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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Chronic venous insufficiency and varicose veins

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Active bleeding from a varicose vein needs immediate elevation and firm direct pressure, urgent medical assessment and referral to a vascular service; haemodynamic compromise requires emergency resuscitation.

Synopsis

Recognise venous hypertension complications, refer according to NICE criteria and sequence duplex-guided intervention correctly.

  • Varicose veins are dilated tortuous superficial veins caused by venous reflux; chronic venous insufficiency describes the oedema, skin change and ulceration produced by sustained venous hypertension.
  • Refer immediately for bleeding varicose veins.
  • Refer symptomatic primary or recurrent varicose veins, venous skin changes, superficial vein thrombosis with suspected incompetence, a venous ulcer unhealed after 2 weeks or a healed venous ulcer.
  • A vascular service uses duplex ultrasound to confirm truncal reflux, map anatomy and plan treatment.
  • For confirmed truncal reflux, NICE treatment order is endothermal ablation, then ultrasound-guided foam sclerotherapy if unsuitable, then surgery if foam is unsuitable.
  • Do not offer compression hosiery as definitive treatment for varicose veins unless intervention is unsuitable; hosiery may still relieve symptoms or manage oedema/ulcer risk in selected patients.
  • During pregnancy, do not perform interventional treatment except in exceptional circumstances; compression hosiery may be used for symptom relief.
  • Unilateral sudden swelling or pain requires DVT assessment rather than being attributed automatically to chronic venous disease.

Key red flags

Bleeding varicosity

External bleeding can be brisk from a small skin breach, especially with dependency; elevate, apply firm direct pressure and refer immediately.

Acute thrombotic mimic/complication

A tender cord suggests SVT; sudden diffuse unilateral swelling, deep pain or PE symptoms require urgent DVT/PE assessment.

Investigation priorities

01
Lower-limb venous duplex ultrasoundFirst step

Confirm diagnosis, define truncal reflux and plan intervention.

Management branches

bleedingBleeding varicose vein

Active or recent spontaneous bleeding from a varicosity.

  1. First: lie the patient down, elevate the limb above heart level and apply firm direct pressure with a pad until bleeding stops.
  2. Next: assess haemodynamics, haemoglobin and anticoagulant use; resuscitate and transfer urgently if bleeding is ongoing or significant.
  3. Next: refer immediately to a vascular service even after haemostasis because rebleeding risk persists.
  4. Escalation: urgent duplex and definitive ablation/sclerotherapy of the reflux source according to the vascular team.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG168: Varicose veins—recommendationsReferral criteria, duplex and treatment sequence.
  • NICE CKS: Compression stockingsCompression assessment and safe use.
  • NHS: Varicose veinsSymptoms, complications and patient advice.
  • NICE NG158: Venous thromboembolic diseasesAcute DVT pathway for sudden unilateral swelling.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom