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my name is dr haroun gajraj, i am a vein specialist,and i trained as a vascular surgeon in london and did most of my surgical training in london.i took up an appointment in somerset as an nhs consultant seventeen years ago now andtreated the whole range of vascular problems, arteries, veins and other problems, but aboutfive years ago i left the nhs to concentrate exclusively on the treatment of veins andthat's all i've been doing now for five years. i've given up all my arterial work and i justdeal with vein problems well, what are varicose veins? well you don'tneed to be medically trained, you don't need to be a doctor, to look at your leg or somebodyelse's leg and know that there's something wrong with the veins. so, for example, thisperson has a cluster of spider veins at the
back of the leg with varicose lumpy veinsto the side and medically they are abnormally large, they are wider and bigger than theyshould be, they are obviously twisty and turny and they have a condition in them called reflux.veins should be carrying blood up the leg back from the foot to the heart - if the littlefolds in the lining are not meeting properly and gravity is pulling blood down in the wrongdirection then we give this the term 'vein reflux', and the underlying problem with thesethread veins and these spider veins is that the direction of flow is wrong, the valvesare not working properly and blood is coming down in the wrong direction, that's the medicalunderlying problem. what causes varicose veins? well, top of thelist is heredity. unfortunately you can pick
your friends but you can't pick your parentsand most cases of vein problems are inherited or have a genetic basis. it's been estimatedthat if both your parents have a vein problem, then you unfortunately have an 80% chanceof developing a vein problem yourself. it's not inevitable, but it's a high risk if youhave a strong family history. other things on this list don't actually cause varicoseveins but they contribute, so if you've inherited a weakness of your veins and you have an underlyingproblem, often veins will appear for the first time during pregnancy because of the addedstrain on the vein circulation. it doesn't actually cause it but it's another risk factorwhich declares itself if you have an underlying problem and all these other things contribute.
having said that we know lots of people, don'twe, who have had lots of children, who are possibly overweight and don't have a particularlyhealthy lifestyle - not a blemish on their legs, doesn't seem fair does it really - butequally there are many young men who are quite athletic and very fit, obviously they've neverhad any children themselves, and they've got dreadful varicose veins so it does appearthat heredity is the main risk factor. what causes thread veins? well, i've alreadymentioned that reflux is the underlying problem so it's not a surprise really, is it, thattop of the list is heredity. again many people have not a blemish on their leg because they'veinherited good veins from their parents. others, unfortunately, haven't had any children, notoverweight, very healthy and they're covered
in spider veins and thread veins. the underlyingproblem is a weakness of the veins and it's a problem called reflux, so heredity topsthe list. all these others are contributing or risk factors, they don't actually causethem, however i would say that reflux, which also causes varicose veins, varicose veinsare often associated with thread veins. in fact when i see people with thread veins,one of the important things is that you check very carefully for underlying reflux so thatthe problem is treated correctly. are they simply cosmetic? well, a questioni get asked a lot is "i've been to my doctor with my veins and he tells me that treatmentis not available on the nhs" and often that person is told that they're simply cosmetic.well, they're not simply cosmetic -- as you
can see from this slide, a healthy vein isnice and straight and it's got strong folds, strong valves in the lining that meet properly,keeping blood directed upwards from the leg back to the heart. on the right we have avaricose vein, it's wider than it should be, it's tortuous, it's wiggly and the valves,these little folds, are weak and floppy and they're allowing blood down in the wrong direction,so varicose veins are unhealthy veins with faulty valves and this condition called reflux.so it's not simply a cosmetic issue. as you can see in this slide, we've got aleg where we've got a superficial vein, that's a vein underneath the skin that is refluxingand faulty, and the blood is coming down in the wrong direction from the top of the thighdown into these lumpy varicose veins and further
down into these little spidery veins. so theunderlying problem is reflux, it's not simply a cosmetic issue, it's a shorthand way ofsaying the majority of people don't get major problems but to dismiss them as simply beingcosmetic is not correct. this is a lady i saw a few years ago and shetoo was denied nhs treatment initially. she had quite bad reflux in the veins in her thigh,feeding into varicose veins in her calf, which were causing quite a lot of swelling of herleg, and they were causing quite a lot of thread veins and spidery veins around theankle, and also after a little while were causing a condition called varicose eczema,which i'll come on to in a moment. in her case they weren't simply cosmetic, she actuallyhad to argue her case quite strongly and at
