Quality standard

Quality statement 3: Treatment of varicose veins

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

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

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 – the number in the denominator offered endothermal ablation.

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

Data source: Local data collection.

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

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

Denominator – the 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.

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 – the number in the denominator offered surgery.

Denominator – the 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.

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 – the number in the denominator offered compression hosiery.

Denominator – the 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.

What the quality statement means for different audiences

Service providers (secondary care) ensure that the local treatment pathway is consistent with the evidence-based treatment order in NICE's guideline on varicose veins.

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's guideline on varicose veins.

Commissioners ensure that the full range of treatments for varicose veins is commissioned in accordance with NICE's guideline on varicose veins.

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

Varicose veins: diagnosis and management. NICE guideline CG168 (2013), recommendations 1.3.2 and 1.3.4 (key priority for implementation)

Definitions of terms used in this quality statement

Suitable treatment order

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. [Adapted from NICE's guideline on varicose veins]

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 NICE's full guideline on varicose veins, page 122 and glossary definition of reflux]

Endothermal ablation

There are 2 types of endothermal ablation in common use: radiofrequency ablation and laser ablation (see NICE's interventional procedures guidance on radiofrequency ablation of varicose veins and endovenous laser treatment of the long saphenous vein). 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 NICE's full guideline on varicose veins, 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 NICE's interventional procedure guidance on ultrasound-guided foam sclerotherapy for varicose veins). [NICE's full guideline on varicose veins, 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. [NICE's full guideline on varicose veins, 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 NICE's full guideline on varicose veins, glossary definition of compression hosiery]

Reflux

Reflux is the backflow of blood through a venous valve. [NICE's full guideline on varicose veins, glossary definition of stripping]