In order to understand what varicose veins are, it is important to know what normal veins are.

Whereas arteries are blood vessels that carry blood away from the heart to organs and tissues, veins are blood vessels that carry blood back to the heart from organs and tissues.

In the legs, there are 3 types of veins:

1. Superficial veins just below the skin surface. These veins can often be seen or felt. In healthy veins, these are ‘low pressure veins’ because they manage low pressure flow within their walls.

2. Deep leg veins – located in the muscles, these are ‘high pressure veins’ that are squeezed by the muscles when we walk, to eject blood against gravity all the way back up to the heart.

3. Perforator veins – these are connecting veins that transmit blood from the superficial veins to the deep veins. They cross through the layer of connective tissue (fascia) that separates the muscle from the skin.

The valves are made up of two leaflets that act like a one-way valve.

When the leaflets are 'open', the blood is allowed to pass upwards through them.

When the leaflets are down ie meet each other in the centre, then blood is prevented from passing back down.

When the one-way valves become faulty, they allow backflow of blood. This allows a build up of pressure in the superficial veins, which are ordinarily only able to cope with low pressures.

Therefore when placed under higher pressure, they enlarge and dilate into varicose veins.

It is not known what causes varicose veins, however multiple theories have been put forward. Multiple factors, including age, gender, pregnancy, weight, height, race, diet, bowel habits, occupation, posture, previous DVT, genetics, climate, and others, have been proposed as predisposing factors for the formation of varicose veins.

It is likely that faulty venous valves in main superficial (surface veins) and/or deep (muscular) veins results in venous hypertension, reflux, and subsequent dilatation, causing varicosities and transudation of fluid into subcutaneous tissue, which results in swelling of the leg.

Reticular veins are larger than spider veins, measuring 1-3mm in diameter. Also known as feeder veins, they are the dilated blue/green veins beneath the skin.

Spider veins (or telangiectasias) are a collection of small veins (venules) within the skin (dermis) that are less than 1mm in size. They range in colour from light pink to dark purple.

It is not known what causes spider veins, however contributing factors include hereditary, hormonal changes (oestrogen levels in puberty, pregnancy, breast feeding), weight gain, prolonged standing or sitting or being immobile for prolonged periods.

There are certain medical indications for treating varicose veins:

• skin changes such as disclouration (brown pigmentation), venous eczema (itching), lipodermatosclerosis (fibrosis and hardening of the fat layer under the skin, causing thickened and red skin).

• ulceration

• superficial thrombophlebitis (Clotting and redness and tenderness of the skin veins)

• bleeding

• Symptoms such as aching, throbbing and tenderness of the legs and veins.

Quality of life

People may be embarrassed by the appearance of their legs due to varicose or spider veins. As well as affecting self-esteem, it may restrict their activities and social lives. A vein treatment may result in improved self-esteem and increased self-confidence. This in turn improves one's quality of life and allows people to feel comfortable about themselves.

Choosing a doctor to treat your veins can be confusing! This is especially the case in Australia because anyone with a basic undergraduate medical degree can open a vein clinic i.e. there are no government regulations concerning the minimum qualifications required for vein treatment.

The following aims to help you understand how different "Vein doctors'" training in venous disease may differ. This could mean that your treatment advice may significantly differ depending on the type of training and expertise a doctor has.

An overview of the different types of 'Vein Doctors' is provided for your information below:

Vascular and Endovascular Surgeon

A 'Vascular and Endovascular Surgeon' is a qualified medical specialist with advanced post-graduate training. To practice vascular surgery in Australia, they must have fulfilled certain criteria in order to receive their Fellowship of the Royal Australasian College of Surgeons in Vascular Surgery, which is formally recognised by the Australian Medical Council.

Vascular Surgeons have formal advanced specialist training in:

• Endovenous (minimally invasive) and open surgical treatment for varicose veins, venous occlusive disease (such as DVT) and other venous pathology throughout the body.

• Endovascular (minimally invasive) and open surgical treatments for arterial conditions such as peripheral vascular disease (blocked arteries).

• Furthermore, a Vascular Surgeon has formal training in the medical treatment of venous and arterial diseases.

Therefore, a vascular surgeon can offer patients a very comprehensive array of treatments for vascular problems - venous and arterial - as well as the knowledge to recognise the 'less common' pathologies that may present with varicose veins.

By seeing a vascular surgeon, a patient can be confident that 'all their bases are covered'.

Phebologist

A 'phlebologist' is a broad term for any practitioner who treats veins, usually varicose veins. The pre-requisite is a basic medical school degree.

However, in Australia, there is no formal recognition of phlebology as a distinct medical specialty by the Australian Medical Council (AMC). Therefore there are no prerequisites for further training or qualifications to call one's self a phlebologist.

Although membership to a phlebology college, society or group may sound 'prestigious' to the lay-person, it is important to understand what this actually means:

- A phlebologist who does not hold an Australian Medical Council-recognised specialist qualification does not have admitting rights to a public or private hospital. Therefore in the event of a complication, their patients must present to emergency to be cared for by a specialist such as a vascular surgeon.

-Futhermore, patients can not use their private insurance to be treated by a phlebologist unless that phlebologist also holds AMC-recognised specialist qualifications. Therefore treatment recommendations may be biased to 'outpatient' treatments only.

Radiologist/Interventionalist

A 'radiologist' or 'interventionalist' is a qualified medical specialist with advanced post-graduate training. To practice radiology in Australia, they must have fulfilled certain criteria in order to receive their Fellowship of the Royal Australian and New Zealand College of Radiologists, which is formally recognised by the Australian Medical Council.

