Louise King

Good evening everyone, welcome to our webinar on treatment for varicose veins. My name is Louise and I’ll be your host this evening. Our expert presenter is Consultant Vascular Surgeon, Mr Aaron Sweeney, who you can see on screen. Our presentation tonight will be followed by a Q&A session, if you'd like to ask a question during or after the presentation, please do so by 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 the webinar is being recorded so if you do provide your name then your name will be within the recording. If you'd like to book your consultation, we have Sarah from our Private Patients team on hand to take phone calls after the webinar and we'll provide a phone number at the end of the session for you to do this. I’ll hand it over now to Mr Sweeney and you'll hear from me again shortly.

Mr Aaron Sweeney

Thank you very much. Hi there, I hope everyone can hear me and thank you very much for tuning in. My name is Aaron Sweeney, I’m a vascular surgeon and I specialize in vein surgery along with my colleague Eddie Chaloner. We have been doing lots of veins for some time here and over the past 15 or 20 years or so we have lasered, mostly lasered multiple varicose veins. When we started as little surgeons as junior doctors, we used to do various operations on varicose veins but they were mostly stripping type procedures, which we always felt were very brutal and so we both saw a laser treatment performed around the year 2000. Both of us thought it was a fabulous procedure and hence the reason why we got into it then and keep doing it now. We do a lot of varicose veins here at Benenden, we're the largest provider in England at the moment and in fact, we do more than a thousand a year, which is a very large number of varicose vein operations and we've been doing that for many years, so for 10 years or so, that's the number we do it is the commonest operation that we do for varicose veins and we like to think that we have organized or helped organize things to so that it's very slick and very safe and we do it as a walk-in walk-out procedure, which we mostly do under a local anaesthetic. We think that reduces risks of complications and we're the only people who do the operation so you're operated on by a consultant vascular surgeon if you choose to have an operation and you're certainly seen by one of us, I like to see people and then operate on the people that I’ve seen.

I thought we should talk a little bit about what varicose veins are and a lot of people find them a little bit confusing, people mention various things like stripping and lasers and foam but often people don't understand what a varicose vein is so if I tell you that you have an artery that brings blood down your leg and a vein that takes the blood out of your leg and if you think the main vein that takes it out of your leg is called your deep vein and I think it's helpful to think of veins like a Christmas tree, you have one main trunk and hundreds of smaller veins joining that main trunk and for the most part they work perfectly, the blood, however, is going up against gravity and it does require a few valves to help make sure the blood goes in the right direction, there are some of those branches that have a little difficulty because they're draining the blood from your skin they are just onto the surface and sometimes those valves break. The commonest one breaks up in your groin and you can have a little break, then all of a sudden you have a branch of your vein that's not working correctly, allowing a bit of blood to pour back down your leg and you don't normally see it in your thigh but you often see that vein appearing in your calf and occasionally that can be really painful but relatively small. So you can see a very tiny vein in your calf and wonder why is that producing so much ache and pain and what you don't realize is that there's a vein lying under the surface going all the way up to your groin and that can be 50 centimetres long, so it's a bit like having a yard of ale sitting under you under the surface producing a lot of back pressure and a lot of pain.
So there are loads of things that varicose veins cause but most times people are not entirely sure if it's their vein that's causing trouble because you can sometimes have a sore knee sore aching bones little many different conditions that mimic varicose veins, so it's often a little bit difficult to work out if varicose veins are the cause of your problem, most times people present with varicose veins with a little bit of swelling, to begin with, and sometimes a bit of aching it's nearly always at the end of the day because if you think a valve has to be broken if you're lying in bed at night there's no gravity causing trouble so most people don't get too many problems at night with varicose veins, nor indeed do they get those problems first thing in the morning, but as the day goes on and the vein fills up and refuses to empty properly. Aches, pain, cramping or soreness occur often, with people after they have their varicose vein operation come back and say my legs feel so different they're lighter I don't get those weird cramps at night in bed and the itchy dry skin that I used to have has gone.

