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Programme 5. - Varicose Veins
RADIO 4
THURSDAY 31/08/06 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTOR: BRUCE CAMPBELL
PRODUCER:
HELENA SELBY
NOT CHECKED AS BROADCASTbr />
MYERS
Hello. They may not be very attractive but are they such a problem? You may live quite happily with your varicose veins, especially if they don't cause you too much discomfort. But you don't have to be a hypochondriac to wonder if the blue bulges on the back of your legs will become even more prominent with time. Could the distended veins lead to blood clots? If blood isn't flowing properly might you end up with leg ulcers? Well having your varicose veins removed is one way of dealing with those kind of concerns but then there are decisions to be made about what kind of procedure you should opt for - injections, surgery or the latest laser therapy? Is there anything you can do to help yourself? Do surgical stockings still have a role? What are they? Do they still sell them?
Well whatever your question about prevention, management or treatment call us now - 08700 100 444 - or you can e-mail checkup@bbc.co.uk and put your questions about varicose veins to vascular surgeon Professor Bruce Campbell, he joins us from the Royal Devon and Exeter Hospital.
And our first caller is on the line. She says her legs hurt - Mrs Brown in Dorset, your legs hurt but you don't know if you've got varicose veins?
BROWN
Well it wasn't quite that. They hurt a little bit sometimes when I'm walking - my legs that is generally, sort in the calf region. But I'm not always sure whether that's just stiffness or something or whether it is the dreaded spectre of varicose veins. Because what I have got is veins at the back of my legs that are not all that purple but have multiplied greatly in the last couple of years. And when I walk sometimes it's the - it's very peculiar, because I can walk on the way down to the sea and they will hurt but when I'm walking back, having had a bathe, they don't hurt.
MYERS
And you're doing the best for yourself of course in general terms by walking, for your health.
BROWN
Indeed.
MYERS
Okay but - so is this then actually the varicose veins that is causing the problem? Let's put the Professor on and see what he - what light he might shed on this.
CAMPBELL
Mrs Brown good afternoon.
BROWN
Good afternoon.
CAMPBELL
I think your symptoms are unlikely to be due to your varicose veins because varicose veins normally cause symptoms when you're standing up for a long time, perhaps after you've been for a long walk and at the end of the day. The symptoms walking up hill, perhaps due to the circulation, they might be due to some narrowing of the arteries with the restriction to blood flow and you ought to perhaps have that checked. One of the big problems with varicose veins and symptoms is that so many people have varicose veins and many people have all sorts of leg symptoms and trying to be sure which ones the varicose veins cause can be very difficult.
BROWN
Yes exactly.
MYERS
Just on that you said so many people can have varicose veins, they are very common, I mean really common aren't they, what one in three?
CAMPBELL
Yes about one in three.
MYERS
Age related?
CAMPBELL
Yes to an extent. They become more common with increasing age, no doubt at all and by the time people reach their 60s they affect about one person in three.
MYERS
And when you see someone who comes with varicose veins is it entirely obvious what we're talking about, it's not just the sort of - what I call the blue vein that sticks out at the back of my leg, it's more than that isn't it?
CAMPBELL
Well varicose veins - they are blue veins that stick out, little tiny thread veins, little blue blemishes, those aren't varicose veins. Varicose veins are the bulging veins that you can see beneath people's skin. And alright you might just have one of them it's still a varicose vein.
MYERS
And what's actually going on thou in the legs when you get these varicose veins?
CAMPBELL
We don't really know why veins become varicose, I mean for example why do people often get varicose veins in one leg and never the other. But when varicose veins have formed the veins are distended, they're bulging, the little valves in them which ought only to allow blood to flow upwards don't work properly. And so when you stand up or sit with your feet on the ground there's a head of pressure in the veins and that's what causes them to bulge and that's what can cause them to ache and throb and make the legs feel heavy and if you're very unlucky to develop problems in the skin.
MYERS
So a final thought for Mrs Brown then with her aching legs, what would you do if she came to see - you're a vascular surgeon, would you be able to treat her, would you need to treat her?
CAMPBELL
I'd probably ignore any varicose veins she had and measure the blood pressure at her ankle actually and see whether there's any restriction in blood flow that might explain her symptoms walking uphill.
MYERS
Okay there's the tip, thank you very much indeed for the call and we'll move to an e-mail and this one is from Sophie. And Sophie is 23 weeks pregnant, her first pregnancy, congratulations, but suddenly she says she's got varicose veins. What are the chances of them going away once she's delivered the baby?
CAMPBELL
Well almost certainly they'll get better. What one can't say is how much better they'll get. Varicose veins are always worse in pregnancy and if she goes on to have further children and she's had varicose veins in this pregnancy almost certainly they will gradually worsen with further pregnancies. Now many people find that the veins bulge in pregnancy then they get completely better. Some people find that they go away very little at all. What is important is considering when and if one wants something done to them, that if you're going to have several children then the ideal is probably to wait until you've finished your family before having them treated because if they are treated and you go on to have further children then the chance of them recurring is somewhat higher.
MYERS
And do we know whether it's the weight of the baby causing extra pressure on the leg veins or is it something to do with the hormonal changes?
CAMPBELL
It's both, it's both, I mean it's a number of factors and those are the two main ones.
MYERS
Clearly for men it's not hormonal so are there other factors that come into play when these varicose veins set in?
CAMPBELL
We don't really know, if anyone knew precisely what the cause of varicose veins was they'd have answered the $64,000 question.
MYERS
Alright. Well we've got a question from Norma who's in Edinburgh, she has varicose veins, and eczema. Are they connected Norma?
NORMA
Yes the eczema's definitely - I've got quite severe veins in both legs which collapsed about 12 years after a previous injection treatment. I've got no pain but very severe and increasing eczema on both legs. I've been offered stripping, which I think is very invasive and I've also been told that any treatment I have may not necessarily now correct the eczema, so I'm just not sure what the best way forward is.
MYERS
Oh quite a conundrum there, can we try and unpick that a little bit. So what's the first thing to do would you say Professor?
CAMPBELL
Well the first thing is just thinking about the eczema, particularly if it's jolly itchy - is your eczema itchy?
NORMA
Well I'm managing to treat that with emollients, so that it's not itchy, but it just doesn't go away.
CAMPBELL
Well you're doing the right thing, I mean certainly putting on any kind of moisturiser regularly is a good thing. If eczema becomes very itchy then using a steroid cream from your doctor for a brief period of time is a good way of settling it.
NORMA
Yeah but the problem there is ulcers which is what I'm frightened of because my mother had those.
CAMPBELL
Of course, of course and I mean that's a very reasonable fear and that's why you certainly must take things seriously if you're one of the unlucky few who does go on to get eczema or damage to the skin. And certainly you should consider having some treatment for your veins. The thing that you can do quite easily is to get some kind of compression hosiery, usually well fitted, below the knee compression stockings, those act against the head of pressure in the veins and if those together with moisturising creams on the skin keep the skin in reasonable condition and your eczema doesn't progress there's no need to do anything more. If either you've found stockings unacceptable or unpleasant or too hot or if you want to be rid of your veins anyway or the eczema got worse then some form of treatment - conventionally an operation - would be the right thing to do.
MYERS
So is this the problem Professor Campbell that in themselves they're not necessarily a problem if you've got varicose veins but if they lead to some sort of breakdown in the skin, presumably due to the fact that the blood isn't circulating that well, then you can be in difficulty with such things as eczema, ulcers and other things?
CAMPBELL
Absolutely so. I mean we believe the skin damage is caused by the high pressure in the veins at the ankle and certainly when anyone develops those signs then it certainly is important not to ignore them and to consider treatment.
MYERS
I think our next caller has a concern about her varicose veins. Mrs Rossey is in Worthing. What's happened to you Mrs Rossey?
ROSSEY
About a month ago I was rather taken back, I got out the bath and my vein in my ankle just burst and blood went everywhere.
MYERS
Oh dear.
ROSSEY
So I went to the hospital and the first thing they asked me if I was on aspirin or anything, so I didn't understand why but I know now, and I said no and they stopped it. They said go to your doctor. So I went to the doctor but within six days later it went again. And that's about two and half, three weeks ago and yesterday it went again and I haven't got varicose veins, I've got little veins around the ankle to the main vein.
MYERS
Mrs Rossey I can see that Professor Campbell, who's listening intently, is looking a bit concerned about this. Are you worried - bleeding from the ankle in this case?
ROSSEY
Yes I am.
MYERS
So is the Professor I think.
CAMPBELL
Well absolutely. I mean this is something that does demand urgent treatment. In fact NICE - the National Institute for Health and Clinical Excellence - produced referral guidance for general practitioners about varicose veins four or five years ago and this comes top of the list as the one complication of varicose veins that demands emergency referral. And certainly if you were sent to me with bleeding this is something for which I would offer you treatment really without - without delay because it is something that can be dangerous, particularly if someone has a little crusted area which could bleed again, for example you knock it with the other leg in bed at night, you can lose a lot of blood.
MYERS
Okay so the message is very clear Mrs Rossey, get off the phone now and go to the doctor.
ROSSEY
Well I went to the doctor this morning and she's given me plasters and said don't worry about it, just keep it covered.
MYERS
Right, well perhaps you can quote Professor Campbell and go back and have another look at that, it sounds as though that really does ...
ROSSEY
Because I'm very worried about it.
CAMPBELL
Certainly it is right, while you're trying to get it sorted out, to protect it and I'd suggest not only having a plaster but even just putting a bandage over it to offer physical protection. If it does bleed again the right first aid treatment is to press on it and get someone to put a bandage on and that will always control the situation because the pressure of blood in the veins isn't high unless you're standing up, so if it's pressed on a bandage that's the best first aid treatment. But certainly you ought to seek treatment to get the veins sorted out.
MYERS
Thanks very much for your call. And just some general terms - how can you sort of pre-empt something like this, if you have got varicose veins and they haven't given you any real trouble but of course you may be wondering whether they will lead to these serious things. I mean what proportion of people do develop medical problems as a result of the varicose veins and can you know if it's going to happen to you?
CAMPBELL
It's a relatively small proportion. With regard to the bleeding it is almost unknown for a varicose vein with healthy skin over it to bleed, a lot of people are worried about that. But bleeding happens from areas that are quite clearly unhealthy, there's sort of blackened areas of skin, little bulges of veins under very thin skin, it looks highly unusual. So just a varicose vein with normal skin over it isn't going to bleed. The business of skin changes and eczema, again people don't develop severe skin changes or ulcers overnight, you notice that something's going wrong - some eczema, some discoloration of the skin - and as a rule people have plenty of time to realise there's something happening and to seek advice.
MYERS
And what about the other concern I've heard expressed that your varicose veins may lead to a deep vein thrombosis? After all if the blood is not circulating as it should and is pooling somewhat in these distended veins does it mean you're going to get clots?
CAMPBELL
Very, very unlikely, I mean one has to be very clear about the difference between the varicose veins, which are under the skin, and the deep veins to which they're connected but which are really a completely separate system of veins. And there is no evidence at all that varicose veins predispose to deep vein thrombosis outside the context of having major surgical operations, there is some connection in that regard. But otherwise people who are worried about long air flights and the like just because they have varicose veins, I mean that I don't think is a real concern nor should it be.
MYERS
Elizabeth in London is worried, she's got bad veins and was wondering whether surgery might improve things. How bad are these veins from your point of view Elizabeth?
ELIZABETH
Well it's actually on one leg as opposed to two legs - on my right leg a big one down the front and then it's got particularly bad behind the knee in the last year. And I've tried all sorts of alternative methods like horse chestnut and things from the health food shop but it doesn't seem to be making it any better. I've also tried dietary - sort of things that are advised by dieticians but it doesn't seem to be getting any better. And I'm nervous of having an operation.
MYERS
Okay can we say something first about these alternative remedies that people are certainly being offered, generally speaking would you say there's anything that will help a vein that's varicosed?
CAMPBELL
Well nothing is going to make the varicose veins go away. I mean there are a various medications that some people find help but nothing is going to get rid of the varicose veins. The only way that they're going to go away is if they're removed surgically, if they're injected and as you know there are the various different treatments that one now hears about like laser, like radio frequency which are adjuncts or alternatives to surgery, all of which are choices nowadays for people who want to be rid of their veins.
ELIZABETH
Can I ask which are the best of those in terms of if you've only got one vein and a cluster behind the knee which would you recommend?
