Events

Vicky

Once again, good evening. Welcome to our session on varicose veins, EVLT and ThermaVein treatment. My name is Vicky, and I’m hosting this session. I’m delighted to be joined by our expert speakers, Mr Aaron Sweeney, Consultant Vascular Surgeon, and Dr George Taggart, Private GP, and thread vein specialist.

Tonight’s session will begin with a presentation from Mr Sweeney and Dr Taggart, followed by a live Q&A session. If you have questions at any point, please do feel free to submit them using the Q&A icon at the bottom of your screen.

You are welcome to ask anonymously or include your name, but just a quick note that as the session is being recorded, any names shared may be visible in the recording. To help us get through as many questions as possible, we’d ask that you please keep your questions as brief as possible.

If you’re interested in booking a consultation, we’ll share all the relevant contact details at the end of the session. So I’m just going to hand over to Mr Sweeney to present.

Mr Aaron Sweeney

Hello, thanks very much for joining us.

This is just a little picture of me and a little bit about me. So I qualified quite a while ago over in Dublin and came here a couple of years after that, and I was appointed as a surgeon up in central London in 2002.

My main interest always has been varicose veins. Even as a junior doctor, I was there when they first started lasering veins up at University College London, which I think was around 2000.

I, along with my old friend and colleague, Eddie Challener, brought it to the NHS in London, and we did thousands and thousands when we were able to at the NHS for many years.

I’ve been here at Benenden Hospital for over a decade now, and we perform somewhere in the region of a thousand veins here per year, which means we’re a pretty high‑output unit. I think we do the largest number of laser vein treatments in the country and have done that for a decade or so. So hopefully you can be reassured that we know what we’re doing.

Dr George Taggart

Good evening. My name is George Taggart.

I qualified in medicine in 1991 at St Thomas’ Hospital in London and qualified as a GP in 1997. I’ve been a GP partner in the NHS in East Sussex since 1999.

I developed a special interest in the treatment of thread veins back in 2017, about ten years ago, and have been working in that field ever since, and I joined Mr Sweeney here at Benenden Hospital two years ago.

Mr Aaron Sweeney

So we’re just going to run through the various things that are available. I was going to talk a smidgen about varicose veins and just give you an idea of what they are, what happens if you want a consultation, and what treatments are available.

I’m also going to talk about smaller cosmetic thread veins and the various treatments that are pretty effective and available.

The really good part of this webinar is the Q&A session at the end, because I think a lot of people already know what they want to ask, and we encourage that because it often brings on new questions, and things you never thought about are often asked, and it gives you a decent bit of information.

Just to let you know that here at Benenden Hospital they’ve got a CQC rating of Outstanding, which is pretty exceptional. It just means that it’s a clean, nice environment where people do things correctly.

So what are varicose veins? Well, I think most of us have seen big chunky things on people’s legs or swollen or sore legs or remember their granny or their mother having loads of grief from varicose veins.

I’ll tell you that they’re often visible, but sometimes they’re not. And if you want to think about what veins are, you have an artery that brings blood down your leg, and then you have a vein that takes it back up again. The main vein that does that is called your deep vein.

It’s a big thing, about the size of your thumb, and if you’re doing exercise, it can easily drain a litre of blood per minute.

I think it’s helpful to think of veins like a Christmas tree. You’ve got a very large central trunk and then you’ve got branches going in. Those bigger branches are nearly always draining muscle, so they have a little bit of muscle on the outside squeezing the blood and getting it going uphill.

And then you have loads of little, small veins which are draining the skin. There are hundreds and hundreds of these, normally less than the size of a shoelace, normally draining maybe a teaspoon of blood per minute.

Perhaps a million years ago, when we were walking on all fours, they were drinking happily. But because we’ve decided to stand upright, they’re going straight up, they’re vertical, they’re not surrounded by any muscle, and they rely on little flimsy valves to keep everything going in the right direction.

So if they don’t work properly, you sometimes end up with swelling, cramp, blue or large veins visible. But often the skin gets a bit of a rough time because it’s trying to drain old blood. The veins are trying to go uphill, and if any valves have failed to work, it often pools just on the skin.

And that’s why your skin can become dry and itchy and also the reason why you can develop thread veins and chunky varicose veins.

There are quite a few different types of veins. If you think of that Christmas tree analogy, there are the smaller veins which are rather like the pins or needles of the Christmas tree. They can be quite itchy and sore, and Dr Taggart does a wonderful job getting rid of those.

Sometimes they’re slightly larger, so you can feel them under the skin. We call those Grade 2. Again, they can be treated well, usually with sclerotherapy.

Grade 3 is kind of where I come in and start doing some laser treatment to veins like this. Often, the ones you see on the surface, the veins that you can actually see, are not the real story. So the reason that when you come to see me, I do a duplex ultrasound and scan your deeper veins as well as everything nearer the skin is so that I can see exactly where they’re all coming from.

They get a bit more medically important when you start getting itchy or sore skin, and particularly if your skin changes colour. And then the worst‑case scenario is where your skin really isn’t happy at all and can sometimes blister, or you can occasionally develop an ulcer. They’re called Grade 5 and 6. It’s a bit grim, and you don’t need to spend too long on that.

So when you come and see me, it’s me that you see, and I do a scan in clinic with you. I normally do a few diagrams for you, which you can take home, just to try and explain exactly what’s going on and what options are available to you.

Surgery is a day case. You usually walk in and walk out. Many people have it under local anaesthetic; other people have things done under a general anaesthetic. I think it’s entirely up to you how you choose to have that. That’s the most important thing about the consultation that it’s you who decide what you have done.

Previously, you might have heard of people having stripping as a vein operation. It seemed a pretty decent idea. You did a cut in the groin usually, disconnected everything, and put a wire thing down the vein called a 'stripper'.

That worked pretty well, but it was a bit brutal, and it had quite a high recurrence rate. So people have tried to do what we call minimally invasive treatment, which essentially is threading something up the inside of the vein with a laser.

You’re trying to damage the inside lining of the source of all your varicose veins, and it works pretty well. It’s not quite pain‑free. It’s like having a dental appointment, and if you have it under local anaesthetic, there’s a little bit of discomfort from needle jabs.

But it works pretty well in that most people afterwards will be up and walking around, and they certainly walk out of the hospital. It does feel a bit achy.

This is the inside of the right thigh, and the vein that normally causes trouble runs down the inside of your leg. Usually you can’t see it, but branches of that vein normally pop up just around the knee or just below the calf. Normally, that’s the vein we put the laser in.

A laser is just a fancy way of burning things. It’s a tiny wire. It’s not like a James Bond movie where you’re zapping from the outside. It’s actually inside the vein. I treat or burn the inside lining of your vein, which is very, very fragile.

When you burn it, it shrivels up quite quickly, and that turns the tap off. It stops the backflow going down your leg and deflates all the veins below.

That’s a little idea of what’s going on there. There are many different types of treatment. I happen to use a laser, but there are other treatments where you thread something up inside the vein to damage the lining. Sometimes you use electricity, sometimes microwaves, and they work pretty well.

Occasionally, we use a chemical to inject a type of foam up inside the vein. That works pretty well too. I think it works very well for smaller veins. I don’t usually use it on larger veins.

The main thing is that there are lots of different treatments available. If you look on a website funded by the government called NICE, it gives you an idea of what is considered the best technique for treating conditions like varicose veins, or indeed any treatment.

It states that heat treatment is the best first‑line treatment for varicose veins, and that would include lasers or microwaves.

This is the inside of someone’s left leg. On the left side, you can see a few veins popping out. They’re actually coming from a vein running under the surface from the groin. If we just laser that, you will see a few weeks later that it tends to deflate.

It doesn’t quite completely go. Six weeks later, it’s almost gone, but you can still sometimes see a few little bits. Occasionally, at the same time as lasering, I’ll do a few small incisions called phlebectomies, just to speed the process up and make sure it’s cosmetically acceptable for you.

The most important thing about lasering is that it is an operation. Sometimes people read that it’s completely pain‑free and that you can be back to normal the next day.

I would say that for most people it’s relatively okay, but they do usually take a painkiller. They nearly always feel like they’ve done slightly too much exercise, or like the day after the first football match of the year – that kind of cold muscle ache feeling.

In general, people take something like ibuprofen or paracetamol as a painkiller, and although you could technically work the next day, most people take it easy. You can certainly walk the dog the next day, but you wouldn’t be doing a five‑mile walk. I think most people sensibly take it easy.

Normally it takes a few weeks to get back to full speed, back in the gym or playing golf, and it often takes about three weeks before people go back swimming, for example, because it does look a little bruised and is quite obvious for the first few weeks after surgery.

Dr George Taggart

So we’ve heard from Mr Sweeney about the treatment of larger varicose veins, but at the other end of the scale, as already mentioned, are the small Grade 1 or thread veins, which typically occur on the face and legs.

Thread veins generally do not cause any physical symptoms. However, for many patients, they can cause significant cosmetic concerns and problems with self‑confidence.

Here at Benenden Hospital, we use well‑established, safe and effective methods for the treatment of these tiny veins.

For treatment of thread veins on the legs, we use a technique called micro sclerotherapy. It’s a sort of mini version of what Mr Sweeney is doing.

It involves the injection of a liquid, or sclerosant, into the vein. We either use a concentrated saline solution or a chemical‑based sclerosant.

When injected into the thread vein, these liquids cause a reaction in the lining of the vein, which leads to clot formation, fibrosis or scarring, and eventual closing down of the vein.

Once the vein is closed down and empty of blood, it becomes redundant and is eventually reabsorbed into the surrounding tissues, and it is then no longer visible.

An appointment for micro sclerotherapy would consist of an initial consultation, including careful examination and explanation of the proposed treatment.

Subsequent appointments for treatment last around 30 minutes. During an appointment, multiple injections are performed, depending obviously on the number of veins requiring treatment.

Small dressings are applied to each injection site, and these need to be kept dry and in place for three days.

It’s an outpatient procedure, and normal activities can be resumed immediately after the appointment.

Typically, patients would require a course of treatment, and subsequent appointments are usually one month apart.

For the treatment of facial thread veins, we use a technology called ThermaVein.

This technology was established in the late 1990s and has been extensively and successfully used in vascular clinics ever since. At Benenden Hospital, we are using the most up‑to‑date version of the technology currently available.

Attached to the ThermaVein machine via a wire is a tiny nickel probe, which I’m pointing to on the screen. The probe is insulated along its length.

This insulation ensures that all the energy from the machine can only exit the probe at its very tip, which has a tiny surface area, about the width of a human hair.

This allows low energy from the machine to be used and delivered very accurately, which minimises the potential for side effects.

Using the probe, we apply very light pressure to the surface of the skin overlying a thread vein, and this blanches the vein at that point.

We then apply a short burst of energy from the machine with pinpoint accuracy. This heats the wall of the vein, causing it to collapse and stick together at that point.

The probe is then moved along one or two millimetres, and the process is repeated, sealing the vein as we go along.

The vein is now shut down and empty of blood and is no longer visible.

As with micro sclerotherapy treatment, redundant and empty veins are eventually reabsorbed into the surrounding tissue and are no longer visible.

The best way to understand the process is to see it in action, and I have a video of a patient I recently treated. She’s very kindly given her consent for us to watch the treatment in action.

As you can see, light pressure is applied to the skin, and then the machine delivers the burst of energy, sealing the vein.

We can see before-and-after images. This is a small haemangioma, or blood vessel near the surface of the skin, which has disappeared with treatment.

And again, a prominent thread vein on her cheek, disappearing after treatment.

One more example.

ThermaVein is an excellent treatment for red and purple thread veins on the face and vascular blemishes anywhere on the body, and it can also be used as an adjunct to micro sclerotherapy on the legs for veins that are too small to inject.

Due to the heat energy we are applying to the skin, an inflammatory reaction usually follows treatment. This can make the treated area red and slightly puffy.

In this picture, we can see prominent thread veins on the nose that have been treated, leaving quite an inflammatory reaction afterwards.

