Compression-sclerotherapy for varicose veins - Europe PMC

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Compression-sclerotherapy for varicose veins: a Canadian study. KENNETH M. DOUGLAS,* FRCS, FACS. GODFREY FISHER,* FRCS. DAVID REELEDER,t M ...
Compression-sclerotherapy for varicose veins: a Canadian study KENNETH M. DOUGLAS,* FRCS, FACS GODFREY FISHER,* FRCS DAVID REELEDER,t M SC History

In recent years modifications and refinements in treating varicose veins by injecting a scierosant have given this method an important place in the practiThe treatment of varicose disease can be traced to tioner's armamentarium. Specific indications and pre- 500 BC. A variety of methods have been used over the cise technique are essential. Compression-sclero- centuries. Injection methods, which date from the therapy has been used since 1975 in the vein clinic of invention of the hypodermic syringe over 100 years ago, Belleville General Hospital, Belleville, Ont. Some pa- began to be better understood about 50 years ago. In tients have also required limited ligation of veins that recent years important principles for effective treatment were deeper or more proximal, or both. A follow-up of varicose veins have been clarified by Fegan,t and study of patients 2 or more years after treatment various treatment methods have been studied and revealed no major complications and a high rate of compared in Eire,"6 Great Britain,'-3'7'8 France,9-'2 the patient acceptance and satisfaction. The costs of USSR,'3-'5 the United States,'6 Australia," New Zeatreatment were about one tenth those of conventional land'8and Canada.'9 inpatient surgery. Au cours des derni6res annbes, les modifications et Principles and techniques of compression-sclerotherapy amAliorations apportbes au traitement des varices par The "empty vein" technique described by Fegan4- a injections sclbrosantes ont donn4 i cette technique une place importante dans l'arsenal th6rapeutique du significant departure from the older method of injecting m4decin. Des indications sp4cifiques et une technique full veins, which sometimes caused thrombosis - was precise sont essentielles a sa r6ussite. Le traitement used throughout this project. It entails injecting sodium des varices par injections sclArosantes et compression tetradecyl sulfate (Trombovar) into the area of incomla vein clinic de Belleville General petent perforating veins and then bandaging the legs to est en usage Hospital h Belleville, Ontario depuis 1975. Quelques firmly compress the veins until fibrotic closure occurs patients ont aussi nbcessitb une ligature limit4e pour - usually within 6 weeks. We used the sclerosant in les veines profondes ou proximales ou les deux. Une either a 1% or a 3% solution, the weaker solution for 6tude de contr6le r6alisbe 2 ans ou plus apr6s le varicosities that were more distal or more superficial or traitement a r6v6l6 l'absence de complications ma- both. Clinical methods of locating appropriate sites by jeures et un taux blevb d'acceptation et de satisfac- palpation and compression of suspected perforating tion de la part des patients. Les coOts de traitement incompetent veins are regarded as only about 50% sont environ le dixiAme de ceux de la chirurgie accurate. Ultrasonographic and thermographic techniques were not'adopted because they were even less classique chez des patients hospitalisAs. accurate. Ascending venography can demonstrate the The numerous studies that have compared the surgical

treatment of varicose veins with compression-sclerotherapy seem to have shown that the long-term results of the two methods are about the same.'3-Yet in Canada the use of compression-sclerotherapy has received scant attention. To determine the validity and the acceptability of the method in an Ontario setting the Physicians' Services Incorporated Foundation sponsored a pilot project at the request of one of us (K.M.D.) in which a clinic for the treatment of varicosities was set up at Belleville General Hospital in 1975. In this paper we analyse the results of the first 2 years of the clinic's operation. One result of this analysis is that we now regard compression-sclerotherapy as an alternative to rather than a replacement for surgical methods, and we realize that some patients can benefit from a combination of compression-sclerotherapy and surgery. From the Belleville General Hospital, Belleville, Ont. *Consultant surgeon tHealth record analyst Reprint requests to: The vein clinic, Belleville General Hospital, Belleville, Ont. K8N 5A9

site of perforating veins, but locating these sites clinically proved difficult and time-consuming; therefore, this method was impractical for assessing large numbers of patients. We adopted the method described by Hobbs,7 who acknowledges the problem of accuracy by terming the sites he suggests"points of control"(Fig.l). :