CAMPBELL
Very difficult. The problem is varicose veins do need to be assessed properly by a specialist because as soon as you say you have varicose veins behind the knee my ears prick up that you may have an important leaky valve between the deep veins behind the knee and your varicose veins and that needs to be dealt with conventionally by an operation with an incision behind the knee and tiny incisions elsewhere. But nowadays there are alternatives, such as foam sclerotherapy. Which is best we can perhaps move on to in a moment, I don't think there's a straight answer, there's a lot of personal preference about what you have done.
ELIZABETH
I was told by my doctor that - not to touch it unless it hurts because the operations often go wrong.
CAMPBELL
I think that's something of an overstatement. Surgery's been knocked a lot recently because of people who - I think many people want to tell you how good their new treatment is. Properly performed thorough surgery has low levels of complication rates, people get over it quickly and it has good long term results. So whereas I think some of the newer treatments are very good I think scare stories about surgery are often misplaced.
ELIZABETH
How do you find a properly performed one?
CAMPBELL
Well I think probably my best answer is ask your friends and the sort of thing that you want to know is did they see a surgeon who was - who offered them choice, who was sympathetic, who dealt with them well and who when they'd been dealt with they had a good result.
MYERS
We'll come on to some of these alternatives that you very nicely laid out there but skipped over a little bit. But can I just press on that if, let's say, Elizabeth's main concern is safety and quite reasonably so what is the one thing you should bear in mind, is it about finding the surgeon who does that procedure most often and has good results and you can look those up these days on the internet, I mean what could you say in general terms that people should try to get right if they want safety as their key consideration, after all it's an elective procedure, you're not going to die with varicose veins, to an extent it's about removal for cosmetic reasons isn't it?
CAMPBELL
Yes you're absolutely right. I mean I think the main thing that you need to do is to go and talk to somebody and have a really good discussion with them and get them to advise you about pros and cons. I mean if you, as it were, want to test them ask about treatments that they don't offer and ask whether they're happy to send you to somebody else for advice and if they say yes probably they're actually somebody who's actually taking a very broadminded approach and they're worthy of your trust.
MYERS
Let's go to another caller, very much on treatment, Muriel in Pendleton, Lancashire is interested in laser therapy, that's the one you'd like to know a bit more about is it? Is it something you've heard is a good thing or you're worried that it's a bad thing?
MURIEL
About three years ago I read an article in the Telegraph which recommended it. I have been referred by my excellent GP to a consultant in North Manchester who basically on all my three visits to him have said go away and come back when you've decided to have the surgery. When I asked him about EVLT he said - What? Is that the laser therapy? - and I said yes - Is it happening outside London? He didn't seem to know. Now I don't read the medical press I just read the Telegraph ...
MYERS
Well it's a good start.
MURIEL
And I'd like to know if that has - I did ring the hospital where Mr Challoner, I believe he was called, was mentioned in the Telegraph time and time again but there was no secretary in that department ...
MYERS
Okay well let's see if we can get to the answer for you. EVLT, presumably that's a technical term ...?
MURIEL
Endovenous Laser Therapy.
CAMPBELL
Endovenous Laser Therapy. Yes I mean this looks a promising treatment. I mean one of the problems within the medical profession is the fact that the scientific studies on it to date have not been particularly good but the evidence that we have is that this is an effective treatment for varicose veins, it involves usually local anaesthetic but it does mean a number of injections in the thigh to place local anaesthetic and fluid around the veins and then laser probes introduced through a little nick usually near the knee up towards the groin and withdrawn down the main vein and causes that to seal off. Now often other varicose veins round about or lower down the leg then need to be dealt with by injections or by tiny incisions over them, so simply passage of a laser fibre up the vein doesn't necessarily sort the whole problem out. It can be done under a local anaesthetic but then again it depends whether you feel disposed to have something done under local. So there's a lot of personal preference about it but it's a promising treatment and the results, such as we have them, up to three years or so, it does look to be a reasonable alternative to surgery.
MYERS
And let's raise the question of injection - non surgical injections - Jean Smith wants to talk about that, something you've heard about would like to try perhaps?
SMITH
Yes, yes, I've read about it in a magazine recently and was kind of overjoyed because I've had really quite bad varicose veins for 30 years. I think my legs now like something from a horror film and I'd love to go swimming, I love going swimming, and I just won't anymore because I'm so self conscious about them. The only thing is that these lovely new treatments don't seem to be available on the National Health. So if I was to save up and go for one of these treatments - I'm a bit wary of clinics because you hear so many bad stories about operations going wrong - what do we need to look for if you think this - I think it's called foam sclerotherapy or something?
