Louise King

Good evening, everyone. Welcome to our webinar on varicose vein treatments. My name is Louise and I'm your host this evening. Our expert presenter, who you can see on screen, is Mr Aaron Sweeney who’s our Consultant Vascular Surgeon.

This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so using the Q&A icon, which is at the bottom of your screen. This can be done with or without giving your name.

Please note the session is recorded, so if you do provide your name it will show up in the recording. If you'd like to book a consultation, we'll provide contact details at the end of this session and a discount for joining this session.

I will now hand over to Mr Aaron Sweeney, and you'll hear from me again shortly. Over to you, Aaron.

Mr Aaron Sweeney

Hello everybody, I’m Aaron Sweeney and many years ago, when I was a junior doctor, we used to operate on veins almost every day of the week. And the usual operation was stripping, that involved cuts and a general anaesthetic and pulling veins out - and it was pretty brutal.

And then in around about 1999, myself and Eddie Chaloner, who's the other Vascular Surgeon here, we saw a wonderful procedure that started in New York and involved threading little lasers up the inside of veins, rather than pulling them out. It looked quite dainty, it worked moderately well and then over the next few years we did a lot of research on this and essentially fine-tuned it, got the right settings and made it work properly. And then, it was about 2005 that we rolled this out (in the NHS in the first instance) and started offering laser treatment for veins.

So, laser treatment for varicose veins is not the same as some James Bond movies where we zap people from outside. It's actually threading little, small lasers - which are rather like little wires - inside of a vein. We damage that vein from the inside and the vein shrivels up and disappears.

So, I'm a Vascular Surgeon and that just means I've trained in doing all bits with arteries and veins and I've done a fair few laser treatments I've been doing it all the time, since 2005, so obviously you do quite a few. Next slide please.

So, what we’re going to try and talk about is what we do here at Benenden Hospital. I’m going to tell you a little bit about what varicose veins are, the different treatments that are available.

But probably the most important thing is a question-and-answer session at the end, because most people who come to these webinars have varicose veins already, and many people have a question. I find webinars great because sometimes, I think, if you’re in an audience it's a bit embarrassing asking questions but on webinars people can often type a question and you'd be surprised what we're asked and very few of them are inappropriate and hopefully I can answer all those easily for you. Next slide please.

So, Benenden Hospital, we’re the largest provider of varicose vein treatments in the whole of the UK at the moment. I have to say that a few years ago, that was quite hard to do but not anymore because varicose vein surgery seems to almost have disappeared from the NHS, sadly. But we still do very large amount here - well over a thousand a year. Myself and Eddie do probably a thousand each per year which is quite a lot for a single operation.

We're constantly checked down here, so the CQC come in and monitor us and check all our results and we have to audit everything to make sure that we do it correctly and have high satisfaction results. Next slide please.

So, sometimes people are a little confused about what are varicose veins? So, if I tell you that you have an artery and a vein in your leg; the artery brings the blood down your leg and feeds the muscle with oxygen and a small amount goes to your skin and then veins take the blood back up your leg up to your heart, where it's pumped again.

I think it's helpful to think of varicose veins like a Christmas tree; you have one main vein running up your leg which is called your deep vein and then you have hundreds of smaller veins or branches joining that deep vein. Most of those branches are from muscle, they're quite big with large amounts of blood flowing in them, but you do have some smaller veins which drain the skin and, unfortunately, they have a bit of a struggle getting up your leg. They're called your saphenous veins and they have little valves in them to keep everything going uphill. They're normally small - about the size of a shoelace - and unfortunately, if the valves fail in these veins, they swell a little bit, the blood stops flowing upwards - it can sometimes flow backwards - and then you might notice them as little bumpy, varicose veins on your leg.

Veins cause many different problems. Sometimes it can start with a little bit of swelling, occasionally you can see loads of varicose veins, but quite often you only see very small veins or don't even see them at all.

But you do tend to get aching, your legs can feel heavy, cramping at night is one of the common symptoms so many of many the patients I see are taking quinine tablets to try and relieve cramp. But actually, the cramp is caused by their varicose veins.

The problem with varicose veins is that they can make your skin quite dry and itchy and unhealthy. And the main medical reason for treating veins is that, because if your skin has become sore, itchy or discoloured, you're much more likely to go on and develop an ulcer - and developing an ulcer is essentially a failure of medical treatment because your skin will break down. It never goes back to normal, and it takes quite a long time and a lot of dressings and a lot of embarrassment trying to get it to heal properly. Next slide please.

So, there are quite a few different treatments with varicose veins. There is, of course, the old treatment of stripping - which is still done in places - but for the most part that is just not done anymore. There are two main ways of treating veins, really, it's threading something up the inside of the vein or injecting something up the inside of the vein.

I would prefer to use a little laser, but there are other treatments available and most of them can be done under a local anaesthetic. We’ve got extensive experience of using a laser in Benenden Hospital, which works quite nicely, but I'll run through a few extra treatments that are available because - as with all these things - they appear on the internet, there are multiple treatments available and often people try to advertise them to say one is better than the other. In fact, most of the treatments that are available now are equally good when they're done by somebody who knows what they're doing. Next slide please.

So, I thought I'd just show you some veins because people sometimes wonder ‘…are they varicose veins or are they dangerous?’ So, you usually grade varicose veins from one to six, one being small ones and six being troublesome ones.

Grade one is where they're just about visible. They're commonly small thread veins they're usually not a problem and many people like them treated. And you can certainly have them treated. Mostly we treat those with small injections; they're generally not troublesome but can occasionally give you quite a lot of itching. But for the most part, we’d probably regard those as cosmetic. Next slide.

Grade two are when they’re a little larger, you could just about feel them. Most people have these. Again they're generally not troublesome, and I wouldn't be pushing people to have an operation on health reasons really and health grounds for these, but they can be treated, usually again with a little bit of sclerotherapy. Next slide.

Grade three is really where things start to get a little bit interesting because they're usually veins that are bulky, they're giving people some pain, swelling usually and these veins - I mean on that slide they're quite large - but the size of the vein doesn't really matter. Some people have huge varicose veins and no trouble whatsoever and other people can have a relatively small vein but gives them a really a great deal of trouble. But usually around this level we would suggest having something done. Next slide please.

So, then you get to grade four and this is where things start to get a bit complicated. This is where veins are causing damage to your skin. That doesn't happen in everyone, so we know that about 20% of the population will get a varicose vein but - of that 20% - about a quarter go on to have some skin damage. So, three quarters don't. But if you do get skin damage then that's something that you probably need to have treated, because it will just progress and it is wonderful to treat it at this stage because you can essentially reverse everything, get people back to normal and essentially have a procedure and a few weeks later forget about everything and get back to being completely normal.

We'll go to the next slide just briefly, it's a bit grim. So, this is what happens for grades five and six. It's where the skin just becomes so inflamed and sore that it starts to peel away.

Often people have had varicose veins for many years, their skin has been quite sore, and they haven't kind of caught on that the sore skin is actually caused by the varicose veins. Not always that obvious, even to General Practitioners, and sometimes people go for years having various hydrocortisone creams and E45 etcetera and then, finally, a relatively minor injury occurs and all of a sudden, their skin breaks down. And then you have quite a lot of trouble, because there’s quite a few nerves near the ankle - just near your funny bone - and if you have an ulcer, often that same nerve that supplies your funny bone supplies the ulcer. And I don't think there's anything funny about that. It is really, really painful. Next slide.

So, we usually treat varicose veins with a laser. This slide can be a little bit confusing but if I orientate you a little bit; that's the inside of somebody's right thigh. So, looking at it from the inside. So, you have a main vein running up the inside of the leg, loads of little branches - like a Christmas tree - but the commonest branch to stop working actually joins the deep vein right in your groin. It comes out, runs down the inside of your thigh. It's normally about a centimetre or so under the skin - you don't usually see it.

Branches of that vein pop up on the surface, usually in your calf, and they can be quite small and people wonder why they're getting so much trouble but the reason is that they may have 40 centimetres of vein in their thigh - rather like a yard of ale sitting there - allowing pressure to build up as the day goes on and putting pressure then on what looks like a relatively small vein - but producing quite a lot of symptoms. So that vein is the commonest vein we treat.

So, we scan your leg with an ultrasound. We can see this vein, and somewhere along its length we thread the little laser up the inside.

We pass the laser right the way up the inside and then normally, with local anaesthetic, we inject a little local anaesthetic the whole way down your leg and we kind of produce a sausage of local anaesthetic that surrounds the vein. And then we laser the vein and a laser is just a fancy way of burning something, so we give a very controlled burn or singe to the inside of that vein. It shrivels up, it does take a few weeks to disintegrate and - for most people - they tell me feels like a dental appointment not quite root canal work, but about as stressful as a dental appointment.

We try to make it similar to that appointment in that we have you walk straight into the operating theatre, you have your vein treated, you walk out the other side. We have you sit down, have a cup of tea, make sure you feel okay. That probably takes about half an hour and then we escort you out of the hospital. Most people walk out the door and I think they're much happier afterwards. I think most people feel a bit stressful about having any kind of procedure done. Next slide please.

So, there are quite a few things you can hear about, but if I tell you that they are essentially divided in two. So, one is a heat-based treatment and the other is a chemical.

So, the chemical-based treatment you may hear of things called foam sclerotherapy or sclerotherapy or even glue. And what that involves is injecting something into the vein, producing a reaction on the inside of that vein, the veins usually don't like that at all and they go a bit hard. And then you're waiting for your body to essentially dissolve that vein away. That often takes a bit of time. That's not our preferred treatment for larger veins, but it is our preferred treatment for the smaller thread vein type varicosities.

We would usually thread a little laser up, so there's EVLT, the next treatment is called radio frequency ablation - that's actually electricity - and there's a microwave type treatment.

They are essentially all the same and although many argue about which is the best, the proper research trials that have been done show that there's no real difference; they all work equally well and it's up to your preference.

So, I think lasers, radio frequency ablation works equally well. They certainly work better than foam sclerotherapy, which has a much higher recurrence rate. Next slide.

So, we like to see you first and just run through things. We generally do an ultrasound when we see you. An ultrasound scanner has kind of become the stethoscope - our stethoscope. We use it all the time. It just gives us a wonderful view of the inside of your leg and allows us to give you a few options.

What we will do is tell you exactly what you have and give you the options that are available to you - because of course it's your choice, if you choose to have anything done. I would rarely push someone to have a procedure, unless I can see that they're going to end up with an ulcer. For everything else, you can decide. Quite often people just want to know a few things, want to see how they how the land lies, so to speak - and if there's anything going to happen to them if they, say, just ignored things. And I find that quite nice, because it allows you to decide whether you have something done; you're not pushed into having something done and nor do I tell you that wearing compression stockings will sort you out. That's just not true. So, I'd like to give you all your options and then you can decide how you feel.

We normally then send you for a pre-assessment, which is just to make sure that I haven't missed anything and check your blood pressure and stuff like that.

And then when we give you a date for surgery, the next time you see me is actually on that day. The treatment itself normally takes 30 minutes or so and most people are in the hospital for maybe 90 minutes, so it's relatively quick. Next slide.

These are a few pics of kind of what to expect. So naturally we give, we show good pictures and successful treatments, but most people the left-hand side picture of before that's essentially what most varicose veins look like. They nearly always come from the thigh and, in particular, from a failed valve and the groin. We will zap that vein, put you in a bandage for a few days or maybe more - depending on what your vein looks like. A couple of weeks later, for most people their leg starts to go flat and you can't see much - and then about six weeks later nearly always the veins have completely gone.

Now, there's a slight difference between treating veins for medical reasons and doing anything that's cosmetic. So, if you treat them for medical reasons, nearly always two weeks after you have your operation, you have essentially forgotten that I've done anything to you, because your vein is gone, and your leg feels good. Most people will be back in the gym or playing golf or just being normal. I think it takes about six weeks for your leg to look okay and that would be for a holiday and nobody to ask you any questions about what's being done. And sometimes, they often are a little bit more bruised afterwards because we try our best to get rid of every single bit that's annoying them, so that can often take six weeks to look - what I would say is reasonable - to go away, and for you to feel comfortable.

It can sometimes take a little longer just depending on the veins that you have. Sometimes you can hear adverts where people describe varicose vein surgery as a kind of ‘lunchtime surgery’. Yes, certain veins are ‘lunchtime veins’; they're usually very small and short and people can certainly walk in and walk out but for most people who have a vein operation with me, I tell them that's going to feel like you've either exercised like a 5K run or first day with a new trainer in the gym or first football match of the year. That next day feeling where you get up and you certainly know your leg’s attached. It's not agony, you can certainly do everything, but it does feel a little uncomfortable and most people will take some kind of painkiller such as Nurofen or a paracetamol. Other will say they didn't feel anything, didn't even know I did anything. Most people say it was a little uncomfortable, but nothing too special.

Next, we're going to do a patient testimonial:

Jo Crossey explains her varicose veins treatment

My name’s Jo Crossey, I'm 58 years old.

How did varicose veins affect your life?

Well, it did. It was making my legs more uncomfortable as the years went on, feeling very heavy and tired, especially in the hot weather - my feet would swell - and just generally feeling achy most of the time. I did start working part-time and part of that reason was probably unconsciously thinking actually I can't keep on my feet all day long, every day.

Why did you choose Benenden Hospital?

We thought it was worth the drive to go and especially when it was a beautifully new hospital, and it was a very pleasant experience, and I wouldn't hesitate to go back again if I needed to in the future.

How quickly were you seen?

My GP referred me on the 22nd of January, and I had my consultation with Benenden on the 31st of January. So, I was quite impressed by that.

How did you find the operation?

The operation was very straightforward. You are given a booklet to explain what the procedure is and Mr Chaloner, who I saw, also talked me through it. But obviously when you're in consultation it's a lot of information to take in. So, I came home and read the leaflet. I also looked online for him, and he did a very good explanation online. Everything that was in the booklet is exactly what happened on the day; you were talked through it and the staff were very helpful, supportive and talked you through every process.

How did you feel on the day?

I felt as if, walking into a lovely environment like that, that everything was going to be okay - that it would be state of the art technology and processes. So, I felt very confident that I was in good hands.

What was your recovery like?

My recovery was again, like it said on the tin, you know. I had to wear my bandages for five days and then take those off. I couldn't drive for five days, obviously, because they say for insurance purposes, if I had to stop quickly or if I was in an accident, insurance might not be so happy if I was wearing bandages.

And then I was back to work in a week. It was a bit achy and a bit sore, but they give you advice about putting your feet up whenever you can, putting in local anaesthetics - rubbing in local anaesthetic gels - wearing a support bandage if I needed to. And I did that a few times because the weather was quite warm post-surgery. So, I made use of those devices and advice, and it certainly helped.

How is life now?

My life now has changed in that I'm not feeling the heaviness in my legs, and I have been wearing shorts out and about which I hadn't done before, so it certainly boosted my confidence in terms of that and yes getting back to running after two grandchildren.

What advice would you give to anyone considering EVLT?

If anybody was thinking about having their varicose veins done, I would recommend the Benenden Hospital. Their technology and the processes they do; laser treatment is the way forward and in terms of not making you lie in a bed, getting you up and getting you mobile, certainly Benenden Hospital is highly recommended as far as I'm concerned.

Louise King

Great thank you for that interesting presentation, Mr Sweeney!

It's now time for some questions, and we have a few in already. And so everyone please do send your questions in. And the first is, they say what can cause varicose veins in male testes and how can they be treated?

Mr Aaron Sweeney

That's not quite my specialty, that's a urologist’s. But if I tell you that guys can get a thing called a varicocele which is a testicular varicose vein, and that is caused usually in the left side, and it's because of the way that vein drains in your tummy - right up near your kidney. There are treatments for that, just I don't do them. I think they're quite minimally invasive as well; they don't require open operations. But that's quite a common thing in men and - most times - you don't touch them.

Interestingly, girls have the same problem just you can't quite see it. So, ladies can have varicosities around and near their ovaries. That's a thing called pelvic congestion. It's a very well-known problem, can be treated and it often involves quite a lot of ache and pain around period time as the veins dilate, because you get a little spike of progesterone at that time and that dilates veins. So, if you have a load of varicose veins in your pelvis that you can't see, sometimes that can give you a pretty grim time if you're a girl.

For blokes, thankfully, we don't have progesterone, so it doesn't quite affect us so much. But there is a very specific thing called the varicocele with men - but it’s dealt with by the urologists, not by vascular surgeons

Louise King

And we have several urologists at the hospital so if you feel free to call the number below and you can speak to one of those for a consultation as well.

And the second question is from Alan. He had his varicose veins stripped 30 years ago but now they're starting to reappear, but without pain. Are laser treatments in the veins likely to regrow in the future?

Mr Aaron Sweeney

Interestingly, when you have your veins lasered, your risk of recurrence is quite low. It's around about one percent, because essentially, you're lasering a vein, so it's gone afterwards.

But about 10 per cent of people develop a new vein, so it's not absolutely perfect. Stripping veins is different. That has about a 50 per cent recurrence rate because, when you pull a vein out, as your body tries to heal itself, it produces new veins. So quite often you get these smaller veins that appear afterwards - and we can still laser those kinds of veins.

So, we nearly always scan you, have a little look, see what's not working, come up with a plan and give it to you. If you have no symptoms and they're not troublesome and your skin is fine, we might tell you that you can leave them alone, that there's nothing dangerous about things. But sometimes people think that their veins are not causing any trouble and then we point out the discoloration in their skin or the eczema that they have, and they pass it off as something they've had for years but it's actually caused by their veins.

I hope I've answered that question.

Louise King

I think so. Thank you. Will a standing desk help someone's varicose veins?

Mr Aaron Sweeney

No. They don't necessarily help, but they're not necessarily bad because - as you move - you have a pump action around your ankle and that actually gets blood flying up your leg. So in fact sitting is often worse because you kind of crease your veins so they fill up, which is why if you drive a car with varicose veins sometimes you can end up with quite swollen ankles or cramp. But a sort of standing desk though is not bad for varicose veins because most people who are standing at a desk are actually moving a fair bit so, in fact, they're not entirely still so it's not a bad thing.

Louise King

Great! The next person says they fly a lot for work and their legs itch a lot. Do you have any advice for this?

Mr Aaron Sweeney

That could be a varicose vein, or it could just be something else. There's loads of different reasons for our itching. If you had some varicose veins as well then, they are almost certain the cause of the itch and - as you've asked about flying - I would just say that there's no problems with flying with varicose veins. It's not something dangerous and flying has a very low risk of a DVT, despite what people advertise.

So, you don't necessarily we need to wear compression stockings on a plane. Your risk of a DVT in a plane has already been worked out, it's about one in a million, it's quite tiny. In fact, I think you get more trouble putting on very tight stockings. But if you're flying on a plane and you get an itch or if you're in a car and getting itchy that may be related to your veins. Or if you stand all day and your legs feel quite sore.

