On Saturday 17th October I gave a presentation on Facebook. I streamed it live and below is a recording of the live stream and a transcript of what I said.
“Good morning. Welcome. My name is Dr Haroun Gajraj, I am the director of the VeinCare Centre in Dorset. I I have specialised in the treatment of vein condition. My wife Jane and I established the clinic 18 years ago to help people find freedom from unsightly veins, veins causing symptoms and veins causing complications. I am supported by a vascular specialist colleague and a team of healthcare professionals, an operational manager and administrative staff.
In this morning’s live stream, I will talk about the important aspects of varicose veins: Just how huge a problem they are, what causes them, what problems can arise and how they can be treated. I will also talk about spider veins and hand veins.
With the number of COVID19 infections rising, I will also talk about how we keep you and the VeinCare team safe and what will happen if there is a second lockdown in Dorset or the South West more generally.
SCOPE OF THE VENOUS PROBLEM
“We all know that vein problems are common and important. We only have to look around in warm weather to see people in shorts or skirts who have leg vein problems. But just how common are they? Well, one of the largest and most quoted medical study was which was carried out in Germany looked at over 3000 adults: the participants completed a questionnaire, they were examined really carefully by a health care professional and they had an ultrasound scan. They were allocated into one of 7 classes. C0 being a completely normal assessment with no signs of vein abnormality all the way to C6 which is an open leg ulcer. There are 3 striking findings from this study. Firstly, fewer than 10% of the participants had completely normal legs, that is no spider veins, no varicose veins and a completely normal venous duplex ultrasound scan. Secondly, nearly one in 5 people had either swelling, varicose eczema or ulceration- that means they had a really significant problem of their veins. Thirdly, over a third of those in this study had superficial venous reflux on ultrasound and I’ll explain what superficial venous reflux is a bit later.
Closer to home a study from Edinburgh looked at over 1500 adults. It too involved a questionnaire, a standardized assessment and classification of venous disease in the legs, as well as a standardised ultrasound scan to detect venous reflux in the leg veins. This study is particularly interesting, because it tells us what happens if you leave your veins and don’t have anything done. A follow-up 13 years later included a reclassification to see if there had been any deterioration or progression of the varicose veins or if complications had developed. Nearly half of the participants with venous disease deteriorated over the 13-year period, and almost one-third with varicose veins developed a complication.
These 2 studies, the Bonn Vein Study and the Edinburgh Vein Study confirm that vein conditions are common and that they get worse with time. The latest findings from the Bonn Vein Study strongly suggest that early treatment of varicose veins prevents deterioration and helps avoid complications such as varicose eczema and leg ulcers.
What about the cost to the nation of treating complications? Well, It has been estimated that the National Health Service (in the UK) spends over £5bn annually on treating chronic wounds of which at least £1bn annually is spent treating venous leg ulcers. Leg ulcers and other vein complications such as phlebitis, varicose eczema and thrombosis cause distress, pain, time off work and a considerable economic burden to the NHS, so vein problems are indeed common and very important.
So why do we get varicose veins in the first place?
Although surface varicose veins are pretty obvious, the cause of varicose veins is deeper under the skin. I mentioned this thing called superficial venous reflux when I described the Bonn Study and The Edinburgh Vein Stduy. If the one-way valves in the veins that keep blood flowing in the correct direction are faulty and don’t meet properly, then when you are standing, gravity can pull blood back down the leg in the wrong direction, a problem which is called superficial vein reflux. Venous valves are delicate folds in the lining of the vein that open and close keeping blood flowing in the correct direction. In the legs, healthy vein valves direct blood from the foot upwards back towards the heart. Whenever anything travels in the wrong direction in the body, it is called reflux. So, for example, many of you may be familiar with indigestion caused by acid reflux and a hiatus hernia, well, varicose veins and nearly all the common vein conditions such as spider veins, varicose eczema and leg ulcers are caused by reflux in the superficial veins.
