Letters

Editor:
In the article by Dr. Neil Denbow (Endovascular Today. March 2003:21-24) about endovascular management of varicose veins, there are some gross errors of fact that should be acknowledged.
The author notes that incisions for conventional surgery typically involve 3 to 4 inches in the groin, and 1 to 2 inches in the lower thigh. Absurd. My incisions in the groin are usually less than 3 cm, and I try for 1 cm at the distal approach to the vein. No one uses the larger incisions these days. This would be barbaric.

The author cites the need to stay in bed for 3 days. Balderdash. My patients are up the next day and progress over the subsequent week. Some return to work as soon as the third day, but I admit that pain keeps many out of work for a week. There have been no infections and no venous thrombosis. Also, there has been no neovascularization.

The data do not support that there is a greater risk of subsequent recurrence of varicose veins after surgery compared with endovenous repair. In fact, the VNUS data confirm that there is a 15% failure of the ablation at 2 years.

Cost is noted as an issue, but Dr. Denbow notes that a procedure room is used with sedation. That means hospital charges, which are likely comparable to those we encounter for conventional surgery. The catheters also cost a huge amount of money, as opposed to conventional surgical equipment. The comparison for me is a scalpel blade at about $0.50 and a reusable crochet hook for the phlebectomy–this costs less than $2.00 at the local crafts store!

Jeffrey L. Kaufman, MD
Springfield, Massachusetts

Editor:
I am writing to you to express my dismay at the way Dr. Denbow portrayed surgical treatment of varicose veins in his recent article entitled, “Treating Varicose Veins” (Endovascular Today. March 2003:21-24). I am a vascular surgeon in an academic practice with significant training in endovascular techniques. While I have been very pleased with the approaches your new journal takes to current endovascular topics, I cannot say the same for Dr. Denbow’s approach to the surgical management of varicose veins. Since when does a vein stripping procedure require general anesthesia? When is a 4-inch incision used in the groin? What surgeon instructs his patients to remain at bedrest for 3 days? Furthermore, patients are not “weary” of surgical intervention. To the contrary, they usually demand that it be done.

I am anxiously awaiting good, objective, long-term data concerning endovenous techniques. They indeed may represent improvements in the management of varicose veins. However, it should be pointed out that the majority of the cosmetic benefits realized from these procedures are from the surgical stab phlebectomy. All too often, papers presented on newer endovascular techniques seem as if they are paid advertisements. This was the impression I was left with after reading this article. While this of course is not the case with this article, it is noted that Yale, where Dr. Denbow is employed, is a training site for ELVS.

I nevertheless do applaud the diversity of your editorial staff and the “fresh” outlook it takes toward this rapidly evolving field. I look forward to reading future issues.

David S. Landau, MD
Chicago, Illinois

Dr. Denbow responds:
Drs. Landau and Kaufman,
Thank you for reading the treating varicose veins article and taking the time to write your letters. I respectfully disagree with your opinions and hope you will consider offering your patients these newer techniques.

The first issue addresses incision size. Although many incisions are 3 cm to 5 cm in the groin and approximately 2 cm at the knee, it is unfortunately not uncommon for them to be as large as I quoted. Regardless, compared to endovascular techniques in which incisions range from a puncture site to 2 mm, the surgical incision is huge, not to mention the associated trauma of the dissection required to expose the greater saphenous vein. This is akin to debating the size of an open cholecystectomy scar to those of a laparoscopic procedure and misses the point that there is a significantly less-invasive way to durably solve the issue of venous insufficiency secondary to greater saphenous vein reflux.

The next issue is recovery time. Although every doctor wants their patient to ambulate after a stripping or endovenous procedure, the pain associated with a stripping usually limits a patient’s ability to ambulate much more so than does a percutaneous procedure. Patients who undergo the less-invasive endovascular procedures have significantly less pain and recover sooner. Patients treated with endovenous procedures are walking around the day of the procedure. Do some of your patients ambulate sooner than others? Definitely, but nowhere near as fast as those undergoing the endovenous procedure. This has been validated by a report demonstrating that endovenous obliteration offers reduced postoperative pain, shorter absence from work, and quicker return to the activities of daily living compared to conventional vein stripping.¹

Anesthesia used for stripping varies from surgeon to surgeon and from anesthesiologist to anesthesiologist. Some practitioners use general anesthesia, whereas some use epidural or spinal anesthesia administration and will only use local and conscious sedation for small-segment isolated disease. In comparison, endovenous procedures performed in the office setting usually require oral benzodiazepines and local anesthetic. My patients who undergo endovenous procedures in the hospital receive conscious sedation administered by an interventional radiology nurse, in addition to local anesthetic. Once again, this is a case in which endovenous procedures offer significant advantages over conventional vein stripping.

