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Chronic Venous Insufficiency, Varicose Veins and Venous ulcers

NICE CKS Varicose Veins. Last revised Sep 2024. NICE CKS Venous leg ulcer. Last revised Oct 2024.

Background Information

  • Chronic venous insufficiency: functional changes that occurs due to persistent venous hypertension.
Varicose veins and venous leg ulcer can occur secondary to chronic venous insufficiency.
  • Varicose veins: dilated tortuous superficial veins (most commonly found in the lower limb)
  • Venous leg ulcer: break in the skin which has not healed within 2 weeks, in the presence of venous disease

Symptoms of chronic venous disease:
  • Pain / itching / aching / swelling of the affected leg
  • Discomfort after prolonged standing + relieved with leg elevation
  • Restless leg and leg crams (usually nocturnal)
On examination:
  • Varicose veins (dilated >/=3 mm in upright position)
  • Brown-red hyperpigmentation 
    Venous eczema 
  • Lipodermatosclerosis 
  • Atrophie blanche
  • Venous ulcers

Site: gaiter area (ankle to mid-calf), most commonly the medial malleolus:
  • No pain, or mild pain relieved by elevation
  • Irregularly shaped
  • Shallow base
  • Presence of granulation tissue and exudate
Arterial ulcers:
  • More painful
  • Located at pressure point (heels, toes)
  • Regularly shaped deep punched out lesion
Neuropathic ulcer
  • Completely painless
  • Located at pressure points
  • Associated with diabetic neuropathy

Varicose Veins Guidelines

Referral criteria:
  • CVI symptoms 
  • CVI skin changes
  • Superficial vein thrombosis
  • Active / healed venous leg ulcer
  • Bleeding varicose vein
If referral criteria met → refer to vascular service to consider interventional treatment
If referral criteria not met → manage in primary care
  • Lifestyle advise, AND
    • If overweight / obese → weight loss
    • Engage in light to moderate physical activity
    • Avoid exacerbating factors (e.g. prolonged standing / sitting)
    • Elevate legs when possible
  • Compression, stockings,  if arterial insufficiency is excluded 

Varicose veins are common and physiological in pregnancy, they often improve after pregnancy.

1st line: duplex US to confirm diagnosis and plan treatment.

Interventional treatment options:
  • Surgical ligation and stripping of affected vein 
  • Endothermal ablation- radiofreqeuncy or endovenous laser
  • Foam sclerotherapy 
  • Cyanoacrylate glue bio-adhesive occlusion

Leg Venous Ulcer Guidelines

All patients:
  • Wound management by district nurse / tissue viability nurse
    • Wash affected leg normally in tap water and dry carefully
    • Apply simple non-adherent dressings
  • High compression multicomponent bandaging, if arterial insufficiency is excluded
    • Offer the strongest compression that they can tolerate
    • Assess for skin complications within 24-48 hours of initiation
Consider pentoxifylline as an adjunct to aid ulcer healing.

  • Lifestyle advises
    • Encourage compliant with compression therapy
    • Keep mobile with regular walking
    • Elevate legs when possible
    • Avoid trauma and wear well-fitting footwear
    • Examine legs regularly for broken skin, blisters, sweeling, redness
  • Below-knee graduated compression stockings
  • Replace compression stocking every 3-6 months
  • Repeat Doppler US every 6-12 months

Original guidelines

Author: Adams L
Editor:
Reviewer: