Venous surgeons and phlebologists are spoiled for choice when it comes to office-based technology options for varicose veins. This brings questions such as what technologies are best suited for what patients, what factors should be considered to obtain best results and what is the role of open surgery in the field. Mark Whiteley (University of Surrey, London, UK), member of the CX Programme Organising Board, gives his views on the subject. The latest evidence in this area will be discussed in the Venous Controversies sessions of this year’s CX Main Programme.
Physicians now have a great selection of office-based technologies for the treatment of varicose veins; what method is best for what case?
This has been the major area of my research since starting radiofrequency ablation in March 1999 and it is fair to say that there are many different opinions on this. Most importantly, before this question can even be considered, we need to decide on what constitutes “the best”. In my view, technical perfection is the correct outcome, as this will lead to long-term success and therefore should lead to long-term patient improvement.
However, advocates of techniques with inferior technical results that might require less intervention or fewer injections, point to patient satisfaction as the correct outcome measure to use to assess “the best” treatment method. I believe this is not a good outcome measure to use scientifically. Patient satisfaction can be manipulated by factors other than the treatment itself, particularly by misinformation given to patients in some studies by advocates of one method as to the theoretical risks of other methods that might be used.
In addition, satisfaction has to be measured at one or several points in time—often in the relatively short term. Technical imperfections which are likely to progress to recurrence and reduced patient satisfaction in the long term might be present in the short term. But measuring patient satisfaction alone may miss these out due to the time it takes for the patients to experience the clinical outcomes of the treatment failures.
What factors should be considered to obtain best results in varicose veins treatment?
As with all surgical techniques, there are several factors involved in obtaining the best results. Not only does the technology and device design have to be adequate to the job, but the patient selection needs to provide appropriate cases for the chosen technique and doctors and their teams need to use adequate imaging and procedural technique to get the optimal results.
In addition, patient expectation has to be added, such as whether they are looking for relief of symptoms only or cosmetic perfection and also an acceptable cost for the service.
What office-based technologies are currently showing best results?
Generally, in most hands, endovenous thermoablation shows excellent results for truncal and perforator veins ablation, provided the correct technique is used and an appropriate device for the vein to be treated. Glue and mechanochemical endovenous ablation (MOCA) are starting to show promising results in truncal venous reflux in selected patients whereas foam sclerotherapy is technical disappointing in truncal veins. However, advocates will point to patient satisfaction and re-treatments to argue for its use.
Currently, coil embolisation of refluxing pelvic veins with foam sclerotherapy seems to be the optimal treatment for pelvic venous reflux. Foam sclerotherapy alone or ligation of veins at the pelvic exit points are used by some but need to be proven as effective and acceptable treatments.
For incompetent tributaries and varices, ambulatory phlebectomy is probably optimal for larger veins and foam sclerotherapy for smaller veins— although the new technique of combining both as “foam phlebotomies” is gaining popularity in the USA.
When it comes to neovascular tissue, strip tract revascularisation, feeding veins under patches of telangiectasia and primary avalvular varicose anomalies (PAVA) then foam sclerotherapy is the only effective option.
Finally, for telangiectasia themselves, microsclerotherapy is still the best option as it treats both the visible veins as well as the communicating veins hidden below the surface.
With the outcome of many office-based technologies and their comparable efficacy results with surgery, is there still room for surgery?
No.
Unless one calls ambulatory phlebectomies (surgery), then there is no need to ever perform open surgery for varicose veins anymore. Personally, I have not had to use open surgery for any varicose veins case for over a decade.
At the debate “Duplex scanning is mandatory before treatment of asymptomatic cosmetic thread veins” you will present “For the motion”. Could you tell us the reasons as to why you are supporting this practice?
Since 2001, increasing numbers of research papers have shown that cosmetic thread veins frequently occur in association with underlying venous reflux. In many, if not the majority of cases, this venous reflux leads directly into the thread veins. Furthermore, every case of the complication called telangiectatic matting that I have ever seen after thread vein treatment, has an underlying untreated vein refluxing into the affected patch.
Since instituting a policy of duplex scanning in 2002 in which every patient presenting with cosmetic thread veins of the legs are treated for any underlying venous reflux before proceeding to microsclerotherapy of the thread veins themselves, we have never had a case of telangiectatic matting. Those cases presenting to us with this complication from elsewhere invariably have an underlying vein refluxing into the lesion.
With the explosion of cosmetic clinics starting to offer thread vein treatments, often without duplex ultrasound or even hand held Doppler, it is essential for us as phlebologists and venous surgeons to state that we feel that treatment of thread veins without a duplex ultrasound scan first is a sub-optimal treatment.
The CX Venous Controversies Day will take place at the Charing Cross Symposium on Friday 1 May – Main Auditorium, Olympia Grand, London, UK.
Delegates will have the opportunity to get hands-on training on the latest techniques for varicose veins treatment at the CX Venous Workshop on Wednesday 29 April and Thursday 30 April – Gallery Upper Level, Olympia Grand, London, UK
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