the great vein scandal

There are a fair few grisly treatments to be had in the name of beauty, but few educe the wince-factor of vein stripping. Touted as painless minor surgery, this procedure is performed on thousands of legs yearly, often repeatedly. One vascular surgeon says it's a barbaric practise that needs confining to medical history because it doesn't work and can prolong the misery and discomfort of varicose veins.

      Dr Mark Whiteley has been practising for 25 years, and since he founded The Whiteley Clinic in 2001 his casebook of patients who have undergone stripping and had consequent recurrence and complications, has increased year on year. Whiteley is a leg man: he thinks of nothing but leg health and veins (and rugby) and is hellbent on changing the landscape of vein surgery because for him, the fact that stripping is still the mainstream treatment for varicose veins is nothing short of a scandal. Don’t even get him onto claims that it doesn’t hurt and needs little downtime, or that most doctors don’t do a vital ultrasound on patient’s legs before vein treatment, let alone tell them there is an alternative to this archaic practise.
      It is estimated that 20 per cent of us get varicose veins; 100,000 operations are done on them yearly on the NHS, and many more privately. So veins are one of the most operated-on conditions, yet the ‘high tie and strip’ method is based on a practice invented over 100 years ago on the back of an erroneous understanding of the venous system.

      In the 1890’s, Dr Friedrich Trendelenburg – inventor of ‘the Trendelenburg shock position’, in which patients were operated on upside-down – concluded that varicose veins occurred when the valves inside veins were damaged and could not stop blood flowing down. He felt that pressure applied to the abdomen (caused by anything from pregnancy to lifting an encyclopaedia) strained the larger pelvic veins so they pushed down on the top valve of the great saphenous vein, the biggest superficial vein in the leg, worsening the problem. His solution to all this – quite logical given the supposition – was to tie this vein off at its top (groin) end to stop blood falling down and increasing pressure on veins below.

      Trendelenburg’s cork-in-a-bottle method was groundbreaking – as was his theory on the causes of varicose veins. But it was only half right. Had he had the advantage of ultra-sound over dead bodies to observe blood flow he would have realised that his hypothesis was also upside-down because the real focus is the small saphenous vein behind the knee.

      This one connects to another vein deep inside the thigh muscles and regulates blood flow between the pelvis and small saphenous vein like a buffer. But although pressure on veins in the pelvis can’t strain the small saphenous vein because of the buffer vein between them, varicose veins still appear below the knee, which proves that Trendelenburg’s breakthrough idea about them being entirely caused by pressure in the pelvis was wrong.

      By the time ultrasound had arrived, however, high tying and stripping – added to the procedure in the 1950’s – was regarded as the best treatment for varicose veins even though it didn’t work and veins reappeared. In 2007, Whiteley published a study which showed that within five years 82% of patients who had veins removed had seen significant vein regrowth. More proof then that stripping is not the answer because it can’t stop connective vein tissue regenerating. Worse, when veins do grow back they don’t develop any valves at all, so are the same as the ones the surgeon has removed. Which puts the patient back at square one with blood refluxing freely down the legs causing varicose veins.

      You can see why Whiteley is so troubled about the prevalance of vein stripping.
      In 1999, he managed to perform the first keyhole surgery on veins using a technique called VNUS Closure. This uses heat delivered by radio frequency to seal veins and destroy them, and while there was some regrowth after early treatments, Whiteley found that after refining the method – using general anaesthetic and improving contact between the vein walls and electrodes – follow up reports on early patients after 11 years have showed they had no vein regrowth. This breakthrough isn’t the only reason Mark and other forward-thinking surgeons believe keyhole surgery outstrips stripping. Surgeons only need to make tiny incisions in the leg (not groin, a famously tricky area to heal), there is no post-operative pain or immobility (two weeks off is standard after stripping) and much greater accuracy.

      Which begs the question why surgeons are still relying on the very Victorian practice of tying and stripping? While there is, dare I say it, a case for it being something of a commercial venture if repeat treatment is needed, Whiteley cites reasons like ease and attitude: veins are considered by some doctors to be a trivial cosmetic matter and stripping is viewed is basic practise for junior surgeons needing experience for major vascular surgery.

      Thankfully, some surgeons realise that varicose veins merit more thorough thinking and treatment, and that the problem is not just a case of how our legs look in shorts.

VEIN HELP?

• Activity – particularly good for veins: the faster blood flows across a blood vessel the more nitrous oxide is released into the vein wall which keeps it healthy; so exercise helps veins and arteries. Fast-flowing blood is also less likely to develop clots.

• Smoking – damages and causes inflammation within the vein wall, weakening it and making it more likely to form clots within the veins.

• Topicals – creams that claim to reduce veins from the surface, usually based on vitamin K, a nutrient with blood-clotting properties, may fade thread veins but can’t erase them completely and definitely won’t have an impact on varicose veins.

• Sclerotherapy & laser treatment – can both be effective in treating thread veins and even preventing varicose veins, but only if an ultrasound scan is done to see why they are forming as thread veins can be an outward sign of hidden varicose veins. Contact The British Association of Aesthetic Plastic Surgeons (baaps.org.uk) to find an accredited doctor.

ADDRESS BOOK

http://www.thewhiteleyclinic.co.uk/

01483 477180