Title: Surgery for Varicose Veins in the legs

Item 16.120ciii The Clinical Commissioning Groups for Great Yarmouth and Waveney, North Norfolk, Norwich, South Norfolk and West Norfolk, supported b...
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Item 16.120ciii

The Clinical Commissioning Groups for Great Yarmouth and Waveney, North Norfolk, Norwich, South Norfolk and West Norfolk, supported by North East London Commissioning Support Unit

Title: Surgery for Varicose Veins in the legs Date: 2016-07-26

Great Yarmouth and Waveney CCG North Norfolk CCG Norwich CCG South Norfolk CCG West Norfolk CCG

Please check the Knowledge Anglia website http://nww.knowledgeanglia.nhs.uk/ for the latest version of this policy.

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Item 16.120ciii

Implementation date:

Prepared by:

Review date:

Norfolk and Waveney Clinical Policy Development Group (CPDG)

Approved by: CCG Great Yarmouth and Waveney CCG North Norfolk CCG Norwich CCG South Norfolk CCG West Norfolk CCG

Date approved

Variance

Version Control

Version

Section/Para/ Appendix

Version Control Sheet Description of Amendments

Date

Amended by

Equality Statement The CCGs and the CPDG are committed to ensuring equality of access and non-discrimination as enshrined in the Health and Social Care Act 2012. In carrying out its functions, the CPDG will have due regard to the different needs of protected equality groups, in line with the Equality Act 2010. This document is compliant with the NHS Constitution and the Human Rights Act 1998. Clinical Governance statement It is important that the implementation of this policy is seen as an opportunity to encourage team working and cooperation between commissioners, primary and secondary care providers. Service Providers will be expected to collect and provide audit data on request as part of a professionally-led clinical review and audit cycle. Exceptionality For patients not meeting the policy criteria or where a treatment is not routinely funded, an application should be made to the Individual Funding Request (IFR) panel if the referrer considers that there are clinically exceptional circumstances. IFR policy and procedure documents can be found on Knowledge Anglia.

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Item 16.120ciii

Policy Statement Title/topic:

Surgery for varicose veins in the legs

Status:

Prior Approval

Norfolk and Waveney CCGs will fund Surgery for varicose veins in the legs if the following criteria are met:    

Venous ulceration or; Recurrent thrombophlebitis or; Bleeding or; Large varicose veins causing significant symptoms

Note: only those patients with symptoms and demonstrable long or short saphenous incompetence, as assessed by venous ultrasound will be considered for surgery (Group Approval). Severe varicose veins associated with one of the following should be referred as a matter of urgency:  Bleeding from a varicosity that has eroded the skin.  Past bleeding and risk of re-bleeding.

Policy Exceptions: 

Do not carry out interventional treatment for varicose veins during pregnancy other than in exceptional circumstances.

CCG Variation:

Clinical Codes for audit/monitoring

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Item 16.120ciii Evidence Summary Literature searches of Medline were performed to provide an update on those published since searches done for the recent NICE guideline. No high quality evidence was demonstrated which supported a departure from the recently published NICE guideline on Varicose Veins in the Legs (for evidence review see briefing paper, available on request). In view of the high number of people with varicose veins in Norfolk, until all of the stages of the NICE pathway are available locally, patients should continue to be referred using the criteria listed above. Surgical Intervention/Management The updated NICE guidance recommends that after clinical assessment and the use of duplex ultrasound to confirm the diagnosis of varicose veins and the extent of truncal reflux, patients should be offered an intervention, in the following order: endothermal ablation, foam sclerotherapy, surgery (stripping). The final decision about which intervention to offer should be based on clinical judgement. Conservative management Conservative management for patients with mild symptoms should include advice on:  Walking and exercise;  Avoidance of activities that exacerbate symptoms, for example, prolonged sitting or standing;  Elevation of the legs when sitting down to increase venous return;  Losing weight Compression Hosiery Compression hosiery has been widely used as first line treatment for varicose veins as a precursor to secondary care referral; however NICE have assessed the evidence for benefit as being weak, with many people finding compression stockings uncomfortable and difficult to put on. Compression hosiery for symptomatic varicose veins should therefore not be offered if interventional treatment is not suitable or is declined by the patient. Management during pregnancy  Give pregnant women presenting with varicose veins information on the effect of pregnancy on varicose veins.  Do not carry out interventional treatment for varicose veins during pregnancy other than in exceptional circumstances.  Consider compression hosiery for symptom relief of leg swelling associated with varicose veins during pregnancy.

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Item 16.120ciii References NICE (2013) Varicose veins: diagnosis and management, guideline CG168 http://guidance.nice.org.uk/CG168 NICE (2014) Varicose veins in the legs Quality Standard QS67 https://www.nice.org.uk/guidance/qs67 Nesbitt C, Bedenis R, Bhattacharya V, Stansby G (2014) Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD005624. Shingler S, Robertson L, Boghossian S, Stewart M (2011) Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. Cochrane Database of Systematic Reviews 2011, Issue 11. Art No.:CD008819

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