Sometimes people have no symptoms at all and just want their veins done for cosmetic reasons, which I think is entirely reasonable. Most people have varicose veins for a long time and then something happens such as phlebitis, which is where your vein becomes sore or you start to get itchy or cramping in the evening then they come and we treat the vein and that should all disappear. Often people talk about grades of varicose veins if I tell you if you think of them like a Christmas tree again you have the main vein you have branches and then you have the little pine needles I would always think of the grade one veins are a little bit a bit like the tiniest their pine needles, people often call these cosmetic thread veins sometimes they can be itchy most times I treat those with injections clearer therapy that's where we inject a little chemical into the vein to damage the vein and then to allow your skin to get rid of it so your skin to dissolve the vein and for it to disappear those kinds of treatments, there are many of those and many different treatments for those which means that not every treatment works perfectly. I have found that sclerotherapy works well but it often takes a few goals to get it to look perfect. Grade two is slightly bigger veins that you can feel, again you can treat these in many different ways, injections sometimes by actually removing them. That all again can be done under a little bit of local anaesthetic. Grade three are the usual ones we see in the consultation here and they often appear like this and you look and you go I wonder where that's coming from that's the inside of somebody's knee and the commonest place, that vein arises from right up in your groin so that's the reason why we always will do ultrasound scans of your leg just to map out things underneath because it is remarkable. As a junior doctor and indeed up until relatively recently, people didn't do any ultrasound scan they more or less guessed where the vein was coming from so it's not as unsurprising that that resulted in lots of recurrences, nowadays you have to have a scan before you do any kind of operation or even advise someone what to do with their varicose veins. Finally, you get to sort of you know slightly bigger ones that produce a bit of skin discolouration these are the veins that so when you come if you come and see me I will always tell you you've got options for your varicose veins, I nearly always tell people what the if you leave them alone what happens, nearly always I will say they're sore they'll remain sore but they very rarely cause so much trouble that I would push it to have something done when you get to grade four veins that's when the skin starts to become inflamed so it can be slightly red, slightly dark in colour, itchy it's mostly down the lower part of the leg and so when this happens I would tend to push people to have something done. The reason is that if you leave these alone you can end up with some pretty grim things, so on the right, there is a venus ulcer which is miserably painful and on the left is a small one it can be just equally as painful unfortunately when you have an ulcer in your leg the nerve that supplies that area of the skin is the same one that supplies your funny bone which we've all smacked against the side of the bed at night and it's very painful it keeps firing off and it will keep firing off until the skin covers over and that's how I always think this is similar to a burn it just keeps on going and keeps on annoying you. I’ll take that off the screen because it's dinner time. With regards to treating veins we normally or the normal vein is what you're looking at on this scan, you're looking at the inside of what looks like a lady's right leg so you have the main vein and artery running up in the groin and then it's a little branch of that that comes down the inside of your leg.

In terms of treatment options, the thing you think about is that the vein itself is bigger than it should be, it's not working correctly the blood is going in the wrong direction following gravity and it's not being stopped going down your leg by a valve, so the older operation used to be to do a cut on the groin put a wire into the vessel and pull it out and that was called stripping which was a bit brutal. All of the newer treatments involved nearly always involved passing something up the inside, I usually throw a little laser up, so it's not like James Bond, in this treatment we thread the laser up the inside of your vein and essentially we give heat to the for a slight burn to the inside lining of the vein to get it to dissolve away, EVLT is the laser treatment but there are other treatments and they usually consist of things such as radiofrequency, ablation or microwave therapy. Radiofrequency ablation is using electricity instead of a laser to develop heat. There are some chemical techniques where you stick a chemical in the inside of your vein and what you're trying to do there is to give a chemical burn, I don't usually use those techniques. Sclerotherapy is one of those and that works for small cosmetic veins, very well for larger veins I don't think it works quite as well as a laser and indeed NICE which is the government-funded website which will tell you what's the most recommended treatments for varicose veins always says heat-based treatments are the best and they're saying that lasers or electricity or microwave and works best at damaging and causing the vein to disintegrate. There are other treatments clarifain and glue there's some super glue that people inject up the inside of veins, I don't do that and as you can imagine that's going to be stopped soon because although it works very well there have been some complications and I think most surgeons now are a little wary of doing that. Clarifain is a treatment that I have done many hundreds of in the past and that involves a little spinning wire that goes up the inside of your vein and was pretty much pain-free. I found it didn't work as well as a laser so I recommend laser treatment now.

