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CLINICAL REVIEW: Bruce Campbell Varicose veins and their management BMJ 2006; 333: 287-292 [Full text]

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Conventional treatment still holds good for varicose veins

Boby J Sebastian, Lini Cherian   (11 August 2006)

A Patients View

Paul Gregory Harris   (12 August 2006)

Superficial thrombophlebitis: Not as straightforward as we may think?

Roger Dalton, Julian Humphrey, Consultant in Emergency Medicine   (18 August 2006)

Modern management of varicose veins

David J West   (23 August 2006)

The Future of Varicose Vein Surgery

Paritosh Sharma, Constantinos Kyriakides   (7 September 2006)

Conventional treatment still holds good for varicose veins 11 August 2006
Boby J Sebastian, Clinical fellow Dept of surgery, West Suffolk hospital, Bury St Edmunds, IP33 2PA, Lini Cherian Send response to journal: Re: Conventional treatment still holds good for varicose veins	Sir, We would like to thank Prof Campbell for his excellent article 'Varicose veins and their management'(1). It provides a simple overview of practical assessment and management of varicose veins, a common clinical problem. Furthermore, it emphasizes the value of proper clinical assessment, judicious use of investigations and available treatment options. It is nice to know that technology has not replaced all conventional treatment options. We would like to know the incidence of asymptomatic DVT associated with varicose veins and whether it merits routine evaluation of deep veins in all patients - Perthe's test was an integral part of evaluation of varicose veins along with tourniquet tests not long ago. Also, we would like to get Prof Campbell's views on the incidence and evaluation of secondary varicose veins - especially associated with mass lesions in the pelvis. References 1. Bruce Campbell. Varicose veins and their management BMJ 2006; 333: 287-292 Competing interests: None declared
A Patients View 12 August 2006
Paul Gregory Harris, Scientist Brunel University UB8 3PH Send response to journal: Re: A Patients View	I thought it might be of interest to hear a patients view on the treatments now available. I recently had laser ablation treatment to the full length of both legs. I was released after 5 hours at the hospital and missed only two days of work. I had minor discomfort (bruising etc.) but the wounds closed after a few days and I did not have need to use pain-killers. I understand that with conventional approaches I would be lucky to be back in work within three-four weeks. I appreciate that these are new treatments and that our knowledge of the long-term reoccurrence rates is less clear than for conventional approaches. For me, however, the fact that I could resume my life quickly was a massive advantage. For many, time off work for any reason means loss of income, and quite possibly severe damage to their businesses. For others, for example carers, it may cause severe dislocation and require expensive provision of alternative cover. I suspect there are also many who,like myself, are put off seeking treatment because they do not think their employers would be happy with them for taking a month off work for what, in the lay community at least, is often regarded as unessential, cosmetic surgery. As a result I put up with my condition getting progressively worse for 25 years, until the arrival of symptoms I could not ignore (swollen ankles, leg aching, dermatitis) forced me to my GP. Had I realised I could have the condition treated so easily and with such a short recovery period, I would have saved myself years of discomfort and had it treated a long time ago. Paul Harris Competing interests: None declared
Superficial thrombophlebitis: Not as straightforward as we may think? 18 August 2006
Roger Dalton, Specialist Registrar, Emergency Medicine Barnsley District General Hospital, Gawber Road, Barnsley S75 3EP, Julian Humphrey, Consultant in Emergency Medicine Send response to journal: Re: Superficial thrombophlebitis: Not as straightforward as we may think?	Sir We read Professor Campbell's article on varicose veins with interest. Of particular significance to Emergency Physicians was the small section on the problems varicose veins can cause, especially superficial thrombophlebitis. Superficial thrombophlebitis poses a managerial quandry in the Emergency Department due to the association with Deep Venous Thrombosis (DVT), an association which Professor Campbell suggests is "remote". Recent clinical experience in our department prompted us to examine this association more closely. Several studies have been undertaken. Bounameaux reported an incidence of associated DVT of 5.6%. Decousus showed associated DVT or pulmonary embolism in 13.8% of patients. Blumenberg showed symptomatic pulmonary embolism developed in 1% (of 232 patients) with superficial thrombophlebitis. Given the common risk factors these conditions share, we are in the process of re-evaluating our risk stratification for the management of superficial thrombophlebitis. Our recent experience suggests the condition isn't as straightforward as we first thought. References: 1.Campbell B. Varicose veins and their management BMJ 2006; 333: 287-292 2.Bounameaux H, Reber-Wasem M. Superficial Thombophlebitis and Deep Vein Thrombosis. Archives of Internal Medicine, 1997, 157: 1822-24 3.Decousus H. A pilot randomised double-blind comaprison of a low molecular weight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis. Archives of Internal Medicine, 2003, 163: 1657-63 4.Blumenberg RM, Barton E, Gelfand ML et al. Occult deep venous thrombosis complicating superficial thrombophlebitis. Journal of Vascular Surgery, 1998, 27: 338-43 Competing interests: None declared
Modern management of varicose veins 23 August 2006
