Deep Vein Thrombosis

I am particularly interested in the investigation and treatment of varicose veins (VVs) and venous ulcers. ​ I believe varicose vein surgery should only be undertaken by experienced, appropriately trained vascular surgeons. I also believe that careful preoperative assessment and investigations are essential to achieving a satisfactory outcome. In the management of venous disease (my area of research interest), I introduced some ideas and techniques to Ipswich Hospital. For example, the Inversion “Pin” Stripping technique. I acquired this technique from the Middlesex Hospital London (John Scurr and Phillip Coleridge-Smith) where I carried out my PhD research. My experience has indicated that this technique causes less bleeding/bruising compared to the old conventional stripping techniques. I offer my patients with VVs minimally invasive treatment options, including radiofrequency ablation (RFA) and ultrasound-guided foam sclerotherapy, in addition to conventional surgery, if considered appropriate. ​ I am also interested in research into the causes and management of recurrent varicose veins and presented a paper on the subject in the International Union of Phlebology Congress in Rome: ​Abu-Own A, Cheatle TR, Farah J and Shami SK. Suggested preoperative classification for recurrent Varicose Veins (VVs) and operative approach. International Union of Phlebology Congress, Rome Sep 2001. This page has been designed to provide patients with some useful information about varicose veins, the different treatment options that I offer and what to expect throughout the treatment journey. I very much look forward to welcoming patients to my outpatient clinic for an assessment where we can discuss things further.

Varicose veins are veins under the skin of the legs, which have become widened, bulging, and twisted. They are very common and do not cause medical problems in most people. There are two main systems of veins in the legs: ​ 1. Deep veins: The leg muscles squeeze the deep veins during walking, carrying most of the blood back up the legs to the heart. 2. Superficial veins: These occur under the skin which are functionally less important and can form varicose veins. ​ All of these veins contain one-way valves to ensure that the blood flows towards the heart. Failure of these valves allows blood to flow backwards down the veins and results in an overload of pressure when standing. This excess pressure leads to widening of the veins so that they do not close properly. Blood then flows back into the leg along these veins and causes varicose veins to develop. Raised pressure in these veins also encourages the development of spider veins and discoloured areas which look like bruises.

Varicose veins are extremely common. Studies suggest that varicose veins are found in about 3 in 10 people. National Health Service waiting lists suggest that there is still considerable unmet need. Most people with varicose veins do not have an underlying disease and they usually occur for no apparent reason. Varicose veins do not cause symptoms or complications in most cases, although some people find them unsightly. If treatment is advised, or wanted for cosmetic reasons, a procedure to seal them off is used.

Varicose veins often run in families and there may be a hereditary component. Women are more likely to suffer from varicose veins and up to 50% of women may be affected. Hormonal factors including puberty, pregnancy, menopause, the use of birth control pills and hormone replacement therapy (HRT) can all affect the disease. Pregnancy: It is very common for pregnant women to develop varicose veins during the first trimester. Pregnancy causes increases in hormone levels and blood volume which in turn cause veins to enlarge. In addition, the enlarged uterus can put pressure on the main vein bringing blood back to the heart from the legs, causing blood to pool in the legs and varicose veins to develop. Varicose veins due to pregnancy often improve within 3 months after delivery. However, with successive pregnancies, abnormal veins are more likely to remain. ​ Other predisposing factors include ageing, standing for long periods of time, obesity and leg injury.

Many people have no symptoms at all from their varicose veins, except for the fact that they are noticeable and their appearance can be embarrassing for many people. Other than cosmetic embarrassment, the most common symptoms of varicose veins are aching, discomfort and heaviness of the legs, which are usually worse at the end of the day. Sometimes the ankle can swell, too. These symptoms are not medically serious, but can be treated if they are sufficiently troublesome. Although varicose veins can get worse over the years, this often happens very slowly. In a few people the high pressure in the veins causes damage to the skin near the ankle, which can become brown in colour. This is called lipodermatosclerosis (hardened, sclerosed, brown discoloured skin). Varicose eczema (an itchy, dry, red skin rash) can also develop. If these skin changes are allowed to progress, or if the skin becomes injured, a venous ulcer may develop, which can be quite troublesome. Skin changes are therefore a good reason for going to see your GP and for referral to a specialist. Mr A. Abu-Own recommends patients with VVs to seek early assessment for their VVs, as he considers the development of skin changes to be an advanced stage of varicose veins disease. ​ Other problems which varicose veins can occasionally produce: ​ Phlebitis: Phlebitis (sometimes called thrombophlebitis) means inflammation of the veins, and is often accompanied by some thrombosis (clotting of blood) inside the affected veins, which become hard painful and tender. This is not the same as deep vein thrombosis (DVT) and is not usually dangerous, but is considered as an indication for treating the VVs. Bleeding: The risk of bleeding as a result of knocking varicose veins worries many people, but this is rare. The bleeding should be treated prompltly by elevating the leg and application of a firm pressure bandage. Bleeding varicose veins are considered an absolute indication (mandatory) for referral to a specialist for assessment and definitive treatment of the VVs to prevent risk of further bleeding. Deep Vein Thrombosis: Varicose veins are considered an additional causative factor for the development of DVT in some patients. Moreover, DVT may lead to development of secondary varicose veins.