Most varicose vein symptoms occur at the end of the day because, when you're lying in bed at night, the veins deflate - there's no gravity, so when you're trying to work out if the varicose veins are causing trouble, normally I ask people are their legs worse at the end of the day or at the beginning of the day. If it's the end of the day that's much more likely to be vein related.

There are loads of other causes, but if - at the end of the day - your legs are worse, more achy, more itchy then I think that'll point us towards varicose veins.

Louise King

Thank you. Stuart asks if surgery is compatible with Warfarin? He’s had three lower left calf DVTs and has various varicose veins in the same area.

Mr Aaron Sweeney

So, people who are on anticoagulation, we operate on them routinely, we don't stop anticoagulation in general and we would treat the varicose vein even if people are on Warfarin.

The problem with the previous deep vein thrombosis is that that sometimes damages - if you think of that Christmas tree analogy - if the main trunk has been damaged, sometimes these smaller branches are actually vital, so we don't touch them. So especially in people who've had multiple deep vein thromboses, sometimes you cannot operate on their veins, but that's unusual. For most people you can treat them.

Louise King

Okay, Lloyd asks does EVLT just seal the valve or is the laser drawn down the vein, sealing as it goes? Is the sealing always then followed by a phlebectomy to hook onto the vein?

Aaron Sweeney

So, the answer is the whole vein is sealed from the top all the way down as far as we can go. It's usually about 30 or 40 centimetres. Sometimes we do phlebectomies as well. Phlebectomies are small incisions, where we break up some of the larger veins to speed up – I can’t think of the word now - to get rid of them more quickly.

You don't always have to do phlebectomies. Quite often, just the laser on its own gets rid of everything, but sometimes if you have multiple branches we would do a small little nick in the skin and break the vein. And that's a phlebectomy, so I hope that's answered the question.

Louise King

Absolutely, thank you, Lynn says they have hypermobile Ehlers-Danlos syndrome. Are there any additional risks they should consider? They think the varicose vein is grade three and it runs from mid-thigh to the calf down the inside.

Mr Aaron Sweeney

Not usually, so I operate on plenty people with the Ehlers-Danlos. They have a slightly greater risk of recurrence that's the only thing I've noticed, but essentially treating the vein is fine and I would treat you as if you were, you know, a person without Ehlers-Danlos. I was trying to avoid saying a normal person, but you know what I mean. Ehlers-Danlos is, in itself, not something that would be a contraindication to having your veins treated.

Louise King

Okay, thank you, Sian has severe discoloration due to varicose skin on their lower leg will that ever improve?

Mr Aaron Sweeney

It depends. If you get rid of the problem that's causing it - which is usually a vein - you laser the vein, it allows your skin to heal. It depends how far it got. So, if it was very badly inflamed, it's a bit like a burn and there are different grades and sometimes it does leave scarring and discoloration. And quite often it decreases a few grades, so it goes from being very obvious to being less obvious. But quite often, if we catch it early enough, it goes back to being completely normal, so it just depends how far it's got before you had the vein treated.

Louise King

Okay, thank you, and this person is allergic to surgical stitches. Does the laser treatment involve these?

Mr Aaron Sweeney

No there's no stitching. Very, very rarely we'd ever put a stitch in the skin.

Louise King

Okay, what are the risks involved with this treatment?

Mr Aaron Sweeney

So, every operation, not only does every operation carry some risk, I think every operation produces a complication just depends how you classify things. So, everyone who has their veins done has a little bit of discomfort. Sometimes they're a bit lumpy, a bit of bruising, those kinds of things.

I divide the post-op period into things that can sort themselves out and things that cause trouble. So, things that cause trouble is developing deep vein thrombosis following any operation, whether it's a hip repair or an appendix or any kind of gynae procedure. With varicose veins your risk of a DVT is one per thousand procedures we are absolutely hell-bent on making sure that is zero.

So, most of the focus of our post-op period is to make sure that doesn't happen. So, although it's a very unusual complication, it's the only one that I feel is dangerous and it's really the only one that makes people regret they ever had an operation. But at Benenden, our risk of that occurring is quite a lot less than 1 in 1000. It's a very rare occurrence.

