Choosing your surgeon

Why see a specialist vascular surgeon?

It is important that patients get to see the right specialist if they are to get the best treatment.

In short, I believe that the essential ingredients are enthusiasm, experience and expertise.

I have eight years experience in endovenous laser treatment and have performed around one thousand procedures. In that time I have trained more than 30 specialists from all over the UK and Europe from Portugal, Italy, Sweden, Poland and Turkey.

The following article reproduced with permission from www.familydoctor.co.uk summarizes this very well and gives you some simple pointers to getting the best treatment for your varicose veins

Choosing a surgeon for your varicose veins

How the approach to surgery has changed
In the ‘old days’ (before the 1990s) varicose veins were dealt with by all general surgeons, many of whom were neither particularly interested nor very expert in their treatment. Operations were often left to junior surgeons who had been trained in this ‘non-specialist’ approach.
To be fair, the modern methods for investigating varicose veins by ultrasound were not available, and surgeons were doing only what they had been taught. However, this old-fashioned approach often led to patients being poorly informed, having large scars and developing recurrent varicose veins, because their surgery had not been thorough.
In addition, patients had sclerotherapy when they ought to have had surgery, so their veins came back quite quickly. All this cast a shadow on the effectiveness of varicose vein treatments in many people’s minds.
Choosing a surgeon
Some general surgeons have always been enthusiastic and good at treating varicose veins. They tend to have been surgeons with a special interest in blood vessels (arteries and veins), who now form a specialist group called vascular surgeons. ‘Has he or she a special interest in vascular surgery?’ should be the first question to ask when choosing a surgeon to deal with varicose veins.
Even among vascular surgeons, there are some who are recognised as having particular interest, enthusiasm and expertise in treating varicose veins, but identifying them is more difficult. General practitioners will usually know who are the best recognised surgeons for varicose veins in your area. Ask them ‘Which surgeon has a special interest in varicose veins?’.
The experience of friends who have had their varicose veins treated can be helpful in choosing a surgeon. Some pointers to a good specialist in varicose vein surgery are:
• They ask carefully about your symptoms, and how much your veins bother you.
• They use some kind of ultrasound examination.
• They use a duplex ultrasound scan if you have varicose veins that have come back after previous surgery.
• They explain which treatments they could offer you and why.
• If you have a particular wish for a treatment that they cannot provide, they give an explanation and if appropriate offer to send you to a specialist colleague who can.
• If they offer laser or radiofrequency, they tell you whether you are also likely to require foam sclerotherapy or surgical phlebectomies. They explain whether these treatments are likely to require one or more treatment visits.
• They explain the pros and cons of having any treatment.
• They either give you a choice or explain very clearly why treatment is essential (it is seldom essential except for skin changes or ulcers).
• They usually give you some written information and advice.
• Most of the scars that they make at the time of operation are very small.
If you are referred to a surgeon or surgical team who do not do most of these things, then you may want to reconsider your choice.
It may well be that any particular surgeon does not use all of the available treatments but they should normally be able to offer both surgery and/or laser/radiofrequency in addition to foam sclerotherapy – either as an individual or as one of a team that uses the different methods.
Be suspicious of any surgeon (or other doctor) who offers only one kind of treatment and simply tells you it is the best.
NHS or private care?
The quality of specialist treatment in the NHS ought to be just as good as in the private sector. The main differences are that in the private sector you will see and be treated by the consultant of your choice (in the NHS sometimes a specialist trainee), you will have more time to talk with him or her and you will have more choice about when you are seen and treated. Importantly, the NHS in your area may not provide care for people whose veins are not causing damage to the skin, or bleeding, and it may not offer a wide range of treatment options.
Is referral for NHS treatment possible?
Varicose veins have always posed a problem for the NHS because they are just so common. They are usually not a real danger to health but they are often wrongly thought to be ‘cosmetic’ when in fact they are causing troublesome symptoms. All this means that they are a frequent target for ‘rationing’ (this means that the primary care organisation that pays for NHS hospital treatment in a particular area will not fund treatment).
With the strict limits on waiting times (for outpatient clinics and for treatment) that have been imposed on NHS hospitals, varicose veins now ‘compete’ with conditions that are (or are perceived to be) more serious. This is one reason that NHS treatment for varicose veins has become restricted in many parts of the UK.
The main reason for rationing of referral for varicose veins is cost. Other conditions are often judged by primary care organisations to be more deserving of the limited NHS funds available. This is despite the fact that treatment of patients whose varicose veins are causing symptoms has been clearly shown to improve quality of life and to be ‘cost-effective’. Whether or not referral for NHS specialist advice and treatment is possible varies a lot around the UK at the present time. There is a trend to increasing restriction.
It is most unusual for the NHS to provide treatment for varicose veins that are causing only cosmetic embarrassment. Exceptions can be made. I have particular sympathy with younger women who have huge varicose veins that are causing great restriction to their lives. The phrase ‘distressing disfigurement’ is a useful one when making a case for NHS treatment.
For people with ulcers, skin changes, bleeding and perhaps phlebitis, treatment ought to be available throughout the NHS. Patients who have bled should get treatment without delay.
Range of treatments available in the NHS
The ways that new varicose veins treatments have been introduced into NHS hospitals have varied a lot. This has been due in part to which treatments surgeons have chosen to develop and in part to financial and organisational considerations. The traditional arrangement was that varicose veins were mostly treated surgically on operating lists. Different facilities and costs are involved for the newer treatments – for example, the costs of single-use laser and radiofrequency probes and the need for more than one visit for some treatments. There are many different ways of computing the costs and comparing the value of the various treatments and hospitals have taken different approaches.
All this means that any NHS hospital is unlikely to offer all the different types of treatment. For example, in my own hospital at the time of writing we are able to offer only surgery or foam sclerotherapy. Some hospitals use foam sclerotherapy very extensively, whereas others offer laser or radiofrequency ablation.
When faced with a limited choice, it is important to remember that the eventual results of all these treatments are similar.
Guidance from the National Institute for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence (NICE) has produced referral guidelines for GPs about the reasons for referring people with varicose veins to hospital, and the degree of urgency with which they should be seen. These were published some time ago (2001) and NICE will be producing a new and more detailed guideline on varicose veins and their treatment within the next couple of years.
You can ask your GP which vascular surgeon has the shortest waiting time for varicose veins; they should know because hospitals circulate this information.
Private treatment for varicose veins
As a result of the restrictions imposed on varicose vein treatments in the NHS in many areas, private treatment can offer considerable advantages, and may be the only way of getting your varicose veins dealt with if you have ‘cosmetic’ varicose veins for which your local NHS will not fund treatment. If you have private medical insurance, you are well advised to use it if you want advice or treatment for varicose veins.
The following are the main advantages of private care:
• You can see the surgeon of your choice (this might even be a surgeon who is well known for varicose veins outside your own immediate area).
• You will be dealt with personally by the consultant of your choice throughout.
• You will not have to wait long.
• You can have treatment at a time convenient to yourself.
• If you have treatment involving a general anaesthetic, you can have a private room.
If you opt for private care, it is very important to be sure that you get really good specialist treatment. The ‘pointers to a good specialist’ shown above may be helpful; you should feel thoroughly comfortable and confident with the surgeon whom you have chosen.
Costs of private treatment
Never feel embarrassed asking about costs. Most surgeons base their fees on the rates offered by the private medical insurance companies, so that everything should be paid for if you are fully covered by one of the leading private insurers. It is particularly important to check with your insurance company the details of your cover, especially:
• If your veins really are ‘cosmetic only’. Will they pay? This applies to any varicose veins that are not causing symptoms or medical problems.
• If your veins have been treated before. Are you fully covered?
• If you have had varicose veins for a long time, but they have only recently started to cause symptoms. From a medical point of view the problem began when the symptoms started, but occasionally insurance companies argue about this.
• If you have a policy with restrictions depending on local NHS waiting times.
Private hospitals provide ‘packages’ that include all costs (surgeon’s fee, anaesthetist’s fee and hospital charges) and your surgeon will be able to tell you about these. Remember that the consultant’s fees for consultation (before and sometimes afterwards) will be additional to this.
The traditional distinction between private and NHS care has become a little blurred with the use of private hospitals for NHS patients under initiatives such as the ‘choose and book’ system.
KEY POINTS
• There are restrictions on specialist referral for varicose veins in the NHS, which vary a lot around the UK; ‘cosmetic’ varicose veins are seldom treated on the NHS
• Choose a surgeon who is a vascular specialist (preferably known for an interest in varicose veins); ask your GP and your friends; a good surgeon should inform you well, examine your veins by ultrasound and give you a choice
• Private care lets you have treatment when you want, ensures personal attention from the consultant of your choice and means a private room if you need an operation
• Always check with your medical insurance company or ask about costs of private treatment
© 2010 Family Doctor Publications

Reproduced with permission from
www.familydoctor.co.uk

Vasacare Vascular Clinic

Specialising in treatment for varicose veins