What treatments are available? Well, we categorize them into one of these four sections — there’s graduated compression hosiery, that’s medical stockings. We’ve got the surgical stripping operations, which some of you in the audience might have had. There are injection treatments, sclerotherapy, which I’ll cover in a moment, and then there are some new treatments which are done through tiny little punctures on the skin — we call them key hole type procedures– they either involve heat energy or they involve superglue, which is one of the latest developments which I’m going to cover very shortly.

Now whenever anybody thinks of medical graduated compression hosiery they think of Nora Batty, and it is true that a lot of medical stockings are those beige or brown thick wrinkly things that won’t stay up, difficult to get on. This is just to show you that good quality, modern medical compression hosiery doesn’t have to be like that, it doesn’t have to be stigmatizing. It would be nice if you put a pair of stockings on like that and your legs instantly looked glamorous but the important thing to take away is that it isn’t stigmatizing, they do look nice, they are comfortable and your legs tend to feel better when you wear them. Now they’re not support tights, they are very different. They’re graduated, which means that they are firmer at the ankle and they give a certain amount of ‘squeeze’ measured in so-called millimeters of Mercury, that’s the same measurement that we use to measure blood pressure, so it gives a certain amount of squeeze at the ankle and then progressively less as you go up the leg, and it works with the vein circulation. Now some of you may familiar with Calippos or Popsicles, those little ice lollies which you squeeze at the bottom and they come out of the packet — yes, some nods there. Well, if you squeeze firmly at the bottom, up comes the ice lolly. If you squeeze the same all the way up and down, even if you squeeze quite hard, the ice lolly doesn’t move, so it has to be squeezed at the bottom firmer than the rest and up comes the lolly. In the same way,if you squeeze the ankle slightly more than the rest of the leg in that fashion, it works with the vein circulation, encouraging the blood flow back up the leg. Is medical grade compression a cure for varicose veins? Well clearly not.

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Whilst you’ve got the medical sock on, or the medical stocking on, it resists the reflux, it corrects the reflux, but when you take the stocking off obviously the blood comes down in the wrong direction and the varicose veins or the problems recur. But whilst you’re wearing a medical grade compression stocking your legs will feel better, so most of the symptoms will get much better whilst you’re wearing them, if not be abolished completely. There is quite a bit of evidence that it will reduce the progression of the vein problem and reduce the risks of complications. We know that medical grade compression stockings reduce the risks of a deep vein thrombosis in certain situations so, for example, long-haul flights, going into hospital, they reduce that risk of deep vein thrombosis and, if you’re unfortunate enough to have had a deep vein thrombosis, then I would suggest that you should wear good quality medical grade compression hosiery. Again, very recently I saw a man who’d had a very big deep vein thrombosis five years ago. Unfortunately once you’ve had a deep vein thrombosis it does damage those delicate valves in the deep veins. Deep veins cannot be treated by surgery, superficial veins can,but deep veins can’t, and he had damaged his deep veins with his deep vein thrombosis and after five years he’d developed quite a nasty leg ulcer. Unfortunately he hadn’t been advised about wearing medical grade compression hosiery, which I think would have prevented him from developing a deep vein thrombosis. This is something unfortunately we see quite a lot of in our clinic. Surgical stripping — well, some of you might have had this operation. Until recently it was the commonest way of treating veins. I think it is still performed in the NHS in the UK though NICE, that body I told you that says everyone who has symptoms should be referred, NICE has also said that surgical stripping is ‘out’ now.

