Podcast Episode 10: Venous Trends

Hello, this is Professor Mark Whiteley, consultant venous surgeon for the Whiteley Clinics and I'm going to give the second podcast in my series today on behalf of the Lindsay Leg clubs who have invited several experts to talk about different aspects of leg ulcers and venous disease. Today my talk is about the current treatment trends in venous disease. This is actually a massive subject and it's been a lot of my life's work for the last 20 or 30 years and really I could talk for weeks if not months about this and so to collapse this down into just about 10 minutes or so I'm going to really just summarize the where we are. However if you are interested of course there's plenty that I've written or put up on YouTube or my website so please feel free to investigate further if any of this information is interesting to you. So firstly if we're going to think about the current treatment trends in venous disease we have to think about Firstly, which veins do we treat? Before 1985, we really used to think that veins were simple. In the legs, we thought there were superficial veins, the ones just under the skin, and the deep veins in the muscle. And we were always taught by our predecessors that if you had problems in your superficial veins, this caused varicose veins, which were just cosmetic and you could have treated if you wanted, but it didn't really matter. They just came back and if you left them it didn't matter and we thought and we were taught that if the deep veins had gone wrong this was a disaster. Nothing could be fixed in the deep veins and all we could do when you got your leg ulcers or swollen legs was just to have bandaging and unfortunately as you'll know a lot of people still think this and still think that varicose veins are only cosmetic and deep veins or leg ulcers have to be bandaged but this is completely wrong in both aspects. Since the mid-1980s, we've had huge numbers of research projects that have shown that most venous leg ulcers are actually caused by problems in the superficial veins, either varicose veins or hidden varicose veins, or underlying things called perforators that again cause varicose veins or hidden varicose veins. And in fact, only a small number in comparison are caused by deep vein problems. In addition, we now can treat the deep veins, so even that isn't a disaster. Therefore, before anybody is put into long-term compression, they really should have a full assessment by a proper venous surgeon because many people now could be cured and get back to a much better quality of life. So having had a basic idea that the understanding of the difference between deep and superficial veins is incorrect and most of these are now treatable we can then move on to which veins are actually important. Medical students in the 1980s 1990s and unfortunately even the 2000s are often taught that there's only two main veins in the legs that cause venous problems. This is either the greatest venous vein the one that goes from your ankle up the inner side of your leg to the groin or the smaller venous vein, the one that goes up the back of the leg over the calf and into the deep veins just behind your knee. And in the old days, people knew that if they had their varicose veins stripped, the cut would either be in the groin or behind the knee to get to these veins. However, we now know that venous leg ulcers, varicose veins, hidden varicose veins, venous eczema, lipodermatosclerosis, all the problems that we get from having varicose veins or hidden varicose veins that are left for too long, they don't come from just these two veins, they come from over 150 different veins. That is 150 different veins per leg. These can be your great saphenous, your small saphenous, anterior accessory saphenous, posterior accessory saphenous, over 150 different incompetent perforators or the pelvic veins. With this huge number of veins, we now just cannot afford to guess or do quick scans to say, oh, I think is that vein. What we have to do is we have to get a venous duplex ultrasound scan performed by a professional vascular technologist, someone who is trained just to scan veins. So doctors who try to do their own scans really miss out on a lot of diagnoses because they only tend to scan the great and small sphenous vein. What you actually need to get a proper diagnosis is you need to have all of the veins scanned, a process that takes even an expert about 15 or 20 minutes per leg. Now as you can imagine, when we come to talking about what treatments do we use, it really depends on which of those veins we're talking about. If we talk about traditional techniques again, if we go back to the usual tying and stripping, that was only thought to be a good idea when we believed that only two veins were involved. We could either cut into the groin and strip out the great saphenous vein, or we could go in behind the knee and strip out the small saphenous vein or if the veins were severe we could do both. The problem with that is that most patients didn't only have those veins causing a problem but had a combination of perforators pelvic veins or other things and so it was the wrong operation to do. Even in those few patients where it was the right operation to do in other words it was the right vein we found in 2005 which we published in 2007 the fact that if you strip veins out they only grow back and when they grow back, they grow back without any valves and therefore are varicose veins or hidden varicose veins all over again. So basically stripping is a pretty useless operation. So what else can we do instead? Well if we're talking about the long veins, the venous veins in the legs, we now use what is called endovenous surgery. The first case of this was performed by myself in March 1999 and initially we used radio frequency ablation although now it's more common in my practice to use lasers because they have some advantages but many doctors