Vicky

Okay. Good evening, everyone. Welcome to our webinar on treatments for varicose veins and ThermaVein®. My name is Vicky, and I'm hosting this session. I'm joined by our presenters, Mr Aaron Sweeney, Consultant Vascular Surgeon, and Dr George Taggart, Private GP and Thread Vein Specialist.

The presentation will be followed by a question and answer session. If you'd like to ask a question, either during or after the presentation. Please do so by 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 that this session is being recorded. If you do provide your name.

If you'd like to book your consultation. We'll provide some contact details at the end of this session.

I'll now hand over to our experts, and you'll hear from me again shortly. Thank you.

Mr Aaron Sweeney

Good evening, I'm Aaron Sweeney. I'm a Vascular Surgeon, and just briefly, I've been a vascular Surgeon for a fair while now.

I started in 2002 as a Consultant in central London, and even before that I was very interested in varicose veins, and was one of the first guys to get my hands on a laser which was developed in the Us. We started lasering veins initially up at University College, London, and then subsequently down at Lewisham Hospital and throughout the southeast.

I do quite a lot of these, and probably I'm well over 15,000 now, and in Benenden we actually do the largest number of lane vein, laser vein treatments per year in the UK.

Dr George Taggart

Good evening. My name is George Taggart. I'm a GP in East Sussex.

I qualified in medicine at St. Thomas's Hospital in 1991, and have been a GP in East Sussex since 1999.

Developed a special interest in vascular medicine nearly 10 years ago, and I've been practicing ever since, and was delighted to join the team at Benenden last year.

Mr Aaron Sweeney

And just to kind of run through what we're going to talk about. Normally, we give a little chat, tell you roughly what we do.

What's really important, though, is that people ask us some questions at the end. It is amazing how much you can learn from just a few questions.

But what we're going to do is just a little overview of varicose veins tell you what they are, how they occur.

Sometimes people ask about grades of varicose veins, especially if you have an if you're dealing with an insurance company.

We'll talk a little bit about your consultation, and how we assess you, we will then talk a little bit more detail about your treatment options, and then I think Dr Taggart's going to have a chat about some smaller veins, and in particular his expertise in ThermaVein®.

But the really important thing is the questions and answers at the end, so we love people to ask us some questions, because they often surprise us because we didn't think of that particular question, but it also allows us to chat about what veins are, what you can have done, and some of the myths associated with them.

If we go on to our next slide.

And first thing we're going to talk about is Benenden Hospital. It's a essentially a brand new private hospital. It is the largest provider of vein surgery in England.

We like to think it's a wonderfully clean, tidy easy to park at. There's a very, very high satisfaction rating.

The CQC rated us Outstanding, and that's quite unusual, and it is the highest rating, and we do a lot of treatments here, both thread veins and varicose veins treatments, and we seem to get pretty decent results.

First thing I was going to talk about is what are varicose veins. I think we all know what varicose veins are when we see them. But just to kind of explain to you, if you think of varicose veins, think of a Christmas tree, or if you think of your veins in your leg, think of a Christmas tree.

The main vein in your leg is called your deep vein. It's a single vein. It runs up the center of your leg. It can drain one or two litres per minute. If you're a cyclist it will drain even more, and that vein is the most important vein in your leg.

But rather like a Christmas tree, it has loads of branches. The big branches are nearly always draining muscle, so they're surrounded by muscle and that gives a little squeeze to allow the blood to go uphill.

Troublesome veins are skin veins. We have hundreds and hundreds of these. They're normally small little things less than the size of a shoelace. They drain less than a teaspoon of blood.

And many, many hundreds, of thousands of years ago, when we were all walking around on all fours our hind legs were in a zigzag fashion, and when those skin veins were draining they were almost horizontal.

Somebody decided to stand up, and when we stood up all of a sudden all these smaller veins, which were coping reasonably well, suddenly went vertical, and they had to drain uphill.

There was no muscle surrounding them, so there's no helpful squeeze. They do have little valves to keep everything going up.

But sadly these valves are prone to breaking, and when they break it allows blood to pool just under the skin in these veins.

Some of those veins then come up onto the surface, and that's why you see the little bumpy bits. But nearly always there's quite a lot going on underneath.

Veins cause many, many different symptoms. Most people don't attribute the symptoms to their varicose veins.

They often get a little bit swollen, and it's often your ankles or your feet can swell.

They can appear lumpy, bulging, and blue, but that's not always the case. They often give a little ache. It's mostly at the end of the day because when you lie in bed at night there's no real gravity problem. So the blood tends to drain away from those from the skin.

Sadly it drains into your muscles. So that's why sometimes you have to jump out of bed at night because of muscle cramp.

Your skin, which is full of blood, is trying its best to get rid of the old or used blood, and these little veins are helping it, but unfortunately, because they can't drain perfectly. It pools just onto the skin, and that often gives you a dry itchy skin that can sometimes change colour.

