Varicose Veins and the CEAP Classification: What Every GP Should Know

In a fragile patient, angioplasty is best avoided below the knee — it gives reasonable short-term results but nothing very promising long-term. If intervention is genuinely needed, it is more often approached surgically, favouring a reverse femoro-tibial bypass using the patient's own saphenous vein over a prosthetic graft, and favouring open surgery over an endovascular approach in this territory. Below the knee: use the simpler, older, better-proven option, and know when not to intervene at all.

It is a vascular disease, but the vascular problem is not what is causing the pain in this elderly lady — and if medicines can manage the condition, there is no need to intervene, even if that is commercially a loss rather than a win. There has been a silent shift from a doctor-patient relationship to a doctor-hospital relationship, where a patient's data no longer stays with the treating doctor once they change hospitals. Old-school medicine — operating only when needed, never when not needed — is what should endure through that change.

Never confuse varicose veins with cellulitis and simply give a course of antibiotics to send the patient away — that is the wrongest possible thing to do, and it is not a constructed scenario. This happens regularly in real-life GP clinics, and any swollen leg deserves at least a Doppler ultrasound before it is written off as a skin infection.

Out of roughly 25 healthcare facilitators sending referrals, only one or two send a report in a structured format. A recent case arrived with mismatched patient names, ages and even genders across different files for what turned out to be the same patient — a PDF here, a broken image file there, no consolidated record. I would rather give no advice than wrong advice built on poorly collated information.

Absolutely, yes — particularly if the D-dimer is done after the acute phase, in a subacute presentation of a few days. Despite the test's high sensitivity, the result can come back in the low hundreds, nowhere near diagnostic. DVT is an anatomical problem, and for an anatomical problem the answer is to see it directly on ultrasound, not infer it from a blood marker. Vascular ultrasound is learnable within three to four months, and we train nearly all our trainees to do it routinely.

A grading system running from C0 to C6 that determines the management pathway, from no visible disease through to active venous ulceration.

Often, yes. Photographs and a Doppler report can be enough to recommend compression stockings or medication remotely, sparing the patient a trip abroad for what remains a non-invasive treatment.

Standing, lying down, and lying down while performing a Valsalva manoeuvre. A saphenofemoral junction that looks entirely normal at rest can reveal clear regurgitation only once the afterload increases during the Valsalva.

Dismissing it as cellulitis and prescribing antibiotics. A swollen leg deserves at least a Doppler ultrasound of the deep veins, since the underlying cause could be an acute deep vein thrombosis rather than a skin infection.