Varicose-vein assessment and referral

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Varicose veins are dilated, tortuous subcutaneous veins produced most often by superficial venous valve failure and ambulatory venous hypertension. Reflux may involve the great or small saphenous trunks, accessory veins, tributaries, perforators or combinations of these. Family tendency, age, pregnancy, obesity and prolonged standing affect expression, while prior deep venous thrombosis can produce secondary reflux or obstruction. The clinical task is broader than deciding whether veins look prominent: establish the symptom burden, search for chronic venous skin injury, identify thrombotic or bleeding complications, and recognise arterial, cardiac, lymphatic, neurological or musculoskeletal explanations for the same complaint.

Referral is driven by symptoms and complications rather than cosmetic appearance. NICE defines a vascular service as a team able to perform full clinical and duplex assessment and offer the range of treatments. Duplex establishes the presence and extent of truncal reflux and is used to plan intervention. When truncal reflux is confirmed, the NICE sequence is endothermal ablation, ultrasound-guided foam sclerotherapy if endothermal treatment is unsuitable, then surgery if foam is unsuitable. The consultation should prepare the patient for recurrence, possible staged treatment and the higher recurrence risk in recurrent disease; it should also avoid implying that stockings cure reflux or prevent all future veins.

Key points

Immediately refer any person with bleeding varicose veins; first control haemorrhage with elevation and firm direct pressure while assessing circulation.
Refer symptomatic primary or recurrent veins, venous skin changes, superficial vein thrombosis with suspected incompetence, an active venous ulcer unhealed for two weeks, or a healed venous ulcer.
At vascular assessment, full clinical examination and lower-limb duplex ultrasound confirm reflux anatomy and plan treatment; appearance alone cannot map truncal incompetence.
Symptoms include aching, heaviness, discomfort, swelling and itching, typically worse after standing and improved by walking or elevation, but severity correlates imperfectly with visible vein size.
Inspect standing when safe, then palpate pulses and examine oedema, pigmentation, venous eczema, lipodermatosclerosis, atrophie blanche, ulceration and scars from previous treatment or thrombosis.
Compression hosiery is not definitive treatment for ordinary varicose veins when intervention is suitable; during pregnancy it may be considered for symptom relief while intervention is usually deferred.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Primary superficial reflux

Degeneration or dilatation prevents valve leaflets meeting in superficial trunks and tributaries. Retrograde flow during standing raises distal venous pressure and progressively enlarges visible veins.

Secondary venous disease

Prior deep venous thrombosis may leave obstruction, valve damage and collateral superficial flow. Pelvic or iliac obstruction can also recruit abdominal or cross-pubic collaterals, changing treatment safety.

Predisposing influences

Age, family susceptibility, pregnancy, obesity and prolonged standing increase expression or symptom burden. These associations support assessment but do not replace an anatomical duplex diagnosis.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Valve failure
Incompetent valves permit reflux during dependency and calf-muscle relaxation, raising ambulatory venous pressure in distal superficial vessels.
2
Vein wall remodelling
Sustained pressure and altered shear promote dilatation and tortuosity, which further separates valve cusps and creates a reinforcing cycle of reflux.
3
Microcirculatory injury
Chronic hypertension increases capillary leakage, oedema and inflammatory activation, producing pigmentation, eczema, fibrosis, atrophie blanche and ultimately ulceration.
4
Calf-pump interaction
Limited ankle movement, immobility or muscle weakness reduces venous emptying. Symptoms often improve with walking or elevation because both reduce dependent venous pressure.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Typical venous symptoms

Ask about aching, heaviness, throbbing, itching, ankle swelling and fatigue, their relation to prolonged standing, and improvement with walking or elevation. Clarify effect on sleep, work, mobility and daily function rather than judging need from vein diameter.

Standing inspection

With adequate exposure, examine both legs standing when safe. Map visible trunk and tributary varicosities; note corona phlebectatica, oedema, haemosiderin pigmentation, eczema, induration, atrophie blanche, active ulceration and evidence of previous procedures.