When you come to me I think it's really important to see the guy who's potentially doing an operation on you and also to have a few questions, I try to answer all those questions before they're asked but I think it's nice, sometimes people feel that their questions are a little bit dumb but of course, you know I see veins and arteries all day long and you don't so there are very few questions that I have I haven't been asked before and they're always relatively simple things people think “oh my god am I going remove that vein and is that going to stop the blood supply to my leg” no is the answer it's not working that's why it's big, all the blood is just cooling there and you have so many other veins that are unfortunately working a bit of overtime because that one vein is not working. When you get it out of the leg or remove it or damage it and it dissolves away the other veins in your leg suddenly have a holiday because they know how they no longer have to work against that waterfall that's falling down the leg and when you come and see me I’m just I essentially assess you just to make sure that you're fit enough for procedures. I like to scan you myself so that I know how easy your procedure is going to be and for most people, I will book them in as a local anaesthetic because I realize that it's quite a straightforward procedure, sometimes I advise people to have a general anaesthetic and that can be because the vein might be a slightly unusual or they might be nervous in which case it's no great problem. Most people have it as a local anaesthetic walk-in walk-out procedure and nearly everyone thinks that they're coming in for some root canal dental work, I try to reassure them and afterwards almost everyone says that was nothing close to even a normal dental appointment.

This is kind of what you'd expect to see after EVLT, I would point out that these aren't particularly bad and we're never going to show you someone something that hasn't worked so this is kind of an ideal situation where on the left someone has some varicose veins, all we've done here is laser the vein running in the thigh we haven't done any extra work such as small incisions called phlebectomy to help get rid of the smaller ones and six weeks or so post-op most veins have disappeared completely. I would say that when you see adverts for varicose veins surgery, people are forever being told that it's a walk-in walk out rather like a haircut you go home life is wonderful, you never even know you've had an operation and you can go back to being completely normal the next day. I would just caution you a little bit on that I think whatever surgery I do on the leg and that can be mostly EVLT but sometimes I do a little bit of foam, I feel that most people feel like they have exercised too much or pulled the muscle, you would have a bandage on your leg for a few days afterwards and I think if you approach it that it feels like a pulled muscle, that kind of gives you an idea of what to expect in the days following surgery. Most people will take some kind of painkiller like neurofen. I think the next day you'd walk a dog for example and you'd certainly be independent but I think it takes about two weeks to feel that back to normal so that for example going to the gym or playing a proper round of golf, I think it takes about six weeks for the bruising to disappear enough so that nobody would notice that I’ve done anything to you. Most people can fly and go on holidays as soon as they want afterwards, I normally suggest waiting a week because it's a bit miserable having a bandage on your leg and hauling a bag for the mile or so it is between parking your car and getting to a gate so although you could fly straight away I’d say wait a week I think it takes about two or three weeks to feel that you're back to your normal self and you can totally enjoy a holiday or be back to your normal speed. I think it takes six weeks for it to look virtually perfect and for girls who are getting married I normally suggest that any procedure on their leg is about 12 weeks before they get married and that's because for the first six weeks it's a little bit bruised, then they know it's perfect and then they don't get stressed for the final six weeks.