David J West, consultant interventional radiologist university hospital north staffordshire Send response to journal: Re: Modern management of varicose veins	Bruce Campbell’s account of varicose veins and their management was carefully phrased but, nevertheless, those of us involved in the rapidly advancing field of minimally invasive varicose vein treatment, readily detect the traditional surgical bias.(ref1) Despite this however nowhere did the article claim, as was stated on the front cover of the journal, that conventional surgery is still the best treatment. This inaccurate conclusion is highly misleading and is likely to discourage general practitioners from referring their patients to centres which specialise in non-surgical management. Other eminent British vascular surgeons take a very different view on endovascular varicose vein treatment and I quote for example Professor Sir Peter Bell who wrote a year ago “There is no doubt that percutaneous treatment of varicose veins matches the results that are now obtained from surgery” and “Classical vascular surgery is indeed being replaced by endoluminal procedures, even varicose veins are now better treated by percutaneous techniques.”(ref2) This generally excellent review was spoiled also by some inaccuracies which, although understandable considering Professor Campbell has little, if any, personal knowledge of laser therapy, do require correction. 1. To treat both legs by laser requires general anaesthesia. This is not true I regularly treat both legs under local anaesthesia using doses well within accepted limits. 2. Further procedures are often required unless done under general anaesthesia. Again this is not true as either foam sclerotherapy or multiple avulsions can be done under local anaesthesia at the time of the original treatment. 3. Laser takes longer to do than conventional surgery. Not true; with experience a long saphenous ablation can be undertaken start to finish in 20 minutes with the patient walking home 10 minutes after that! Professor Campbell implies that laser is only used to treat the long saphenous vein whereas in fact it is used to treat any large refluxing vein and is especially effective in the small saphenous where surgery is particularly problematic. No mention is made of the difficulties of operating on recurrent varicose veins where again laser treatment is very effective. Incompetent perforators are a common problem and the use of RF ablation of these is ignored as is transcatheter embolisation of incompetent pelvic veins. It is a shame that the references are only up to date when it comes to complications but recent literature on the benefits of endovascular treatments is not quoted. There is certainly now enough evidence on the safety and efficacy of endovascular treatments to justify offering all patients the choice “Do you want an operation under general anaesthesia or a minimally invasive treatment under local?” Ref1 Campbell B BMJ. 2006 Aug 5;333(7562):287-92. Ref2 Bell P. Journal of Cardiovascular Surgery. Aug 2005. Vol. 46, Iss. 4; p. 323 Competing interests: I am a director of Veincentre Ltd a company which specialises in the minimally invasive treatment of varicose veins
The Future of Varicose Vein Surgery 7 September 2006
Paritosh Sharma, Vascular Research Fellow Barts and The London NHS Trust, The Royal London Hospital, Whitechapel, London E1 1BB, Constantinos Kyriakides Send response to journal: Re: The Future of Varicose Vein Surgery	Dear Editor, We read with interest the review article on varicose veins and their management by Professor Campbell (BMJ 2006; 333:287-92). The author suggests that open surgery remains the gold standard for varicose veins and that the place for newer treatments remains unclear. The standard operation for varicose veins involves general anaesthesia and a groin incision with its associated 10% complication rate. The recurrence rate post standard surgery has been reported to be as high as 70% after 10 years2. In addition, the Edinburgh vein study suggests that most patients requesting surgery for varicose veins do so for cosmetic reasons3. This has been the impetus for developing newer percutaneous techniques that are cosmetically more appealing and are associated with a lower complication rate. At our centre, we offer patients a choice of both open surgery and Endovenous Laser Treatment (EVLT). EVLT has the advantage of being performed under local anaesthetic and does not involve a groin incision. It involves the use of intra-operative ultrasonography, which provides for better visualisation of the venous anatomy (including duplex systems), translating to more accurate surgery. The procedure can also be used to treat short saphenous varicosities and below knee long saphenous varicosities, using lesser amounts of energy. Phlebectomies can be performed under local anaesthesia at the time of the procedure, although we understand that some centres do not perform them as up to 45% may not require them post EVLT. One of the recent studies comparing EVLT with standard surgery found that patients undergoing EVLT have a significantly quicker return to work and normal activity4. There have also been suggestions that the incidence of neovascularisation after heat ablation is less than after open surgery5. The short and medium term results for EVLT report recurrence rates to be in the range 0-7% at 2 years6. Even though open surgery has been the traditional treatment for varicose veins, it is difficult to consider this as the gold standard, given its high recurrence and complication rates. Newer techniques such as EVLT offer benefits in terms of lower complication rates and avoidance of a groin incision and a general anaesthetic. The short and medium term results are comparable to or better than open surgery and longer term results are awaited. References 1. Varicose veins and their management Bruce Campbell BMJ 2006;333;287-292 2. Crossectomy and great saphenous vein stripping, Winterborn et al, J Cardiovasc Surg (Torino) 2006 Feb; 47(1): 19-33 3. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey, Bradbury et al, BMJ 1999;318;353-356 4. Endovenous Laser Treatment (EVLT) or surgery for varicose veins? A randomized controlled trial in patients with saphenofemoral and long saphenous incompetence, Beale et al, BJS 2006; 93: 380 5. Radiofrequency ablation (VNUS closure) does not cause neo- vascularisation at the groin at one year: results of a case controlled study, Kianifard et al, Surgeon 2006 Apr; 4(2):71-4. 6. Endovenous Laser Treatment of Saphenous Vein Reflux: Long-Term Results, Min et al, J Vasc Interv Radiol 2003; 14:991–996 Competing interests: None declared