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FIG. 1-With patient standing, varicosities are marked and checked. Spots mark site of (A) significant "leak" and (B) large "leak" in lower thigh (Hunterian perforator) in patient with varicosity of long saphenous vein.

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Injections were made at points progressing up the leg and efficiency, appointment cards with special instrucwith disposable needles and a 1-ml plastic syringe tions, and display notices. The patients were given containing 0.75 ml of sclerosant (Fig. 2). The injection diagrams and tape recordings aimed at providing them site was immediately compressed with firm pads of no. with adequate information in a minimum of time. 7 polyurethane foam (a substance that seldom caused Photographs of the patients' legs, taken frequently and adverse skin reactions) and secured with elastic band- kept on file, proved useful in recording the general ages. To keep pads and bandages in place and to pattern of the particular tenous problem and the provide additional compression the patients also wore injection sites chosen, and in demonstrating to patients regular support hose, for which they had been fitted the changes that had resulted from their treatment. A before they came to the clinic. This injection technique modified version of the usual patient consent form was was used without modification throughout the period signed by all patients. Because of the risk, remote but analysed in this report. Follow-up visits to the clinic with serious consequences, that a patient might suffer every 2 weeks proved to be practical for adjusting the an anaphylactic reaction to the sclerosant, a full bandages, checking the results of injection and injecting resuscitation kit was always available. It was never points of reversed venous flow that had not been used. Since our technique. of compression-sclerotherapy detected earlier. Methods that remove or obliterate all visible varicosi- involved wearing compression pads and bandages at all ties often destroy parts of the superficial venous system times and walking 2 mi every day, we felt that patients that are normal or capable of becoming normal again. might find the treatment uncomfortable or difficult Sclerotherapy attempts to restore the venous pumping both in the hot, bumid weather of July and August and mechanism without destroying normal venous channels in the ice and cold of January to March, when walking and valves.6 We were able to preserve the long saphe- might be hazardous. Therefore, we held 4-hour injecnous vein in many of our patients - tissue that might tion clinics twice a week for 14 weeks each in the spring become useful should the patient require a graft and fall. In the hot and cold weather, consultation because of arterial disease.18 All patients were asked to clinics only were held. Two physicians, one nurse, one start taking an uninterrupted walk of 2 mi daily registered nursing assistant and a secretary attended immediately after the first injection and to continue each injection session. doing so throughout their treatment and afterwards. Quill and Fegan8 suggested that compression- Study methods sclerotherapy, by obliterating incompetent veins in the lower leg, could sometimes lead to the resolution of We reviewed the records at the clinic for the 2-year more proximal varicosities. Although this seemed to period from its opening in 1975 to 1977 to ascertain the occur in a few of our patients, we found it necessary to number of patients treated, the type of treatment given, perform limited ligation of veins at the saphenofemoral the average number of visits per patient and the average junction- and other sites in some patients. This was number of injections in those receiving sclerotherapy. We then contacted all patients for whom at least 2 usually a day-care procedure, for which patients were given a local anesthetic. For a few patients the opera- years had passed since their treatment had been comtion involved limited stripping of some segments, but pleted. These patients either came to the clinic for an this was done as seldom as possible. interview and examination or completed a questionnaire For safe and adequate compression the bandages to assess the results of treatment, the recurrence of must be applied with considerable skill. From experi- varicosities, the occurrence of complications, the paence we learned to adapt the technique to individual tients' opinions of the results of their treatment and the anatomic and pathologic characteristics and even to the patients' preferences should further treatment be necesquality of tissue in the legs. sary. The patients who came to the clinic for assessment were interviewed and examined by one observer who was not associated with the Belleville clinic in any way. Clinic organization We did not attempt to use a double-blind study design Each of the four examination rooms in our clinic as we felt this method would be impractical in a small contained a short couch with a special two-step stool community hospital. The costs of treating patients with varicose veins by and an adjustable light so that the clinician could readily assess patients' legs whether they were standing, surgical methods in a hospital were estimated, and sitting or lying down. The clinic staff used record forms compared with those incurred in treating patients by designed to reduce paper work and yet maintain safety compression-sclerotherapy in the clinic.

