provides both anatomical and haemodynamic data on the functioning of the superficial and deep venous systems [Piazza, 2014; Onida, 2015].
  • Information about the treatments provided in a vascular service is largely based on the National Institute for Health and Care Excellence (NICE) guidelines Varicose veins in the legs: The diagnosis and management of varicose veins [NICE, 2013b] and Varicose veins: diagnosis and management [NICE, 2013a], guidance from the Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society Clinical practice Guidelines for the management of varicose veins of the lower extremities (Part II) [Gloviczki, 2024], and on expert opinion in narrative review articles [Gawas, 2022; BMJ Best Practice, 2023].
  • The information about cyanoacrylate glue occlusion is based on NICE interventional procedures guidance cyanoacrylate glue occlusion for varicose veins [NICE, 2020].
Excluding arterial insufficiency
  • These recommendations are based on the Scottish Intercollegiate Guidelines Network (SIGN) guideline Management of chronic venous leg ulcers [SIGN, 2010] the Wounds UK document Best Practice Statement: Addressing complexities in the management of venous leg ulcers [Wounds UK, 2019], and a expert opinion in a review article [Atkins, 2020].

Supporting evidence

The recommendations in this CKS topic are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Varicose veins in the legs: The diagnosis and management of varicose veins [NICE, 2013b] and Varicose veins: diagnosis and management [NICE, 2013a], guidance from the Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society Clinical practice Guidelines for the management of varicose veins of the lower extremities (Part II) [Gloviczki, 2024], joint Royal College of Surgeons (RCS) and Vascular Society for Great Britain and Ireland publication Commissioning guide: Varicose veins [RCS/Vascular Society, 2013], and on expert opinion in narrative review articles Varicose Veins and Lower Extremity Venous Insufficiency [DePopas, 2018],  Varicose veins in primary care [Atkins, 2020], A Comprehensive Review on Varicose Veins: Preventive Measures and Different Treatments [Gawas, 2022], Varicose veins [BMJ Best Practice, 2023]. For a detailed discussion of the evidence NICE used to base their recommendations, see the full NICE guidance.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guideline and systematic reviews on primary care management of varicose veins.

Search dates

June 2019 - August 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 24th June 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S4    S1 OR S2 OR S3 
S3    AB ( ((leg or legs or limbs or lower extremit*) N5 (varices or varix)) ) OR TI ( ((leg or legs or limbs or lower extremit*) N5 (varices or varix)) ) 
S2    AB varicose vein* OR TI varicose vein* 
S1    (MH "Varicose Veins+") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Abelyan, G., Abrahamyan, L. and Yenokyan, G. (2018) A case-control study of risk factors of chronic venous ulceration in patients with varicose veins. Phlebology 33(1), 60-67. [Free Full-text]
  • Atkins, E., Mughal, N.A., Place, F. and Coughlin, P.A. (2020) Varicose veins in primary care. BMJ 370(m2509), m2509. [Abstract]
  • BMJ Best Practice (2023) Varicose veins. BMJ Publishing Group. https://bestpractice.bmj.com
  • Bradbury, A., Evans, C., Allan, P., et al. (1999) What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. British Medical Journal 318(7180), 353-356. [Abstract]
  • Callam, M.J. (1994) Epidemiology of varicose veins. British Journal of Surgery 81(2), 167-173. [Abstract]
  • Carpentier, P.H., Maricq, H.R., Biro, C., et al. (2004) Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: a population-based study in France. Journal of Vascular Surgery 40(4), 650-659. [Abstract]
  • Chang, S.L., Huang, Y.L., Lee, M.C., et al. (2018) Association of Varicose Veins With Incident Venous Thromboembolism and Peripheral Artery Disease. JAMA 319(8), 807-817. [Free Full-text]
  • Cornu‐Thenard, A., Boivin, P. and Baud, J-M. (1994) Importance of the Familial Factor in Varicose Disease. The Journal of Dermatologic Surgery and Oncology 20(5), 318-326. [Free Full-text]
  • DePopas, E. and Brown, M. (2018) Varicose Veins and Lower Extremity Venous Insufficiency. Seminars in interventional radiology 35(1), 56-61. [Free Full-text]
  • Fan, C-M. (2003) Epidemiology and pathophysiology of varicose veins. Techniques in Vascular and Interventional Radiology 6(3), 108-110. [Free Full-text]
  • Gawas, M., Bains, A., Janghu, S., et al. (2022) A Comprehensive Review on Varicose Veins: Preventive Measures and Different Treatments. Journal of the American Nutrition Association 41(5), 499-510. [Abstract]
  • Gloviczki, P., Lawrence, P.F., Wasan, S.M., et al. (2024) The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. J Vasc Surg Venous Lymphat Disord 12(1), 101670. [Abstract] [Free Full-text]
  • HSCNI (2024) The pregnancy book. Health and Social Care Northern Ireland Public Health Agency. https://www.publichealth.hscni.net [Free Full-text]
  • Ismail, L., Normahani, P. and Standfield, N.J. et al. (2016) A systematic review and meta-analysis of the risk for development of varicose veins in women with a history of pregnancy. Journal of vascular surgery: venous And lymphatic disorders 4(4), 518-524. [Free Full-text]
  • Knight Nee Shingler, S.L., Robertson, L. and Stewart, M. (2021) Cochrane Review: Graduated compression stockings for the initial treatment of varicose veins in people without venous ulceration. Issue 7 (7). John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Laurikka, J.O., Sisto, T. and Tarkka, M.R. (2002) Risk indicators for varicose veins in forty- to sixty-year-olds in the Tampere varicose vein study. World Journal of Surgery 26(6), 648-651. [Abstract]
  • Michaels, J.A., Campbell, W.B., Brazier, J.E., et al. (2006) Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technology Assessment 10(13). [Abstract]
  • Mok, Y., Ishigami, J., Sang, Y., et al. (2022) Clinically Recognized Varicose Veins and Physical Function in Older Individuals: The ARIC Study. Journals of gerontology. Series A, Biological sciences and medical sciences 77(8), 1637-1643. [Abstract] [Free Full-text]
  • NICE (2013a) Varicose veins: diagnosis and management (CG168). NICE guidelines. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2013b) Varicose veins in the legs. The diagnosis and management of varicose veins. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2015) Varicose veins in the legs [QS67]. National Institue for Health and Care Excellence (NICE). https://www.nice.org.uk [Free Full-text]
  • NICE (2020) Cyanoacrylate glue occlusion for varicose veins [IPG670]. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • Onida, S.,  Davies, A.H.,  Franklin, I. (2015) Varicose veins—Who should be referred? Phlebology 30(2S), 4-8. [Abstract]
  • Piazza, G. (2014) Varicose veins. Circulation 130(7), 582-587. [Free Full-text]
  • RCS (2013) Commissioning guide: varicose veins. The Royal College of Surgeons of England. http://www.rcseng.ac.uk [Free Full-text]
  • SIGN (2010) Management of chronic venous leg ulcers. Scottish Intercollegiate Guidelines Network. http://www.sign.ac.uk [Free Full-text]
  • Smyth, R.M.D., Aflaifel, N. and Bamigboye, A.A. (2015) Interventions for varicose veins and leg oedema in pregnancy (Cochrane Review/Cochrane Intervention Protocol). Issue 10. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Wounds UK (2019) Best practice statement. Addressing complexities in the management of venous leg ulcers. Wounds UK. http://www.wounds-uk.com [Free Full-text]
  • Wright, N. and Fitridge, R. (2013) Varicose veins - natural history, assessment and management. Australian Family Physician 42(6), 380-384. [Abstract]
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