Most varicose veins originate from leaking valves at groin level or behind the knee. It is important to accurately locate the site of the valve leaks. During your assessment at your outpatient appointment, the doctor will use a small probe to assess your veins - this is called continuous wave Doppler. The probe can detect the direction of blood flow which is audible, both in the skin veins and in the deep veins. It indicates where the veins have come from and helps in the planning of any operation that might be required. An ultrasound scan (duplex) may be performed. This will allow detailed examination of your deep veins, particularly if there is a past history of deep vein thrombosis (DVT). Assessment of varicose veins behind the knee and recurrent varicose veins will also require duplex scanning.​ ​ Once the initial assessment is complete, all treatments will require duplex ultrasound scanning as part of the selection process and for the monitoring of the treatment itself. ​ Other scans which are occasionally used include MRI and CT.

Very large numbers of varicose veins procedures are performed each year in the UK for medical and cosmetic reasons. The highest priority is to treat those who have developed symptoms or complications. For example: Those with bleeding from varicose veins (usually around the ankle) are considered high priority and should be seen by a specialist immediately. Pain, aching, discomfort, heaviness, fatigue, throbbing, swelling or itching caused by varicose veins. Superficial thrombophlebitis (appearing as hard, painful veins) Development of skin changes (e.g. discolouration, lipodermatosclerosis, eczema) are indicative of chronic venous insufficiency (failed valves leading to persistent blood pooling in the legs) and therefore warrant intervention. Skin changes are considered a warning sign (precursor) to develop an ulcer. Development of a venous leg ulcer or a healed venous ulcer are very important indications for treatment of varicose veins. Mr Abu-Own recommends patients with VVs to seek early assessment for their VVs. He considers the development of skin changes to be an advanced stage of varicose vein disease.

There are different options. Self-help methods.Avoid prolonged standing or sitting still. Try to put your feet up frequently (sit or lie down and raise the feet above the level of your hips). You can, for example, use extra pillows under your feet on a bed or footrest). This helps to reduce blood pooling in the veins. Use a moisturising cream or ointment to protect the skin in the affected area if it is dry, flaky or itchy. ​ Radiofrequency ablation and endovenous laser ablation. These minimally invasive methods involve passing a probe into one of the longer varicose veins, using ultrasound to guide the position. The radiofrequency or laser energy makes the vein heat up, which seals it. Surgery. Traditional surgery may still be the best option for your VVs. Mr Abu-Own will discuss with you if you should consider having surgery for your VVs. Mr Abu-Own's preferred surgical technique is the inversion PIN stripping technique, combined with mini-phlebectomies. Foam sclerotherapy. This technique is used if heat or lasers do not work. It uses a chemical mixed with air to make foam. The foam is injected into the veins, pushing the blood away and making the veins go into spasm. After treatment, a combination of a bandage and a compression stocking are applied. The treated veins may feel hard and swollen for a while before they shrink down. More than one treatment may be needed. ​ Conventional Sclerotherapy. The vein is injected with a chemical that can close and seal (sclerose) it. Mostly replaced by foam sclerotherapy nowadays. Support tights and compression stockings. These counter the extra pressure in the veins. They may help to ease symptoms such as ache, although there is little proof as to how well they work. They may be difficult to put on, particularly by people who have arthritis in their hands. Current guidelines do not recommend that they be used routinely unless treatments to seal the veins are not suitable or do not work. If you do need compression stockings, below-knee class 1 (light, e.g. travel socks) or class 2 (medium) are usually the most suitable. Ideally, they should be put on first thing in the morning, before you get out of bed, and then taken off when going to bed at night. Compression stockings are available on prescription or you can buy them. Note: if you have arterial disease in the legs, you will need a medical assessment of your circulation to decide if compression stockings are suitable (see above).

Many patients with varicose veins are confused as to what to do about them. This is unsurprising as there are several options including doing nothing, conservative treatments such as stockings, having an operation and several new non-surgical treatments like radiofrequency ablation, EVLA and foam sclerotherapy. You may wish to do nothing if you are not bothered by the appearance of your veins and they are not causing significant symptoms. There is no medical need to treat most varicose veins. ​ Compression stockings may be an option for those with symptoms but who are not worried about the appearance of their legs and are willing to wear stockings for the rest of their lives. However, use of stockings as a treatment option for VVs is no longer supported by NICE (National Institute for Health and Care Excellence). ​ Surgery continues to be a definitive treatment suitable for patients with extensive varicose veins on both legs who want all treatment carried out in one session, those who wish to have a general anaesthetic or those who don't like injections. ​ If you want to avoid surgery and general anaesthesia and to get back to normal activities quicker, you may want to consider having one of the minimally invasive procedures. These include the catheter endothermal ablation techniques (RFA and EVLA) and foam sclerotherapy: ​ Radiofrequency Ablation (RFA)is good for those with a long wide straight segment of vein which requires treating. Approximately 70% of patients are suitable for RFA. This is Mr Abu-Own's preferred catheter endothermal ablation technique. Mr Abu-Own usually combines RFA with phlebectomies so that the whole treatment can be completed in one session. Endovenous Laser Ablation (EVLA). The method and results of treatment are almost identical to RFA. Foam Sclerotherapy is especially good for those with less extensive veins who are willing to accept the possible need for several sessions of treatment and the possibility of the veins recurring in the future where further treatment would become necessary. It is the least invasive option, but less effective compared to surgery and the ablation techniques.