Complication pattern

A hard tender erythematous cord suggests superficial vein thrombosis. Thin-walled ankle or foot varicosities may bleed. Gaiter-region skin change or ulceration indicates advanced chronic venous disease and strengthens the case for vascular assessment.

Whole-patient assessment

Record prior DVT or SVT, trauma, pregnancy, pelvic symptoms, previous vein treatment, mobility, occupation and family history. Examine pulses, capillary refill, oedema distribution, abdominal or groin collaterals, and signs of heart, renal or lymphatic disease.

CEAP description

Use CEAP clinical class to communicate visible severity: C2 varicose veins, C3 oedema, C4 skin change, C5 healed ulcer and C6 active ulcer. CEAP describes state; it does not by itself prove causation or measure symptom intensity.

Red flags requiring action

Active or recent bleeding from a varicose vein requires immediate vascular referral even when simple pressure has stopped the bleeding.
A suddenly swollen painful leg, chest pain, breathlessness, haemoptysis or collapse raises concern for deep vein thrombosis or pulmonary embolism and needs an urgent VTE pathway.
A hot rapidly spreading erythematous limb, fever, hypotension, severe pain or crepitus suggests cellulitis, sepsis or necrotising infection rather than uncomplicated venous disease.
Rest pain, tissue loss, a cold pale foot or absent pulses suggests limb-threatening arterial disease; do not assume swelling or ulceration is purely venous.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Full lower-limb venous duplex ultrasoundFirst step
Why
Confirm reflux or obstruction, identify affected superficial trunks and deep veins, and provide the anatomical map needed for intervention.
Interpretation and limitations
Pathological reflux in the symptomatic territory supports venous causation, but findings must be matched to symptoms and skin changes; deep obstruction and collateral function can change whether superficial ablation is safe.
02
Handheld Doppler pulse assessment and ABPI when indicated
Why
Screen for coexisting arterial disease, especially before compression is prescribed for oedema, eczema or an ulcer.
Interpretation and limitations
Normal palpable pulses do not exclude arterial disease. A low index needs arterial assessment; falsely high values can occur with incompressible calcified vessels, particularly in diabetes or renal disease.
03
Focused ulcer assessment
Why
Document site, size, depth, exudate, edge, surrounding skin and pulses when tissue breakdown is present.
Interpretation and limitations
A shallow irregular gaiter ulcer with oedema and venous skin change is compatible with venous disease, while punched-out distal lesions, rest pain or atypical sites require another diagnosis.
04
Targeted systemic investigations
Why
Investigate alternative causes only when history or examination suggests cardiac, renal, hepatic, inflammatory, malignant or pelvic disease.
Interpretation and limitations
Bilateral generalised oedema, systemic symptoms, abdominal collaterals, pelvic mass effects or discordant duplex findings should redirect investigation rather than lead to reflex superficial treatment.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Deep vein thrombosis

Acute unilateral swelling and deep tenderness can coexist with visible superficial veins; use a formal VTE pathway rather than attributing new symptoms to chronic varicosities.

Lymphoedema

Foot and toe involvement, skin thickening and reduced pitting later in disease suggest lymphatic failure, though mixed lymphatic and venous oedema is common.

Peripheral arterial disease

Exertional calf pain, rest pain, tissue loss, cool skin and diminished pulses point toward arterial disease and are particularly important before compression.

Systemic oedema

Bilateral symmetrical swelling with breathlessness, ascites or renal features suggests cardiac, hepatic or renal disease rather than isolated superficial reflux.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Initial assessmentSymptomatic visible veinsFirst stepUse when a patient reports troublesome symptoms or develops skin change around visible varicosities.

1Clarify symptom pattern, functional effect, prior thrombosis, bleeding, ulcer history, pregnancy status and previous venous procedures.
2AlternativeExamine both legs with the patient standing when safe, then assess pulses, oedema, venous skin changes, ulceration and alternative systemic causes.
3Refer to a vascular service when NICE criteria are met; explain that duplex rather than inspection alone determines anatomy and treatment suitability.
4Advise light to moderate activity, weight management where relevant, leg elevation for comfort and prompt help for bleeding, acute swelling or ulcer deterioration.

