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Varicose Veins NICE Guidelines

National Institute for Health and Care Excellence Guidelines


We are delighted to see that the varicose veins NICE guidelines, issued in July 2013, mirror what The Whiteley Clinic has been both teaching and providing for the last decade.

So what are the essentials of the varicose veins NICE Guidelines?

1) A vascular service

First and foremost, the varicose veins NICE guidelines 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 with expert consultants to assess patients and treat them, vascular scientists performing duplex ultrasound scans both of legs and pelvis as required and nurses within our theatre space and outpatients. All of our team are within The Whiteley Clinic working and coordinating as one unit.

This is uncommon in the UK where many “vein clinics” are actually just one doctor in a room performing their own scans – which does not now fit with the new varicose veins NICE guidelines as to who patients with varicose veins should be referred to.


2) Who should be referred for varicose vein assessment and treatment?

Contrary to what the NHS and many insurance companies have said before, the new NICE guidelines have recommended that all of the following people should be referred to a vascular service for assessment and treatment:

  • symptomatic primary or symptomatic recurrent varicose veins – symptomatic is defined as “veins found in association with troublesome lower limb symptoms (typically pain, aching, discomfort, swelling, venous and itching)
  • patients with skin changes thought to be caused by varicose veins such as skin discolouration or venous eczema
  • superficial vein thrombosis (often called superficial thrombophlebitis or just “phlebitis”) thought to have hidden varicose veins (medically called “venous incompetence”)
  • a venous leg ulcer
  • a healed venous leg ulcer

There will be very large numbers of patients who will previously have been prevented from referral for assessment and treatment of their varicose veins or “hidden varicose veins” who will now be able to insist on referral thanks to the new NICE guidelines. Once again, The Whiteley Clinic has always recommended treating such patients as soon as possible to prevent further deterioration.

 


3) Assessment of varicose veins in a vascular service

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

The Whiteley Clinic has always insisted on this despite many doctors maintaining, particularly in the late 1990s and early 2000’s that one could be assessed with a hand held Doppler only!

All patients attending The Whiteley Clinic always have a duplex ultrasound scan performed by a specialist vascular scientist trained to The Whiteley Protocol® standards.

We do not accept that doctors can perform their own scans as it is always been our contention that you need to be performing the scans all day every day to be the standard that we require at The Whiteley Clinic. As has been pointed out in the first section above, NICE recommends referral to such a multidisciplinary practice and not to a single person with their own ultrasound machine.


4) Interventional treatments for varicose veins

At long last, NICE has agreed with what has been promoted for a decade by The Whiteley Clinic – that the first line of treatment should be “endothermal ablation” (although they really mean endovenous thermal ablation) such as endovenous laser ablation (EVLA) and radiofrequency ablation (RFA).

As the whole of The Whiteley Clinic’s research and development was based upon the priority that Mark Whiteley achieved, when he performed the United Kingdom’s first endovenous thermoablation for varicose veins on 12 March 1999, ever since that date but he and The Whiteley Clinic have been trying to convince the rest of the venous world and the public on how much better endovenous thermoablation is then stripping.

For those veins not suitable for endovenous thermoablation, ultrasound guided foam sclerotherapy is recommended.

Surgery is only recommended if neither endovenous thermoablation or foam sclerotherapy is suitable – which should never be the case. Over the last decade, so called “experts” have continued to state that surgery can still be used if endovenous thermoablation goes wrong! As The Whiteley Clinic has always said, it is completely the other way round. Endovenous thermoablation and foam sclerotherapy are used to put right the problems caused by stripping.


5) Compression stockings should not be used to treat varicose veins

The varicose veins NICE guidelines state that compression hosiery (support stockings) should not be offered to treat varicose veins and less interventional treatment is unsuitable.

The Whiteley Clinic has never recommended compression stockings as a treatment for varicose veins and indeed has supported many patients whose general practitioners or private medical insurance companies have insisted on a trial of support stockings before referral. Thanks to NICE, no patient should be fobbed off any more by being given compression stockings before a referral to a vascular service to have their veins treated.


Summary of Varicose Veins NICE Guidelines:

Since bringing endovenous surgery into the UK in March 1999, Mark Whiteley and then subsequently The Whiteley Clinic have both been and have stayed at the forefront of varicose vein research and treatment.

Despite many years of fighting against opinion of the time, it has come as a great relief that NICE has now produced guidelines that echo all the messages that The Whiteley Clinic have been producing over the last decade.

Of course The Whiteley Clinic has continued with more research into varicose veins and varicose vein treatments, including perforator vein physiology and treatment and pelvic vein of physiology and treatments. It is highly likely that in another decade these will also be passed by NICE … Although it would be nice to think that these areas developed by The Whiteley Clinic pass quicker into everyday clinical practice.

Read the full guidelines here »