The only way to accurately find out what’s wrong with the leg veins is with a venous duplex ultrasound scan. You are examined while you are standing and using sound wave a detailed picture of the deep veins which are deep in the muscles of the leg, the superficial veins which are under the skin and their connections are checked as well as the function of the valves. With a duplex ultrasound scan, problems such as obstruction and blockages as well as reflux and thrombosis can be accurately diagnosed and identified. A duplex ultrasound scan is the only reliable way to accurately diagnose the cause of leg vein problems and it provides the information essential to formulate the correct treatment. That’s not just my opinion: NICE, the National Institute for Health and Care Excellence provides evidence-based national guidance on health matters and it recommends in its clinical guideline CG168 to use duplex ultrasound to confirm the diagnosis and to plan treatment. In its Quality Standard QS67 it also recommends that successful treatment should abolish reflux and the only way to confirm that this has happened is with a venous duplex ultrasound scan. So as you can see, ultrasound is necessary at all stages of vein diagnosis, treatment and aftercare.
Surprisingly, superficial venous reflux may exist even in the absence of visible surface varicose veins. Only last week, I saw a patient in the clinic who had only a few varicose veins, but she had very severe ache, throbbing and heaviness. She commented that her legs made her feel old. Although she didn’t have much to see, she had severe vein reflux. Not only can you get symptoms without visible varicose veins, but medical problems such as varicose eczema and varicose ulcers can develop without anything much to see. As the superficial venous reflux is the underlying cause, and as venous duplex ultrasound is the only way to identify superficial venous reflux reliably, I hope you can see that everyone with suspected vein problems, including spider veins, varicose eczema, leg ulcers, phlebitis or even deep vein thrombosis must have a venous duplex ultrasound scan to establish an accurate diagnosis.
COMPLICATIONS OF VARICOSE VEINS
Before I tell you what can be done for varicose veins and superficial venous reflux, I’d like to tell you briefly what can happen to vein is they get worse. The medical complications are phlebitis, varicose eczema, leg ulcers and deep vein thrombosis.
Phlebitis
Phlebitis should really be called Superficial Vein Thrombophlebitis. In this condition, thrombus or clot formation is the main concern and threat. In Superficial Vein Thrombophlebitis there is thrombus – or clot – in the superficial vein, and inflammation in the tissue surrounding the vein. Often, a tubular-shaped lump can be felt which is red, tender and painful. The most frequently affected vein is the saphenous vein on the inner part of the thigh or calf. It can also occur in the veins of the arms or neck, usually after intravenous cannulation and drug administration. The important feature in Superficial Vein Thrombophlebitis is the clot formation rather than the inflammation. The clot in the superficial vein can extend into the deep veins causing deep vein thrombosis and possibly pulmonary embolism – a clot in the lungs. The diagnosis of Superficial Vein Thrombophlebitis is established on clinical signs: that is a painful, tender, red lump along the course of a superficial vein and on the basis of an ultrasound scan. Venous Duplex ultrasound should be carried out to confirm the diagnosis as well as to check for deep vein thrombosis in the affected leg and the opposite leg. That is to say, both legs should be examined by ultrasound. Superficial Vein Thrombophlebitis has traditionally been considered a rather trivial condition, with treatment mainly focusing on the relief of symptoms. However, it is now clear that there is a strong association between Superficial Vein Thrombophlebitis and deep vein thrombosis as well as pulmonary embolism and we now know that blood-thinning medication is often necessary to prevent clot spread. Superficial Vein Thrombophlebitis can sometimes be confused with cellulitis or an infection. These conditions, which can be hard to distinguish simply by looking at the leg. This is important because the treatment is very different. Superficial Vein Thrombophlebitis often requires blood thinning medication because the clot can spread and lead to deep vein thrombosis or even death. Cellulitis on the other hand is an infection that requires antibiotics and if it is not treated properly, the infection can enter the blood stream causing sepsis. An ultrasound scan is the only way to confidently distinguish these 2 important conditions.
Varicose Eczema
This is a very confusing term. This condition is a complication of superficial venous reflux. It can exist in the absence of varicose veins. Furthermore, it is not a skin condition as the term “varicose eczema” might suggest. In fact, it is a vascular issue and the reaction of the skin is a response to continued damage to the microcirculation. The skin is actually being deprived of nutrients and oxygen and the area becomes vulnerable and may ulcerate. The importance of “varicose eczema” is that it indicates venous reflux or sometimes venous obstruction and if varicose eczema is neglected it may progress to a leg ulcer. Its presence is a warning sign that should not be ignored. The condition should be investigated by a duplex ultrasound scan followed by treatment of any reflux. It should not be managed with creams or stockings alone. Long term use of steroid creams in particular should be avoided if possible. Steroid creams will give very prompt relief of redness and itch and can be used very briefly if symptoms are very distressing, but prolonged use, thins the skin and actually cause deterioration. A leg ulcer can actually be more likely.