02Emergency pathwayBleeding superficial varicosityUse for active bleeding or a credible recent spontaneous bleed from a varicose vein.

1Position flat and elevate the leg above heart level, expose the site and apply uninterrupted firm direct pressure with a pad.
2EscalationAssess haemodynamic status, medication including anticoagulants, haemoglobin if significant loss is suspected, and escalate resuscitation according to clinical severity.
3DefinitiveSecure a compressive dressing after control and arrange immediate vascular referral because recurrence is possible without definitive assessment.

03Special situationVaricose veins during pregnancyUse when symptoms or visible veins arise or worsen during pregnancy without an acute thrombotic emergency.

1Explain that pregnancy can worsen venous distension and that symptoms may improve after delivery, while checking carefully for DVT or SVT features.
2Do not arrange interventional treatment during pregnancy except in exceptional circumstances; consider correctly fitted hosiery for troublesome swelling.
3Review after pregnancy if symptoms persist, skin changes occur, or intervention is desired, then use duplex-based vascular assessment.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Superficial vein thrombosis

Thrombus within an incompetent superficial vein produces a painful indurated cord and can coexist with or extend toward deep vein thrombosis.

Venous skin damage

Pigmentation, eczema and lipodermatosclerosis reflect sustained microcirculatory injury and may progress to painful recurrent ulceration in the gaiter area.

External haemorrhage

Thin-walled superficial veins, especially near the ankle or beneath fragile skin, may rupture spontaneously or after minor trauma and bleed briskly.

Recurrent disease

New reflux pathways, untreated tributaries or progressive disease can produce recurrent varicosities after intervention; recurrence is more likely after treatment of recurrent veins.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Ask whether aching, swelling, itching and activity limitation are stable, progressing or relieved by conservative measures while vascular assessment is awaited.
Re-examine skin for new eczema, pigmentation, induration, atrophie blanche, ulceration or a tender venous cord; these findings change referral priority.
After treatment, check wound sites, sensory symptoms and venous thromboembolism warning signs, and ensure the planned vascular follow-up or staged procedure is understood.
Explain that new or recurrent veins can develop; reassess recurrent symptoms clinically and with duplex rather than assuming the original reflux pattern persists.
During pregnancy, review for abrupt unilateral swelling or pain and route suspected thrombosis through an urgent pregnancy-appropriate VTE assessment.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Symptoms and size diverge

Small visible veins can cause marked aching while large veins may be minimally symptomatic. Referral decisions depend on troublesome symptoms, complications and skin injury, not a cosmetic diameter threshold.

Duplex answers an anatomical question

A standing clinical examination identifies phenotype, but duplex determines whether truncal reflux, deep disease or obstruction explains it and whether a superficial target can be treated safely.

Healed ulcers still matter

A closed ulcer is C5 disease rather than cure. NICE includes healed venous ulcer among vascular referral criteria because venous correction and ongoing prevention may reduce recurrence risk.

Bleeding needs definitive follow-up

Elevation and pressure treat the immediate event but not venous hypertension. Even apparently minor spontaneous bleeding warrants immediate referral because another episode may be severe.

Pregnancy changes timing

Intervention is generally deferred, yet evaluation should not dismiss sudden pain, a hard cord or unilateral swelling as normal pregnancy; thrombotic complications need prompt assessment.

11Common pitfallsFrequent interpretation and management errors.

01
Reassuring a patient after bleeding stops and omitting immediate vascular referral leaves the source untreated and risks recurrent haemorrhage.
02
Ordering intervention from visible-vein anatomy without duplex can miss deep obstruction, recurrent anatomy or a different source of reflux.
03
Using long-term compression hosiery as routine definitive treatment despite suitability for intervention conflicts with the NICE varicose-vein pathway.
04
Calling all leg swelling venous can miss heart failure, renal disease, lymphoedema, DVT or pelvic obstruction; examine both the limb and the patient.
05
Treating venous eczema repeatedly with topical therapy without referring the underlying chronic venous insufficiency delays causal assessment.

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