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FIG. 2 While patient's leg is raised (A) injection is given slowly, (B) pressure pad is applied before needle is removed, (C) leg is firmly bandaged and (D) stocking is apphied to keep pads and bandages in place. 924

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Results and comments Of 696 patients referred to the clinic during the period studied 158 (23%) did not receive treatment at our clinic because we found that their symptoms were not related to varicose disease. Of the 538 (77%) selected for treatment 98% had significant varices and 1% had minimal varices, while 1% showed evidence of deep venous insufficiency. Although 85% of the patients underwent compression-sclerotherapy only, 11% also had, at the clinic, limited ligation of veins that were deeper or more proximal or both, and 4% received only the surgical procedure because the location and depth of the incompetent veins would have made it difficult to apply adequate compression. The type and number of treatments given are shown in Table I. Of the 412 patients asked to participate in the follow-up 2 or more years after their treatment 243 (59%) came to the clinic for examination. Questionnaires were sent to another 98, of whom 52 (53%) responded. Thus, 295 patients were assessed either by personal interview (82%) or by questionnaire (18%); however, as the responses obtained by these two methods were not directly comparable, we analysed those of the 243 interviewed patients only. At the time of treatment the patients' ages ranged from 19 to 81 years, with a mean of 53 years. There were approximately four times as many women as men. A minority of patients (27%) were relatively inactive, but this reflected their greater age rather than problems with their varicosities. For the 112 patients employed outside the home the amount of time off work necessitated by treatment is shown in Table II. Of the interviewed patients 24 had large residual varicosities 2 years or more after treatment (Table III) and 13 needed further treatment, all of them returning to the clinic for it; compression-sclerotherapy alone was Table I-Treatment of varicose veins at the clinic

Compression-sclerotherapy

Measure

No. (and %) of patients

No. of visits Mean no. of visits per patient Reason for visits (%) Injection and bandaging

Rebandaging after injecton 43 Reassessment only No. of injections Mean no. of injections per injected patient

Alone

460 (85)

With limited surgical ligation

57 (11)

Limited surgical ligation alone

21 (4)

2162 4.7

388 6.8

23 1.1

28 30 1321

-

-

2.9

-

244

4.3

used in all but 1 of the 13. Of the patients who had received compression-sclerotherapy 90% claimed to have worn the bandages as prescribed, though 36% reported having had mild skin problems, such as blisters from bandage friction. The only other complication of any importance was superficial but limited phlebitis in 7%. One patient had had extensive superficial thrombophlebitis, probably due to inadequate or uneven pressure because of faulty bandaging; there had been no evidence of deep venous thrombosis. A few patients had suffered a skin rash that might have been a minor allergic reaction. There were occasional complaints of chest pain, but investigations for pulmonary embolism had given negative results. None of the patients had suffered an anaphylactic reaction to the sclerosant. Nearly all the patients (96%) reported they had taken a daily walk during treatment, as directed; 79% had found it enjoyable and 58% claimed to have continued to walk regularly after their treatment was finished. The general physical benefits to patients of regular outdoor exercise was apparent to the clinicians. When asked about the effects of the weather on the comfort of the bandages as well as on taking exercise, 68% of the women commented on the problems of hot weather and agreed with the decision not to give treatment during July and August. The remainder of the patients had divided opinions on the effects of the weather. Most of the patients said that their legs now felt normal or improved (84%) and looked better (81%) (Table IV). The seriousness of the reported symptoms was not always related to the size of the varicosities. Aside from reactions in individual patients, symptoms are related to the degree of venous stasis or to the magnitude of the increase in venous pressure and how efficiently the abnormality is compensated for. The amount of compensation is related to such factors as the extent of development of the venous (muscular) "pumps", the size, number and sites of incompetent perforating veins, general cardiovascular efficiency, obesity, hormonal environment, lifestyle and heredity. Since few of these factors can be completely controlled, the aim of our treatment was to improve venous return as much as possible (rarely to 100%) by using the simplest and safest method available, and by giving the patient careful, simple and realistic advice. Patients are less likely to be concerned about residual signs and symptoms when their expectations are realistic. The Table Ill-Residual varicosities among all 243 patients interviewed