I think we're going to give you a little patient testimonial now just so we're going to take a few minutes and then after that, I’ll come back and then we can take some questions. I find the question part is often much better than my presentation because people often have a lot of questions and I urge you to ask them because sometimes you might feel it's a dumb question but please don't because we've been asked them all before and often my answer answers loads of other questions so it's really helpful.

Joe Crossey

My name is Joe Crossey I am 58 years old. Well, it did it was making my legs more uncomfortable as the years went on feeling very heavy and tired and especially in the hot weather my feet would swell and just generally feel achy most of the time, I did start working part-time and part of that reason was probably unconsciously thinking I can't keep on my feet all day long every day.
We thought it was worth the drive to go and especially when it was a beautiful new hospital, it was a very pleasant experience, and I would not hesitate to go back again if I needed to in the future.
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 that 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 would talk through it and the staff were very helpful and supportive and talked you through every process.

I felt as if I am walking into a lovely environment that everything was going to be okay and that it would be state-of-the-art technology and processes, so I felt very confident that I was in good hands.
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 and I or if I was in 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, sorry rubbing in local and anaesthetic gels, wearing a support bandage if I needed to and I did that a few times because the weather was quite warm and post-surgery so I made use of those devices and advice and that 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.

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

Louise King

Right thank you, let's move on to the questions if you just go onto the next slide we can see the number at the bottom on the screen, perfect and that video won't want to start playing again with the music. Okay, so we do have some questions so I will go through them. Roshan says whenever I’ve had a surgical incision I have developed a keloid might this happen with your procedure?

Mr Aaron Sweeney

Yes, is the answer to that however the incisions that you have done are usually done with a cataract knife so it's an eye surgeon's knife which is very very thin and very very fine so you would normally just have a few dots that look like you've had a blood sample taken, so in general, people who suffer from keloid don't have much trouble with varicose vein treatment. I think if you have a scar that's more than a centimetre or so you probably find if you're prone to keloids they occur but we have well so far I’ve never seen anyone develop that keloid but I’m always mindful that anyone who's who does develop keloid the scars are never quite invisible afterwards you can always see the mark because you sometimes get a slight red halo around the scar so it does look a little more obvious than say normal but I’ve yet to see someone develop a big lumpy keloid after EVLT.

Louise King

Thank you, another one is when they have had even minor surgery, they have developed a fever afterwards we are quite far from them what would they do if that happens after the procedure?
Yeah I’m not quite sure why you should develop a fever can be I suppose a reaction to some anaesthetic drugs but the one that you're given with us is lignocaine and I’ve never seen that produce a fever. What you might be saying is if anything happened to me what happens so because you're some people are nearby you call us you know we see you straight away, if you're miles away you still can contact us but it might be for example if I don't know little bleed or something like that it might be better to go to the local minor op centre because we know that it just requires a bit of pressure but for most people, if anything happens they come straight back to us both we are always available, certainly on the days we have operations and we would be called if there was any complication but there aren't the specifics of a fever post-surgery. I’m not entirely sure I haven't seen that happen so I’m not entirely sure why that would happen but essentially once you have your procedure we keep you for a little longer than that we might need to and that's to make sure you're absolutely perfect before you leave the hospital and then there is someone available to take a phone call after that and to be honest following vein surgery probably the biggest complication is that you bleed a little bit a spot of blood comes through or the dressing looks a little bit off, that happens straight away it very rarely happens on the way home and the and if it did you just turn around and come back to us but for her and we can sort it out but for most people we kind of keep you for about half an hour or more just to be absolutely certain and for those people who live quite a long way away we generally keep you a little bit longer and that's just to make sure you're absolutely happy that the dressing is comfy you feel perfect everything is sorted so there's no turnaround an hour or so into the journey.

Louise King

Yes, this question relates to that actually and I suspect I know the answer, they asked if they could drive home on the day of the operation. It would be a long drive for them East-Midlands.

