Expert Commentary: Steven D. Bines M.D. 12/04/2009

Posted by Admin on December 4, 2009

There has been a revolution in the treatment of painful varicose veins. Once a procedure done under general anesthetic in a hospital, utilizing multiple large and painful incisions, today it can be performed under local anesthesia in a doctor's office. Part of this revolution has been a change in the type of doctor treating varicose veins. There are two new procedures. The first is called Endovenous Laser Ablation (EVLA) - where a laser is inserted into the diseased vein. The second Evdovenous Radiofrequency Ablation (RFA) uses a radio frequency catheter. Both techniques destroy the diseased vein, and blood flow is naturally rerouted. The varicose vein is absorbed back into the body and disappears from view.

Typically the procedure does not require the type of surgical skills that the traditional varicose vein stripping of the past required.  For this reason, the new procedures are being offered by doctors without the surgical training that is required to become a vascular or general surgeon. This is fine as long as everything goes well. But when there is difficulty placing a catheter or a catheter breaks inside the vein, traditional surgical techniques are sometimes urgently needed.

Additionally, the laser or RFA catheter is positioned in the vein using ultrasound guidance. The use of ultrasound is part of the daily practice of the interventional radiologist, vascular surgeon and general surgeon. In general surgery, my field of certification, ultrasound is used daily for the evaluation of the gall bladder and its ducts, the breast and the abdomen.

Competency to perform surgery, including vein surgery, is monitored by the American College of Surgeons. This Certification licensing process assures patients that their doctor is competent to not only perform the simple ablation but can deal with any complications if they should arise.

Blue Cross Blue Shield’s maneuver to limit the practice of out-patient EVLA and EVRFA procedures to facilities approved by the American College of Radiology or the Intersocietal Commission for the Accreditation of Vascular Laboratories will severely limits patient access to the procedure, limit the number of qualified surgeons who can perform it, and probably make the procedure more expensive.

It is not the facility that guarantees the success of treating varicose veins. It is the quality of the surgeon. Patients should focus on the qualifications of the surgeon, ask about certification, their years of experience. That is what makes the difference safe and unsafe surgery and  between good and poor outcomes.


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