% of patients 6 27 57 10

Residual varicosities None Small Medium Large

Table IV-Patients' opinions on the results 2 years after treatment

Question How do your legs feel now? How do your legs bok now?

Normal 28 7

Opinion; % of patients Improved Unchanged Worse 56 74

12 13

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least satisfactory results are likely to be reported by those whose concerns about their legs are largely cosmetic. As a further measure of our patients' assessment of the results of treatment, we obtained their preferences for future treatment of varicosities, should it become necessary. Nearly three quarters chose compressionsclerotherapy (Table V). A final measure that could be interpreted as an index of patient satisfaction with treatment was the extent to which patients were willing to travel to the clinic. Although many of the patients lived in the Belleville area, 31% had to travel 16 to 80 km and 15% more than 80km.

The average saving of outpatient compression-scierotherapy was $1460.19 per patient. The length of the average hospital stay that we used for our estimates reflects that data were included on patients with complications, such as ulcerations for which the treatment was bed rest. Even if we base our estimates on an assumed average stay for uncomplicated surgery of 4 days, the cost differences are still significant. These cost estimates are comparable to those reported by centres in Europe and elsewhere in Canada.20'2' Since the need for economy in health care delivery is generally recognized, this obvious cost difference is important, even though the figures may vary with individual patients, physicians and hospitals.

Costs Conclusions

During the first 5 years of operation of the clinic 1070 new patients were referred, an average of 214 patients per year. Representative annual costs of operating the clinic (for the year ending in March 1980) are given in Table VI. The costs of treating varicosities by an inpatient surgical procedure vary greatly with local conditions and practices. At Belleville in the year ending March 1980, 32 patients underwent surgery for varicose veins. These patients stayed in hospital an average of 8.7 days, at a cost of $156 a day, for an average total cost of $1357.20, as compared with $63.14 per clinic patient. Professional fees vary with the type of treatment and practice. However, if we assume that the average clinic patient had a consultation, 3.7 visits and 3.9 injections, and that 15% had outpatient surgery, whereas the average hospital inpatient undergoing surgery had multiple ligations and stripping, general anesthesia for 11/2 hours and the care of a surgical assistant as well as the surgeon, the professional fees would be $90.96 and $257.80 respectively. Combining these averages we estimate that in 1980 the management of varicose veins in the outpatient clinic cost $154.10 per patient, whereas surgical management in hospital cost $1615, or more than 10 times as much. Table V-Patients' choice of method should further treatment be required Choice Compression-sclerotherapy Surgery No strong preference .treatment

$ of patients 73 7 13 7

Table VI-Clinic expenses for the year ending in March 1980 Item Staff salaries (2 half days weekly) Staff fringe benefits (15$) Rental of clinic rooms Telephone Medical and surgical supplies Drugs Miscellaneous Total Cost per patient* Calculated from the average yearly number of patients referred (214). 926

Cost ($) 4595.83 689.37 4296.24 80.00 2913.23 836.93 100.40 13512.00 63.14 to the clinic