Surgical stripping, which was invented about 200 years ago, in 2013 NICE said that’s the end of surgical stripping. It should be third choice after endo-venous thermal treatments, which I’ll talk about in a moment, and injection treatments, sclerotherapy. But what it involves is going into hospital, having a general anaesthetic and then a cut in the groin here, and then this refluxing vein in the thigh has a piece of surgical wire put down it and the surgical wire often travels down to the ankle or into the calf, another surgical cut is made in the calf to find that wire and then the surgical wire is pulled out. A lot of you are cringing now at the sight of that or the description of that. Yes, it wasn’t something that most people wanted to have done, very few people wanted to go into hospital and have a painful cut in the groin and their veins pulled out. It did have a reputation for being quite painful. A lot of people, particularly if they had both legs treated, couldn’t go to work for six to eight weeks it was that painful. They couldn’t drive for ten days, I think two or three weeks off work for one leg if you’re very motivated, if you have both legs treated you’re going to need a month or two. And after being subjected to all of that, the real problem with surgical stripping is that it had what’s called a very high recurrence rate, which meant that the veins come back. Having been through all of that, a few years later the veins come back and we now know that surgical stripping, when you cut a vein and tie it off and pull a portion out, the two raw ends of the vein want to regrow and rejoin. We didn’t believe, as surgeons, that this could happen, if you cut a vein here at the top of the thigh and pulled it out to the calf or below the knee, that that vein could regrow, but because we now have the widespread use of ultrasound we can follow patients at intervals and we can see the veins regrowing and again, being doctors, we like to give a fancy name to this, we call it neovascularisation,which just means that new veins have regrown. So third choice now according to NICE, and the dominance of surgical stripping is over. Hopefully in the next year or two we should see surgical stripping coming off the scene altogether and this slide will probably have to be taken out of my presentation. But we’ll still see a lot of people who’ve had surgical stripping five, ten, fifteen years ago who will be coming back with their recurrent veins because, as I was saying, it does tend to be associated with recurrence.

Sclerotherapy is an injection treatment. We can now identify faulty veins with ultrasound and, guiding the needle into the vein, we can inject a prescription medicine called a sclerosant into these veins. So veins that were previously only treatable by stripping can be injected with a prescription medicine, and it works by removing the lining of the vein — it does that within a few seconds of the injection, and that doesn’t hurt, surprisingly– and the vein responds over the course of time by shrinking and closing. So this vein here in the thigh that would be surgically stripped in days of old, we can now identify with ultrasound and inject with a sclerosant. Now the sclerosant that we use can be turned into foam, some of you may have heard of foam sclerotherapy. We can take the prescription medicine that comes as a liquid in the ampoule and, because it is biochemically a detergent,we can mix it with air in a certain way to turn it into foam. If you take washing-up liquid and splish and splash, it makes bubbles and foam, well we can do this in a more controlled way with the sclerosant and turn it into foam and we can inject that into this refluxing vein. Now it’s not like cavity wall insulation, it doesn’t stay in the vein forever. What it does is it will displace the blood, it will push the blood out of the way, sit in the vein, do its job and then, after a few minutes, it will disperse back into a liquid and be eliminated from the body. Foam sclerotherapy has revolutionized treatment of refluxing veins. It was invented in 1995 and there have been a number of medical studies now showing that it’s just as effective as surgical stripping and that’s why it has replaced surgical stripping,it’s now in number two slot according to NICE.

Surgical stripping is number three slot. The advantages are that it doesn’t require a general anaesthetic, you have very minimal time off work, it’s a walk-in walk-out procedure and it has been described as a lunch-time procedure. There are no cuts or scars and you can get back to normal activities pretty much straight away, so a lot of advantages compared with surgical stripping. The other treatments we have are so-called endo-venous thermal treatments. Now this isa way of saying that the vein can be treated from the inside using heat energy, and here you can see a little schematic which shows that the refluxing vein has a very small catheter inserted into it under ultrasound guidance. That catheter is then inserted or guided right up to the top of the leg — you don’t feel that, surprisingly, you may feel a little tickle under the skin of the thigh but you don’t tend to feel that — and, once it’s in position very carefully, again confirmed by ultrasound, you can numb this vein up with local anaesthetic and you can heat the vein to a temperature at which it is closed. It’s cauterised, sterilised and devitalised and, as the catheter is withdrawn, that vein is closed all the way down so that when that person gets out of bed first thing in the morning and stands up, blood is no longer refluxing down this vein and is no longer filling the varicose veins and thread veins further down and, as you can see in this little schematic, the varicose veins shrink and return to a more normal size. Now one of the questions I get asked quite a lot is “I’ve got bad varicose veins, if I have my veins treated or removed, what happens to the blood?” Well, that’s a very good question. The important thing to realize is that we have two sets of veins in our leg, a deepset which lie deep within the muscle, and a superficial set which lie just underneath the skin. It’s the deep set which carry most of the blood up your leg, the veins under the skin don’t actually carry very much blood at all and, even more important than that,is that we only treat unhealthy veins.

