GO WITH THE FLOW

If you have varicose veins and travel frequently, you’d be well advised to get them checked – it could help to prevent you getting DVT

Keep an eye on your veins to help prevent DVT

Deep vein thrombosis (DVT) can be a worry for frequent travellers. It occurs when altered blood flow leads to the formation of a blood clot in a deep vein of the leg. Symptoms include a swollen or painful calf or thigh. In uncommon cases, part of the clot moves to the lungs, causing a pulmonary embolism (blocked blood vessel) that, if severe, may cause the affected lung to collapse. DVT isn’t caused only by travelling. Each year, it occurs in between one and three people per 1,000, according to the Department of Health, and, of those, only one in 100 cases is fatal. Nevertheless, frequent travellers may be more at risk than others. Professor Mark Whiteley, a consultant venous surgeon and phlebologist, explains why: “The things that cause clots are the Virchow’s Triad [named after German physician Rudolf Virchow]. These are changes in the blood, changes in the blood flow and changes in the vessel wall. Any one of those can cause a clot. “When you fly, you have a change in the flow, since you’re just sitting there, so the blood isn’t flowing as it should. You’re up in the air, so you have decreased oxygen and have changed the consistency of the blood. Finally, if you have varicose veins, then the vein wall is stretched and bulbous, allowing blood to clot on this altered vein wall. So when you fly, you’ve got the perfect storm for DVT.”

RISK FACTOR

Our 2019 article on this (see businesstraveller.com/ feature-category/smart-traveller) dealt with some of the practical ways to guard against DVT, such as staying hydrated, moving regularly on the plane and wearing compression socks. The publicity around these measures has probably saved many people who would have suffered from DVT from having serious problems. There’s no doubt, though, that some of us are more at risk than others, and so if you have varicose veins it would be a good idea to see a specialist.

Whiteley points out that a significant proportion of the population is unaware that they have varicose veins, as not all are visible on the surface. “Venous disease affects around 30-40 per cent of people, and of that 30-40 per cent, only 15-20 per cent of people know they have got problems with their veins, because they can see them. The others are hidden under the skin’s surface,” he says.

“Whether they are visible or not, most vein disease will cause aching and painful legs and can lead to swollen ankles and, ultimately, can go on to cause leg ulcers and clots. Yet even in those cases, if you go to the doctor you will often be given leg stockings or steroid treatments, neither of which really work because they don’t fix the underlying problem.”

For those people who do have veins that show, who have suffered from leg ulcers or superficial vein thrombosis

(phlebitis), or who have a family history that might indicate problems are likely, Whiteley recommends having a pre-emptory scan.

DIAGNOSIS

Since my own varicose vein was visible, I thought it worth at least having a scan. My attitude towards undergoing surgery is that I have successfully avoided it all my life, and I intend to continue doing so. Nevertheless, a scan isn’t painful, and at least then I could make an informed decision. So it was that I found myself having an initial consultation with Whiteley at his clinic just off London’s Oxford Street (he also runs clinics in Guildford and Bristol).

The scan, performed by a highly trained technologist, was extremely thorough – but then, in many ways, it is the most important part of the treatment. The scan should ensure that every problematic vein, whether visible or not, is identified, and also help the surgeon to decide on what sort of treatment will be appropriate.

The duplex scanning technique used is, in fact, a threefold process (it’s called “triplex scanning” in some parts of the world). It starts with a greyscale/B-mode ultrasound scan that is similar to the standard kind used for pregnancy.

Then there is a “Doppler ultrasound” scan, beamed into the specific area of the body and capable of being directed inside the vein. By combining the ultrasound picture generated with the specific Doppler waveform, this can be used to measure blood flow in the vein.

“The third part of the scanning process is the colour flow/colour-coded element,” Whiteley explains. “Computers these days are so fast that any movement on the black and white ultrasound picture can be picked up and ‘coded’ as either blue or red depending on the direction of flow. This means we can see blood flow in a vein in real time and judge whether blood flows up the vein normally and down abnormally, if the valves are not working.”

All of this is then brought together so that a bespoke treatment can be suggested to the patient. In my case, apart from some aching, the vein had never bothered me, but the scans showed that as well as the visible vein, there were other, deeper problems. Of course, as with all medical matters, the moment you are told that something affects you, then it’s time to start researching, initially on Google, then ringing friends who have absolutely no specialism in the area you are asking about but who try to be helpful, and, finally, listening to the specialist in front of you.

“In the UK, we get taught that there are only two layers of veins: deep in the muscle and superficial. This is wrong and there are in fact three layers,” Whiteley says.

“So it’s generally understood that if you have a clot in the deep veins, that’s bad because it can go to the lungs, and if you get a lump in the superficial, you don’t need to worry, because it’s just painful, and most doctors just give antibiotics.”

This more complex view was interesting, because that advice was exactly what happened to a frequent-travelling colleague of mine, who has twice suffered from a painful lump just underneath the skin after flying long-haul. The first time he was prescribed antibiotics, the second time he was given a scan and some anticoagulants (medicines that help to prevent blood clots).

“If something is hot and red, doctors tend to reach for antibiotics,” Whiteley says. “But if you got punched in the nose it would be hot and red and you wouldn’t give antibiotics. It is the irritation of the clot that causes a hot, red area because the body is trying to heal.

“Instead, there are two things that should be done. The latest guidance from the British Committee for Standards in Haematology and the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines since 2012 is to come and have a scan. What we know is that if that clot is within 5cm of a junction to the deep vein, it can turn into a DVT.”

Worryingly, Whiteley says that these guidelines show that about 1 per cent of people who have a clot in the superficial veins that is close to the junction end up with a clot in their lungs. “Yet doctors are still giving non-steroidal anti-inflammatories and aspirin to patients and telling them to put a stocking on. If it’s close to a deep vein, they must get a scan and then be offered an anticoagulant.” (I have advised my colleague to go for a scan. We shall see.)

‘What we know is that if the clot is within 5cm of a junction to the deep vein, it can turn into a DVT’

TREATMENT

So what was the advice for me? Would it be necessary to have the veins removed (or stripped, as I’ve heard it called, normally with a wince)? Thankfully not. “In the UK, we still have some people having their veins stripped out, but it’s pointless because they almost always grow back, and grow back without valves, which means the problem has returned,” Whiteley says. “We did a study showing that at eight years [after treatment], 82 per cent of those who had their veins stripped had grown their veins back again. The latest research shows you also get smaller new veins developing as well, making it more difficult to treat.”