Introduction

"Varicose Veins are the result of improper selection of grandparents".

- William Osler

Varicose veins are the most common manifestation of lower extremity vascular pathology in general and venous pathology in particular. Regarded, basically, as mainly a benign cosmetic condition, due to its high prevalence/penetration, mainly in our female population, the demand for consultation and treatment is significant. By definition, varicose veins are dilated, elongated, winding, and tortuous superficial leg veins. Heredity, upright posture, meager tissue (skin and subcutaneous fat) support, gender (female hormones/pregnancies) and sedentary lifestyle, may all contribute in distending the superficial leg veins triggering secondary valvular incompetence and abnormal gravitational down-flow (reflux). This reversal of the normal flow, in turn, is responsible for the increased venous pressure and the progressive nature of the condition.

The reader is reminded that any unwanted (i.e. of purely cosmetic concern) vein, or for that matter any diseased vein - such as varicose veins - can be managed either by closing the vein or by removing the vein. Please imagine a vein, any vein, as a tube located just under the surface of the skin and visible because dark color blood flows in it. A vein is basically similar to a straw used for sipping coffee or juice from a cup. A closed or plugged straw becomes ineffective, so does a closed vein: blood unable to flow in a closed vein, in any direction, makes the vein "invisible". The principle can be duplicated by simple elevation of the hands or for that matter legs. While the hand or leg veins have not been closed, the lack of blood in them -pulled out by gravity-makes them invisible as long as elevation persists...

Closing a vein is possible but questionably properly achievable by a injection sclerotherapy and by endovenous thermal ablation. Removing the vein as the only definite procedure, is by surgery only.

There are many controversies in medicine, the management of varicose veins (VV) is just one of them. It originated in the surgical establishment's belief that VV is not a disease. It is true, one can not compare varicose veins (VV) to a challenging occlusion of a major limb's artery with possibility of gangrene, limb loss even death. Therefore, surgeons (general/vascular) trained to cure real diseases, save lives or limbs paid little if any interest in VV considered by them basically a “cosmetic nuisance”. This disinterest was also compounded by two other facts. Firstly, the traditional stripping surgery for varicose veins was not a "glamorous" procedure and was hated by the surgeons and also by the patients, obviously for different reasons. Secondly, in the last thirty years we witnessed the continuous sliding reimbursement for VV surgery from $2-3000 in the eighties, to today's only few hundred dollars. As nature abhors vacuum and since VV have a high (10-15%) possibly even higher incidence in the population, the patients demanded treatment and they got it from mainly non-surgical specialties in search for additional income and offering less traumatic and also office procedures as alternatives, however, not always necessarily better ones...

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"Dr. Goren, Mrs. Schwartz is on the phone. She is choosing the color scheme of her drapes and is asking what shade of blue her varicose veins are: Tiffany blue or Violet blue...

Due to veins proximity to skin, dermatologist were the first to use injection sclerotherapy for all type of veins, VV included. Starting in the nighties, when high tech modalities for VV became available such as ultrasound-guided injections and especially catheter based endovenous thermal ablations (with RF current and lasers) the reimbursement rose again, treating varicose veins became very attractive to physicians, inclusive few surgeons as well. Suddenly, vein clinics mushroomed all over the country owned and staffed by “over-the-night vein specialists” who by certification were and still are: gynecologists, internists, family practitioners, emergency medicine specialists, radiologists as well as even… cardiologists. You guessed it, nowadays, practice of medicine is income driven, much more than ever and for sure these procedures are much abused.

Please keep also in mind that companies that have invested millions of dollars in hardware R&D (research and development) are eager to see profits ASAP. Some companies have given the hardware needed for the novel high tech procedures for free to physicians and some of them were made even shareholders as well, assuring by such policies that only "excellent" results will be trumpeted to patients and to other naive and interested colleagues, hungry for additional income. If convinced, purchase of another hardware is assured... Here you have it, the objectivity of medical research has been flushed down the toilet the moment the researcher is making money from company's hardware sales. Please remember, cost per one single hardware unit can run in tens of thousand dollars therefore the profit margin is quite high.

The over 100 years old traditional stripping surgery was a traumatic event and was hated by surgeons as well as most patients who had to have the procedure. Therefore, changes needed to happen… and they did; true, with relatively slow pace but right direction! I am referring to the introduction of the European minimally invasive surgical approach (Ambulatory Phlebectomy) that can be performed (like sclerotherapy as well as the high tech procedures) in an office setting and local anesthesia, procedure that in my humble opinion is much superior in results when compared to sclerotherapy (liquid, foam, ultrasound guided) or any form of high tech endovenous thermal ablation (RF current or lasers). Besides, Ambulatory Phlebectomy has by far the least complication rates when compared the the just mentioned two alternative: sclerotherapy and thermal ablation as both these options can trigger thromboembolic complications such as a deep vein clot (DVT) and the potentially lethal pulmonary emboli (PE). Indeed, should anyone opt to have these high tech procedures - personally I do not perform - will have to sign a consent form were these dreaded complications will be clearly mentioned . My philosophy is simple. In my humble opinion no therapeutic option for a cosmetic condition (as basically VV are) should ever trigger potentially dreaded (and certainly never lethal) complications, as all the above mentioned non-surgical procedures can. Of course unexpected, disastrous complications are possible with one simple Aspirin tablet but thromboembolic complications are imbedded/possible in all high tech approaches for varicose veins.

I intend to share with the reader - potential consumer of medical services - my thoughts on the presently available “therapeutic options” for varicose veins, a high incidence condition in our population (at least 10-15%). I recognize that as a surgeon I am biased, yet I will try to be objective as just possible having in mind results and safety.