that time had to appeal to the primary caretrust, the pct. eventually she was granted nhs treatment but her operation was cancelledthree times, twice on the day of her operation - she'd been all prepared and got ready andin frustration she decided that she would have her veins treated privately and she wasconcerned, quite rightly, about the possibility of ulcers. so what problems can arise? one of the questionsi get asked again quite a lot is "i've got bad varicose veins, will i get a leg ulcer,i'm worried about leg ulcers". well in fact the majority of people with even quite severevaricose veins do not come to any harm and i think this is the main reason why the nhsdoesn't treat veins. they do, however, cause
a lot of ache, a lot of itch, swelling, thesesymptoms do tend to be worse in hot weather. they tend to be worse at the end of the dayand they are also very unsightly. i think it's sometimes difficult for us mento understand how much distress they cause to women particularly, and increasingly men.it interferes with what you can wear, what sort of holidays you can take, what sort ofsocial activities you might be involved in. i came across a lady not so long ago who wouldn'ttake her children swimming because she felt so embarrassed about the sight of her legs,and the distress that some of these unsightly veins cause can be quite severe. i say 'even' thread veins - we now know thatthread veins and spider veins are associated
with this condition called reflux, so it'snot surprising that even thread veins cause symptoms or are associated with symptoms.until we knew a little bit more about the condition we didn't really, as doctors, believepeople who say "well my thread veins hurt and they burn and they itch" but they do,and we now know that if you treat thread veins properly the majority of people get reliefof their symptoms as well. so, as i say, a frequent question is "i'vegot bad varicose veins, will i get a problem". well, the majority don't but if you do getmedical problems they come under one of these four headings. as i say, the majority willnot. the first one i'd like to talk about is phlebitis.a frequent question is "i've got phlebitis,
what is it and will it cause me any harm?".another condition is varicose eczema, a condition of the skin caused by reflux and these otherconditions, deep vein thrombosis, bleeding and ulcers. let's talk about those very brieflyin turn. now phlebitis is often a misused term, bothby the public and by doctors. the strict medical definition of phlebitis is an inflammationin the vein, that's all it means really, doctors add the word 'itis' on the end of the wordto indicate inflammation. i think 'phleb' is a greek or latin word that means vein and'itis' means inflammation, so it's an inflammation of the vein. it appears clinically, that ison the surface, as a hard, tender lump underneath the skin, so it's quite superficial - phlebitisinvolves the superficial veins, it's superficial
and it has all the features of inflammation,so if you've ever had inflammation elsewhere you'll know that it's red, warm, tender andit's quite a severe condition. these people often can't go to work it's that painful,and it used to be thought to be quite a trivial condition so if you went to see your doctorhe'd say "oh that's just a bit of phlebitis, take some painkillers and go away". we now know, however, that to diagnose phlebitiscorrectly, you should have an ultrasound scan. people who are diagnosed as having phlebitisare often misdiagnosed, and when you look with an ultrasound scan there's another condition,so having an ultrasound firstly confirms that it is phlebitis because you can actually lookat the superficial vein and the appearance
on ultrasound is quite characteristic of thecondition and you can make sure there's nothing else amiss, because we now know that phlebitisis frequently associated with deep vein thrombosis. the clot that occurs inside these veins canextend further and into the deep veins and that can be quite a significant problem, quitea severe condition. last week i saw a patient in bristol who hadbeen treated by his doctor with phlebitis and in fact he had a deep vein thrombosisall along so the diagnosis was wrong -- it would have been established with an ultrasoundscan -- and he had quite a significant deep vein thrombosis that put him at risk. so phlebitisis not a trivial condition, it should now have an ultrasound scan, that's the recommendationof two very influential bodies, one in the
united kingdom and one in america, and thatrecommendation came out last year that all people with phlebitis should have an ultrasoundscan. i don't know if anyone here in the audience has had phlebitis and whether they had anultrasound scan but i think now if you have been told, or you suspect you have got phlebitis,you should have an ultrasound scan. varicose eczema -- this is a condition thataffects the skin, usually just above the ankle. now this is a term that is misleading, youmight think well varicose eczema, it's a skin problem and indeed i see many people who aretreated with creams, often steroid creams. these conditions are very itchy, they candrive you mad and they can keep you awake and cause a lot of distress, and there's nodoubt that there is inflammation of the skin