Mr Aaron Sweeney

Yeah, well you certainly could but I wouldn't and the reason is that we would give you be giving you some local anaesthetic and you have a bandage and if you crash having a bandage on your leg will automatically produce a whole heap of questions and perhaps trouble, so what I say to people is I leave the bandage on for a few days three don't drive with the bandage on because just in case. I’m not sure whether everyone follows my advice there, so I think quite a few people may well be driving very quickly but I would be careful about driving directly home because the bandage has just been placed on your leg you are a little bit sore you could cramp potentially and that's kind of one of those things you could avoid by just not driving that day.

Louise King

That makes sense. Okay and Susan says that her calf is very itchy, sorry very achy continuously but she doesn't have ugly veins. Would this benefit from a consultation? Is it a varicose vein?

Mr Aaron Sweeney

Lots of thread veins can all be treated at the same time not quite so if you don't necessarily have to have visible varicose veins to have an ache caused by a vein so varicose veins you sometimes see them on the surface but quite often they are coming down the inside of your leg or come from the back of your knee and that vein can be instead of the size of a shoelace, it can be the size of a pointing finger so sometimes when we scan you we can tell you that thing is the cause of your ache and pain people who have thread veins. Thread veins don't usually cause pain but they're sometimes a sign that you have an underlying precarious pain so to answer your question if you come to us we would do a scan and tell you if the vein is the cause of your ache and as I hopefully told you there are a few other causes but in general if you're reasonably fit and well and you don't have any obvious problem with your knee that kind of egg in your calf or itchiness in your calf is nearly always caused by is quite often caused by a varicose vein. The worst thing that would happen after your consultation is that I would tell you everything is normal which can be quite annoying, doctors are forever sending people for scans and sort of being happy that everything is normal of course it doesn't make you any better and you are you do have to pay for things so it's a bit annoying but when I scan you it's a very easy way to tell you exactly, I can very easily tell you if it's your vein causing the trouble or not and nearly always I can tell you what is causing trouble just from doing a scan on your leg.

Louise King

Cool, thank you. Janice says she's had her veins stripped before so could she have a second procedure? I assume she means on the same leg.

Mr Aaron Sweeney

Yes, interestingly it all depends on what people did to you the first time, so on some occasions, people usually around about the late 90s used to do a procedure where they just disconnected the vein from the groin and they didn't actually pull the vein out in your thigh and that nearly always leads to a recurrence, but I think people thought that it would be a less painful procedure and on other occasions, surgeons have done a very good job where they've technically removed the vein completely but in the healing process after that new veins have developed and sometimes people who've had their veins stripped even done very well can end up with much more veins afterwards. What I always do is scan your leg first to see if something has been left behind or hasn't been removed fully and if you have a recurring vein is it something that I can thread a little laser up so you might be surprised, if you look online people say that people with recurrent varicose veins can't have minimally invasive treatment, I think that's untrue virtually everyone I treat is treated with a laser even if they've had previous operations.

Louise King

Thank you. These people say they've had varicose veins in their legs which also show in the feet. Would the procedure improve the appearance of the feet, I assume as well?

Mr Aaron Sweeney

Yeah, so I quite often do feet and hand veins they're quite straightforward to remove if your veins however in your legs are large and they've stretched the veins in your feet if you get rid of everything from your ankle up and get your leg nice and smooth. It takes quite a long time for those veins in your feet that have been stretched to go back down to a reasonable size they sometimes don't go completely and quite often I would remove some of them. I’m very careful about foot veins because you have loads of little nerves down there and sometimes they can be irritated or damaged rarely most times the biggest complication from having your foot veins removed is that you have to wear shoes afterwards and go back to work etc and sometimes have to be careful about which pair of shoes you wear because it's a little tender and it can take a few weeks to settle down, but to answer your question just lasering the veins in your leg once they get rid of varicose veins in the leg they reduce the size of the veins in your foot but sometimes they don't go down enough for you to be totally happy cosmetically with them and they sometimes require a little small incision just to remove them and we can do that at the same time if it annoys you.