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There was a good response to the establishment of this clinic by referring physicians and an enthusiastic response by clinic staff and patients. Most patients felt better or improved, seemed to have benefited from regular exercise, and enjoyed the routine. They agreed that outpatient therapy was preferable and were glad to avoid admission to hospital. The principles of compression-sclerotherapy appear sound in the light of present knowledge of venous hemodynamics. Treatment should be tailored to the individual patient's needs. About 15% of patients may require supplementary minor surgery, but it can be done on an outpatient basis in most cases. A few may still require conventional surgical treatment. The classic method of radical vein stripping would have been irrational for many of our patients, since the origin of the venous stasis was not the main trunk of the long or short saphenous vein. Moreover, the preservation of normal saphenous veins appears to be increasingly important in view of their use in arterial grafting. Major complications from compression-sclerotherapy were almost absent in our patients. The costs of compression-sclerotherapy are a fraction of those of conventional inpatient surgery. Extension of the practice of compression-sclerotherapy appears to be worth while for the majority of selected patients. The technique should be performed in a purpose-specific clinic associated with an active treatment hospital by personnel experienced and skilled in the methods. We acknowledge the invaluable assistance of the Physicians' Services Incorporated Foundation, which granted funds for the pilot project, as well as the board of governors, the executive director and the staff of Belleville General Hospital, and the Belleville General Hospital Foundation, which granted funds for the survey. We thank the staff of the clinic. References 1. DORAN FSA: A clinical trial deaigned to diacover if the primary treatment of varicose veins ahould be by Fegana method or by an operation. Br J Swg 1975; 62: 72-76 2. The treatment of varicoaeveina (E). Lancet 1975; 2:311-312 3. Tailored treatment for varicoae veins (E). Br Med J 1975; 1: 593-594 4. FEGAN wG: Continuoua uninterrupted compreaaion technique of injecting varicoae veina. Proc R Soc Med 1960; 53: 837-840 5. FEGAN WG. KLINE AL: The cauae of varicoaity in superficial veins of the lower limb. BrJSsirg 1972; 59: 798-801 6. FEGAN wG: Conservative treatment of varicose veins. Prog Surg 1973; 11: 37-45 7. HOBBS iT: Surgery and aclerotherapy in the treatment of varicose veins. A random trial. Arch Surg 1974; 109: 793-796 8. QUILL RD. FEGAN wG: Reversibility of femorosaphenoua reflux. Br J Surg 1971; 58: 389-392

9. BASS! G: Sur Ia role de la m6tbode scl6rosante dsns Ic traitement des varices. Phlebologue 1974; 27: 71-75 10. SUCHY T, RECEK C: Resultats du traitement ambulatoire des varices. Phlebologie 1979; 32: 415-419 11. WALLOIS P: Indications Ct techniques de Is sclbrose des varices. Phiebologie 1978; 31: 455-466

12. Idem: Ls scl6rose des varices restantes aprbs intervention chirurgicsle. Ibid: 467-468 13. ALEKSEEV PP, BAGDASAR'IAN VS. KOVALEVA AG: Varicose disease of the veins of the lower extremities: surgery or aclerotherapy? Sow Med J 1974; 10: 56-60 14. AFTAKOY EN: Advantages and disadvantages of aclerotherapy. Ibid: 60-63 15. POLUBUDKIN MS: Prevention of errors and complications in treating varicose veins of

the lower extremities. Vestis Khir 1980; 124: 62-66

16. CRANE C: The surgery of varicose veins. Surg Clun North Am 1979; 59: 737-748 17. CONRAD P: Continuous compression technique of injecting varicose veins. Med J As,st 1967; 1:1011-1014 18. COLE DS: The society for the preservation of the saphenous vein (SPSV). NZ Med J 1973; 77: 127 19. SLADEN JG: Compression sclerotherspy, techniques, complications and results. Presented at annual mecting of the Royal College of Physicians and Surgeons of Canada, Sept 18, 1981, Toronto 20. PIACHAUD D, WEDDELL JM: The economics of tressing varicose veins. ml J Epidemiol 1972; 1:287 21. Idem: Cost of treating varicose veins. Lancet 1972; 2:1191-1192

