Are my varicose veins too ‘twisty’ for laser? “I’ve got awful varicose veins doctor and I want this new laser treatment. I’ve seen a vascular surgeon and he tells me my veins are too twisty for the laser and I’ll have to have them stripped out. I don’t want that and I don’t want a general anaesthetic.” Barely a week goes by without a patient telling me a similar story. Yesterday the chirpy barber who related this to me in my Manchester clinic seemed to disbelieve the advice he had been offered and was confident from what he’d read on the internet that someone would be able to do the laser. How right he was. A quick ultrasound scan confirmed valve damage and reverse blood flow in two veins on his right leg and one on his left. The pressure caused by this was distending his surface veins and causing his ankles to swell and his legs to become very uncomfortable after a long day on his feet serving his customers. Given his story of “twisty veins” I should have been surprised when we found that the veins causing the problem and requiring treatment were straight as dies with not a twist in sight. I was, however, not at all surprised as my experience has been that if a vascular surgeon is not happy performing laser treatment rather than the traditional surgery “your veins are too twisty” seems to be the stock explanation or excuse given to patients. Presumably, they think patients will be too gullible or cowed to question such opinion. The NICE guidance states that varicose veins should be treated by Endovenous Thermal Ablation (EVTA); minimally invasive (laser or RF) treatments undertaken under local anaesthetic as outpatients. Such techniques have been proven to be safer, kinder and more effective than traditional surgery. Only in the event that a patient is unsuitable for this should an alternative called foam sclerotherapy be offered. Unfortunately and for obscure reasons NICE leave a door to traditional surgical stripping slightly ajar by then adding that only if the patient is unsuitable for treatment by either EVTA or foam sclerotherapy should they be offered surgery. In our practice surgery is never required. All patients can be managed by one of the treatments recommended by NICE. Sadly this is not the case generally as many surgeons offering treatment for varicose veins have little experience of the newer methods, were not primarily trained in them and often only reluctantly offer anything but surgery. The doctor’s code of practice requires doctors to be open and honest in their dealings with patients. Such honesty or probity should extend to informing patients of the doctor’s own limitations. Pride and self-interest should take a back seat and patients who the doctor knows he/she cannot treat by NICE recommended methods should be told and given the option of seeing another specialist who can. Sadly with varicose veins this rarely happens and large numbers of patients are still subjected to surgical stripping under general anaesthetic and are unaware that an experienced specialist could have used a far safer, kinder and more effective method. As this happens frequently in relation to varicose vein treatment it is likely to happen across a huge range of other conditions. Until doctors and the GMC take probity and openness more seriously patients should be very sceptical if their specialist claims some reason why they are not suitable for a modern treatment option that they were hoping for.