A comprehensive portfolio of techniques for varicose veins

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Professor Roger Greenhalgh, Charing Cross Hospital, UK, discusses the dangers of leaving decisions regarding varicose vein treatments to primary care doctors.

“At the CIRSE special venous session there were a number of important messages and the session was well received. One significant message was the danger of leaving the decisions to doctors in primary care

To begin the session, Lindsey Machan, Vancover, Canada, gave a very compressive resume of the venous anatomy and covered the background with an excellent preparation of the session.

Dr DJ West, Staffordshire, UK, discussing the procedures available for patients recommended that there should be a “comprehensive portfolio of the techniques.” He stated, “It is no use offering to ablate the greater sapheous vein only to come across a patient who also has a lesser sapheous vein incompetence and have to refer elsewhere.” He concluded, “We need a range of non-surgical treatments that can be carried out in a simple treatment room or x-ray room which can together carried out on 95%, if not all patients.”

West stopped short of saying that surgery was obsolete, but did imply that the primary care referring doctors in his region would make the decision whether the patients with varicose veins would be referred to him (a radiologist) or a surgeon. The implication of which is that the primary care doctor determines the type of treatment whereas, Dr West original comments of recommending a comprehensive range of techniques, including surgery, is clearly the right way to go. But the manifestation of his practice is that it excludes surgery.

However, Dr Worthington-Kirsch, went further, “In my opinion, endovascular ablation therapy is superior to surgical techniques, such as ligation and stripping. I feel that ligation and stripping is an obsolete procedure and should no longer be considered within the standard of care for most clinical situations.

Mr A Mavor, UK, a vascular surgeon, argued that surgery should be on offer and again made the point that it is vital that patients with varicose veins are offered the full range of treatments. However, the overall impression was that all surgery for veins was obsolete.

Best treatments for patients… avoidance of turf war

Greenhalgh maintains that it would be most regrettable if the turf war issues left the decision making of patients with varicose veins to the primary care doctors. If there is not collaboration within the specialist centres to offer the full range then the primary care referring doctor will choose to refer either to a surgeon or a radiologist.

If the surgeon only offers surgery, they will receive surgery and if the radiologists only offers everything but surgery then the patient will get that. Neither can be right. What is required is for the vascular specialist to cover the full lot, as eloquently described by Mavar and West. However, this should not encourage the referral of GPs directly to just one specialist as West encouraged. Certainly the position of Dr Worthington-Kirsch, that surgery is obsolete, is dangerous.

There can be instances were it is not – for example, the easiest way to manage an incompetent perforated vein is careful Duplex marking and correction through ligation through a tiny incision, which can be done by local anaesthetic. It is inappropriate to say ‘never’ – in James Bond’s terminology, “Never say never again.”

In a patients’ interests it is better for specialists to offer and explain the full range and agree between themselves how this can be provided, than leave that decision to the primary care, where the referring doctor simply does not have the knowledge of how best advise the patient. If the turf war continues, precisely that decision in primary care will occur. That is what we must avoid.”

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