Now there are different grades which can sometimes be useful. The grade one veins are small veins. They we would classify them as cosmetic thread veins.

Dr Taggart, will tell you exactly how we can treat those. Most insurance companies don't cover those.

Many people. Get completely fed up with these. They are sometimes associated with varicose veins, but quite often they are an entity on their own.

The exact reason why they occur. We're not sure it might be something to do with hormones.

Grade. two veins are a little bit bigger. They're the rays on the skin. And again, these generally don't produce symptoms, but sometimes they can produce quite a lot of itching in the skin.

Next we go on to grade three, and that's when they start to pop out on the surface. Give people a little bit of ache and pain, and these veins nearly always require some kind of treatment.

You can try and wear stockings. I have found those to be relatively useless. Surgery can help a great deal.

But sometimes people just have a vein that's not particularly painful, and not giving them any trouble with their skin. And so you can leave that alone. It's not an absolute emergency to fix them.

Grade four is a different matter. That's when the skin starts to change colour. It's a sign your skin is getting a little bit fed up with this pooling old blood, and your skin can sometimes become a little darker in colour.

Then move on to slightly worse stuff and be quite quick. five and six is when really they start to give you a load of hassle.

The skin becomes sore, and can sometimes break down and produce an ulcer. Ulcers are a disaster. I would regard them as a failure of medical treatment.

They take ages to develop. They don't occur overnight, but there's lots of signs beforehand.

Sometimes, however, you just don't realize what's going on, and so you can end up with an ulcer. Once you have one, they are there for a while, and they sometimes take a long time to settle.

If you come to Benenden you will see me, I think a full consultation is necessary. I write down everything, draw things for you, and explain exactly what you have.

I use an ultrasound scanner to check exactly what vein is not working.

I can tell you what your options are. I'm deliberately not trying to force you into an operation. And indeed, many people, I tell them they don't necessarily need one.

I think I only ever push people to have something done. If their skin is on the brink of ulceration. Other than that, I think it's up to you to decide.

I give you an idea of what to expect, how long you'd be out of action, and how quickly things can resolve.

After many years I can kind of work out exactly what people want to know, but essentially we do it all in a relatively short consultation.

I draw everything in front of you with diagrams. Many people take a picture of the note just so they can remember what I've said.

I write a little letter to you as well, but sometimes it's helpful just to take a photo of the of the notes.

So you think of that Christmas tree analogy so varicose veins. You see them on the surface. I scan you just to make absolutely certain the deep vein is perfect, and then I look for which superficial vein is not working nearly always. It's a vein running down the inside of your thigh, but sometimes it can be one running from the back of your knee.

Now when you talk of laser treatment. You sometimes think of James Bond and zapping things on Goldfinger. That's not exactly the way a laser works. It's actually using a laser inside the varicose vein.

90% of those can be done under local. I dare say 100% could be done under local. But I give you a choice.

I do have to inject local anaesthetic around the vein. Some people don't like needles, and would prefer to be asleep. That's fine. Whatever you wish is fine.

We often treat veins with the laser. There are many other different treatments available. Laser is just one of many, and in Benenden we perform quite a few operations, and it can be in some years. It's well over a thousand.

We have performed well over 10,000 in Benenden, which quite a lot in most hospitals they wouldn't get anything close to that.

Now, this picture is a little bit confusing. So if you can imagine this is a pretty thin right thigh, and we're looking at the inside of the thigh and up the top is the main vein and artery.

And coming off that is a small vein, or it should be a small vein the size of a shoelace running down the inside of the leg. But that's the vein that commonly goes wrong, so I thread. I do a little injection somewhere around your knee, thread a little laser up the inside.

I then do some more injections just to cover the vein in a tunnel of local anaesthetic.

That means that you don't necessarily feel like you shouldn't feel me doing the laser. But you do feel me doing the injections. I always use an ultrasound scan just to make sure we're safe and a laser, it's just a fancy way of burning something.

So I give a very, very controlled singe to the inside lining of your vein, which is very, very sensitive, and it doesn't work very well. Afterwards the pain swells a little bit.

And although often on the Internet, people talk about laser vein treatments as being completely painless, I would say kind of the actual treatment is painless because they'll have given you an injection or some injections of local anaesthetic, and afterwards it does hurt a little bit because it swells slightly.

So it often feels like a pulled muscle, something like a pulled hamstring. So it does limit your mobility.

But most people are back to normal within a couple of weeks, and certainly are walking the dog the next day, and perhaps even driving the car after a few days.

So this is kind of a little look inside. There's quite a few different ways nowadays.

In previous decades the commonest operation was stripping. That's where you do a cut in the groin, and you pull out the vein, and that seemed like a good idea, but as your body healed it produced new veins.

And that's why you hear people say, don't ever have your veins touched, because a year or two later they come back, and they're worse than they ever were. And indeed, that used to happen with stripping.

The big advantage of all these minimally invasive treatments is that that doesn't seem to happen.

So there are a couple of different ways. So the endothermal ablation. There's all these wonderful medical terms.

If you basically heat treatments work pretty well, and you can also put a chemical up the inside of the vein, and they work not really well, but in certain circumstances the chemical ablation works better, and in many, many cases the endothermal or laser treatment is the best option.

So you're sealing the vein inside. That's I would call it searing the vein where you're heating it up.

There is a thing called radio frequency ablation, and that's essentially an electricity. Probe that you thread up and it works just as well as a laser. I don't think one is better than the other.

There are chemical techniques where you inject a chemical sometimes that's called sclerotherapy. If you make it up into a few bubbles, it's called foam sclerotherapy.

There's a machine called clarivein, which I've used and works quite well, and that's where you spin a little wire up the inside of the vein which gives you a vibration sensation, but damages the inside lining and use some foam as well.

And there are other things where you can use a glue which is superglue, and I tend to not use that as I have a slight, I'm a little bit scared of injecting stuff chemicals that stay up inside veins, especially superglue.

I think Dr Taggart may well talk about the micro sclerotherapy and ThermaVein® shortly as well.

So when you have your veins done, obviously we're going to show you some nice legs, so the leg on the leg shows a few bumpy bits.

They always appear in the lower part of the leg. They nearly always have a vein running the whole way up the inside of your thigh. It's often about a centimetre or so under the skin, so you don't see it.

Sometimes you do see a little bump, and you wonder why is that so painful? And that's explained by the fact that you have a 40cm tube of vein running all the way up from the bumpy bit right to your groin, and rather like a yard of ale. It's producing quite a lot of pressure in the lower part of your leg.

If you just had the vein lasered, it deflates so you can see a couple of weeks post-op. It tends to get a little flatter, but it's not quite gone completely.

In about six weeks or so. It looks pretty good. Sometimes people would regard that as fine. If you're a bloke with hairy legs, you might say. That's enough for others, you might say I'd like it to look perfect, and sometimes we do a little small incision just to break up the vein under the surface.

I find that that cosmetically works very well the whole thing about lasers, and how they how and how things turnout is all to do with the fact that you are actually doing a surgical procedure.

So it is a little bit sore afterwards and I think so long as you accept that and realize that. Yeah, you probably won't go to the gym for a couple of weeks, but after you will certainly walk the dog very quickly, and we really encourage you to do that.

And from a cosmetic point of view I think it always takes about three weeks before people go swimming, because they're a little bit embarrassed by the bruising.

If you have problems such as itchy skin cramping or soreness, that goes pretty quickly. I think it takes about six weeks to pass your leg off as a normal leg, and for nobody to look twice at you, and occasionally I have girls who are getting married, and I just say, make sure it's about 12 weeks before the wedding, and that's because I know that at six weeks it'll look okay. And that means there's no panic for the final six weeks before the big day.

Dr George Taggart

Thank you, Mr Sweeney, so we've heard from Mr Sweeney eloquently about the treatment of larger varicose veins, but at the other end of the scale. As he's already mentioned, we have the grade one or smaller thread veins. These typically occur on the face and legs.

Thread veins generally do not cause any particular physical symptoms, however, for many patients, they can cause a lot of cosmetic concerns and problems with self confidence.

So here at Benenden we are using established safe and very effective methods of treating these veins.

So the treatment of thread veins on the legs, we use a treatment called micro sclerotherapy.

This involves the injection of a liquid otherwise known as a sclerosant into the vein.

So I either use a concentrated solution of saline, or a detergent based sclerosant, called fibro vein.

Both liquids work in the same way and they cause a reaction once injected into the tiny vein, a reaction in the vein wall which leads to clot, formation fibrosis, or scarring, and then closing down of the vein.

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

Typical appointment for micro sclerotherapy consists of an initial consultation where we take your medical history and perform a careful examination and explain any proposed treatment.

Subsequent appointments for treatment last 30 minutes and typically you'll have multiple injections depending on the number of thread vanes requiring treatment.

Small dressings are applied to each injection site, which need to really be kept dry and in place for about three days, just to help the healing process. and the procedure is an outpatient treatment.

You can walk in and walk out, and there's really no restriction after the treatment other than keeping the dressings dry.

Usually treatment, for various reasons, consists of a course of treatment. There's a limit to how much of the liquid we can use each time and often veins are very close to each other.

So we have to have repeat treatments, and these follow up appointments are about a month apart, and that gives the skin the best chance time to recover and so you can assess the results so far, and the need for further treatment.

So thread veins also occur on the face and we can't inject veins on the face. So we use a different technology called ThermaVein®.

The ThermaVein® was initially established in the late 1990’s and has been used extensively and very successfully in vascular clinics around the country and the and indeed the world ever since here at Benenden we are using the very most up to date version of this technology.

Now attached to the ThermaVein® machine is a tiny nickel probe as you can see on this diagram.

The beauty of the this technique is that the nickel probe is insulated along its length, other than the tip. So all the energy from the machine can only exit the probe at the very tip.

So this means that we can use the lowest possible amount of energy and deliver it in the most accurate way, minimizing the potential for any side effects.

Using the probe, we apply gentle pressure to the skin, overlying a thread vein and this causes blanching of the vein at that point and then a short burst of energy is delivered from the ThermaVein® machine with pinpoint accuracy.

This heats the wall of the vein, which causes it to collapse, and the walls stick together.

We then move the probe one or two along the course of the vein and repeat the process as we go along we conceal the vein, and it disappears from view because the blood has been removed.

If we have a video that we can see. So just on the right of the probe is the vein that's being treated.

You'll hear beeps on this video, and each beep represents a pulse of energy from the machine.

You can see the vein is removed as the needle is moving along it.

Yeah, really impressive result, and the vein is gone.

As with micro sclerotherapy treatment, once we've closed down a vein it becomes redundant and empty of blood, and eventually the vein is reabsorbed into the surrounding tissues.

Here we have another video of the process of the treatment in action, and if you look at the lower two veins of this cluster, the doctor is going to move along this vein, applying the pressure to blanch the vein, and then using the impulsive energy to seal it off.

There is no noise on this video.

As you can see, the vein is blanched and then sealed by the energy of the machine and that pain is now disappeared from view. The vein is still there, but the process of healing will now start.

So the two veins that were there, you can no longer see.

So ThermaVein® is really an excellent treatment for the red and purple veins that typically occur on the face.

Also, we can use it for any vascular blemishes anywhere on the body and we also use it as an adjunct to micro sclerotherapy on the legs for veins that are too small to inject.

Due to the heat energy that we are applying to the skin, the treatment causes an inflammatory reaction almost always and this can make the treated area slightly red and puffy.

I just go back to this slide, these typical thread veins on the patient's nose have been treated, and, as you can see the skin is left slightly red and again veins on the chin leave you the slightly inflamed appearance.

The inflammation usually settles after two to three days, but sometimes lasts up to a week, very rarely longer than that immediately after the treatment we apply aloe vera gel, and this has a really good soothing effect, and I'd recommend that after treatment you continue to apply aloe vera, really, until the inflammation settles down.

So for a couple of days most patients require a course of treatment.

And the number of treatments depends on obviously the extent of the thread veins.

At your initial consultation we decide or discuss how much treatment is required, and also examine you for other skin conditions which may be aggravating redness, or the veins such as Rosacea.

If we do find that you have Rosacea, we often recommend you have some treatment for that before commencing ThermaVein® treatment, as from experience, we know that results are much better.

As with leg appointments or leg. Sclerotherapy appointments, treatments are one month apart, then we can really assess the benefits of the previous treatment and the need for further treatment.

So here we have some more photographs of typical thread veins around the nose, obviously before treatment and after treatment.

This is a vascular blemish that is very amenable to ThermaVein®, and really good result.

Again, another small blemish on the upper lip and a linear vein facial thread vein, with excellent results.

So in summary, thread veins are a very common problem and can be debilitating for some people.

With micro sclerotherapy and ThermaVein®, we have well established safe and really effective techniques for their removal.

Vicky

Thank you very much, Dr Taggart, and thank you both of you for that really interesting presentation. So we're now going to take some questions.

Okay, the first one, I think, probably for you, Mr Sweeney, and this is from Christine, and Christine asks, I had my veins removed nearly 10 years ago. Can I have more removed now, or is it not recommended?

Mr Aaron Sweeney

You certainly can have them removed again sometimes I normally would do a scan just to make absolutely certain. It depends what kind of operation you had. If in the past you had a stripping type procedure, they're often a little twisty.

So there's often a combination of techniques to fix them. People sometimes think they only have enough a certain number of veins. But actually, I like people to think of varicose veins as abnormal veins. They're not working correctly, they're just sitting there pooling blood.

So all the other veins in your leg which are doing their job. But they're also doing a bit of overtime because they're taking care of this blood that's pooling so quite often, you might think I shouldn't remove any more veins, because that'll put more pressure on the surrounding veins.

But what I would say is that actually, varicose veins themselves are putting extra pressure.

So I would say, it's reasonable to get rid of them. I do check you, though, because you need to be just certain that the deep vein is perfect, and that's the reason why I arrange and do the scan myself.

Vicky

Thank you very much. Hope. That's helpful, Christine.

Next question is from Jackie, probably for you both. Here I have a combination of varicose and spider veins, which I'm sure is common.

Can they all be treated in one session and both legs? Can I leave after one session with lovely legs?

Mr Aaron Sweeney

If I answer the varicose vein thing, I would say, just varicose veins, you can have them treated, and if you think of varicose veins as the lumpy, bumpy bits. Yes, you can get rid of those. You should end up with flat skin. So no bumpy veins visible.

However, I always feel that takes about a six weeks before that happens, and I think Dr Taggett might give you a bit of an idea in thread veins.

But the simple answer is, you can't do everything at in one go if you have a combination of thread veins and varicose veins.

Dr George Taggart

Yes, I think spider veins can be a result of the varicose veins and so, if you have reflux disease which Mr Sweeney deals with that can improve the spider veins. But generally you have to treat the bigger veins first.

Treatment isn't instantaneous, and so there is always going to be a delay for the results you're after. But generally we need to treat the varicose veins and that involves a scan and then we can treat the spider veins afterwards.

Vicky

Okay, lovely. Thank you very much, Jackie. I hope that answered your question

Next is from Julie two parts of this question. The first one is, Julie suffers with blotchy areas on one ankle, but she's not sure if they're thread veins can thread veins be red.

Dr George Taggart

They certainly can. The colour of the vein generally indicates the size of the vein, so the smaller veins are red, and as they get bigger they go from purple and then to blue, and then obviously varicose veins tend to be obviously dark blue, so absolutely veins are.

It means your veins are very small and can hopefully be treated.

Vicky

And the next part of Judy's question is, my main question is injecting around the ankle area affecting the main veins. Stroke circulation in the leg

Note I have varicose veins, too, and I get cold feet, which I think is a circulation issue.

So she's got some concerns around in having an injection around the ankle which might affect the main veins or circulation in the leg.

Dr George Taggart

We tend to avoid injecting below the bony parts of the ankle, because the technique doesn't work as well generally because there's more pressure on those vessels.

So I would avoid injecting below your ankle bones. We can use a ThermaVein® in that area for small veins, but I would certainly not be injecting around your ankles and feet.

Vicky

Okay, lovely, thank you.

Jackie, who spoke to earlier, just has another quick question, she said. Looks so instant and amazing. Can it not be used on legs with similar thread veins?

Dr George Taggart

It certainly can. So ThermaVein® is used as an adjunct to the injection therapy. It works best for the smaller veins.

Some of the large, slightly larger veins, or larger thread veins in the legs don't respond as well to ThermaVein®, because there's more blood and more pressure. But for the right size vein it's really an amazing treatment.

Vicky

Great lovely. I hope that's encouraging for you, Jackie? Next question. I have chronic Utica, and on omalizumab injection every month. So how will ThermaVein® treatment be for me?

Dr George Taggart

We often are obviously careful when there are other medical issues or drugs, and we'd have to be very sure that we're not going to aggravate or cause any other problems by using ThermaVein® treatment.

So this would be something we would talk about very carefully in a consultation. There's no reason why you can't have ThermaVein®, but obviously you would need to go through one's medical record and other drugs just to make sure that is safe.

Vicky

Lovely. Thank you.

Sally asks. What's the recovery time for thread veins, and how quickly afterwards can you exercise?

Dr George Taggart

Thread veins in the legs, we encourage you to exercise because we use dressings and sticky tape, vigorous exercise, which would make you very sweaty. It's probably to be avoided for the first three or four days, but we'd encourage you to walk. So exercise you can carry on.

Recovery time for thread veins. We leave a month between treatments that gives the vessel completely enough time to get back to normal. So I mean, the recovery time is extremely quick. But I would in order to judge the treatment fully. It's a month.

Vicky

Okay. Thank you very much hope that answered your question, Sally.

Teresa's asked, do you need a GP refer? I believe not. If you're paying for your own treatment?

Dr George Taggart

Correct. Yes.

Vicky

Next question is from Francis. Francis asks after treatment. Will it be more comfortable when standing afterwards? I've seen? That's varicose veins, treatment.

Mr Aaron Sweeney

No, I think it's more comfortable when you're moving around so for most people they would have a bandage on their leg for a few days they would be well able to walk the dog.

But I think jobs where you're standing all day. So in particular, things like nursing or hairdressing. If it's if you have to be in work the following day, you will be. But I think you'll probably take some neurophen or a painkiller like that. So I do think it feels like a pulled muscle.

And it's a little worse when you're standing still. If you're in a job where you're whizzing around. It slightly takes your mind off things, but I would say that I would suggest most people, after having a varicose vein treated reasonably quiet week afterwards.

So, and people who work for themselves nearly always go back to work the next day. But when I see them afterwards, they say, I wish I could have taken a couple of days off. That bandage was a little annoying. I couldn't wash myself properly for the first day or so, and I wish I could have spent a couple of days at home.

Vicky

Okay, lovely. Thank you.

Next one for Mr Sweeney as well. I've had quite thick dark blue veins on the left side of my right shin for many years. How long do you think it will take to get rid of these, and how safe is it to remove?

Mr Aaron Sweeney

Safety. Wise it's pretty safe procedure.