Louise King

Excellent, okay this person says they've had reactions to lignocaine and prilocaine for dental treatment, they now use bupivacaine with no adrenaline which is okay.

Mr Aaron Sweeney

Yeah, I usually use the same local anaesthetic all the time which is plain lignocaine without adrenaline. I have found it very difficult to use bupivacaine as a local anaesthetic for varicose veins because it's quite slow and it takes forever to work, whereas lignocaine works straight away. I don't use adrenaline with the injection, often dental injections nearly always have adrenaline and that's because the adrenaline reduces bleeding, however, adrenaline when it's injected is absorbed by your body and adrenaline will give you a fast heart rate and sometimes why you feel a bit weird when you're having you're having any injections in your gum. So I don't use adrenaline, I would normally use lignocaine and I found bupivacaine very difficult to get a decent result and I would say if it's the adrenaline that has made you get reactions with a dental appointment, I just don't use that and that's nearly always the commonest reason because bupivacaine or marcaine is kind of similar anaesthetics but if you've had a reaction to a local anaesthetic so some people have had it's very rare but occasionally people have had an allergic reaction to anaesthetics I would be very cautious about doing you under a local anaesthetic.

Louise King

Wonderful, okay so this person's had a few bouts of cellulitis in the last few years, twice after horse fly bites. Will the laser treatment be okay for them?

Mr Aaron Sweeney

The answer is yes, so what often happens when somebody has a varicose vein is that they don't realize that it's the varicose vein that's producing the redness and soreness in your leg. I think when you look at somebody who has varicose vein inflammation the outside of the leg sometimes looks red but the inside so underneath is often quite raw and it only requires a very minor insect bite or little small mossy bite in the garden and all of a sudden it flares up it's often confused with cellulitis and it can also occur with cellulitis, so I think varicose veins tend to predispose people to have little trouble with insect bites around the ankle and if your skin is in any way discoloured that's a sign that it's a little scarred and it's never as good as it used to be and I can't quite fight off that reaction to a mosquito bite or horse fly. If you had a varicose vein with repeated attacks of cellulitis, I would suggest nearly always suggest having EVLT just to get rid of the varicose veins, and allow your skin to be as healthy as it could be whether that means that you never have trouble in the future again I’m not 100% sure because if your skin has been damaged, well that's what's happened, what you're trying to do, what I would be trying to do is to make sure that your skin is in as good nick as possible so that it can avoid getting too inflamed after any kind of treatment.

Louise King

Carol says that she had she has grade three, perhaps four veins and walks several miles with the dog every day. She's in her 80s, is she too old to have them done?

Mr Aaron Sweeney

No, the oldest person I’ve operated on is 96 and she's still around thankfully. The commonest age groups often people think that the only people who ever have an operation for varicose veins are 18. Most people 18 don't have any varicose veins at all and the communist age group we operate on are people around about 60ish. Most people are too busy when they have kids and young families to think about their legs so they often wait until they're passed when the kids have gone to proper university or something like that and then the second group of people that get caught is those people in their 80s and I always say to people in their 80s you know if you're fit and well in your 80s, you're going to make it into your 90s and why do you need to put up with the problem for the next 10 years. The other side of that I would say is well if you've got grade 3 veins, that means they're visible but they're not aching, they're not necessarily dangerous. If you have a grade 4 vein, which is got skin inflammation or itching that's a different thing, that's a sign that your vein is not happy, your skin is not happy with that vein, so I would say to those people who have symptoms or some itching or soreness, I would push you towards having something done, no matter what age you are and once you're reasonably fit and well. If you just have a varicose vein that you don't notice much, it doesn't cause you any trouble, or your leg barely notices apart from its looks, then I wouldn't dream of pushing you to have anything done. I don't think it's dangerous.

Louise King

Thank you, very comprehensive. We have a few more questions. This person asks you to explain the risk of DVT before and after the procedure.

