Ideally, color Doppler and treatment should be done by the same physician
IDEAL VEIN CARE; DIAGNOSIS, TREATMENT AND FOLLOW UP IN ONE CENTER
Problems related to Color Doppler diagnosis
In many western countries, clinical and color Doppler examination, treatment and follow-up are performed by the same center or physician. In some countries however, the patient applies to a surgeon first, but since the surgeon has no ultrasound training or experience, he/she sends the patient to a radiologist for color Doppler ultrasound examination. The radiologist, who is well-trained and experienced on ultrasound but has little idea on the treatment of varicose veins, performs ultrasound in the patient and writes a report. The patient who receives the report goes back to the surgeon and shows the report. The surgeon who sees the report draws a treatment plan based entirely on the Doppler ultrasound report. As a result, the patient is referred between the surgeon who is experienced in varicose vein treatment but not in the ultrasound and the radiologist who is experienced in ultrasound but not in the treatment of varicose veins. This inadequate communication between two physicians often results in incomplete or incorrect treatment. This is mostly because an inaccuracy in ultrasound examination will directly lead to inadequate or incorrect treatment. In my personal experience, approximately half of color Doppler ultrasound examinations performed in varicose vein patients have serious deficiencies or errors. This situation may give an idea about the rate of inappropriate varicose veins treatments in general population.
Problems related to the technique of varicose vein treatment
Today, all modern varicose vein treatments are performed under ultrasound guidance, but surgeons performing these treatments do generally not have any ultrasound training or experience. Therefore, for the treatment, the patient has to choose either a surgeon who knows the treatment of varicose veins but cannot do this by using ultrasound, or a radiologists who knows ultrasound well but have no idea of the general principles of varicose vein treatment. Since varicose vein patients usually apply to surgeons first, surgeons who do not have ultrasound experience usually do the treatment. However, modern varicose vein treatments may be too difficult to perform for a physician without experience in ultrasound. To give a simple example, puncturing a vein under ultrasound guidance can be a 5-10 second procedure for a physician with sufficient ultrasound experience, while for a physician who is not familiar with ultrasound, it can become a tedious process that takes hours and sometimes even not possible. Therefore, in many centers, it is not uncommon for surgeons to seek help from radiologists for a simple vein access. Likewise, the procedure of administering local anesthetics around the incompetent vein that cause varicosities is not a procedure for a physician who is not experienced in ultrasound. This procedure, called an tumescent anesthesia, protects the surrounding tissues from the effects of laser and radiofrequency. In recent years, MOCA and Glue treatments have been developed for surgeons who cannot perform tumescent anesthesia with ultrasound. It is declared by the manufacturers that these treatments do not harm the surrounding tissue and can therefore be performed without tumescent anesthesia. However, tumoral anesthesia not only protects the surrounding tissue, but also empties the vein and directs the blood within the vessel to other healthy vessels. In this way, it makes the ablation more effective and prevents clot formation (thrombophlebitis) in the treated vein. Therefore, it is disadvantageous for the patient that the physician does not perform tumescent anesthesia even in MOCA or glue treatments.
Problems related to use of ultrasound during the treatment
The lack of ultrasound experience in the physician who treats varicose veins can sometimes lead to more dangerous situations. The aim of treatments such as laser, radiofrequency, MOCA and Glue is to close and destroy the incompetent vessels without damaging other vessels. However, all incompetent veins are connected deep into the main veins and the closure should start 1-2cm from this junction point. Normally, if this procedure is performed under ultrasound guidance, there is practically no risk since the vein and the catheter are seen instantly. However, if ultrasound is not used, the level of the catheter tip cannot be seen, its location can only roughly estimated. If the catheter is pushed a little too far by mistake the catheter tip may reach the deep vein causing damage on the inner layer of the vein which may result in deep vein thrombosis.
So far, I have tried to explain the drawbacks of performing color Doppler ultrasound and varicose vein treatment by separate physicians as well as the risks that may be caused by physicians who apply new varicose vein treatments although they do not have ultrasound experience. My aim is not to claim that varicose veins should be treated by a spesific group of physicians, but to establish the standards of the most accurate, most effective and least risky treatment approach possible for the patient. In the world, varicose veins are treated not only by interventional radiologists, but also by vascular surgeons, general surgeons and dermatologists. However, these doctors should be capable of doing the clinical evaluation, color Doppler ultrasound and the treatment using ultrasound by themselves without referring patient to other doctors.
To reach these standards, it may be useful to solve following problems:
1. Physicians who will perform varicose vein treatments must have color Doppler ultrasound training. This training is already a natural part of interventional radiology, but other physicians must be trained separately. The training should be sufficient to perform detailed varicose veins examination with color Doppler and to be able to perform varicose vein treatments by using ultrasound guidance.
2. For varicose veins, it should be a standard that a single physician performs clinical examination, color Doppler ultrasound (diagnosis), treatment and color Doppler follow-up. This approach will eliminate the difficulties experienced by patients, increase confidence between the patient and physician and provide a more accurate treatment for varicose veins.
Ideally, diagnosis, treatment and follow-up should be done by a single physician who is experienced in both ultrasound and varicose vein treatment.