The risk I always think about in terms of varicose veins is something like a deep vein thrombosis that occurs in about one in every 1,000 people that I operate on a bit less than that, probably. And just to put that in perspective. If you had a baby, your risk of a DVT is one in every 100 pregnancies, and if you broke your leg skiing, it's as high as one in 10. So

I regard I'm a vascular Surgeon. So I always look out for the worst possible thing that can happen. And then I make sure that doesn't happen, because everything else is fairly straightforward to sort out. So

DVT’s are what I worry about. But for most people they don't occur, and once. You're mobile afterwards it. They certainly don't occur.

With regards to fixing the vein. Well, it depends. So if you're in a discomfort or itchy, or getting cramps, they nearly disappear almost instantly.

The procedure is done from a cosmetic point of view. I think it depends. You need a little bit of fat on the skin for the vein to dissolve away after I treat it.

Areas that are a little bit slow to go are the front of the shin where there's not much flesh, so it sometimes takes six weeks or so for that to look good enough to walk around in a pair of shorts. But if it was painful and aching that normally disappears literally within days.

Vicky

Okay, lovely. Thank you very much.

Next question is from Maxine, and she's got a couple of questions, actually. And she asks, I like going on long walks with my son once or twice a week. How long would she have to wait to get back to doing this?

Mr Aaron Sweeney

From a vein point of view. I think you walk the next day, but I think it takes you about two weeks to get out of bed and go for a walk without even thinking about your leg.

Walking is really good, and in fact, it's really good following vein surgery, because the blood flows much better, and it helps dissolve away the bits that I have lasered.

Other people may have questions about. When can they get back to the gym, or play golf or even go cycling or spin, or go to spinning classes, and I feel you can do that whenever you feel like it.

But in my experience most people don't feel like. At the first week, the second week they go back to the gym, but they probably wouldn't do a spinning class, and normally on week three they start playing tennis again or running in the gym.

So it's quite a quick recovery in comparison to what it used to be like, but I do think it takes you a couple of weeks to get back to full speed.

It is interesting that people who play golf are nearly always back playing golf almost instantly. I think they consider that a good walk.

But I think on a more serious note, people triathletes when I operate on them they say it took them about two weeks before they started going out cycling and slightly longer before they felt comfortable going for long runs on Tarmac. They said it sometimes took them three weeks to get back to full speed.

Vicky

Did you have anything to add to that

Dr George Taggart

No, I think with treatment of thread veins, there's really little restriction. You can get back to normal activities almost straight away. There's no pain problem. It's just really keeping the dressings dry for three or four days.

We're trying to avoid excessive increase in blood flow to the face and limbs so gentle walking for the first three or four days, and then back to normal exercise. After that

Vicky

Thank you and Maxine goes on to ask with either of these procedures affect the heart?

Mr Aaron Sweeney

From a vein point of view, shouldn't do. You're essentially surgically. You are miles away from the heart, and I can't see a reason why it should make any difference.

You might be asking me if you had a problem with your heart such as you had fibrillation, or you were on a blood thinning tablet, such as Rivaroxaban or warfarin. I operate on people with those routinely. It doesn't seem to make any difference to the outcome.

So any heart medication. I just assess you beforehand to make sure that I'm doing it for a good reason, and that can be cosmetic. But mostly, for when people have heart trouble. It's because their legs are swelling and they're getting ache and soreness.

And then I just check your medication to make sure there's nothing that's contraindicated. But, to be honest, I don't think it makes that much difference.

Dr George Taggart

So for the ThermaVein® treatment. We're not allowed to use that. If you have a pacemaker because it can interfere with the electrical impulses, but otherwise there's no problems with heart problems.

Vicky

Great, lovely. I hope that's put your mind at rest there, Maxine.

So the next question is from Zoe, and another question for both of you. What is the lasting success rate of both treatments?

Mr Aaron Sweeney

If I say per veins, I usually quote a few figures to people, so if it is a

first time operation and I use a laser. I tell people that about 1% of people pop back to me within a year, and they show me something. It's usually a very tiny vein that's popped up. It is almost never the vein that I've treated.

I think after 10 years about 10% of people come back with another vein. It's usually another vein. It's very rarely the same vein, and it's nearly always on the other leg, and for whatever reason you got varicose veins in the first place, and there are many reasons.

And in fact, we don't know most of the reasons. Sometimes you're just a bit more prone to getting them.

Now, sometimes online people talk about 100% success rate. And that's kind of true because if you laser a varicose vein, it essentially disintegrates. So you could possibly say to people, I have a zero recurrence rate.

But I don't think that's entirely what people are asking. Normally, people are saying, how likely am I to be back, and if you do my veins, am I going to be back with you every year for the rest of my life?

The answer is the reason I do the scan beforehand is to tell you exactly what your risk is, and for almost everyone. I tell them I very occasionally see you back.

It's usually a little cosmetic thing that's popped out in the first year, but I rarely see people back for the same varicose vein. I can almost count that in 30 years of doing this and I think a small number of people.