Deep Vein Thrombosis
The association between varicose veins and DVT is now very well established. In 2013, a study from Germany looked at over 80,00 people over a three-year period and it found that people with varicose veins were approximately 9 times more likely to develop a deep vein thrombosis. A study from Texas in 2012 showed that people undergoing total hip replacement were at an increased of DVT if they had varicose veins. Very importantly – the study also showed that people who had had treatment for their varicose veins and who were undergoing total hip replacement had the same risk of DVT as people who had never had varicose veins. So these results dispel any doubt that might remain that varicose veins are indeed a risk factor for deep vein thrombosis and now there is considerable evidence that this risk is reduced by successful treatment of the varicose veins.
Leg Ulceration
This is a feared complication of venous disease. Approximately 90% of leg ulcers are due to an abnormality of the veins, and the majority of these are due to superficial venous reflux, which can be cured. Most leg ulcers will develop in an area of varicose eczema and so, not only are the majority of leg ulcers treatable and often curable, the majority can be avoided in the first place.
TREATMENT
In 2013, The National Institute for Health and Care Excellence – NICE- published clinical guideline CG168 and stated that patients with varicose veins should be referred to a vascular service – a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and who can provide the full range of treatment options. NICE recommends that endothermal ablation should be the first option, ultrasound‑guided foam sclerotherapy the second option and that surgery is now the last resort.
Let’s look at these in turn.
Endothermal Ablation. During endothermal ablation, the veins which are unhealthy are treated from the inside with heat energy. I use laser under local anaesthetic under ultrasound guidance. With an ultrasound probe on the skin, the unhealthy vein is located and the skin overlying the vein is numbed with local anaesthetic and then a small needle is inserted into this vein. It’s the same sort of needle I use for a blood test. Through the needle I insert a very fine laser fibre a fine catheter. Then numb the vein with a series of local anaesthetic injections, again, guided by ultrasound. Thereafter, the vein is heated from the inside using laser energy – hence the term endothermal ablation – to a temperature at which the vein is closed and cauterised and the cells of the vein are sterilised. After this, the vein cannot recover, re-open or re-join with the deep veins and the superficial venous reflux is effectively cured. After endothermal ablation the varicose veins disperse, varicose eczema or leg ulceration can heal, and any associated spider veins will also disperse. Large varicose veins can be extracted at the same time, a procedure called Phlebectomy.
Ultrasound Guided Foam Sclerotherapy. Ultrasound Guided Foam Sclerotherapy is appropriate for those people who are not suitable for various reasons for endothermal ablation. Usually, they are not suitable because the vein is tortuous (very twisty), or there is some other feature on the ultrasound that means that endothermal ablation cannot be performed. Ultrasound Guided Foam Sclerotherapy involves the injection of a prescription medicine called a sclerosant into the vein guided by ultrasound. The sclerosant comes in a vial and looks like a clear liquid. It can be mixed with air in a special way to produce foam. When injected, the foam sclerosant removes the delicate lining of the vein, called the endothelium and the veins react over the following weeks by shrinking and closing off. Now the foam is not like “cavity wall insulation”. It doesn’t stay in the vein forever. It turns back into a liquid in a few minutes and it is eliminated from the body just like other medicines like paracetamol. After a few hours, it has been completely removed by the body. The veins that are treated may become a little lumpy and tender as part of the healing process, but the foam has gone completely.
Phlebectomy is the gentle extraction of the lumpy varicose veins through pricks in the skin. Under local anaesthetic the visible varicose veins are removed completely. It sounds gruesome, but most people feel nothing at all or just a slight “pulling sensation”. It is not to be confused with vein stripping. Phlebectomy is extraction of veins just under the skin and the small pricks in the skin are almost invisible after a few weeks.
I use endothermal ablation by laser together with ultrasound guided foam sclerotherapy and phlebectomy in combination. I perform these 3 treatments for varicose veins under local anaesthetic as a walk-in walk-out procedure and now I never perform surgical stripping. The avoidance of general anaesthetic ensures that these treatments are extremely safe. NICE – the National Institute for Health and Care Excellence – does not comment on the use of local anaesthetic versus general anaesthetic. However, in my opinion, local anaesthetic is much, much safer. Serious complications after endovenous treatments performed in this way are almost completely avoided. Since these endothermal treatments are performed through pinpricks in the skin guided by ultrasound at all times, there is virtually no scarring and complications such as infection and nerve injury are extremely rare compared to surgical stripping. In addition, these treatments can be performed without admission to hospital and after treatment people can return to normal activities such as driving and get back to work very quickly.