CAMPBELL
Yes it's easier to call it injections. Sclerotherapy or injection treatment, it's been around for years, just injecting a small amount of liquid sclerosant. it's like an irritant that you inject into the veins and then puts a bandage and a stocking on for a while and it seals them off. Now that just ordinary old fashioned injection of liquid works well for small veins, particularly those below the knee, which haven't got a particular head of pressure of them. The innovation of foam sclerotherapy involves mixing small quantities of that liquid with air or with another gas to form a tiny amount of stuff with air bubbles in it. And you can watch that spread through the veins under an ultrasound machine and that can be used to treat more extensive and larger veins. I mean the things you have to bear in mind about it, yes it's an outpatient treatment, it just involves an injection or two, it's probably the least painful of anything to have done, you have then got to wear a support stocking and bandage on each leg for at least two weeks and often the veins are pretty lumpy and hard for some weeks afterwards, so if you've got huge big lumpy veins you've got to bear in mind they may take quite some time to shrivel up. So there are a lot of pros and cons. Do you want to avoid a general anaesthetic? Do you mind being bandaged? Do you mind having lumpy veins? Lots of pros and cons to consider.
MYERS
Well I think you don't have to answer those, I think they're rhetorical questions but take them away and think about them. But can I just press Professor Campbell on behalf of the question about clinics, I think you were talking there Jean about obviously private clinics and here's a key question - can you get this treatment or indeed any of the surgical or other treatments available now on the NHS and if so what do you have to do?
CAMPBELL
Desperately variable. You can get surgical treatment for varicose veins anywhere in the UK, different parts of the country have different thresholds and principles in terms of the kind of patients they're prepared to offer it to. The newer treatments - laser, radio frequency foam - I don't think you can find anyone who offers all of them. The important thing is to find someone who offers you choice and you'll find many people, for example, I'll offer people surgery or foam but I don't do laser or radio frequency. So I think it's patchy in that respect, it's patchy in terms of the availability. And I think the difficulty is actually, as you've said, finding out what's available in your area.
MYERS
Okay thank you very much. We'll take another caller Margaret Hickling has had some treatment, a recurrence I think then of your varicose veins is that right?
HICKLING
Yes that's right. I had the veins stripped about 20 years ago and gradually over the years they've come back. My main problem now is about 18 months ago I had a sudden pain in my leg and I was told that probably a valve had given way. My leg swelled and my foot swelled at that time and although the swelling in my leg has now gone down frequently my foot still swells. And what I need to know is does it matter?
CAMPBELL
Very difficult to know, there are lots of causes of foot swelling and it's unlikely to my ear that that was caused by your varicose veins. I think if you do come to the business of having your recurrent varicose veins treated, I mean that's a situation in which some of the new treatments like foam sclerotherapy can have advantages because surgery for recurrent varicose veins is almost always possible and it can be very successful but foam is one way of dealing with recurrent veins which could be difficult surgically.
MYERS
Okay thank you very much, I hope that's very helpful. Let's take an e-mail - I think we may have to finish with this one - which is from Agnes Eaton who says she wants to extol the glories of compressed stockings for varicose veins, although they're expensive, she says, they stop the aches. Can you tell us briefly why that should be and whether you are a great fan of compressed stockings or does she mean compression stockings?
CAMPBELL
Compression stockings - compression stockings come in many forms, support tights which you can buy in the high street, full length compression stockings, there are various grades of them class 1 which are weaker, class 2 which are the usual ones, class 3. Below the knee ones are often the most comfortable ones to use. Certainly they work and they work by compressing the veins and acting against the high pressure in them. It's really a question of whether people find them acceptable and whether they're prepared to wear them everyday. But if you've got bad symptoms from varicose veins and you're prepared to wear them there's no doubt they work.
MYERS
So to answer my earlier question yes you can still buy them and yes they are very useful.
Thank you very much indeed. Thanks for all those questions and thank you particularly to our expert today Professor Bruce Campbell. You can listen to the whole of this programme again if you wish on our website at bbc.co.uk and if you'd like further information and to speak to someone then call the helpline 0800 044 044. Join me again at the same time next week, Thursday at three, for children's health problems. Does going back to school put them at risk? Bye for now.
ENDS
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