So, for example, if you come to me and you're 18, and you have some varicose veins. I think it's pretty obvious you have a you're genetically prone to them, and you're probably going to get a few later on in life, I would say.

One of the great things about minimally invasive, varicose vein surgery is that you treat just the vein that's not working.

It's minimal complications, and if another one pops up in 10 or 15 years well, you can just have that one lasered. It could be a bit annoying. But sometimes you're just dealt a bad hand when it comes to varicose veins.

The big difference between the older operation of stripping is that I shouldn't be giving you any new veins, and that was the main disadvantage of stripping. It produced new veins that often made people's lives a bit of a misery afterwards.

Vicky

Dr Taggart?

Dr George Taggart

Yes, it's difficult. I don't have specific figures of success rates, and it's how one defines success. What we're after is really improving the appearance of thread veins.

The theory of the treatment is once a vein is treated, as Mr Sweeney says it disappears, but if you produce veins, or you genetically predisposed to having thread veins and varicose veins.

You are likely to have more but it shouldn't be the same vein. Often people will have a course of treatment, and then over couple of years or so, we'll come back for a top up treatment.

 So specifically answering your question is difficult. But the theory of the treatments is that they do not recur.

Vicky

Okay, lovely, thank you both.

Our next question is from Christine. Christine says a friend of hers had sclerotherapy treatment. Not at Benenden Hospital.

She's been left with a very large mark, a brown in colour, which is quite large, and that concerns Christine about having this treatment. Could this be a side effect?

Dr George Taggart

Following sclerotherapy, it depends which, if it was a varicose vein or a thread vein, you can have staining from hemosiderin deposits staining does improve over time, but it certainly is a side effect that can happen with foam and injection micro sclerotherapy.

Mr Aaron Sweeney

Sometimes people have laser treatment, and then they have a foam sclerotherapy afterwards to treat the smaller veins. I generally shy away from that, and I would do normally a little nick in the skin to break up the vein under the surface. And the reason is that I find that cosmetically doesn't produce staining.

I've in my practice. I am very careful about injecting larger veins, especially in the calf, as it can produce that brown, hard lump. Sometimes it's necessary for medical reasons, but certainly for cosmetic reasons. I would avoid foam in preference to actually removing the little bumpy vein below the knee.

Vicky

Lovely, hope that's answered your question, Christine.

And next question is from Bernice, and she asks, how quickly can you fly? And also is high blood pressure at risk?

Mr Aaron Sweeney

So I would say first thing, I'll answer the blood pressure thing. So quite often people come to me and they say they've had veins for donkeys years, and then, a couple of years ago, they all started swelling and giving them loads of pain.

And then, I ask, are you on some blood pressure tablets and blood pressure tablets relax your circulation to allow your blood pressure to drop, but they also give you ankle swelling, and they make your veins sometimes more achy.

So sometimes people who are having their varicose veins done have quite high blood pressure and on medication, and in fact, I treat the veins anyway, and it gets rid of their symptoms.

And the second thing is flying. Flying is one of those controversial things. I think everyone says you can't fly for six weeks, and then some other people say it's a risk factor for a deep vein thrombosis.

I don't know where they get all their information from, but it's not necessarily based on a lot of research. So your risk of getting a DVT in an airplane is tiny. I feel a lot of people buy flight socks because they're a little bit worried.

Flight socks are great for stopping your ankles swelling in a flight to Miami, but I don't think they make that much difference in terms of deep vein thrombosis. Your risk of a DVT on a flight is virtually zilch.

With regards to operations. I just say to people I once measured how far it was from the car park in Gatwick to the gate, the EasyJet gate, and it's a mile. It's a long way to pull a bag with a bandage and a sore leg.

So I say to people, I mean, if you, if you want you, could fly away the next day medically, doesn't really make that much difference, but it's a little bit achy as you pull your bag around.

If you waited a week or two, then that you often feel quite a lot better, but it's still a bit bruised.

So if you're lucky enough to have a place in the sun. That's fine, because nobody needs to look at your leg. But I think if you go away within three weeks of having a varicose vein operation.

Your leg looks a bit bruised, and I think you'd be telling everyone about your varicose vein operation, and it might drive you absolutely nuts. But from a medical point of view. You can fly as soon as you wish. There's no particular restriction on that.

Vicky

Okay, thank you. Did you have anything to add about high blood pressure?

Dr George Taggart

I think high blood pressure is something that needs to be. You don't want to be wandering around with high blood pressure. And so it's best get that treated just as general medical principle.

How quickly can you fly? I always advise people not to fly within a week of micro sclerotherapy treatment, not because there's any associated risk between it and flying.

But if you did have a DVT from a flight I wouldn't want there to be any association with the treatment you've had, or any thought of an association, but there is no evidence of any association with risk to flying.

Vicky

Okay, thank you. And we've got time for a couple more questions.

