Treatment of Varicose Veins: The Present and the Future – A Questionnaire Survey

Abstract

INTRODUCTION

The treatment options for varicose veins have increased over the last few years. Despite alack of randomised trials comparing the various modalities, many surgeons are changing their practice. The aim of this study was to assess the current practice of surgeons in Great Britain and Ireland.

MATERIALS AND METHODS

A postal questionnaire survey was sent to surgical members of the Vascular Society of Great Britain and Ireland and the Venous Forum of The Royal Society of Medicine. Of 561 questionnaires sent, 349 were returned completed (62%).

RESULTS

The types of varicose vein treatments offered by each surgeon varied widely in both NHS and private practice. The vast majority (96%) offered conventional surgery (CS) on the NHS. Foam sclerotherapy (FS) endovenous laser (EVL) and radiofrequency ablation (RF) were more likely to be offered in private practice than in NHS practice. Overall, 38% of respondents for NHS practice and 45% of respondents for private practice offered two or more modalities. Of the respondents who were not yet performing FS, EVL, or RF, 19% were considering or had undertaken training in FS, 26% in EVL and 9% in RF. When asked to consider future practice, 70% surgeons felt that surgery would remain the most commonly used treatment. This was followed by FS (17%), EVL (11%) and RF (2%).

CONCLUSIONS

Over one-third of respondents are now offering more than one treatment modality for the treatment of varicose veins. Whilst there is movement towards endovascular treatments, the problem of cost has yet to be solved. At present, surgery remains the most popular modality in both the NHS and private practice; however, improved outcomes and patient preference may lead to a change in practice.

The fundamentals of conventional varicose vein surgery have not changed for many years. Its prime position in the UK in the management of varicose veins was briefly challenged in the 1960s by injection sclerotherapy¹ but the pendulum swung firmly back to surgery after Hobbs² reported his controlled trial which showed that, if there was trunk incompetence, after 2 years the advantage lay with operation. It has been suggested that Fegan's methods were not properly taught so, with inferior results, interest waned. Now there is change. Foam sclerotherapy (FS), endovenous laser (EVL) and radiofrequency ablation (RF) are all, according to their proponents, poised to take over from conventional surgery (CS) as the leading technique. The problem for the practising surgeon considering achange is the relative lack of controlled trials particularly with long-term follow-up. This is despite the fact that all the new modalities have been available for some years.

A number of reviews are available.^3–6 The National Institute for Health and Clinical Excellence (NICE) is a source of information both for surgeons and patients; its website (<www.nice.org.uk>) provides information on foam sclerotherapy, endovenous laser and radiofrequency ablation. All of these sources point to arelative lack of good, randomised, controlled trials with adequate follow-up.

Perrin's recent review⁵ emphasised that there is more data from controlled trials for RF than for EVL and that, whereas the procedure for RF is well standardised, that for EVL is not with variability between operators. Nevertheless, the early results suggest a benefit from both these endovenous methods compared with conventional open surgery in terms of less bruising and more rapid return to normal activities and work. As far as data are available, in the short- to medium-term, RF and EVL seem as effective as conventional surgery. The problems of recurrence after CS are well known and there is now acceptance that the groin incision in CS may provide the stimulus for neovascularisation.⁷ Hence, the avoidance of the groin incision in RF and EVL could possibly benefit these methods in the long term.

Foam sclerotherapy was brought to prominence by Cabrera et al.⁸ and Frullini and Cavezzi.⁹ We now have the benefit of the results of the Varisolve® trial,¹⁰ which had not been published at the time of our questionnaire. It showed good results for Varisolve® microfoam at 6 and 12 months; however, in the part of the trial comparing it to open surgery, the latter was superior. Where Varisolve® was compared to alternative forms of sclerotherapy administered according to the phlebologist's preference and usual practice, Varisolve® was superior. The great advantage of foam is low cost and repeatability. Disadvantages include superficial thrombophlebitis, pigmentation and matting but these can be limited by careful attention to good post-sclerotherapy compression. Persistent or recurrent varices are a manageable problem as further treatment is readily administered. No special equipment is needed a part from duplex ultrasound.

Many surgeons will be wondering if they should spend time and effort mastering one or all of these new techniques, particularly when their employing trusts are unlikely to be supportive because of fears about additional costs. Many will be concerned about possible loss of private practice if they do not offer the new treatments. Enthusiasts for the new methods are vocal and persuasive. Pressure to change comes from industry and from patients who may be well informed from the daily press or Internet. If results are equivalent then patients will demand the less-invasive treatments. They may accept less-painful treatments even if the long-term results are somewhat inferior. Proponents of FS advise patients that further treatments are likely but of no great consequence or inconvenience.

We felt it would be useful at this stage to discover how widely the new modalities have been adopted. In simple terms, safe, effective treatments will gain wide-spread acceptance provided they are not too expensive. Conversely, unsafe or in effective treatments will not, however vocal their proponents. We thought surgeons with an interest in this field might be helped by knowing what their colleagues were doing now and what they thought would develop over the next 5 years.

