Varicose Veins / Venous Disease - Adult CPC

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the Vascular Registrar on call 24 hours a day, 7 days a week.

For patients who are unstable and require immediate assessment, please refer to the ‘Referral to emergency’ section.

Central Adelaide Local Health Network

• Royal Adelaide Hospital (08) 7074 0000

Northern Adelaide Local Health Network 

• Royal Adelaide Hospital (08) 7074 0000
  

Southern Adelaide Local Health Network

• Flinders Medical Centre (08) 8204 5511

Exclusions

• cosmetic varicose veins
• CEAP (Clinical Manifestations, Etiology, Anatomic Distribution, Pathophysiology) classification C0, C1 or C2; that is venous disease with these clinical characteristics:
  
  • no visible or palpable veins
    
  • telangiectasia (spider veins) or reticular veins
    
  • varicose veins without skin changes or current/previous ulceration
    
• varicose veins with oedema, CEAP classification C3, unless alternative aetiologies including sleep apnea, medication-induced oedema, and congestive cardiac failure have been excluded
  
• lymphoedema / lipedema without ulceration
  
• patients with nonulcerative skin changes and body mass index (BMI) ≥ 46
  
• patients with a BMI > 40 not actively engaged in an active weight management plan
  
• patients seeking compression hosiery alone should be referred to specialist allied health lymphoedema services or private providers
  
• for further information regarding alternative treatment pathways please refer to HealthPathways SA.
  

Triage categories

Please be aware your patient may be assessed and managed in a nurse led clinic

Category 1 - appointment clinically indicated within 30 days

• haemorrhage from varicose veins

Category 2 – appointment clinically indicated within 90 days

• venous leg ulceration, CEAP C6, unresponsive to current management

Category 3 — appointment clinically indicated within 365 days

• chronic venous disease with CEAP classification C3 to C5 manifesting as:
  
  • oedema, pigmentation/eczema, lipodermatosclerosis/atrophie blanche, corona
    phlebectatica, or active/healed ulcers and BMI < 46 kg/m2
    
    • for patients with oedema, CEAP 3, alternative aetiologies, including but not limited to sleep apnoea, medication-induced oedema, and congestive cardiac failure, should be excluded prior to referral to vascular
      
• post thrombotic syndrome
  
• previous ulceration
  
• history of ultrasound proven superficial thrombophlebitis 

Vascular outpatient services accept statewide e-Referrals. For information on e-Referral forms and how to import them, or to download referral forms, please view general referral information.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

• CEAP (Clinical Manifestations, Etiology, Anatomic Distribution, Pathophysiology) classification score
  
• symptoms
  
• description of oedema and investigation results performed for alternative causes
  
• current and previous imaging results including location of imaging provider
  
• previous intervention for venous disease, including previous surgery and use of compression therapy
  
• body mass index (BMI)
  
• complete past medical history
  
• current medication list
  
• smoking status - if active smoker, strongly consider referral for smoking cessation
• identifies as Aboriginal and/or Torres Strait Islander
  
• identify within your referral if you feel your patient is from a vulnerable population and/or requires a third party to receive correspondence on their behalf
  
• interpreter requirements
  

Additional information to assist triage categorisation

• complete blood examination (CBE)
• urea, electrolytes and creatinine (UEC)
  
• liver function tests (LFT)
• estimated glomerular filtration rate (eGFR)
• glycated haemoglobin test (HbA1c)
• ankle brachial pressure index (ABPI)
• clinically infected wounds - swab microscopy/culture/sensitivity
• if wound present, histology results if previously completed

CEAP classification system

Clinical Manifestations, Etiology, Anatomic Distribution, Pathophysiology (CEAP)

Clinical management advice

For patients who are unstable and require immediate assessment, please refer to the 'Referral to emergency' section.

Medical Grade Compression Stockings & Velcro Wraps

Medical Grade Compression may be prescribed and help with:

• pain from varicose veins
  
• post operative varicose vein surgery, as required
  
• oedema of the lower limb
  
• post thrombotic syndrome
  
• lipodermatosclerosis
  
• lymphoedema - see SA Lymphoedema Compression Garment Subsidy Scheme

There are a variety of different brands, sizes/lengths, open/closed toes and compression strengths available in stores and online which can make it difficult to find the right one.

To ensure the correct garment, size and fit along with education with don/doffing and washing and care, it is important to be measured and fitted by someone who is trained to do so. There are a variety of aids available to purchase to help with application of garments as required.

To make sure compression is appropriate and will not cause harm, a prescription is required from a clinician for:

• moderate compression up to 20 to 30 mmHg at the ankle (Class II)
  
• high compression 30 to 40 mmHg at the ankle (Class III)

If you require custom fit made to measure medical grade compression garments, it is best to source a clinician trained specifically in this on the Australasian Lymphology Association website.
Some public clinics may not accept referrals for people without a diagnosis of lymphoedema or phlebolymphoedema from a GP.

Good skin hygiene and skin care is important when wearing medical grade compression. Some creams and ointments can damage your garments or leave stains. To extend the life of garments it is vital to:

• take note of the manufacturer’s washing and drying instructions
  
• safely put on and remove garments
  
• keep toe and fingernails trimmed so as not to tear the garment
  
• replace garments regularly to ensure they don’t lose their elasticity

The following are quality brands that you may consider when sourcing medical grade compression garments:

Clinical resources

• HealthPathways SA, login required
  
• Royal Australian College of General Practitioners - Smoking Cessation
  
• European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis
  

Consumer resources

• Australian and New Zealand Society for Vascular Surgery - Venous disease and varicose vein consumer information
  
• Be smoke free SA
  
• Australasian Lymphology Association, for sourcing trained clinicians to assist with compression garment prescription and fitting
  
• SA Lymphoedema Compression Garment Subsidy Scheme

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

• full name, including aliases
• date of birth
• residential and postal address
• telephone contact number/s – home, mobile and alternative
• Medicare number, where eligible
• name of the parent or caregiver, if appropriate
• preferred language and interpreter requirements
• identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

• impact on employment
• impact on education
• impact on home
• impact on activities of daily living
• impact on ability to care for others
• impact on personal frailty or safety
• identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery, where surgery is a likely intervention.
• Choice to be treated as a public or private patient.
• Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.