We identify the refluxing veins with ultrasound and we’re only treating those, so imagine a situation in which your deep veins are pumping the blood up your leg and the superficial veins are letting blood down your leg. That would be a little bit like carrying water from one place to another in a bucket with a hole in it. You need to make more trips. If we plug the hole, you need to take fewer trips. Well, by dealing with refluxing veins in this way, the deep veins can pump the blood up the leg and there’s less spillage down the leg, so actually your deep veins can do their job more efficiently and that’s why, by treating reflux and varicose veins, your leg will feel better because we’ve taken the pressure and the work off the deep veins. The good thing about endo-venous thermal treatments is, again, they are local anaesthetic, they are walk-in walk-out, there’s no painful cuts and scars, and there’s minimal time off, there’s rapid results, and the really good thing is that they have the lowest recurrence rate,so the risk of that vein ever recovering is very, very low, in fact I haven’t seen a vein recover from an endo-venous thermal treatment done properly in twelve years. So it’s a very good treatment. There are various ways of heating the vein – there’s microwaves or radio-frequency,which is the VNUS Closure, there’s laser, which is very powerful electro-magnetic energy,and there’s also steam.

Steam is very popular in France, it was invented in France. I’ve been to Lyon to see steam treatment and I’m not convinced that it’s the right way to go, it’s a little bit uncontrolled for my liking, and certainly NICE have put endo-venous thermal treatment by VNUS Closure and laser as number one, so the ranking now is endo-venous thermal treatment number one, number two ultrasound-guided foam sclerotherapy and coming in a poor third is surgical stripping. People say, well which treatment’s best? Well, the best treatment, number one, is endo-venousthermal treatment by laser or radio-frequency, VNUS Closure. There may be some reasons why foam sclerotherapy would be more suitable and that rather depends on the appearance of the veins on our ultrasound, but these are things that you need to consider. Obviously the cost, how quickly you want your veins to look better and feel better, time off work. I’m going to have to take some of these out now, I don’t think anybody wants to go into hospital. There are some people who do feel a little anxious about having their veins treated under a local anaesthetic. There are lots of advantages to having your veins treated under local and certainly my preference is to treat veins under local anaesthetic, so much so in fact that I don’t perform any of my treatments now under a general anaesthesia.

Sclerotherapy may be more appropriate if the appearance is such that an endo-venous thermal treatment is not possible, but some people who are paying for themselves, who can’t get treatment on the NHS, may feel that for them it’s the most cost-effective way of having their veins treated. But when you come for your consultation and we do your scan, we’ll have an individualized program for you. Often people have more than one option and they have these various criteria to consider before making their own choice. Now this is the latest treatment, it’s superglue, it’s produced by an American company called Sapheon and it’s called VenaSeal, and the vein is bonded in seconds, it doesn’t use heat energy, there’s only usually one local anaesthetic jab necessary, and there’s no need for any stockings, bandages or compression afterwards so it’s a so-called tumescentless,that means it doesn’t require very much local anaesthetic, it’s non-thermal, there’s no heat energy involved, and it’s very quick and very minimal aftercare. People have no restrictions on them at all after this treatment. Now I’m going to show you a little short video of VenaSeal procedure, there’s nothing gory here so you don’t need to look away.

So this is the superglue itself, it comes in a little vial, it has a dispenser and a catheter that gets put into the vein. This is the glue being loaded onto the dispenser,and that’s the catheter being inserted into the vein and a little ultrasound showing the catheter being pulled along the vein. There’s the applicator, and there’s a little scheme of the glue coming out of the vein and this is our first case in the South West where the gentleman was chatting to our nurse and he was very, very comfortable. So one of the questions I get asked quite a lot is “what happens to the glue, where does it go, will it move around my body or is it toxic?” Well, this is not just an ordinary superglue, it’s not the superglue you get from B&Q. It’s a medical superglue that’s been used in the body for fifty years, it’s used to treat blood vessels in the brain,it’s used to treat damaged internal organs after road traffic accidents, and it’s been shown over the fifty years to be very safe, it doesn’t break down into anything toxic,it doesn’t cause cancer and the formulation for veins which VenaSeal is has been in development for five years so it’s a particular formulation, it gets put in the vein that’s refluxing, it doesn’t move, it stays where it’s put, it’s very quickly bonding so it closes the vein very, very quickly and it won’t move around the body and go to the heart or the brain. So it’s very safe. It’s been available in Europe for about nearly three years now and we now have data coming out, albeit quite short-term, but the data we have shows that it’s as good as endo-thermal treatments and for people who don’t want a lot of local anaesthetic jabs, who don’t want to wear stockings, who want to be able drive straight away, it does have some potential advantages – and that’s superglue.