Mr Aaron Sweeney

Okay, so there are a few myths, I’ll include a kind of a longish answer to that. The first thing is that people say if you have a varicose vein you're more likely to get a DVT, no that's not true at all. The next thing people will say is if you fly in an aeroplane you're going to get a DVT, no your risk on an aeroplane is somewhere in the region of one in a million, it is tiny. I think perhaps at the beginning they thought there might be a risk and then quite a lot of people do very well selling flight socks, I don't wear flight socks myself. If I was going to the states I’d wear flight socks perhaps to stop leg swelling because that sometimes happens on a plane, but to be honest I never wear them they don't make any difference. So your risk with a varicose vein of having a DVT out of the blue is no more than anyone else. Sometimes varicose veins can get inflamed and you can get a thing called thrombophlebitis, so that's a complicated varicose vein, now sometimes that can predispose you to get a DVT you might think well is that because you get a little bit of a clot in the leg forming where it's sore? Not really, it's where the where you're in quite a lot of pain afterwards, so if your veins become red and raw and sore often, people basically can't walk and the biggest predisposing factor to a DVT is not being able to walk and it's nearly always to do with being in too much pain to do that. So after an operation with varicose veins, once you're up and walking, your risk of a DVT is as close to zero as you can get the only people I’ve ever seen having a DVT complication from a varicose vein operation were unfortunately in pain afterwards, stayed in bed for a few days, didn't know who to contact and then developed a DVT. I think that was because they were immobile and most they were immobile because they were in pain, it's a similar thing to you might say what risks of various procedures or things and how do they all how do they all add up and if I tell you that if for example when you do a varicose vein operation with me or even Eddie under a local anaesthetic, your risk of a DVT is less than one in one thousand so it's quite small and that's because you're up and walking and it's also because the two of us are absolutely paranoid about people being at home in pain and not knowing who to contact, so that's the reason why you get lots of phone numbers etc, so that if you're ever sitting at home thinking my god what's he done to me, this is way worse than he explained, you just get in the blower and we see you and work it out and if I tell you every year I maybe get one person and it's nearly always because I put the bandage on too tight and I always put the bandages on myself and I say to myself don't put it on too tight and then once every year or so I do I usually spot it straight away but occasionally I don't and if I just put it in perspective, if for example you were skiing broke your leg your risk of a DVT is really high, it's about one in ten and that's because you're effectively immobile afterwards. If you're lucky enough to fall over and crack your hip, your risk can be as high as one in twenty and that's again because you're lying in bed sore and a bit messed up. With veins, part of the reason why EVLT or the other minimally invasive treatments are so good or are so safe is that your procedure is not that uncomfortable afterwards so you're able to walk around and the moment you walk your risk of a DVT is virtually zero.

Louise King

Okay, Sean asks how long does the procedure take if grade one?

Mr Aaron Sweeney

So he has lots of little thread veins, so normally it's about 20 minutes and you might say well if you do some sclerotherapy on somebody, can I drive there and drive home? Yes, this is different to having an operation on your veins. If you have thread veins treated with skeletal therapy, that's little injections I put you in a bandage afterwards that bandage is a piece of window dressing to stop any spots of blood trickling down your leg. If you're lucky enough to have to stop at the service station so it's really to avoid any risk of embarrassment, those bandages come off when you go home and then you're back to your normal self. Most people if they had thread veins would generally have them on their way to work, on the way from work. It shouldn't be something that causes you to make a massive detour in your day and the bandage is just until you get home to avoid any spots of blood on your clothes. For example, people have said to me that they've been advised to wear stockings for six weeks after having thread veins treated, I initially thought that was the way to do it but, after speaking to some surgeons who work in very hot climates such as LA, nobody ever wears the stockings because it's too hot and they get quite good results and I stopped using stockings many, many years ago and it made happier people but it certainly didn't reduce the efficiency of sclerotherapy.

Louise King

Okay, I think this is related. This person has spider veins and they're not painful, should she have the surgery or not?

