Which specialist should patients with venous insufficiency be referred to?

Referral Specialist for Venous Insufficiency

Patients with venous insufficiency should be referred to a vascular specialist, which may include a vascular surgeon, interventional radiologist, interventional cardiologist, or general surgeon with specialized training in vascular disease, depending on local expertise and the severity of disease. 1

Specialist Options by Clinical Context

For Routine Venous Insufficiency Management

• Vascular specialists are the primary referral target for patients with venous insufficiency requiring evaluation beyond conservative management 1, 2
• The term "vascular specialist" encompasses multiple disciplines with appropriate training in venous disease 1
• Specific specialists include:
  • Vascular surgeons 1
  • Interventional radiologists 1
  • Interventional cardiologists 1
  • General surgeons with specialized vascular training and experience 1

When to Refer to a Vascular Specialist

Immediate/Urgent Referral Situations:

• Patients with critical limb ischemia (CLI) or acute limb symptoms who have diabetes, neuropathy, chronic renal failure, or infection represent vascular emergencies and require immediate assessment by a specialist competent in treating vascular disease 1
• Patients with skin breakdown and venous insufficiency should be referred to healthcare providers with specialized expertise in wound care 1

Routine Referral Indications:

• Severe venous disease requiring interventional therapy 3, 2
• Patients being considered for duplex ultrasonography when interventional therapy is contemplated 3
• Patients with more severe manifestations of chronic venous insufficiency (CVI) for consideration of interventional therapies 2
• Patients with prior history of CLI or successful CLI treatment should be evaluated at least twice annually by a vascular specialist due to high recurrence rates 1

Training Requirements for Vascular Specialists

The appropriate vascular specialist should have completed Level 2 training in vascular medicine, which includes 1:

• 12 months of dedicated training 1
• Outpatient vascular medicine clinic experience 1
• Inpatient vascular medicine consultation service experience 1
• Noninvasive vascular laboratory training with specific procedure volumes:
  • 100 venous ultrasounds 1
  • 100 carotid artery ultrasounds 1
  • 100 limb artery ultrasounds 1

Specialized Referrals for Complex Cases

For Nonthrombotic Iliac Vein Lesions (NIVL)

• Patients with suspected NIVL causing symptoms of chronic venous insufficiency or pelvic venous disease should be referred to specialists experienced in endovascular venous interventions 1
• These specialists should have expertise in intravascular ultrasound (IVUS) evaluation and venous stenting 1

For Post-Thrombotic Syndrome (PTS)

• Patients with severe PTS requiring endovascular or surgical venous reconstruction should be referred to centers with specific operator expertise 1
• If such expertise is not available locally, transfer to a center with these resources is recommended 1
• Outcomes of these procedures are highly dependent on surgical expertise 1

Common Pitfalls to Avoid

• Do not delay referral for patients with skin ulceration, as specialized wound care expertise is essential 1
• Avoid referring to non-vascular specialists for complex venous disease requiring intervention, as outcomes depend heavily on operator expertise 1
• Do not assume all general surgeons have adequate vascular training; confirm they have specialized experience in treating peripheral artery disease and venous disease 1
• Recognize that local availability matters: if a vascular specialist is not rapidly available, strongly consider patient transfer to a facility with such resources, particularly for urgent cases 1