For Physicians: Modern Vein Therapy 2020 – Possibilities and Limitations
Dr. Johann C. Ragg, Chief Physician of the angioclinic® Vein Centers
Approximately a quarter of the population in Western nations develops venous insufficiency over their lifetime. This is still referred to as “chronic”, although this only applies to a small percentage of cases. The majority of cases are not chronic over the first decades of their course, just like tooth decay or obesity. This alone shows how much misjudgment is applied to this common disease.
While in the last 100 years, severe cases of epifascial insufficiency and varicose veins were primarily treated surgically, and patients with mild findings received relatively stereotypical compression stockings, today we have a very wide range of options: In diagnostics, high-resolution ultrasound devices are widely available, enabling the diagnosis of incipient venous weakness decades before symptoms appear. Diagnostics can now identify restorable valve functions. Insufficient vein segments requiring treatment can be distinguished from merely secondarily overloaded and thus non-treatment-requiring sections. However, the application of this knowledge is sparse even among experts, and the question of when interventions are indicated based on findings urgently needs discussion.
For the actual treatment, endovenous occlusion techniques have been added to the surgical options since the turn of the millennium. These techniques use laser energy, radiofrequency, steam, chemical sclerosants, or medical glues to achieve vein closure in diseased segments. On closer inspection, however, for laser alone, there are at least five fundamental variants with different indications, and the chemical sclerosing techniques, which are increasingly performed using foam techniques, are even more diverse. The culmination is the “one-step” procedure, which, in combination with several techniques for saphenous vein, side branch, and perforator lesions, leads to stable success in a single session. This can be achieved endovenously with more detail than was ever possible with surgery, because even smaller reflux sources can be included if relevant, while reactivatable veins can be preserved in the body—with minimal recurrence tendency. With perivenous valvuloplasty, a focal vein shaping using ultrasound-guided injection of hyaluronic acid or dextranomer, early stages of valve defects can be corrected for many years—and within a few minutes. This technique, developed by me in a Swiss laboratory and tested in Germany (presented, among others, at the annual meeting of the European Venous Forum Zurich 2019), fundamentally changes the understanding of venous weakness because it helps to understand veno-venous interactions like never before and represents the key to true cures. We therefore like to say: “Heal veins instead of operating”.
Which patients should now be referred for surgery, which for endovenous techniques, and which genuinely benefit from other “novelties”? Besides insurance-related arguments, there is the professional decision: The surgery for venous insufficiency is mostly simple, well-established in all Western countries, and mastered by many physicians. Endovenous methods, however, are relatively complex if their potential for reliability and safety is to be fully exploited, especially since all interventions must be performed under consistent ultrasound guidance. This is rarely truly mastered due to the short learning curve, so usually only “simple” cases are selected for endovenous methods, although these can also be treated surgically with low risk, and problem cases should rather be selected for endovenous procedures due to risk reduction. Unfortunately, great surgical expertise does not imply corresponding skill with endovenous methods. According to a survey, not even 20% of vascular surgery chief physicians master the necessary interventional ultrasound. According to literature, the successes of surgical and endovenous methods, if performed by experienced hands, are roughly equal in the short and long term (documented over 12 years), but the risks are significantly lower for endovenous procedures. One should consider that these never require anesthesia and cause no loss of activity. Dedicated working people are happy when vein therapy allows them to return to work immediately. Patients with comorbidities such as diabetes mellitus, dermatitis, obesity, neurological disorders, immunodeficiency, orthopedic conditions, and many others are also very grateful recipients of modern non-surgical procedures.
