Modern Vein Therapy: Possibilities and Limits
Dr Johann C. Ragg, Chief Physician of the angioclinic® Vein Centers
About a quarter of the population of Western nations develops venous insufficiency in the course of their lives. This is still called 'chronic', although this is only true in a small proportion of cases, but the majority of cases are as less chronic than tooth decay or obesity. This alone indicates how many errors of judgement are made in dealing with this frequent clinical picture.
Whereas in the last 100 years severe cases of epifascial insufficiency and varicose veins have been treated primarily surgically and patients with mild findings have only received relatively stereotypical compression stockings, today we have a very wide range of options: in diagnostics, high-resolution ultrasound devices are available across the board, enabling the diagnosis of incipient venous insufficiency decades before symptoms occur. Diagnostics today can detect recoverable valve functions, and insufficient venous segments requiring treatment can be distinguished from sections that are only secondarily overloaded and therefore do not require therapy. However, the application of this knowledge is sparse, even among experts, and the question as to which findings indicate interventions is in urgent need of discussion.
In addition to the actual treatment, endovenous occlusion techniques have been in use since the turn of the millennium, which use laser energy, radio frequency, water vapor or chemical sclerotherapy to close the veins of diseased segments. On closer inspection, however, there are at least 5 basic variants of the laser alone with different indications, and even more diverse are the chemical sclerotherapy techniques, which are increasingly being carried out using foam technology. The crowning glory is the 'one-step' procedure, which, in combination with trunk vein and perforator/side branch techniques, is intended to lead to lasting success in a single session. This succeeds with greater detail than surgery has ever been able to, because smaller reflux sources can also be included. New in testing is the possibility of endovenously bonding diseased veins - here the hope for a symptom-free healing phase has not yet been fulfilled. Even more recent and not yet assessable is the option of inducing a genuine valve restitution by hyaluronic acid encapsulation (valvuloplasty), completely preserving the veins and without surgery.
Which patients are to be admitted to surgery today and which to endovenous techniques? In addition to the insurance law arguments, there is the professional decision: the surgery of venous insufficiency is predominantly simple, it is well developed in all western countries and has been mastered by many doctors. Endovenous methods, on the other hand, are relatively complex if their potential for reliability and safety is to be exploited to the full, especially since all procedures must be performed under ultrasound vision. This is rarely really mastered, so that usually only 'simple' cases are selected for the new methods, although these in particular have to be treated with low-risk surgery and the problem cases would rather be selected because of the risk reduction for endovenous procedures. Unfortunately, a great deal of surgical expertise does not allow the conclusion to be drawn that endovenous methods are suitable. According to a survey, not even 20% of vascular surgeons master the necessary procedure for interventional ultrasound. The success of the surgical and endovenous methods, if performed by an experienced hand, is about the same in the short and long term (documented over 12 years), the risks for the endovenous procedures are considerably lower, especially since they never require anesthesia and do not cause any loss of activity. Patients with concomitant diseases such as skin diseases, diabetes mellitus, obesity, nervous disorders, immunodeficiency, orthopaedic clinical pictures are also grateful recipients of modern non-surgical procedures.
The most frequent cause of surgery is the truncal vein insufficiency of the veins saphena magna and parva. From a technical point of view, any size (even over 30 mm) and any manifestation, including phlebic areas with thrombi, venous aneurysms, elongations and any number of perforating and side branch defects can be treated endovenously - but only in specialized centers with the provision of various tools. Surgery is the first choice if there is a lack of appropriate expertise. A significant difference in the quality of modern methods can be seen in the planning of the intervention. In contrast to stripping surgery, often only the stem vein is treated with a catheter technique.
Due to a lack of diagnostic differentiation, insufficient cross-section knots, growths, perforating and side branch defects unnecessary recurrence potentials remain. External findings are often subjected to costly outpatient second procedures. An optimal procedure, on the other hand, records all relevant findings, including small details, and treats them in a single session using combination techniques.
The methods are equivalent for large and very large external varicose veins, which can be treated either surgically (phlebectomy) or interventionally (foam sclerotherapy with medium viscosities). In the case of other asthma insufficiencies, the deeper they are below the skin level, the more interventional techniques should be chosen, since they lead to the goal without tissue trauma. The same applies to special cases such as varicoceles or abdominal varices. Recurrences after previous surgical vein operations should not be approached surgically, because the re-operation is always even more difficult and complicated than the first operation. Furthermore, it is never possible to completely identify the often confused and deeply rooted recurrent varices intraoperatively and to remove them without collateral damage. The best option is undoubtedly foam sclerotherapy via selective microcatheters under sonographic and/or fluoroscopic view, not to be confused with the much more unreliable 'simple' foam sclerotherapy.
Isolated perforator defects are preferred for the so-called selective foam sclerotherapy, with the rare exception of very short (< 20 mm) or very large (> 15 mm) defects in connection with conservable veins of conduction and trunk, which can currently be better treated by ligation. The type of accompanying compression treatment is also important for the patient's success and comfort in all types of treatment. Since, in contrast to surgery, interventional procedures are not associated with a relevant bleeding risk and there is also no increased risk of thrombosis due to the absence of tissue trauma, compression has a completely different meaning here: it must primarily serve to support the degeneration of disused varicose veins so that they quickly become impalpable and invisible, and also serves only prophylaxis. There is therefore a tendency towards compression class 1 instead of 2, which considerably improves performance. New possibilities have also opened up with regard to prevention, because ultrasound technology and associated examinations make it possible to identify individual muscle groups that can help improve venous function through training. It goes without saying that every vein patient should receive a personal activity analysis and counselling to improve their vein-specific movement habits.
The usefulness of an annual vein check is to be discussed, which initially causes additional costs, but on the other hand allows a qualitative assessment and coaching of the preventive measures taken. In addition, any small medically relevant re- or new findings could be treated immediately and effectively with just a few francs, thus ensuring an optimal vein status. Studies on this are still pending, but the analogy remains, for example, to the convincing success of prophylaxis and annual inspections in dentistry.
If you are a colleague and have concrete questions regarding 'modern methods' - for learning, problem solving or in emergencies - I will always be happy to help you. You can contact me personally at 0041 79 938 95 71 (Dr Ragg).
You can find my current academic work areas at www.venartis.org.