That I consider to be a proper complication. The other things, such as being a bit sore, or a bit too bruised - you could either take a few extra painkillers or just wait a little time and that sorts itself out.

So really from a complication point of view, DVT is all I ever worried about or worry about. And to give you an idea of comparisons, DVT rate in veins maybe 1 in 1000, having a hip replaced might be one in 50, having a baby one in 100, breaking a leg while skiing can be as high as one in 10. So, they're proper risky problems. But veins, relatively - not quite risk-free - but usually a very low risk procedure.

Louise King

Okay, thank you, Rebecca says they have a horizontal bumpy vein across the back of the thigh just at toilet seat level. It's very painful. Is this position a concern? They've been told that it comes from internal so it cannot be treated.

Mr Aaron Sweeney

That's not necessarily true. That's a very common vein. It usually comes from the groin, and you can certainly treat that. That's often one that drives people bananas, not just on the toilet but also sitting in a car and that's a very common vein to treat. And I think if you have a scan done, you can virtually always treat that. That's not one you'd say no to.

Louise King

No, they then go on to ask, how long does the laser treatment last for? And will other veins then take more pressure?

Mr Aaron Sweeney

No. So what I always say to people is think about like a Christmas tree. All the veins are trying their best to get things up and there's one vein not working and it's pouring everything back down like a waterfall. And all the other little veins that are trying their best start just getting fed up with all this blood pouring back down.

The moment you get rid of that vein, everything has a holiday because they now no longer have all blood coming down it's all going in the correct direction and that's why the symptoms disappear.

When you laser that vein it shouldn't come back. There's about a one percent chance of us not lasering the vein properly and it's coming back quickly. But for 99%, most of the time that's the end. But, depending on your age, if I laser someone's vein and they're 18, I will tell them that they have a 10 per cent chance of another vein popping out somewhere that will need an operation in the future. So, it's not technically a recurrence - but I describe it as a recurrence because it's a trip back to see a vascular surgeon. But the risk is about one in 10. But from the vein that’s treated.

I think most surgeons - and sometimes you can advertise it saying - you know, your recurrence rate is tiny. And that's true, when you laser things properly they don't come back - but you can develop another vein. So occasionally one pops out in the years after you have treatment, but it's much less than the older operation which was 50% after a few years.

Louise King

Thank you, just a few more questions. Jerry asked if there's a limit to the number of varicose vein operations on one leg. They had theirs injected years ago and subsequently stripped twice.

Mr Aaron Sweeney

Yeah, sometimes. I have to say I was one of the junior doctors who used to do all these stripping operations back in the last century and I didn't really do it very well. It wasn't superbly supervised and so the actual operations you have can sometimes be a bit hit and miss.

And I think sometimes when you scan people, you realise that actually they missed a particular vein and also, they didn't have the advantage of having an ultrasound with them all the time during the operations, so occasionally veins are missed, they didn't spot them the next time they did an operation so you can have had multiple operations that were effectively useless.

So, the number of operations you have doesn't necessarily mean that you can't have any more. It sometimes means that they missed something on the first go and unfortunately, they haven't been able to fix it afterwards.

So, surprisingly I often scan people who've had multiple operations and find this very long vein sitting the whole length of the leg and kind of wonder how everyone missed that! But they didn't have the advantage using an ultrasound so it's kind of easy for me to say that. But you can then treat it and get rid of vast majority of those veins relatively easily.

Louise King

At what point in their development should someone seek treatment? And is it better to wait until they are prominent?

Mr Aaron Sweeney

The answer is, whenever you're irritated by them. So, if they're sore, I'd have them fixed. Some people are told ‘Have all your babies before you ever have your veins treated’. I just think that's mad. You end up with multiple pregnancies with legs that are aching and giving you loads of grief!