Materials and Methods

The Vascular Society of Great Britain and Ireland and The Venous Forum of The Royal Society of Medicine kindly supplied postal addresses of their members. We sent questionnaires to 561 individuals having eliminated the names of those whom we knew not to be surgeons. We asked about CS, FS, EVL and RF and which treatments were currently offered in the NHS and in private practice. If the individual was not practising these methods, we asked if they had undertaken, or had considered undertaking, appropriate training. Finally, weasked which methods the surgeon thought would be most used in 5 years time.

Trainees were included in the mailing but we did not know the names of trainees and we had not asked respondents to state whether they were trainees. Retired surgeons were also included in the mailing and we asked them to identify themselves so that we could have the benefit of their long experience.

Results

From the 561 questionnaires posted, 349 completed responses were available for analysis (62%). Of these, 336 surgeons (96%) offered conventional surgery to NHS patients, 95 surgeons (27%) offered foam sclerotherapy, 66 surgeons (19%) offered endovenous laser (EVL) and only 12 surgeons (3%) offered radiofrequency ablation (RF). The endovenous modalities were more frequently offered in private practice (Fig. 1).

Figure 1.

Treatment modalities offered (349 respondents).

The number of modalities offered varied widely. For example, 209 surgeons (60%) offered only one modality in their NHS practice and in all but two cases this was conventional surgery. Ninety-eight surgeons (28%) offered two modalities (most commonly conventional surgery and FS), 29 (8%) offered three and 1%, or just four surgeons offered all four modalities. Of the remaining 9 respondents, 8 were retired and one did private practice only (Fig. 2). In NHS practice, 38% respondents offered two or more modalities compared with 45% in private practice; thus, the latter is likely to offer the patient awider range of options.

Figure 2.

Number of treatment modalities offered (349 respondents).

Surgeons who were not currently offering FS, EVL, or RF were asked to state whether they were undergoing, or were considering, training in any of the new modalities. Replies indicated that 19% of surgeons were considering or having training in FS, 26% in EVL and 9% in RF.

Predictions for future practice

Having established current practice, we asked surgeons to rank the modalities from arank of 1 (for the method they thought would be most commonly used) to 4 (for the method they thought would be least commonly used in 5 years time). Only 165 respondents completed the question correctly of whom 115 surgeons (70%) thought that conventional surgery would still be the most commonly used modality in 5 years time, 29 (17%) suggested foam sclerotherapy would be the most commonly used, 18 (11%) chose EVL and only three surgeons (2%) chose RF (Fig. 3). Interestingly, 58% of those offering EVL guessed it would rank first or second for future practice, but only 39% of those offering RF expected it to become first or second in the future. However, 78% of those offering FS thought this would rank as first or second most popular treatment in the future. The figures were similar for retired surgeons with the majority (72%) suggesting that conventional surgery would remain the most commonly used modality for the treatment of varicose veins.

Figure 3.

Predictions for future practice: (A) 165 respondents, (B) 23 retired members.

Discussion

We think the views expressed are representative of UK surgeons interested in varicose veins. The response rate was reasonable at 62%. The actual response rate from consultants was probably higher. The names and addresses from the specialist societies did not include the status of the addressee. We had a tick box for retired status but failed to distinguish trainees from consultants. Previous experience has shown a low response rate from trainees because of frequent changes of address.

There is little doubt that the movement from conventional surgery to endovascular treatment is gaining momentum in the UK. As far as the NHS is concerned, there is a problem over costs.³ Under the national tariff, defined by the UK Department of Health, payment for varicose vein procedures in 2007/8 is £1018 (<www.dh.gov.uk>). According to data from Nottingham (B Braithwaite, unpublished data), the respective costs in ascending order, for FS, CS, EVL and RF, were £315, £933, £1250 and £1600. Hence, FS is the endovenous technique most likely to gain favour in the NHS. However, in general, the primary care trusts will not accept FS as an operative procedure, deeming it an out-patient procedure, so they pay less. With continuing pressure on budgets for primary care trusts and for hospital trusts, the numbers of varicose vein procedures are likely to fall and the prospects for endovenous laser or radiofrequency ablation within the NHS do not look good. There is likely to be pressure both from patients and surgeons for the less aggressive endovenous treatments but the ability of either group to influence hospital trusts or primary care trusts is limited. It is unlikely that commercial companies will make much progress marketing their products within the NHS unless they can reduce charges. These companies find it easier to access the private sector and our responders indicated greater use of these techniques in private, as opposed to NHS, practice.

Subramonia and Lees⁶ have recently pointed out that, under the NHS, patients are increasingly denied the benefits of varicose vein procedures despite clear evidence of improved quality of life.^11–13 Evidence of this reduction comes from the Department of Health's own statistics for completed hospital episodes (<www.hesonline.org.uk>). For England over the 7 years from 1998/9 to 2005/6, there has been a 35% reduction in procedures, from 52,412 to 34,318. By comparison, the number of privately performed procedures was reported to be 13,428 in England and Wales in 1992/3¹⁴ but more recent data are not available.

Guessing the future is always risky. Endovenous treatments will not go away. We note that retired surgeons gave the same prediction for the future as active surgeons. No one thinks it is apassing fad.