This usually settles within two to three days, but it can occasionally last up to a week, or very rarely even longer.

Immediately after treatment, we apply aloe vera gel to the skin. This soothes the skin, and we recommend you continue this until the inflammation settles.

Most patients require a course of treatment. The number of treatments depends on the extent of the thread veins.

This, along with any other aggravating skin conditions such as rosacea, is assessed and discussed at the initial consultation.

If rosacea is present, I would often prescribe a treatment for that to prepare the skin for ThermaVein treatment, as results are better in this way.

As with leg treatments, subsequent appointments are one month apart, and this allows the patient to fully assess the results and the need for more treatment.

Here we have some more typical nasal thread veins before and after treatment.

In summary, thread veins are a very common problem and can be debilitating. With micro sclerotherapy and ThermaVein, we have well‑established, safe and effective techniques for their treatment.

Vicky

Thank you both very much. Now it’s time to move on to our Q&A session, as we’ve already got a few questions. Please do feel free to ask.

The first question is from Laura. Laura says, Can you have laser and foam treatment at the same appointment?

Mr Aaron Sweeney

You can. Normally, I would laser the vein first, and if the foam is only required in a very small amount, I might do that as well. Often, just by lasering the main vein, everything deflates quite a lot. So it really depends on how many veins you have and exactly where they are. But the simple answer is yes, you can have both done at the same time.

Vicky

I hope that was helpful, Laura.

The next question is, is it safe to have varicose vein treatment while taking statins?

Mr Aaron Sweeney

Again, that’s fine. In fact, you can take everything. Some people are on blood thinners such as apixaban or rivaroxaban or warfarin, and I’m happy to treat their veins while they’re on those types of drugs.

There’s virtually nothing I can think of from a medication point of view that would stop you having your veins treated.

Vicky

Okay, lovely, thank you.

Next question. Is there a benefit to waiting until my veins get worse in a year or two before treatment to avoid multiple treatments?

Mr Aaron Sweeney

And the answer is, it depends. If you are worried that having a vein operation is somehow going to mean that for the rest of your life you’re having your veins fixed every few years, well, because we don’t really strip veins anymore, normally I only see people once to have their veins treated with a laser. So I don’t really see much point in waiting.

Most people who come to me for varicose vein treatment have had them for about ten years. They’re nearly always of an age where they’ve had kids and have been taking care of other people. So it often takes about ten years before people come and see me, and when they do, I don’t see much point in waiting further.

Occasionally, if you’re planning on getting pregnant, I might suggest that it’s not wise to have them done just before pregnancy or while you’re trying. Sometimes people are told that they should have all their babies first before ever having their veins treated. I think that’s quite an old opinion, and it’s related to stripping rather than modern treatments.

Varicose veins can be quite unpleasant during pregnancy because your hormone progesterone rises quite a lot, which dilates veins and makes them more uncomfortable. So normally, if you’ve got a varicose vein and it’s giving you a bit of grief, I’d usually suggest having it treated.

If it’s not causing you any trouble, there’s no particular urgency. You certainly shouldn’t feel pressured into having something done just because it’s there.

Vicky

Lovely, hope that was helpful.

The next question is for Dr Taggart. I have very sensitive skin and have to be very careful with makeup and skincare products. Would I still be suitable for ThermaVein, or could it irritate my skin?

Dr George Taggart

So anyone can have ThermaVein treatment. Some people are more sensitive to it than others, and it’s difficult to predict that. Usually, at the first treatment I perform, I’m very cautious and gentle.

Sometimes, during the consultation, I would perform a small test area, for instance, behind the ear where it’s not very visible, just to see how you react to the treatment. We then assess that when you come back. You certainly could react to the treatment, and the secret is not to overtreat at the beginning, so we would proceed with caution.

Vicky

Okay, lovely, thank you.

Next question. I have patches of veins that look like bruises on my legs. Are these varicose veins?

Mr Aaron Sweeney

Not sure. If you can feel them and they’re bumpy, they can sometimes be described as varicose veins. Occasionally, you can have a type of thread vein appearing near a varicose vein that looks like that. I would need to see them to be able to tell you one way or the other.

