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Varicose Veins and Venous Leg Ulcers

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Checked: 01-05-2024 by Vicky Ryan Next Review: 30-04-2026

Overview

Varicose Veins

Please see the CKS guidelines for advice on management: Varicose Veins

The BNSSG ICB varicose vein surgery policy was updated in May 2024 to bring into line with these guidelines.

Varicose Veins Surgery Criteria Based Access & Prior Approval Policy

Leg Ulcer

For further advice on management of leg ulcers see the Leg Ulcer page.

Before Referral

Before Referral - please consider the Referral Criteria as stated in the policy and as below:

Criteria Based Access:

1. A venous ulcer (a break in the skin below the knee that has not healed within 2
weeks).
OR

2. Recurrent venous ulceration of the lower limb*

* Patients with persistent or recurrent venous leg ulcers should be managed conservatively in primary care initially. If persistent leg ulcers do not respond to treatment after 6 months, or if there are 2 or more episodes of recurrence of venous ulceration within a 12 month period, then refer for consideration of varicose vein surgery.

Prior Approval:

Severe changes of the lower limb including:

External bleeding from a varicosity that has eroded the skin and is at risk of
recurring as evidenced within the Primary Care Records.
OR
Superficial vein thrombosis (characterised by the appearance of hard, painful
veins) AND suspected venous incompetence as evidenced within the Primary Care Records.
OR
Recurrent superficial thrombophlebitis as evidenced within the Primary Care
Records.

If Referral is not indicated

If criteria for referral are not met, offer compression stockings (after excluding arterial insufficiency). Please see the Hosiery page for advice on the use of compression stockings

If the person is pregnant

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. 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.

Advise the person to seek further medical help if:

Veins are hard or painful.
There are skin changes (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.

Red Flags

Chronic leg ulceration may also be caused by skin cancer. If malignant change in an ulcer is suspected then refer to dermatology 2WW pathway

Patients with infected diabetic foot ulcers should be referred immediately to the Vascular Hot Clinic.

Referral

Criteria Based Access Referrals

If a patient with varicose veins meets the criteria for referral with the CBA section of the policy then a referral can be made via eRS - please state clearly how criteria have been met.

Prior Approval Referrals

If a patient with varicose veins does not have features that meet the criteria in the CBA section of the policy but is eligible for referral via the prior approval route, then the PA form should be submitted at the same time as a referral. The PA application will be reviewed by the Referral Service and if adequate evidence has been supplied to support the application this will be forwarded on to the vascular service as below

Vascular referrals are sent via eRS to the Vascular Surgery RAS. Clinics are held in Southmead, BRI, WGH & Bath RUH. Referrals will be triaged on a daily basis by the vascular team and booked into appropriate clinics. Please include all relevant clinical and contact details in referrals to help facilitate the triage process.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.