The most common reason for interventions is saphenous vein insufficiency of the great and small saphenous veins. From a professional perspective, any size (even over 30 mm diameter) and any manifestation, including phlebitic areas with thrombi, venous aneurysms, elongations, and any number of perforator and side branch defects, can be optimally treated endovenously—however, only in specialized centers with the availability of diverse tools. In the absence of appropriate expertise, surgery would be the first choice. A significant quality difference of modern methods is already recognizable in the intervention planning. Here, often analogous to stripping surgery, only the saphenous vein is treated with a catheter technique, leaving insufficient cross branches, cross stumps, perforator and side branch defects due to a lack of diagnostic differentiation, and thus unnecessary recurrence potential. External findings are often subjected to costly outpatient second interventions. An optimal approach, however, captures all relevant findings, including small details, and treats them using combination techniques in a single session.
The varices—often just the “tip of the iceberg”, but the correlate that usually leads the patient to the doctor—can be treated either surgically (phlebectomy) or interventionally (foam sclerotherapy with medium viscosities). While conventional sclerotherapy often leads to discoloration, this is not the case for the “Foam&Film” technique developed by us. This technique uses a medical film to keep the veins bloodless during aftercare, which a compression stocking cannot achieve. We generally prefer this pain-free technique over phlebectomy, as it leaves no scars and causes no tissue damage whatsoever. For other branch insufficiencies, the deeper they are below skin level, the more likely interventional techniques should be chosen, as these achieve the goal without tissue traumatization. A special word applies to recurrences after previous surgical vein operations: These are always anatomically significantly more complex than the normal situs. Nowadays, they should fundamentally no longer be approached surgically, because re-operation is always more difficult and prone to complications than the initial intervention. Furthermore, it is never possible to completely identify and remove the often tangled and deeply rooted recurrent varices intraoperatively without collateral damage. The best option is undoubtedly foam sclerotherapy via selective microcatheters under sonographic and/or fluoroscopic guidance, not to be confused with the significantly less reliable “simple” foam sclerotherapy.
Isolated perforator defects are preferably indicated for so-called selective foam sclerotherapy, with the rare exception of very short (< 20 mm) or very large (> 15 mm) defects in connection with maintainable main and saphenous veins; these would be better treated by ligation. For all types of treatment, the type of accompanying compression therapy is also important for success and patient comfort. Since interventional procedures, in contrast to surgery, are not associated with a relevant risk of bleeding and, due to the absence of tissue traumatization, there is no increased risk of thrombosis, compression here has a completely different meaning: It must primarily serve to support the regression of decommissioned varicose veins so that they quickly become impalpable and invisible, and beyond that, it merely serves for prophylaxis. There is thus a tendency towards compression class 1 instead of 2, which significantly improves compliance. New possibilities have also opened up in prevention, as ultrasound technology and associated functional examinations allow individually determined muscle groups to be identified that can help improve vein function through training. It goes without saying that every vein patient should receive a personal activity analysis and advice on improving their vein-specific movement habits.
We are currently evaluating the usefulness of an annual or biennial vein check, which initially incurs additional costs, but on the other hand allows for a qualitative assessment and coaching of the preventive measures carried out and significantly reduces pathological findings or recurrences. We believe that any small medically relevant re-findings or new findings can be effectively treated immediately with a few euros (5 minutes of ultrasound-guided microfoam), which would again ensure an optimal vein status and eliminate large and more expensive interventions. Final results on this are still pending, but an expected analogy to the convincing success of prophylaxis and annual inspection in dentistry is already emerging.
Finally, I would like to mention that, according to the latest findings, phlebitis without involvement of deep leg veins should generally no longer be treated “classically” (weeks of anticoagulation, compression therapy, finally surgery). We advocate for a methodology that first clarifies the cause of the phlebitis (98% pre-existing insufficiency) and, in this case, remedies the insufficiency endovenously as early as possible. Advantages include immediate symptomatic improvement, simultaneous elimination of the cause (insufficiency), significantly shortened anticoagulation duration (a few days), and substantial cost savings.
If you are a colleague and have specific questions regarding modern methods—for learning, problem-solving, or in emergencies—we will always be happy to assist you immediately.
You can find my current scientific work topics at www.venartis.org.