Mr Aaron Sweeney

You don't necessarily need surgery for tread veins, that would be more injections and sclerotherapy. Usually and for example if you had thread veins on your legs and I spotted that you had a little varicose vein lying underneath if you didn't notice the varicose vein and if I just picked it up on a scan I wouldn't necessarily advise you to have an operation for that. I think thread veins are slightly different to varicose veins and I think you should nearly always just do sclerotherapy on the thread veins.

Louise King

Thank you. Okay, just the last couple of questions. You said bandages after laser treatment, so does that mean that support stockings are not required after treatment?

Mr Aaron Sweeney

Yeah, I don't usually tell people to wear support stockings, I don't know what leg is suitable for compression stockings you can be mega chunky or you can be skinny as a pencil, I think none of those stockings ever fit correctly and what I worry about is that people put on ill-fitting stockings thinking that they're doing them some good when in fact they're just hurting them. So we put a bandage on which is cotton it's not sticky it's kind of like very soft velcro that sticks to itself and I asked people to wear that for a few days, there is no great evidence that wearing stockings for weeks after the operation is any good. Some people however find that they're a little bit sore or a little bit swollen and they like wearing stockings if the stocking is comfortable, you can wear it for weeks afterwards. I have no problem with those stockings themselves don't reduce your risk of a DVT, the walking mix reduces your risk of the DVT so I like you to walk and not to be annoyed by a stocking that's fallen around your ankle every time you walk out the door. The stockings can be good for some people and they sometimes fit certain legs they sometimes fit well but I must say I think most people if they have a little bit of arthritis in their hands can't get a compression stocking on and then most other people are trying to get the stocking to stay up and it just falls when you start walking around so I find them mostly useless and I think they're over-egged a little bit and people saying oh you have to wear them because of DVT risks I would say that's just that's not born out by any great evidence. Once you're walking, your risk of a DVT is really low.

Louise King

Okay, the last question is I’m afraid all we have time for today. This person just simply asked can they shower after the procedure.

Mr Aaron Sweeney

Yeah, but it's sometimes a little acrobatic so if I put a bandage on your leg after EVLT it's nearly always just to below your knee, you need to keep that dry so sometimes people use a bag or there are bags you can get in the chemist which like Velcro tops on them and keep everything dry. I have to say that most people just stick their legs out if they can do a little bit of acrobatics and wait for three days to have a proper good old shower and I think some people put cling film over it just to keep it dry. The answer to your question is I like you to keep the bandage dry if you can and that always involves a little bit of a palaver in the first few days, it's one of the reasons why I tell people not to necessarily plan to go back to work in the office the next day because you'll probably feel fine and then you go try and have a shower and it'll just be an hour of misery in the morning and just stress you out so bandage itself I like it to keep dry, it's a bit awkward washing with it.

Louise King

Excellent, thank you.

Mr Aaron Sweeney

I would say though after the operation, once the bandage is off, you are back showering normally so on day three or day four back in the shower doing your normal stuff.

Louise King

Okay, well thank you very much for that that's insightful and I hope everyone watching and listening enjoyed it sorry if we didn't answer all of your questions. If you have provided a name we’ll do so after the event or you could email us and we can answer any questions. If you would like to book a consultation with Mr Aaron Sweeney or Mr Eddie Challoner, our other consultant, please contact us on the number on your screen before 7.30 this evening, or between 8am and 6pm, Monday to Friday. At the end of this, you'll receive a short survey and I’d be grateful if you could spare a few minutes to just provide your feedback because it just helps us improve future events and yeah it's great to hear what you think. Our next webinar is on the 15th of September, it is with Mr Ahmed Hamouda our Consultant Surgeon and if you join that you'll find out how fast-track access to a range of permanent and reversible self-pay options for weight loss surgery. So, on behalf of Mr Sweeney, myself and the team at Benenden Hospital, I’d like to say thank you very much for joining us this evening and we look forward to seeing you again soon at another webinar or in the hospital itself. Thank you very much and have a lovely evening.