I think whenever they're bothering you, you can have them fixed. I think if they're sore or the skin is itchy, you definitely should have them fixed. If you just don't like the look, well it's kind of up to you, too -  whenever you wish.

Smaller veins are much easier, and you get a much nicer result. Veins that have been left for 10 years, they sometimes damage the skin a bit so you don't quite get a perfect result cosmetically - but I would say treat them whenever they're bugging you.

Louise King

Okay, can you treat the veins that look like bruised spiders?

Mr Aaron Sweeney

Yes. If I tell you that it's quite easy (for me) to treat large veins, get rid of those make everything look lovely and smooth. Smaller veins are a bit more difficult because it often takes a few treatments. I bruise you each time I treat them, usually with some sclerotherapy, which is little injections. And I think that kind of treatment is a bit like watching paint dry. You're bruised, you're waiting for it to settle down, you come back, I do it again, you're bruised again. So, it can sometimes take a couple of months to get a decent, good cosmetic result. But I would say that for most thread veins you can - if not reduce them - you can get rid of them completely.

For many people, the initial treatment is quite annoying because it takes a while to get everything looking good. But, after that, people sometimes come back for a little MOT every few years and it's just the odd little thread vein here and there. It's not unusual, especially this time of year, for people just to come back for one session and I wouldn't see them again for a few years. So, the answer is yes, you can certainly treat those type of veins.

Louise King

So just our last question. A few people have actually asked this. If you have diabetes, can you have your veins removed?

Mr Aaron Sweeney

Yes, if you have diabetes, heart failure, any of those kinds of complications. It's amazing things that you think will stop you having a varicose vein operation. In fact many times you should have an operation, because if your leg is swollen and itchy and sore and you're a diabetic, the last thing you need is an ulcer - because that will send your sugars all over the place.

So many people, even up to - you know, the oldest person I've operated has been 96, so it's not something that's exclusive to 18 year olds, and in fact if I tell you the commonest age group that have their varicose veins treated are in their 50s. They often have them for years and people notice their veins when they're young but people are often in their 50s or 60s when they have their veins done or older. They always have a few medical problems; very few people get away scot-free.

The other interesting thing is that the timing that people get their veins treated is nearly always when they start blood pressure tablets, because tablets - like a lot of painkiller - relax veins, relax your blood pressure and that's often the time where you suddenly notice your veins, which were just annoying to look at suddenly give you loads of grief. It's often the veins dilate a little bit with a lot of pain.

So, the answer to that question is almost never would I refuse to do a vein operation on someone - remembering it's really always done under local, so a relatively straightforward procedure.

I would say if you had multiple medical problems then it would need to be a medical need to have the vein treated, but to be honest, you'd be quite surprised. The vast majority of people who come to me with varicose veins don't come because they don't like the look of them. They come because they've had them for years and they've just finally started to get symptoms and they usually go for a couple of years with sore, achy legs especially in summer. And then normally, as the days get a bit brighter, and the sun appears again they say this year I can't take any more of this itching or swelling or cramping.

So, it's interesting that often people don't come the first time they ever see a varicose vein. That's the reason why their average age is a little older than you might imagine. And everyone who arrives nearly always is on some kind of medication or has had a couple of problems before they get to see me.

Louise King

Great thank you, so that's all of our questions. Thank you very much to everyone for submitting your questions it's provided a really interesting Q&A session, I believe.

If you would like to discuss or book your consultation, Chelsey, from our Private Patients team will be available to take your call this evening until 8 pm or she and her colleagues are available between 8am and 6pm, Monday to Friday. As you can see on the screen, we are offering a discount for joining the session for the next seven days.

You'll receive a short survey at the end of this session, and we’d be really grateful if you could spare a few minutes to let us have your feedback as it helps influence future events.

And please visit our website to sign up for our range of other events in April and May. So, on behalf of our expert team at Benenden Hospital, Mr Sweeney and myself, I'd like to say thank you for joining us today and we hope to hear from you very soon.

So, thank you very much and goodbye.