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Vein treatment advances converge: ultrasound indispensable

Cosmetic Surgery Times Jan-Feb, 2005 by John Jesitus

Austin, Texas -- Modern vein treatment is benefiting from both new technology and new uses for existing tools and treatments.

One recent change is our knowledge that detergent sclerosants such as sodium tetradecyl sulfate and polidocanol can be made into a foam by mixing them with air," says Steven E. Zimmet, M.D., F.A.C.Ph., a private practitioner based in Austin and president of the American College of Phlebology. "That increases the strength of the medication considerably and can be very useful in treatment of primarily larger veins. But it's very important that one be experienced in sclerotherapy and ultrasound, as well as knowledgeable about foam sclerosants, before embarking on their use. Since they're stronger, we probably have a higher risk of deep vein thrombosis if they're used incorrectly. And there may be a higher incidence of other side effects like visual disturbances and neurological phenomena, which have all been transient, if used incorrectly."

Of equal importance has been the development of endovenous techniques, including endovenous laser and radiofrequency occlusion, for treating venous disease.

These techniques offer results that appear to be as good as or better than surgery, and can be done in-office under local anesthesia without incisions," Dr. Zimmet says.

These techniques would not have been possible, however, without the development and use of ultrasound in diagnosing, and now treating, venous disease.

Ultrasound has been used for venous disease over the last 15 to 20 years or so," he says. "Initially, it was used primarily to diagnose deep vein thrombosis. But more recently, it's become an indispensable tool in managing superficial venous insufficiency. Ultrasound has revolutionized our understanding of varicose veins and enabled the development of these newer treatment techniques."

It's important to realize that surface varices are often fed by underlying incompetent veins. To convey the importance of distinguishing between superficial varicosities and the deeper ones that feed them, Dr. Zimmet offers the image of a wet wall. There's no sense patching it without addressing the leaky pipe it conceals. In this regard, one approach involves using a hand-held Doppler device as a screening tool to listen for evidence of reflux in veins underlying areas of concern.

Ultimately, Dr. Zimmet recommends duplex ultrasound, which allows one to visualize the veins on a monitor.

With duplex ultrasound," he says, "you see an image of individual veins and are able to evaluate them for their function. With a hand-held Doppler, you simply manipulate a probe over the skin and try to hear what kind of flow patterns exist in the vein you're listening to, but you don't know much more about that vein, such as which vein it is, how big it is and what it connects to."

Neither ultrasound nor foamed detergents are recent developments (Wollman JC. Dermatol Surg. 2004 May;30(5):694-703; discussion 703).

But foam has enjoyed a big surge in interest over the last five years," Dr. Zimmet says. "It was rediscovered at a time when, thanks to ultrasound techniques, people had a much better idea of what needs to be treated and the results of treatment. The ability to better evaluate what's going on with the patient and with our treatments has enabled the rapid development of the foam technique."

Improved evaluation and treatments benefit not only patients, but providers as well.

There are millions and millions of patients out there with venous disease," Dr. Zimmet concludes. "More physicians are becoming very interested in this field, and it's partly because treatment techniques have developed to the point where generally excellent results are obtained with very low levels of risk when these procedures are done properly. There have been significant developments in terms of what can be done. Also, the difficulties with insurance reimbursement have people looking for new areas (of practice), which may side-step the insurance issue. While treatments for larger veins are often covered by insurance, those for spider veins typically are not."

Disclosure: Dr. Zimmet is a consultant for Diomed, which manufactures an 810 nm diode laser used for Endovenous Laser Treatment (EVLT).

For more information: www.phlebology.org, www.evlt.com

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