and there's no doubt that if you put steroidcream on you will feel better, the itching will go, your leg will feel better and itwill give you some relief. but - varicose eczema is not principally a skin condition,it's due to this problem called reflux and what this indicates is that the skin is beingdamaged by this faulty vein circulation. it looks like eczema but it actually indicatesthat there's damage to the skin and that that skin is vulnerable and at risk of ulceration,so this condition is often the precursor of a leg ulcer. not tomorrow, not the day after,it takes time, but the skin is vulnerable and at risk and this should be treated toprevent an ulcer. it's not a skin condition, it shouldn't really be treated with steroids,in fact steroids, if you put them on long-term,
they actually thin the skin and they makethe skin more vulnerable, more liable to ulceration. so varicose eczema should be treated by avein specialist or a vascular surgeon, not a dermatologist, not with skin creams. deep vein thrombosis -- well, this is thefear of most people, in fact it's not very common as a complication of veins, it's onlyrecently that we are confident now to be able to say that varicose veins are a risk factorfor deep vein thrombosis, there's now good evidence in the medical literature to supportthat. it doesn't mean you're going to get one inevitably but, if you have an additionalrisk factor, varicose veins will contribute. so, for example, if you were to go into hospitaland have major surgery, say a hip replacement
or a major operation for bowel cancer, andyou had bad varicose veins, it would slightly increase your risk of a deep vein thrombosis.if you were to go on a long-haul flight with bad varicose veins, it would add to your risk.it doesn't cause it but it is a risk factor, and anyone under those circumstances -- comingout of hospital after surgery, stepping off a plane after a long-haul flight -- who hasone leg more swollen than the other, this should ring alarm bells, have i got a deepvein thrombosis. and again, the only way to diagnose a deep vein thrombosis accuratelyor to exclude it, to say no, you don't have a deep vein thrombosis, is to get an ultrasoundscan. now the next slide is a little bit scary,i'm sorry, i keep meaning after these presentations
to take it out and put a less scary slidein. it is a little bit scary, if you're squeamish, look away. having said that, most people wakeup at this stage and it's the slide they all want to see. this is a leg ulcer, this isthe dreaded complication of varicose veins and reflux. once they develop - this is quitea severe one -- once they develop, they are very difficult to heal, they are very difficultto eradicate. even when you do get them healed, they heal with a lot of scar tissue. the areais quite vulnerable and it's never quite normal, so it's always a little bit more vulnerableto knocks and injuries. so leg ulcers, once they're established, do tend to recur, evenwith the best available treatment, because of the vulnerability and the scar tissue.so avoid leg ulcers if you can - i'm sure
nobody wants a leg ulcer, but if you've gotvaricose eczema and you've got any complications from your veins, we know that early treatmentwill give better results and will reduce the risks of complications. so as i mentioned, many people go and seetheir doctor, they say "i've got vein problems" but the nhs doesn't treat them. why is this?well, the nhs doesn't see veins as a priority and the majority of people, even with quitesevere vein problems, don't get a major complication. the nhs is strapped for money, i think wehave to accept that, and there are other, more pressing requirements. there's no nationaltarget for veins, there's no two-week wait for veins, and there's no targets as thereare, as you'd expect, for an ambulance arriving.
we all expect, if we're injured, that an ambulancewill arrive within a certain time, we all expect that it will take us to a well-equippedhospital with an operating theatre if we need urgent surgery, and we all expect that ifwe suffer a heart attack, we're taken to coronary care and that we're looked after. this allcosts money, and obviously the nhs has limited resources. i don't want to get too political,but you can imagine that if the majority of people don't get a major problem from theirveins, the nhs can't treat everybody, it has to ration treatment. the national institute for care and healthexcellence (nice) last year 2012, or no 2013, earlier this year, only in the summer of thisyear, made several recommendations about the
treatment of veins and it said specificallythat anyone who's got symptoms from their veins should be referred to a vascular surgeon.however, we know and i know that currently people, even with varicose eczema, are findingit difficult to get nhs treatment. so although nice believes that people should have advice,the reality here in this area is that people are finding it difficult to get access totreatment. other reasons -- thread veins are often regardedas cosmetic, when we now know that the majority of people, even with thread veins, have reflux.varicose veins are not a priority, as i've mentioned. there are other, more pressingproblems for the limited resources of the nhs. i was going to say it's rationed by strictcriteria, they seem to be getting stricter
and stricter and access seems to be gettingpoorer and poorer as time goes by, and i see people who have had bad phlebitis or who havehad varicose eczema who can't get treatment -- very difficult. and, obviously, your doctorneeds to keep up-to-date with all sorts of new developments in diabetes and blood pressureand child care and dementia. he finds it very difficult to keep up-to-date with all thelatest treatments on veins. not surprisingly, your gp may not be able to refer you to thelocal hospital for veins so, at the end of a busy surgery, he's hardly going to spendhours reading up on the latest developments on veins.