Regarding patients being weary of stripping, I believe this is the case. I base this on discussions with surgeons who had previously used conventional stripping and have subsequently switched to endovascular techniques, with phlebologists, and with the 200 or so patients with this disease that we have treated at Yale.

It is not uncommon for patients to have had a friend or relative who had a stripping and, for the patient in question, to decide to live with their varicose veins rather than seek treatment. It is only with the advent of this technology that these informed patients have now sought treatment.

With respect to cost, yes, the disposable cost is greater with these techniques, but I think that less pain and quicker recovery more than justify this expenditure. Once again, I think a valid analogy is comparing laparoscopic cholecystectomy to the open procedure. The disposable costs are greater for the less-invasive procedure, but the quicker recovery time is the benefit. The technology is expensive, but the benefits derived from it, in this case, more than justify the expense. Furthermore, the majority of these endovenous procedures are being performed in outpatient centers without conscious sedation. This eliminates the cost of an anesthesiologist and the associated hospital operating room and recovery room costs. The office-based practice represents significantly less cost to the patient and/or insurance company than that of a hospital-based endovascular center or surgical center. Furthermore, the overall cost to society is arguably less with endovenous procedures because the patients are able to return to work sooner. This conclusion is supported by the Rautio et al data in a comparative study of conventional vein stripping and endovenous procedures.¹

The 15% failure rate that I quoted is based on an initial learning experience in 30 patients in which the operators likely pulled back too quickly. Separate studies presented at the 16th Annual American College of Phlebology,^2-4 reported occlusion results are in the 90% to 95% closure rate, which I think more accurately reflect reality. These data only further confirm that this is a highly effective, durable way to treat patients with this disease.

With respect to the quoted rates of deep vein thrombosis, infection, and neovascularization associated with conventional stripping, my data were obtained from numerous published studies. The deep vein thrombosis data I used are from three separate published studies,^5-7 which show 0.15%, 1.1%, and 1.8% rates of occurrence, respectively. The infection rates I quoted are from several published studies.^8-10 These studies demonstrate infection rates of 4.5%, 6.0%, and 13.7%, respectively. The neovascularization rate I quoted for conventional stripping was 52%.¹¹ I believe these published data to be accurate.

With respect to this article being a paid advertisement, nothing could be further from the truth. I am required to disclose any and all present corporate relationships, which is exactly what I did. I do believe this technology is as effective as conventional vein stripping and I hope that my enthusiasm and the data supporting it allow you to consider using it in your practices.

Neil Denbow, MD
New Haven, Connecticut

1. Rautio T, Ohinmaa A, Perala J, et al. Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs. J Vasc Surg. 2002;35:958-965.
2. Min R. 2-year follow-up results on endovenous laser treatment of the incompetent greater saphenous vein. 16th Ann Cong Am Coll Phlebology. November 7-10, 2002 [abstract].
3. Navarro L, Bone’Salat C. Endolaser—A three year follow-up report: implications on crossectomy and ligation and stripping. 16th Ann Cong Am Coll Phlebology. November 7-10, 2002 [abstract].
4. Weiss R, Weiss M. Endovenous FR occlusion for treatment of saphenous reflux and associated varicose veins: long-term results at 3 years experience. 16th Ann Cong Am Coll Phlebology. November 7-10, 2002 [abstract].
5. Hagmuller GW. Complications in surgery of varicose veins. Lagenbecks Arch Chir-Suppl Kongressbad. 1992:470-474.
6. Dale WA, Cranley JJ, DeWeese JA, et al. Symposium: management of varicose veins. Contemp Surg. 1975;6:86.
7. Miller GV, Lewis WG, Sainsbury JR, et al. Morbidity of varicose vein surgery: auditing the benefit of changing clinical practice. Ann R Coll Surg Engl. 1996;78:345-349.
8. Mackay DC, Summerton DJ, Walker AL. The early morbidities of varicose veins surgery. J Roy Nav Med Serv. 1995;81:42-46.
9. Einarsson, Eklof B, Neglen. Sclerotherapy or surgery as treatment for varicose veins: a prospective randomized study. Phlebology. 1993;8:22-26.
10. Corder AP, Schache DJ, Farquharson SM, et al. Wound infection following high saphenous ligation: a trial comparing two skin closure techniques: subcuticular polyglycolic acid and interrupted monofilament nylon sutures. J R Coll Surg Edinb. 1991;36:100-102.
11. Jones L, Braithwaite D, Selwyn D, et al. Neovascularization is the principal cause of varicose veins recurrence: results of a randomized trial of stripping the long saphenous vein. Eur J Endovasc Surg. 1996;12:442-445.