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Varicose Veins NICE Guidelines CG168


National Institute for Health and Care Excellence Guidelines

Varicose veins NICE Guidelines CG168 were produced in July 2013.

What do the NICE guidelines for varicose veins say?

Varicose veins:

Who needs referral

Before the varicose veins NICE guidelines, nobody agreed on which patients needed to have their veins treated. Indeed, different NHS areas and insurance companies gave different criteria for eligibility for treatment. Now, the guidelines are clear. The following patients are recommended for referral to a “vascular service” for assessment and treatment:

Why have varicose veins NICE guidelines changed who gets treatment?

Medical research has shown several new things about varicose veins and venous leg ulcers.

  1. Patients with varicose veins who have treatment have a better quality of life after 2 years than those who have not. This was shown in the REACTIV trial. This reduced quality of life covers symptoms such as aching and pain. It also covers complications like clots or ulcers.
  2. Patients who do not have their varicose veins treated can deteriorate. About a 1 in 20 (5%) deteriorate every year. This deterioration goes varicose veins – swollen ankles – skin damage – leg ulcers.
  3. Patients with venous leg ulcers can be cured by endovenous surgery. This was shown by The Whiteley Clinic in 2013. Furthermore, treating venous leg ulcers with endovenous surgery speeds up their healing and reduces the risk that the ulcers will recur.

There are many patients with varicose veins and leg ulcers who have been turned down for surgery in the past. This has usually been for economic reasons, not medical reasons.

At The Whiteley Clinic, we have always treated patients who have varicose veins (including “hidden varicose veins“) and any symptoms or signs. Signs include brown stains, venous eczema and leg ulcers. It is very pleasing that the varicose veins NICE guidelines agree our practice since 1999.

Referral to who and where

Patients with vein problems can only be assessed adequately by seeing a doctor who specialises in veins and having a venous duplex ultrasound scan. For optimal results, vascular technologists, or someone who only does duplex scans all day every day, does these scans. The explaination for this is in the next section.

Hence the varicose veins NICE guidelines clearly say that patients need to be assessed and treated by a team of people. This has always been the case in The Whiteley Clinic.

NICE guidelines recommend referral to a “Vascular Service”. NICE CG168 defines a vascular service as:

“a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and provide a full range of treatment.”

The Whiteley Clinic has always provided such a team. Consultants assess patients and treat them, vascular scientists perform duplex ultrasound scans and nurses work in our operating theatres and outpatients. The whole team is unified by working to a strict protocol – The Whiteley Protocol. This ensures the same excellent quality of assessment and treatment by all members of the team in all clinic locations.

This is uncommon in the UK where many “vein clinics” are actually just one doctor in a room performing their own scans. This does not fit with the varicose veins NICE guidelines. Patients should be aware of such non-compliant practices.

How patients with varicose veins should be assessed

The varicose veins NICE guidelines state that venous duplex ultrasound must be used to assess the extent of the varicose veins and to plan treatment.

As pointed out above, this needs to be performed by a vascular technologist or a specialist doing only duplex ultrasound all day, every day. As popularised by Malcolm Gladwell in his book Outliers, it takes 10,000 hours to become an expert in something. Doctors who do their “own quick scan” and who also see patients and operate, do not get to the same levels of expertise in scanning.

The Whiteley Protocol has always insisted on venous duplex ultrasound scans performed by specialist vascular technologists. Furthermore, at The Whiteley Clinic, we only allow our own vascular technologists to do duplex scans, as they have all been trained in The Whiteley Protocol. We never use locums or agency vascular technologists as they do not understand our protocol and we cannot risk our excellent results from slipping.

We do not accept that doctors can perform their own scans. These are usually the doctors who still think varicose veins only occur from 2 or 3 veins. They do not understand, nor treat, incompetent perforating veins, pelvic veins, PAVA nor any or the more complex veins that we are happy to treat.

As pointed out above, NICE guidelines recommend referral to such a service – NOT to a single person with their own ultrasound machine.

What treatments are the best

Despite endovenous surgery having been introduced into the UK in March 1999 by Mark Whiteley and Judy Holdstock, it has taken until 2013 for this to become the recommended first-line treatment.

The varicose veins treatment (NICE CG168):

  1. Endothermal ablation (to be correct “endovenous” thermal ablation) ie: endovenous laser, radiofrequency ablation
    If not available or not suitable:
  2. Ultrasound-guided foam sclerotherapy
    If not available or not suitable:
  3. Stripping – open surgery 

The Whiteley Clinic was set up initially as Mark Whiteley performed the first endovenous thermal ablation in the UK. He performed this in 1999 – even though many seem to claim to be “first to do laser” or other techniques in 2001 or later!

Determined to prove the effectiveness of this new approach, Mark set up a research unit at The Whiteley Clinic. This has now shown how endovenous treatments actually work. He has shown this in laser, radiofrequency and even sclerotherapy.

Research shows that these techniques give the optimal treatments for varicose veins. However, the best results only come if the doctor knows how to change the settings for individual patients. This is a major part of The Whiteley Protocol.

Furthermore, no-one ever needs vein stripping nowadays. Not only have we shown how varicose veins grow back after stripping, we have also shown that no varicose vein is too big for endovenous laser using The Whiteley Clinic techniques.

Compression stockings are not a treatment

The guidelines state that compression hosiery (support stockings) are not a treatment for varicose veins. The only exception is if the patient refuses endovenous treatment, or is unsuitable for it.

The Whiteley Clinic has always done this, and we never recommended compression stockings as a treatment for varicose veins. However, support stockings do have many excellent uses.

Use of support stockings in veins patients:

  • After sclerotherapy to get the best cosmetic result
  • Reduce swelling before or after vein surgery
  • Patients with varicose veins / venous leg ulcers unsuitable for surgery
  • Immobile or poorly mobile patients

Therefore, no patient should be given a support stocking instead of referral for assessment and treatment. However, support stockings are essential in venous surgery. Nearly every patient needs support stocking either in the short or long term, as part of their treatment.

Varicose veins NICE guidelines - screenshot of NICE CG168 Clinical Guidelines downloaded on 27 Dec 2018

Varicose veins NICE guidelines – screenshot of NICE CG168 Clinical Guidelines downloaded on 27 Dec 2018

NICE stands for the National Institute of Health and Care Excellence. It is a national body in the UK. NICE appoints experts to use all available evidence to produce clinical guidelines. These guidelines recommend the most cost-effective investigations and treatments for patients. The NICE clinical guidelines for varicose veins are CG168.

Because NICE guidelines are based on published evidence, they do not cover cutting-edge treatments. Thus although Mark Whiteley and Judy Holdstock performed the first endovenous surgery in the UK in March 1999, these guidelines recommending it did not appear until 14 years later!

We are pleased that NICE now recommend what we at The Whiteley Clinic have been recommending for years both to doctors in research journals and to the public in newspapers. Therefore, it is not surprising that our latest cutting-edge techniques have not been approved by NICE yet! These include TRLOP to treat incompetent perforating veins and pelvic vein embolisation to treat both pelvic congestion syndrome as well as varicose veins of vulva, vagina and leg.

Summary of varicose veins NICE Guidelines (CG168)

  1. Patient with varicose veins and any symptoms need to be referred
  2. Referral to a vascular service (a team of specialists – not a doctor working by themselves)
  3. Assessment by duplex ultrasound (by a member of the team)
  4. First-line treatment is endothermal ablation, then foam sclerotherapy – only stripping if nothing else available
  5. Compression stockings are not a treatment for varicose veins or leg ulcers unless unsuitable for surgery