IQ_2012_06_venus - Report

Voting with Their Wallets


Minimally invasive treatments for varicose veins are offering patients more choice than ever, and even where they are not offered by public health insurers, patients are voting with their wallets and seeking out private treatment.

Dr. Kieran McBride runs the Scottish Vein Centre, a private clinic in Edinburgh that offers varicose vein sufferers the gentle options they are looking for. He tells us why the procedures are so popular, and why, having trained as both a surgeon and an interventional radiologist, he favours the minimally invasive approach.

The Public Purse

The term ‘endovenous ablation’ sounds complicated, but it’s basically burning the vein from the inside. Data has been building up over the last 10 years, and there’s a lot of indisputable evidence now. Nonetheless, there is a reluctance in Europe to provide it on the public purse.

The US Experience

In the US, ablation has now become the accepted standard for patients, surgeons and insurance companies. Endovenous laser is the proven superior treatment – there’s plenty of data to support it.

In 2005, the American private insurance companies decided to pay for it, as it was the cheaper option. So literally overnight, surgeons were realising that a less invasive, non-surgical outpatient procedure meant better re funds. Now, only about 10-15% of veins are being operated on in America. It’s the other way around in the UK.

The Public Mood

In Europe, people who are experiencing heavy, uncomfortable legs, or who are unhappy with the appearance of their legs are often reluctant to opt for surgery. But their veins have a huge impact on their quality of life, and when they know interventional radiology (IR) is an option, many are happy to pay to have their knarled and painful veins rectified.

The Limitations of Surgery

Surgeons generally cut at the groin and tie off the incompetent vein, then pull it out: but stripping can be very inefficient. Little bits of vein come out, but not the whole vein. Even if the procedure is completely successful, patients are still left with scars.

With certain veins, such as the short saphenous (the veins at the back of the knee), there’s a high recurrence rate and a high complication rate with surgery and these veins especially do better with the less invasive methods.

Another drawback to surgery is neovascularisation: 25 of my patients have had a recurrence from surgery called a varix. That’s when a large number of small veins regrow from the cut vein, and they’re difficult to deal with surgically. So I introduce a catheter, followed by a fibre optic. Before I turn on the laser, I inject a foam sclerosant, which fills all of the varices that are all bunched together. I’ve had really good results, even at 4-year follow-up.

Neovascularisation is avoided with laser or radio frequency where the vein remains closed. So you actually inhibit new growth, you’re preventing that recurrence.

Patient Choice
Ultimately, it’s about patient choice. The big question that I put to surgical colleagues is “how do you get fully informed consent without giving patients all the options?” A lot of patients don’t know about the new procedures, but neither do all general practitioners (GPs), which is really unfortunate for a lot of people.
Missed Diagnoses
In most cases, varicose veins cause discomfort and embarrassment, but patients can also end up with bad ulcers, real problems. They may already have hidden deep vein thromboses (DVT) or other underlying problems. A lot of GPs don’t examine legs: they don’t know how. So there’s a bit of education needed in primary care.

Many of our patients find out about IR from newspapers or from websites; they type ‘varicose veins’ into Google, and come across websites like mine. When I see a new patient, I inform their doctor, and I make efforts to spread the word.
The Scottish Vein Centre
I’ve based my Scottish Vein Centre on the American walk-in-off-the-street set-up – I work out of private consul - ting rooms. We have adapted our consulting room to be able to perform sterile procedures in a relatively relaxed and informal environment. The patients are kept very com - fortable and have an attendant with them throughout the procedure, while pleasant background music is playing.

Every new patient undergoes an assessment, a consultation and a fully detailed ultrasound examination. We give them maximum information, and send them away to think about it. I always tell them to call the following day or the following week. It’s important that they’ve thoroughly considered their options.

We do our procedures on a Saturday on an outpatient ba sis, and the patient is usually back at work by Tuesday. It’s done under local anaesthesia and is finished within an hour. We put the patient in some compression bandages and compression stockings, and they can walk out of the department and to the shops, or whatever they feel like.
Satisfied Clients
We’ve always had very satisfied patients. My clinic has been running for six years now, and we’ve never received a complaint and have had a full 100% technical success rate. An important part of that is making sure that patients have realistic expectations – we do emphasise that we’re not going to give them Sofia Loren’s legs! But they will be rid of their varicose veins.

However it’s not just about cosmetics: quite a number of patients are actually quite symptomatic – probably about 70-75% will have some degree of symptoms and although serious outcomes are rare, varicose veins are very distressing for many people – so much so that they are willing to pay privately for a solution to their problems.

I’m delighted to be able to provide this service – it’s wonderful to be able to make a difference to people’s everyday lives.

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Minimally invasive treatments for varicose veins are offering patients more choice than ever, and even where they are not offered by public health insurers

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