still try to use radio frequency ablation because that was the first thing that came in. Both of these techniques and some of the more modern techniques such as microwave which we've just introduced two years ago and also steam which some doctors have used. All of these have one similar aspect. What they do is you pass a catheter or a device into the vein under a local anaesthetic. Nowadays since 2005 you should never have a general anaesthetic for vein treatments for these sorts of vein processes. You should only ever have walk in walk out local anaesthetic treatments. The catheter is passed into the vein and past the top of the vein under a local anaesthetic and using ultrasound to find exactly where it is. Your tipped head down and then the device is activated heating the end of the device and also the vein. The vein gets very hot, the protein contracts, the cells are killed and the vein is ablated and the catheter as it's pulled back at a set speed down the vein, the vein completely shrivels away. Now many people quote a 90 or 95 success rate although in fact many people only get 70 or 80 success rate but if you use the protocol such as we've developed the Whiteley protocol you should now expect 99.9 success rate with every time you use these devices provided you're using the latest devices and doing them the correct way and under ultrasound guidance having had a proper diagnostic ultrasound scan to make sure you're in the right vein. Now really these sorts of endovenous thermal ablation techniques as they're called they've been approved by NICE the National Institute of Health and Care Excellence and it is the first-line treatment for these long truncal veins and really everyone should be being offered these if it is appropriate. However there are other veins that cause venous leg leg ulcers and varicose veins. Although many doctors in the UK ignore these. These veins are called perforator veins and when they start going wrong they're called incompetent perforators. Now the incompetent perforating veins are veins that allow blood to shoot out when you walk causing pressure jets coming out hitting varicose veins or the skin which causes inflammation and this inflammation can either damage the skin causing leg ulcers an eczema or if you're more lucky can just stretch the veins causing varicose veins. In normal life of course these perforators are doing the opposite, they're taking blood into the muscle so it can be pumped back to the heart and it's only when the valves go wrong that they become incompetent. Now unfortunately there were two very incorrect papers published in the early 2000s that suggested that if you treated the saphenous veins above these perforator veins they all went, they all became competent again and therefore you didn't need to treat them individually. That is subsequently shown to be incorrect but many doctors who don't like treating perforators because after all they are quite difficult to treat, many doctors still quote those papers just because they don't want to treat them. However there's now very good randomized controlled trials showing that especially if you have venous leg ulcers or you have any skin damage around your ankles or lower legs, you will almost definitely have perforating veins and if you have the perforator veins treated as part of your treatment you'll get far better results than if those perforator veins are left alone just on the off chance that they might close by themselves which in fact they almost never do if not never do. However doctors if they don't like treating perforators will still quote the old papers because they simply don't want to do the techniques or learn them. The difficulty is perforators are quite small they're usually between two and four millimetres wide and a great many doctors don't have the skills to treat them. The treatment of choice at the moment is a process called the TRLOP or Transluminal Occlusion of Perforator Trollop Technique which was invented by myself Mark Whiteley and Judy Holdstock in 2001. Now some American doctors have seen this technique and they saw it at some meetings we went to in the 2002, 2003 and 2004 and they took the technique and renamed it PAPS or Perforator Ablation Procedures. However as has been the subject of quite a few arguments in the past particularly in one of the big journals and this is clearly just a copy of the trollop procedure. Now the trollop procedure is very simple, an ultrasound is placed over the incompetent perforating vein, local anaesthetic injected in the skin, a device such as a laser or radio frequency or microwave is passed into the perforator, local anaesthetic around the perforator and then it's closed just the same sort of way that you would close one of the long saphenous veins, such as the great saphenous vein or the small saphenous vein. So one of these longer veins. You can treat these small perforators using the same sort of technique and once again you should expect in good hands an 80 to 90 percent success rate. It's not quite as high as the these long veins the ones called the saphenous veins because they're much easier to get into and treat. But certainly in my own practice we've recently published a paper where we have a 92 percent success rate of the perforator veins with a 99 to 100 percent success rate of the saphenous veins. So nowadays you should be able to walk in have a local anaesthetic what's called ambulatory surgery and should be going home about two or three hours later without any general anaesthetic or sedation which reduces your risk of deep vein thrombosis and reduces your risk of any other complications such as nerve damage. Very very occasionally pelvic veins can be involved in causing leg ulcers. More commonly they're involved in just causing varicose veins and quite often we have to perform a treatment of the pelvic veins called coil embolization. That's quite specialist and so I'm not really going to