Vicky

Okay.

The next question is from Judy. Judy says, 'Are there any risks?' For example, is there a greater risk of blood clots from treatment? And also, do the veins come back?

Mr Aaron Sweeney

So in terms of risk, yes. The only real risk I worry about is a deep vein thrombosis, and that can occur after any operation. I normally quote people a risk of around one in a thousand procedures, which is pretty low.

Just to put that in perspective, having an appendicectomy carries a risk of about one in a hundred operations, having a baby is about one in a hundred, and breaking your leg skiing can be as high as one in ten. So I would consider those much higher‑risk situations.

From a varicose vein point of view, I nearly always give a blood thinner called Clexane on the day of the procedure, and we’re very particular about you being up and walking afterwards. If you weren’t able to walk after the procedure, we would ask you to call us, and we would bring you straight back.

People sometimes ask what their background risk of DVT is anyway, and interestingly, about one in a thousand people per year develop a DVT for no obvious reason. So yes, there is a small risk, and I do everything I can to minimise it.

In terms of veins coming back, because I scan you in clinic, I’m pretty certain which vein is causing the problem. When I laser that vein, technically it does not come back. What people usually mean is whether they’ll need more procedures in the future.

I usually quote that about one per cent of people will come back within a year with a small additional vein, which can usually be treated with an injection. About ten per cent of people might come back after ten years with a new varicose vein, and that’s almost always in the other leg.

So if you have veins, you are slightly more likely to develop them again, but one of the advantages of laser, microwave or radiofrequency treatment is that the risk of recurrence is very small. That’s partly because ultrasound is used to make sure the correct vein is treated.

Vicky

Thank you; that was very comprehensive and helpful.

Next question would you recommend EVLT treatment before a hip operation or after?

Mr Aaron Sweeney

That depends. If you’re not able to walk because your hip is really quite bad, I would say you should probably get that fixed first before having any varicose vein treatment. If, however, it’s a more chronic problem and your hip is a bit sore and your vein problem is giving you swelling or discomfort, I think it’s entirely reasonable to have the vein treated first so that you go into your hip operation in as good a condition as possible.

Vicky

Okay, thank you very much.

The next question is from Michelle. Michelle asks, 'I've got a small vein visible on the surface of my skin on the outside of my leg, just around the calf. ' After an hour of sitting at a desk or driving, it’s really painful, and the pain is right where the vein is. Sometimes I press it to relieve the pain. It’s not lumpy or large, which is why I wasn’t sure if it was a varicose vein. Should I get it treated?

Mr Aaron Sweeney

And that also depends. There are lots of different reasons why you can get aching in your legs. Varicose veins nearly always give you more trouble as the day goes on. If you’re lying flat in bed, gravity isn’t an issue, so you usually wake up with your legs feeling fine. As the day progresses, and particularly if you’re sitting or driving, things tend to get worse.

Sometimes you can get pain coming from your back, causing referred pain down your leg, or you can get joint pain. These things can be confused with vein pain. So when I see someone, I usually make sure there is a varicose vein nearby that correlates with the pain.

In general, people don’t tend to have two separate things going on at the same time. So if you have a lumpy vein and it’s painful, it’s almost certainly the vein. If it’s not lumpy, you need to be careful about treating a vein unless you’re certain that is the cause of the pain.

Vicky

Okay, I hope that was helpful, Michelle.

The next question is from Elizabeth. Elizabeth asks, 'Are there any side effects to having laser treatment?'

Mr Aaron Sweeney

When I laser people, I try my best to explain that it isn’t “lunchtime surgery” where you walk in and walk out and forget about it the next day. It depends on what you mean by 'side effects'. Every operation has a set of things that happen afterwards.

I would expect some discomfort and bruising. Sometimes the bruising can look quite dramatic, but it settles fairly quickly. When people ask about side effects, they’re usually asking about things that are out of the ordinary.

Occasionally people can have a bit of numbness where the laser or the local anaesthetic has irritated a small skin nerve. That usually resolves by itself. Most people find that about six weeks after the operation, they’ve essentially forgotten about it and aren’t thinking about their legs anymore.