Drug addiction among Quebec physicians HUBERT WALLOT, * MD, FRCP[C] JEAN LAMBERT,I PH D

Data collected by the Quebec Board of Physicians show that during the 5 years from 1974 to 1978 the prevalence of addiction to opiates among Quebec physicians was 2.8/1000. The physician addicts had greater mobility and a higher attrition rate than their peers. The typical addict was male, a general practitioner and married. He often suffered from pain, fatigue, overwork, and financial and marital difficulties. His addiction had begun at approximately 35 years of age and had become evident about 31/2 years later. Meperidine was the preferred opiate. Some of the physicians lost their licences to practise for variable periods of time; for these the prognosis was gloomy. Depression was the main psychiatric disorder diagnosed. Les donnbes recueillies aupr.s de l'Ordre des m6decins du QuAbec r6v4lent que durant les 5 ann6es 4coulbes entre 1974 et 1978 Ia pr6valence de Ia toxicomanie aux opiacbs parmi les m6decins qubbbcois a 6t6 de 2.8/1000. Les m.decins toxicomanes avaient une plus grande mobilitb et un plus haut taux d'abandon de Ia pratique que leurs confr.res. Le toxicomane type est de sexe masculin, omnipraticien et mari4. II a souvent des probl.mes de douleur, de fatigue et de surcharge de travail; il rencontre des difficult4s financi.res et maritales. Sa toxicomanie est apparue vers l'Ige de 35 ans et elle est devenue Avidente 31/2 ans plus tard. La m6pbridine est l'opiac6 prbf6rb. Quelques mbclecins ont vu leur permis de pratique suspendu pour une pbriode de temps variable; pour eux, le pronostic s'av.re sombre. Le principal diagnostic psychiatrique est celui de dbpression. *Psychiatrist, h6pital Robert Giffard, Beauport, PQ and professor, universit6 du Quebec, Chicoutimi, PQ t Assistant professor, d6partement de m6decine sociale et pr6ventive, universit6 de Montr6al Reprint requests to: Dr Hubert Wallot, Universit6 du Qu6bec, Chicoutimi, PQ G7H 2B1

In this article we present the results of an epidemiologic study of drug addiction among physicians in Quebec, comparing the data obtained with similar data on American physicians, assess the significance of previous published clinical observations on Quebec physicians with this problem, and challenge some existing views about drug addiction among physicians in general. Methods Arrangements wer.. made with the Quebec Board of Physicians to obtain anonymous information from the records of all physicians known by the board to have been "actively" addicted to opiates as well as other drugs at any time during the 5-year period 1974-78. Included in this group were those who were not considered fully recovered even though they might have completely stopped using drugs. We obtained data on 37 physicians who were considered to have been "active" drug addicts during that period. Data on a physician who had also been an addict but who died during the study period were also included in the analysis of the characteristics of physician addicts. Both the quantity and the quality of information were variable. The records for some physicians included data from two or even three psychiatric assessments, reflecting that since 1974 the Quebec Board of Physicians has had the power to impose a medical and psychiatric examination on any physician whose ability to provide proper health care is in doubt, and in situations in which the board expects such examinations to yield useful information. In most instances the board requests such examinations on the basis of information it receives from the bureau of dangerous drugs (drug directorate, health protection branch) of the Department of National Health and Welfare, which keeps detailed records of narcotics prescriptions and purchases. However, as physicians already known to be addicts are not examined, comparable data were not available for all our subjects. For those physicians on whom psychiatric CMA JOURNAL/APRIL 15, 1982/VOL. 126

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