The results of endothermal ablation, ultrasound guided foam sclerotherapy and phlebectomy at my clinic are excellent. My clinic complies with NICE Clinical Guideline CG168 and it meets the NICE Quality Standard QS67.
Other endovenous treatments that have been approved by NICE, but which are not yet included in their list of recommendations are Clarivein® and VenaSeal®. If you’ve heard of these and you want to know more, I can advise you as to whether these treatments might be appropriate for your veins.
SPIDER VEINS
Expert consensus confirms that people with spider veins on the legs should be assessed by venous duplex ultrasound in most instances and that where appropriate superficial venous reflux and feeder veins should treated first by endothermal ablation or ultrasound guided foam sclerotherapy. Thereafter, the most effective treatment for thread veins and spider veins on the legs is by direct injection of a prescription medicine called a sclerosant solution – a treatment called microsclerotherapy. This prescription medicine removes the lining of the vein and a healing process ensues so that over the following weeks and months, the spider veins disperse.
OUR RESPONSE TO THE COVID-19 SECOND WAVE
So given that COVID is on the rise and that more restrictions seem to coming each week, how do we keep you safe and how have we prepared for the second wave? I’ll talk about that next.
Before reopening after Lockdown, The VeinCare Team completed a deep clean of the clinic and all members of the VeinCare Team undertook enhanced training in relation to infection prevention and control with particular reference to COVID-19.
We are now COVID-secure and we are delighted to welcome you back to have vein treatment in our safe healthcare environment. In addition, we come to work only when we feel well and after we have had our own temperatures checked and recorded when we arrive.
Throughout the day, we all wear a disposable surgical mask and eye-protection (only removed and replaced when eating or drinking), we maintain social distancing and we regularly wash our hands with soap and water or an alcohol-based hand gel, in line with WHO Guidance. These measures are followed by all staff (even in the administrative office) and they are aimed to keep you and ourselves safe in the clinic.
We are in a rural location, a little bit off the beaten track and we have a large carpark just outside. We have staggered appointments to ensure that you will not meet the patient before you as they leave or the patient after you as you leave. When you arrive at our clinic, you will notice that the door is kept locked. Only one patient is admitted into the clinic at a time. You will need to ring the bell and then you will be allowed in by a member of staff. Before the nurse opens the door, she will have sanitised her hands and she will be wearing a mask and eye-protection. Once inside the building, the nurse will take your temperature and if this is normal she will ask you to confirm that you feel well and then she will ask you to apply an alcohol-based hand gel and to put on a clean surgical mask which we will provide. You will also be asked some COVID-19 screening questions.
We have always had a strict cleaning regime, but now we have instigated an enhanced cleaning schedule between patient appointments and we have allowed extra time between patients for this to take place. After each patient leaves, the chairs and equipment that have been used for the consultation are cleaned. In addition the waiting room chair is wiped down and the toilet is cleaned after use by both staff and patients. The stair banister is also wiped down after each patient leaves. So when you arrive, you can be assured that you can touch any surface with confidence.
You can find full details of our response to COVID-19 on our website which is updated regularly.
Regrettably, cases of infections are rising and inevitably, new restrictions may be imposed. Will these restrictions affect the clinic and will we need to close?
Well, firstly, unlike the situation in March, PPE is not in short supply now and so we are not in competition with the NHS for masks, alcohol gel, disinfectants and other important clinical supplies.
We have adequate supplies of PPE and related items for the weeks and months ahead.
Secondly, we now know a lot more about COVID-19 transmission, and we are confident that the measures we have in place in our clinic are keeping our staff and patients safe now and that they will continue to keep all of us safe even in the event of a serious second wave.
Thirdly, we are COVID-19 Secure and as a healthcare facility, The VeinCare Centre is exempt from the need to close under the current legislation.
So, given that the situation is very different now compared to that in March, as well as the fact that we have already seen significant deterioration of our patients’ veins during the first lockdown, The VeinCare Team will keep the clinic open even in the event of a serious second wave. If you have appointments booked, please be assured, we will remain open.
TREATMENT OF FACIAL VEINS
As the rate of COVID-19 infections is rising, we have suspended facial vein treatment. We will provide this service as soon as it is safe to do so.