I hope that was helpful, Elizabeth.

Vicky

The next question is about pricing, which we’ve got displayed on the screen. If you’d like a quote, please do contact our private patient team. Their details will be on the next slide.

Laura has come back with another question. She asks, 'Is there a best time of year to have treatment, and do you have to wear support stockings afterwards?'

Mr Aaron Sweeney

I don’t usually advise support stockings. Most people find them extremely uncomfortable, difficult to put on, and difficult to tolerate. Very few people wear them properly or consistently.

In an ideal world, January would be a good time to have veins treated, when it’s cold and you’re not concerned about bandages or bruising. By the time it gets warm, everything has settled. In reality, most people notice their veins more in the summer because heat dilates veins and makes symptoms worse.

There isn’t really a perfect time of year. You just need to allow a few weeks where you wouldn’t want to show your legs, which can affect holidays.

Vicky

Okay, lovely.

The next question is from Nikki. Nikki asks, 'Do you have a scan for lighter thread veins on the legs, or is it assessed visually only?'

Dr George Taggart

If they’re clearly thread veins, we assess them visually. If there’s any doubt that there may be underlying varicose veins, I would arrange for a scan with Mr Sweeney.

Vicky

The next question is from Bea. Bea asks I had a Doppler test done, and the pressure in one leg is very low. Is that a problem with veins?

Mr Aaron Sweeney

That test measures arterial blood flow, not veins. If the pressure is low, it suggests reduced blood flow down the leg, which is an arterial issue. It’s not usually related to varicose veins.

I don’t routinely use that test because it can cause more confusion and anxiety. If arterial flow is genuinely reduced, people usually have significant pain on walking and would need further arterial assessment.

Vicky

I hope that was helpful, Bea.

The next question is from Lorraine. Lorraine asks, 'How do you know which treatment you need if you have a few different issues?'

Mr Aaron Sweeney

Nearly always, varicose veins are bumpy, lumpy, and sore. Thread veins are flat and cosmetic. Usually, I would treat the larger veins first to deal with pain, aching and swelling, and then Dr Taggart would deal with the smaller veins for cosmetic reasons.

If you can’t feel anything and it’s just on the surface, it’s usually thread veins. If you can feel lumps, that’s more likely varicose veins.

There’s also a question about compression stockings. If they’re fitted perfectly and worn consistently, they can reduce symptoms. Sometimes I ask people to try flight socks for a short period to see if symptoms improve, which helps confirm a venous cause.

However, many people find compression stockings extremely difficult to put on and uncomfortable to wear, and most people don’t tolerate them well long term.

The problem with compression stockings is that if you’re prescribed them on the NHS, it often effectively ends the consultation, because a treatment has technically been offered. Whether you wear them or not is then up to you.

I find that most people don’t wear them because they find them completely miserable. That said, I do occasionally see people who have worn compression stockings for decades and find that they work wonderfully well for them. However, that is not the majority of people.

Vicky

Okay, I think that’s a fairly definitive answer on compression stockings.

So that was our last question. Thank you again for all your questions and for being part of this evening’s session. If you don’t mind moving on to the next slide, please.

Okay, that’s great.

As a thank you for attending, we’re pleased to offer 50% off the value of your initial consultation using the code shown on the screen.

You may also receive a call back from your dedicated private patient adviser, an email with the recording of this session, treatment information, loyalty reward points, and updates on future events and health news.

We’d really appreciate it if you could take a moment to complete the short survey that will appear at the end of this session, as it really helps us to improve and tailor future webinars to your needs.

If you’d like to speak with someone to book your consultation, our private patient team is available until 8.30pm this evening and from 8am to 6pm, Monday to Friday. You’ll find their contact number displayed on your screen.

We also have other webinars coming up over the next couple of months on a range of topics, including plastic and cosmetic surgery, heartburn and acid reflux, hip replacement surgery, and treatment for knee osteoarthritis. You can sign up for these on our website.

So finally, on behalf of Mr Sweeney, Dr Taggart, and all of us here at Benenden Hospital, thank you very much for joining us this evening, and we hope to hear from you very soon.