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Excerpt
Varicose veins are dilated, often palpable subcutaneous veins with reversed blood flow, most commonly found in the legs. Estimates of the prevalence of varicose veins vary. Visible varicose veins in the lower limbs are estimated to affect at least a third of the population. There is little reliable information available in the literature on the proportion of people with varicose veins who progress to venous ulceration. One study reported that 28.6% of those who had visible varicose veins without oedema or other complications progressed to more serious venous disease after 6.6 years.83 However there was no information about the numbers progressing to ulceration. Other data on the lifetime prevalence of varicose veins estimate that approximately 3–6% of people who have varicose veins in their lifetime will develop venous ulcers.71 Risk factors for developing varicose veins are unclear although prevalence rises with age and they often develop during pregnancy. In some people varicose veins are asymptomatic or cause only mild symptoms, but in others they cause pain, aching or itching and can have a significant effect on their quality of life. Varicose veins may become more severe over time and can lead to complications such as changes in skin pigmentation, eczema, superficial thrombophlebitis, bleeding, loss of subcutaneous tissue, lipodermatosclerosis or venous ulceration.
There are several options for the management of varicose veins, including:
- advice and reassurance
- interventional treatments
- compression hosiery
Interventional treatments include surgery, foam sclerotherapy and endothermal ablation. Surgery is a traditional treatment that involves surgical removal by 'stripping' out the vein or ligation (tying off the vein). In foam sclerotherapy sclerosant foam (irritating agent) is injected into the vein to cause an inflammatory response which consequently closes it. There are two main endothermal methods: radiofrequency and laser ablation, these methods heat the vein from inside causing irreversibly damage to the vein and its lining and closes it off. All treatments may be performed under general or local anaesthesia and do not usually require an overnight stay in hospital.
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%. One of the aspects which prevents being able to provide clear figures on retreatment rates is that many of the treatments are relatively new and the long term rates have not yet been published.
In 2009/10 there were 35,659 varicose veins procedures carried out in the NHS indicating a considerable financial cost and impact on workload. There is no clear simple system to identify which people benefit the most from interventional therapy and currently there is no established framework within the NHS for the diagnosis and management of varicose veins. This has led to considerable regional variation in the management of and in the treatments offered to people with varicose veins in the UK. Hence this guideline was developed with the aim of giving healthcare professionals guidance on the diagnosis and management of varicose veins in the leg, in order to improve patient care and minimize such disparities in care across the UK.
Contents
- Guideline development group members
- Acknowledgments
- 1. Introduction
- 2. Development of the guideline
- 3. Methods
- 4. Guideline summary
- 5. Patient perceptions and expectations
- 6. Referral to a vascular service
- 6.1. Review question: a) In people with leg varicose veins at CEAP class C2 which signs, symptoms and/or patient characteristics are associated with disease progression to i) C3, ii) C4, iii) C6: b) In people with leg varicose veins at CEAP class C3 which signs, symptoms and/or patient characteristics are associated with disease progression to i) C4, ii) C6? c) In people with leg varicose veins at CEAP class C4 which signs, symptoms and/or patient characteristics are associated with disease progression to C6?
- 6.2. Review question: In people with leg varicose veins are there any factors (clinical signs and symptoms or patient reported outcomes) that would predict increased benefits or harms from varicose veins interventional treatments?
- 6.3. Recommendations and link to evidence
- 7. Assessment prior to treatment
- 7.1. Review question: What is the diagnostic accuracy of hand held Doppler compared to duplex scanning in patients with varicose veins?
- 7.2. Review question: Does the use of duplex ultrasound during assessment improve outcome after interventional treatment compared to no duplex scanning in people with leg varicose veins?
- 7.3. Recommendations and link to evidence
- 8. Conservative Management
- 8.1. Review question: What is the clinical and cost effectiveness of compression therapy compared with no treatment or lifestyle advice in people with leg varicose veins?
- 8.2. Review questions: What is the clinical and cost effectiveness of compression therapy compared with a) stripping surgery; or b) endothermal ablation; or c) foam sclerotherapy in people with leg varicose veins?
- 8.3. Recommendations and link to evidence
- 9. Interventional Treatment
- 9.1. Review question: What is the clinical and cost effectiveness of stripping surgery compared with foam sclerotherapy in people with truncal leg varicose veins?
- 9.2. Review question: What is the clinical and cost effectiveness of stripping surgery compared with endothermal ablation in people with truncal leg varicose veins?
- 9.3. Review question: What is the clinical and cost effectiveness of foam sclerotherapy compared with endothermal ablation in people with truncal leg varicose veins?
- 9.4. Review question: What is the clinical and cost effectiveness of avulsion surgery compared with foam sclerotherapy in people with tributary leg varicose veins?
- 9.5. Review question: What is the clinical and cost effectiveness of truncal vein treatment accompanied by tributary treatments compared with truncal vein treatment alone in people with leg varicose veins?
- 9.6. Original economic model
- 9.7. Recommendations and link to evidence
- 10. Compression post interventional treatment
- 10.1. Review Question: What is the clinical and cost effectiveness of interventional treatment followed by compression compared with interventional treatment alone in people with leg varicose veins, and, if so, what type of compression, pressure of compression and/or duration of compression is optimal?
- 10.2. Recommendations and link to the evidence
- 11. Pregnancy
- 12. Reference list
- 13. Acronyms and abbreviations
- 14. Glossary
- Appendices
- Appendix A. Scope
- Appendix B. Declarations of interest
- Appendix C. Review protocols
- Appendix D. Clinical article selection
- Appendix E. Economic article selection
- Appendix F. Literature search strategies
- Appendix G. Evidence tables clinical studies
- Appendix H. Evidence tables economic studies
- Appendix I. Forest plots
- Appendix J. Excluded clinical studies
- Appendix K. Excluded economic studies
- Appendix L. Cost-effectiveness analysis of interventional treatments and conservative care
- Appendix M. Network meta-analysis
- Appendix N. Research recommendations
- Appendix O. References
Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.
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- Varicose Veins in the LegsVaricose Veins in the Legs
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