When should a patient with varicose veins be referred to a vascular (VASC) surgeon?

When to Refer Patients with Varicose Veins to a Vascular Surgeon

Patients with varicose veins should be referred to a vascular surgeon when they have symptomatic varicose veins with documented reflux, signs of more serious vascular insufficiency, or when conservative measures have failed to provide relief. 1, 2

Indications for Vascular Surgery Referral

Symptoms and Clinical Presentation

• Symptomatic varicose veins with:
  • Pain, aching, burning, heaviness, cramping, throbbing
  • Symptoms worsening at end of day or after prolonged standing
  • Swelling in legs that resolves with elevation
  • Symptoms affecting quality of life or daily activities 1

Physical Examination Findings

• Signs of advanced venous disease (CEAP classification C3-C6):
  • Changes in skin pigmentation (hemosiderin staining)
  • Venous eczema
  • Lipodermatosclerosis (hardening of skin and subcutaneous tissues)
  • Superficial thrombophlebitis
  • Venous ulceration (active or healed)
  • Loss of subcutaneous tissue 1

Diagnostic Findings

• Documented venous reflux on duplex ultrasonography 2
• Venous Clinical Severity Score (VCSS) of 10 or higher 2
• Vein diameter >4.5mm with reflux (particularly in Great Saphenous Vein or Small Saphenous Vein) 2

Referral Algorithm

1. Initial Assessment:

   • Classify using CEAP system (Clinical, Etiologic, Anatomic, Pathophysiologic)
   • Document symptoms and their impact on quality of life
   • Assess for complications or advanced disease

2. Conservative Management Trial (unless advanced disease present):

   • 20-30 mmHg compression stockings
   • Leg elevation
   • Weight management if applicable
   • Exercise and avoiding prolonged standing 2

3. Immediate Referral if:

   • Active venous ulceration (C6)
   • Healed venous ulcer (C5)
   • Lipodermatosclerosis or atrophie blanche (C4b)
   • History of superficial thrombophlebitis
   • External hemorrhage from varicose vein 1

4. Referral After Conservative Management (3 months) if:

   • Persistent symptoms despite compression therapy
   • Documented reflux on venous duplex ultrasound
   • Significant impact on quality of life 1, 2

Important Considerations

Diagnostic Testing

• Venous duplex ultrasonography is the modality of choice when interventional therapy is being considered 1
• Ultrasound should be performed in the erect position by a specialist trained in ultrasonography 3

Treatment Options After Referral

• Endovenous thermal ablation (first-line for saphenous vein incompetence)
• Sclerotherapy (for smaller veins)
• Surgical options (microphlebectomy/stab phlebectomy)
• Radiofrequency ablation 2

Potential Complications Without Treatment

• Progressive worsening of symptoms
• Development of venous ulcers
• Superficial thrombophlebitis
• Rare but significant external hemorrhage 1

Common Pitfalls to Avoid

• Delaying referral for symptomatic patients with documented reflux
• Prolonged conservative management without offering interventional treatment when indicated
• Focusing only on cosmetic concerns while missing signs of underlying venous insufficiency
• Failing to obtain venous duplex ultrasound before deciding on treatment approach 1, 2

Current evidence suggests that referral for interventional treatment of symptomatic varicose veins should not be delayed for extended trials of external compression when valvular reflux is documented 1. Early referral can prevent progression to more advanced stages of venous disease and improve quality of life.