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FOREWORD

Can We Still Perform Phlebology in an  Old Fashion Way?
Lecture
A. Scuderi
Chairman of 15th World Congress of Phlebology – RIO UIP 2005

Phlebology is a study practiced from immemorial times. A historical review on medicine practice shows that concern with vein diseases and their complications began when man learned how to stand in an erect position. According to one of today’s most important phlebology investigators, Glauco Bassi (Italy), one of the founders of the “Union Internationale de Phlebologie”, modern man, referred to as Homo Erectus, might as well be referred to as “Homo Phlebopaticus”.
Lymphatic and veins diseases have been the focus of most renowned physicians, from Hipocrates to the present date, passing by Galen, Avicena and other major important names.
Many modern techniques for treatment of varicose veins are, indeed, techniques that were updated from those previously mentioned ancient ones.
Knowledge upon venous return’s physiology began to be made clear from discovery by Hieronymus Fabricius d’Aquapendente of the anatomy of venous valves, in the 16th Century.
However, in ancient times, it took centuries until new theories were acknowledged, modified or contested.
This is why it took more than 1500 years until Ambroise Parré, called “Prince of Surgeons” (16th century), opposed to the Galenic theory (1st century AD), which prescribed that ulcers in the legs should not be cicatrized as such procedure would allow drain of “peccant humors”, or else the patient would be subject to death by “melancholy”.
It is quite common in our work to find patients with long-term leg ulcers who ask us about the possibility of dying should they cicatrize their ulceration!
A modality of treatment widely spread in ancient times was the “elastic compression”. It is quite evidenced that ancient roman soldiers used to wear linen bands as a means for relieving weighing-legs during forced long marches. Knowledge upon benefits of bandaging the inferior members was yet mentioned in bible texts of the Old Testament. Both, the Hippocratic and the Alexandria schools described in details the techniques and benefits of treatment with elastic and inelastic compressions for venous pathologies. It is worth mentioning that still nowadays elastic compression is one of the main forms prescribed for treatment of lymph and venous pathologies. The technique is adopted during all phases of treatment of the disease, many times being the only suitable form of treatment.
New modern technologies for the manufacturing of textile products allowed development of new products faced to the elastic, inelastic or partially inelastic/elastic-compressive treatment of venous ulcers known as “Unna’s Boot”, described by Paul Unna in 1885, in Hamburg. Thus, this worldly well-spread form of treatment is more than centenary. Up to the present date, despite one or two modifications, the principle for healing of ulcers remains the same.
Another very important form of treatment is the sclerotherapy. Described by the Hippocratic school, which employed red-hot iron to “sclerose”, “stiff”, “harden” and render useless the vein, this form of treatment was only considered as an acceptable modality from the time of Pravaz on (inventor of the syringe), and from the studies conducted by Raymond Tournay in France and Karl Sigg in Switzerland.
Some years ago, an endless discussion took place upon the best manner for treating varicose veins, whether sclerotherapy or surgery. Such discussion appeared to have come to an end when both schools (surgical and sclerotherapeutic) reached the conclusion that both schools were complimentary and non-competitive.
The new millennium was inaugurated with the remarkable 14th World Congress of Phlebology held in Rome in 2001. From that time, in a fantastic speed characteristic of our new times, some technologies were quickly incorporated to therapy and diagnosis of venous and lymphatic pathologies and the bases of said conclusion were broken. With introduction of “foam” and new chemical formulations for esclerosants, the Esclerotherapic School experienced a new drive reopening the debate on surgery versus sclerotherapy as the best means for treating great varicose dilatations.
Further, new modalities of treatment, not as new indeed, were reintroduced with technological improvements (Laser and other similar technologies such as Radio Frequency), proving their feasibility for treatment of both major and minor varicose veins.
All such process have developed on very quick bases in the past four years, to an extent that they occupy large spaces in scientific discussions, what can be confirmed at this 15th World Congress of Phlebology, in the laser matter occupies considerable part of our program.
Surgery for varicose veins, which stood alone as the best means for treatment of varicose veins, experienced significant improvements in the last years of the 20th Century. Esthetic Surgery, with tiny incincisions using hooks, was considered as a major revolution. Indeed, it is a revitalization of a millenary technique described by Galen for treatment of dilatation of the legs. using hooks. According to ancient Chinese writers, they also used hooks for removal of veins and hemorrhoids. Followers of this surgical technique are convinced that surgery is the best means for treatment of varicose veins.
Another technology revolutionized knowledge on physiology and diagnosis of veins diseases. Ultra-sonography with concomitant flow readings (duplex or triplex).
Modern technology allowed obtainment of accurate data and extraordinary images. From the time the first contrasting radiographic images were obtained many years ago by the Portuguese school of Cid dos Santos, there had never been such a significant advancement in such a short period of time in image-diagnosis of vascular pathologies in general, and particularly of varicose veins.
