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Compression therapy for uncomplicated varicose veins – Too little for too much?

Varicose veins are common, affecting approximately 40% of men and 32% of women. The results of the National Venous Screening Program report that, in the evaluated population of patients, 23% had uncomplicated varicose veins (clinical-etiology-anatomy-pathophysiology classification [CEAP C2]) and 21% suffered from a more advanced form of chronic venous disease (CEAP C3-6). The rate of disease progression is difficult to establish in light of the heterogeneity of available longitudinal studies exploring this question, particularly with respect to study methodology and outcomes. Nonetheless, there is some evidence to suggest that uncomplicated varicose veins of saphenous origin are at higher risk of progressing to more advanced stages of chronic venous disease, as defined by the CEAP classification, compared to nonsaphenous varicose veins. The Bonn Vein Study estimated the annual progression rate for patients with uncomplicated varicose veins of saphenous origin at approximately 4%. Varicose veins result in loss of work days, disability and significant impairment in quality of life. Studies have shown that treatment of symptomatic varicose veins is cost-effective. In a randomised controlled study comparing conservative management to surgery among patients with uncomplicated varicose veins, the incremental cost per quality-adjusted life year (QALY) for surgery was £4682 with a 70% chance of being costeffective at the National Institute for Health and Care Excellence (NICE) threshold of £20,000 per QALY. Cost-effectiveness has also been demonstrated for minimally invasive techniques. Despite evidence for cost effectiveness, treatment provision by healthcare funders is often influenced by perceived treatment costs, namely the cost of the intervention. This can have a direct impact, for example restricting funding solely for the treatment of more advanced disease classes, such as venous ulceration or in the presence of bleeding varicosities. This was the case in England prior to the 2013 NICE guidance implementation, when treatment for uncomplicated varicose veins was not routinely recommended. This period was associated with a potential reduction in annual varicose veins procedures of 34% between 1998 and 2008. Despite a more proactive approach advocated by the latest NICE guidance recommending interventional treatment of symptomatic C2 disease, there is evidence that interventional therapy is not always implemented by individual clinical commissioning groups (CCGs), resulting in differences in the management of primary varicose vein disease across the UK. Limited evidence for compression in uncomplicated C2 disease exists, with current Society for Vascular Surgery/American Venous Forum, European and NICE guidance recommending its use only when interventional treatment is not suitable or in pregnancy; despite this, in many places compression therapy remains a common first management option. Its non-invasive nature and lower perceived cost compared to interventional treatment (estimated annual cost per person of £182/$225), combined with positive physiological and haemodynamic effects (including enhancing venous return, lymphatic drainage and improving tissue oxygenation) make them a safe conservative option. However, not all is as it seems; compression stockings, despite being non-invasive in nature, may cause significant complications, including contact dermatitis, pressure necrosis and impaired lower limb perfusion. Despite the true incidence of these adverse effects being uncertain, a survey study of Scottish surgeons reported 73 cases over a five-year period. Undesirable appearance, difficult application (particularly in the elderly) and excessive heat production have all been suggested to lead to an estimated noncompliance rate of up to 65%. This results in poor outcomes and raises questions regarding their longerterm cost-effectiveness in this cohort of patients. Compression therapy improves venous ulcer healing; however, the lack of consensus regarding its use