talk too much about that now apart from saying we have to use a non-thermal technique because these pelvic veins inside the abdomen and pelvis, you mustn't use anything that's too hot, because if you use a technology that is hot to try and shrivel the veins away, you can damage some of the very sensitive structures in the pelvis. Therefore, we use platinum coils if we want to close the veins. Much less commonly, we actually want to open some of the veins in the pelvis, and for this doctors use stents, which means you blow the vein open with a balloon and put a metal stent in to hold it open. Fortunately that's a very, very rare thing to have to do. There's only a few specialist centres that do it and that's the only thing we sort of do now under a general anaesthetic. However, that's for blocked veins with people who've had what's called post-thrombotic syndrome, usually from multiple deep vein thromboses and fortunately it's very rare and very small print. There has been a quite a lot of research about foam sclerotherapy and certainly people who have leg ulcers get very good results if foam sclerotherapy is injected in the network of veins that are just underneath the ulcer. You can't see these with the eye but with an ultrasound you can see these dilated veins and we call them the sub-ulcer plexus and there's a technique that that was invented by a man called Ronald Bush over in the United States, where he injected these veins with foam sclerotherapy and the ulcers healed. And that's called the TIRS or TRIS technique. The only thing to say about it is, if you only do the foam and you haven't closed the perforators and you haven't closed the truncal veins, the chance of it working well in the medium to long term is much, much less. What you actually need to do is you need to combine that foam sclerotherapy with truncal vein ablation. So treat the great sphenous veins, small sphenous vein or perforated veins with endovenous laser or one of the other techniques, the trollop technique or one of the other heat techniques and then once all of that is closed come back at a later stage and use foam sclerotherapy for the sub-ulcer plexus and that then gives the best results for the long term. However we do also have to think about could we just use the foam sclerotherapy in the subossuplexus and but also use it for maybe the varicose veins and the long veins like the perforator veins and the saphenous veins. Well unfortunately as a lot of research has shown both clinical research and our own histological research when you try and close the bigger veins with foam sclerotherapy, it doesn't work very well. It works well in the short term but after one year 25% of people have had their veins reopen again and by the time you get into three to four years it really is disastrous and very few veins remain closed. So using foam sclerotherapy in large varicose veins to try and replace the endovenous thermal ablations, the heating the veins with the catheters has been shown to be not a very good option and it's not very cost effective to do so. Therefore that's why at the Whitely Clinic and other protocols such as ours we now all look at using the endovenous laser or other heating techniques, sometimes radio frequency but rarely nowadays, much more commonly microwave or other heating techniques that can shrivel the veins away both the saphenous veins and then the perforating veins and then come back at a later stage usually eight weeks or more later to do the foam sclerotherapy if there's any residual varicose veins or if there's an ulcer for the sub-ulcer plexus. And doing this staged sort of procedure we get excellent results and we've now published our 15-year results that show very very good long-term results from this sort of approach. There are some other new techniques coming in and we need to keep an eye on these. One in particular is called Haifu or high intensity focused ultrasound. This is a completely non-invasive technique where you can put the treatment head on the skin overlying the veins and we can beam ultrasound in a cone down through the skin, not damaging the skin at all but concentrating the energy on the vein itself and using this energy to form heat and ablating that vein just the same way as if we had the laser or radio frequency in the vein itself. So this high intensity focus ultrasound or ecotherapy is the latest way to treat veins. However at this moment in time it is still very much a development or research tool. We have treated some patients with variable success rates, some people getting wonderful results, some people are needing a second or even third treatment. So I think for the future we do need to think that these non-invasive techniques which don't even need a needle might be something that are going to come in and take over treatment. But at this moment in time we still have to look at that as something we should aspire to rather than thinking is here. So I hope this has all been very helpful to you. surgery is much more interesting but also much more complex than most people think. The difficulty as I've said in my previous podcast is that many doctors who treat venous disease and many nurses who treat venous disease don't go into how complex it is and certainly doctors are often vascular surgeons who spend most of their time thinking about arteries rather than veins and don't understand quite how complex not only the diagnosis but also the treatments have become. If you see an expert who actually diagnoses you correctly and uses the right combination of treatments in the veins, making sure that they're treating not only the truncal veins but perforators and then any smaller veins including the subossal plexus, the results now should not only be excellent in the short term but also the long term. I hope this has stimulated your interest in venous treatments and the whole of the subject And I look forward to talking to you again in my next podcast.