In addition, specialists began to better comprehend the images, improving exam techniques and rendering them more accurate and precise. Equipment manufacturers started a technological race in connection with who manufactures the best, smallest and more economic equipment. Very quickly, in just four years, such equipment carried along the definitive idea that Phlebology would no longer be the same. Equipment becomes obsolete in a short time, requiring permanent upgrades, what significantly increases the price of venous diseases treatments.
Further, a new specialization was created: the “Vascular Ultra-sonographist”.
Concomitantly, the same occurred with radiology, which not willing to be left behind in the race for better diagnosis solutions, had improvements on equipment and started developing a new and revolutionary technique called “Intervention Radiology”.
Utilization of special catheters, stents, “coils” and foam injections opened a new frontier in diagnosis of pathologies, which not too long ago could only be suspected and which at the present date, once definitely proved can be treated during the same procedure: pelvic and other venous pathologies of the Deep Venous System.
The latest, kept for a long time as a partially prohibited terrain (a quicksand) for surgery, is starting to consistently experience its handling by means of endovascular radiological techniques. It is true that it is still inaccessible to most part of vascular and phlebology surgeons, as it requires expensive equipment, especially trained personnel, whereas the results presented do not encourage all surgeons to face a delicate and unstable territory, with some extent of recurrences and complications. Nowadays, due to the hard work of some modern phlebologists, results of these procedures have consistently improved and encouraging the new phlebological generations.
We are talking about just four or five years of evolution!
Therefore, today discussions are returning only differing from the formers by the impressive increase in options: what is the best way to treat varicose veins? Surgery? Mini surgery? Foam Sclerotherapy? Conventional Sclerotherapy? Endovascular Laser light? Surface Laser light? Radio Frequency? And what about saphenous veins? Are they always the cause of varicose diseases? Or could their removal be the cause of recurrences? Should the Saphenous Femural Junction be disconnected to all its tributaries or would it be better to keep one or another inoffensive tributary? When is removal of the Great or Lesser Saphenous vein indicated? Should “stripping” of Saphenous veins be total? Radical distal? Proximal? Which criteria shall be observed?
It looks as if we have returned to a state of total confusion. What looked well-defined (surgery for major veins, sclerotherapy for telangiectasies, mini surgery for those more dilated veins, clinical treatment for deep venous pathologies) is once again controversial.
We had come to the point of asking ourselves: Can we still perform phlebology in an old fashion way?
New equipment seem to tell us: traditional medicine is obsolete and those who do not enter the new technological era will be left behind. Out of date. A real “angiossaur”, as many like to cite.
We observe worldwide that doctors, mainly the younger, no longer examine their patients. They limit themselves to requesting subsidiary exams such as the duplex scan and blindly trust the results of conclusions made by other colleagues.
They examine exams instead of examining the patient.
One of the most important characteristics of our profession is thus lost: our relationship with the patient. Physical contact during patient’s examination was replaced by high technologies.
In defense of their methods, those who prescribe Laser treatments point out bad results of surgeries, whereas surgeons point out bad results of Laser treatments. The same occurs between surgery and sclerotherapy, sclerotherapy and Laser treatment, Laser and radio-frequency, etc.
In the same way, some believe that the better way to heal ulcers is with boots and compressions, or with surgeries and treatment, or still, with the combination of all such procedures.
What to do in such a mess of techniques? Do as your experience recommends. Use common sense. Do not practice what you don’t command, or at least learn it well before beginning with new technologies. The more sophisticated is the equipment, greater will be the apprenticeship curve.
Be aware! Machines are likely to and shall domain us in the future! We are each time more dependant on technology.
It is frequently heard from renowned physicians: “I can no longer practice phlebology without a duplex”. We do not agree with such thesis.
One of phlebology’s most important characteristics is that it can be practiced with good results even without recurring to high technologies.
Undoubtedly, a good treatment for varicose diseases may be accomplished with a good anamnesis, along with an accurate and detailed physical examination. A good surgery, with esthetic refinements, or a sclerotherapy with excellent results may be achieved counting only on data from detailed anamnesis and physical examination.
Any medic who had gone through adequate training, residence or internship shall be apt to practice phlebology anywhere with excellent results, even with limited resources.
The “Union Internationale de Phlebologie” is strongly committed with habilitation and recycling of doctors with an interest in Phlebology.
We foresee a great future for Phlebology as a specialty.
In response to our initial question: Can we still perform Phlebology in an old fashion way?
Undoubtedly, the answer is yes.
All it takes is a good knowledge on venous physiology and pathologies, good training and m mainly, common sense. Examine your patients with care and dedication.
Success is guaranteed.

Angelo Scuderi
Chairman of 15th World Congress of Phlebology
 

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