This one's from Denise, and she asks, I have thrombophlebitis in my car veins after a long flight, and it's still hard. What would be the best treatment? The leg has already been stripped. 20 years ago.

Mr Aaron Sweeney

Okay. So the reason that's happened is that if you have varicose veins, especially if they've recurred following stripping, they're often very thin. They're very tortuous, and they're often around your knee, and the reason they cause you trouble on flights or on a train journey, or just from car journeys is that you crease the vein just around your knee, and if you're in that position for a long time, it sometimes gets a little bit irritated. Sometimes it gets irritated by wearing flight socks.

They sometimes give you trouble as well , but if you think those veins should be the size of threads.

They've been stretched, and the wall eventually, rather like a balloon, just gets a little bit too weak. It cracks a little bit, and it forms a clot.

Now, when you form a clot inside your vein. It can be a little tiny clot, a centimetre or so, or it can clot off the whole varicose vein, in which case it becomes painful because your body tries to dissolve that clot. So it sends loads of fluid and swelling around it.

And sadly, veins are a little bit tough. They're kind of leathery in texture, even though they're thin. They take a while to break down so quite often after you end up with phlebitis. You end up with a hard lump that goes quite dark, I would say there's not a great deal you can do about that.

Most of the lump is actually hard, because there's a high pressure of fluid around it dissolving it.

So I generally tell people you need to use some kind of painkiller, and that can be ibuprofen or voltrol gel.

Maybe even an ice pack, just to reduce the swelling, and there is a great drug called hirudoid, which is a thinner blood which you can buy over the counter in the chemist, and it works pretty well at reducing the lumps. But it's not a painkiller.

So unfortunately, if you get thrombophlebitis, you end up with a rough time because you can't remove that clot. It's kind of everything is all stuck together, and it takes forever to for that to disappear.

And I often see people six months after they've had a bad attack of thrombophlebitis, and they still have a little bit of lumpiness and a little discoloration in their skin.

It's unfortunately just one of those things that don't disappear quickly.

If you've got a very large amount of thrombophlebitis. It usually makes you not very mobile, and it's a moderate amount of clot inside the leg, and sometimes you go on a blood thinner, and that's to prevent you getting a deep vein thrombosis.

So if you think of the Christmas tree analogy, if you have one of the branches that's clotted off, you want to make sure that bigger vein, the central core doesn't clot off and give you a deep vein thrombosis.

So quite often you'll be put on a blood thinner, such as Rivaroxaban or Edoxaban, or one of them, just to make sure that doesn't happen. That, of course, doesn't sort out the pain, but it stops it, getting any worse.

Vicky

Hope that's helped.

And our last question is from Kim, and Kim asks if you have varicose veins that are beginning to bulge. Is there anything you can do yourself to prevent them from getting worse?

Mr Aaron Sweeney

Kind of, if you walked around on your hands all day, it would reduce the pressure and stop them stretching. But essentially, once you got varicose veins. You got them.

They're going to stay there. The question, you might say, is, well, if I have them fixed now, will that save me a load of hassle in the future. It might do, but not everyone has to have their veins treated, and I always emphasize to people that if you come to me with varicose veins that are just beginning, and they're a little bit annoying.

I would say you don't have to have anything done. There's no great risk associated with first time varicose veins. So you can sort of wait and assess and see how you go.

But to be honest, if you've got varicose veins. They're going to stay there. If you are of childbearing age, and you have varicose veins, they're going to give you a bit of grief during pregnancy, because your hormone progesterone spikes a little bit, spikes a great deal in your last trimester, and Progesterone is there to relax things to allow a baby to come out, but it also relaxes your veins.

So that's why poor girls get a bit of a rough old time from Progesterone if they have varicose veins. So sometimes people say don't have your veins treated until you have all your kids, I would say, if they're giving you grief, get them treated.

But if you're just visible and you're not bothered, I wouldn't necessarily rush to it, and the last thing I would say is that most people come to me with varicose veins after having them for 10 or so years. Most people are too busy with their kids life and everything else.

And it's only really when they start to give them grief like pain, ache, or itchy skin that they generally come to me. It's very rare for someone to come the moment they see a varicose vein popping out.

So most people have had a long time waiting to see what happens. They notice they get bigger, but not enormously, over the space of a year.

And if you start to get ache and pain, that's usually the period where I say you should have something done. But of course it's entirely up to yourself.

Many people haven't done for cosmetic reasons as well. I think that's entirely reasonable. It's not particularly dangerous operation, and it does make people feel pretty good afterwards.

Vicky

Lovely, thank you both for that.

Sorry if we didn't answer all your questions. If you've provided your name, we will answer them via email.

So finally, just what's left for me to say is as a thank you for joining this session. We're offering 50% off the value of your first consultation, using the code on the screen.

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So on behalf of Mr Sweeney and Dr Taggart and the expert teams here at Benenden Hospital. I'd like to say thank you for joining us tonight, and we hope to hear from you very soon.

Thank you, and goodbye.