They possess endovascular skills in treatment of venous and arterial conditions. However, they do not have formal training in medical treatment of vascular disease or vascular health, nor do they have surgical training in venous or arterial disease.

General surgeon

A 'General Surgeon' is a qualified medical specialist with advanced post-graduate training. To practice general surgery in Australia, they must have fulfilled certain criteria in order to receive their Fellowship of the Royal Australasian College of Surgeons in General Surgery, which is formally recognised by the Australian Medical Council.

They do not have training in endovascular or endovenous surgery, and are not trained in medical treatment of vascular disease or vascular health, or surgical treatment of arterial disease.

What does this mean for you as a patient?

A vascular surgeon must undergo many years of rigorous advanced specialist training through the Royal Australasian College of Surgeons. Vascular surgeons are not only trained to recognise when other vascular issues may be co-existing but in addition, they would have the skills to treat those conditions as well.

A Vascular Surgeon is be able to provide you with comprehensive care.

Peace of mind. The advantage of seeing Mr Ling is that you can be assured that you are receiving treatment that is comprehensive and tailored to your needs.

"When all you have is a hammer, everything looks like a nail".

Since Mr Ling performs a very wide range of treatments (his 'venous tool belt' has many tools including sclerotherapy, Venaseal Glue, Radiofrequency and Endovenous laser ablation, endovascular stenting and coiling and surgery), he is able to offer you a balanced opinion about what would be best for you. The advantage for you is that you can rest assured that all treatment possibilities would be considered for you.

In addition, as a qualified Vascular and Endovascular Surgeon, Mr Ling has endovascular and surgical skills, plus expertise in diagnosis and treatment of medical vascular health problems (venous and arterial diseases). Therefore, Mr Ling is able to diagnose - as well as treat - other vascular problems. For instance, when Mr Ling sees a patient who has a non-healing ulcer, he is able to diagnose any underlying venous as well as arterial issues and in addition, he has the skills and expertise in treating this.

Furthermore, Mr Ling often performs 'hybrid' procedures, that combine different techniques of endovascular and open surgery. This often means he can offer you a comprehensive and appropriate treatment approach that is tailored to your specific requirements. This results in less procedures and 'returns for further treatment', with resulting quicker return to normal activities and daily life.

Mr Ling is qualified and very experienced in various forms of varicose vein treatments, including:

• Sclerotherapy

• Venaseal Glue

• Radiofrequency ablation

• Endovenous laser ablation

• Surgery

• Endovascular coil embolisation for pelvic congestion syndrome

No.

1) Spider veins - these are treated in the consulting room. No local anaesthetic is required, as the injection of local anaesthetic often causes more pain than the tiny needles that are used to treat the spider veins.

2) Varicose veins treated with radiofrequency ablation or endovenous laser - these can be treated using 'tumescent anaesthesia' - you remain awake, but needles are required to inject saline and local anaesthetic around the vein that is being treated, so as to protect the surrounding tissue and muscle from heat damage.

Those with private insurance may elect to have the procedure as an inpatient. Many patients like the idea of having sedation so that when they wake up, the procedure is finished and they did not feel a thing. Mr Ling will discuss these options with you during your consultation.

3) Venaseal Glue. The advantage of this treatment is that there is no need for needles for tumescent anaesthesia. It can be done with you awake and with minimal pain.

Yes. As a specialist surgeon, Mr Ling has admitting rights to private hospitals. This means that for some of the procedures (radiofrequency ablation, endovenous laser, endovascular coil embolisation and surgery) the procedure can be rebated by your private insurance because it is done as an inpatient day procedure. Furthermore, some insurance companies do not charge their 'excess' for day cases.

Modest gap fees apply for varicose veins, however it works out to be much more cost-effective for you than having it done in an outpatient setting such as vein clinics.

Vein treatment costs vary quite significantly around Australia, and also within Melbourne. Many clinics offer various 'treatment plans' that have an initial procedure and then subsequent return visits, each incurring further charges. Some clinics charge a large out of pocket expense for the initial consultation and also for an initial ultrasound. Therefore it is recommended you question what the full cost will be.

The costs vary for the type of procedure and whether it is done as an inpatient using private insurance, versus as an outpatient (where private insurance does not apply).

In determining costs, one should factor in any 'pre-procedural costs' such as ultrasounds. Mr Ling uses a specialised vascular-specific ultrasound service that does not charge out of pocket costs for pre-procedural scans.

In general, the following is a guide only, for varicose vein treatments with Mr Ling:

- Radiofrequency ablation/endovenous laser/surgery - as a private patient in hospital - Mr Ling is a 'known gap provider'. The amount varies according to number of veins and legs treated.

This is different to a health fund 'excess', which is the agreement you made with your health fund that you pay to your fund when you use your insurance. Mr Ling's vein treatments in the private setting are all done as day procedures.

- Venaseal Glue - this is only done as an outpatient and therefore you cannot use insurance to have this procedure.

Cost of ultrasound

- Mr Ling offers a diagnostic vascular ultrasound service that is bulk-billed.

- If you are having a procedure that requires ultrasound, there is a procedural ultrasound fee that is included in the total fee.

It is recommended that you are fully informed about costs and ask about these before you commit to treatment. It is worthwhile seeking another opinion if you feel that the costs proposed to you are very high, as they do vary between practitioners.