Vein Disease Management for Arterial Surgeons: A Waste of Time?

The management of vascular diseases traditionally encompasses the diagnosis and treatment of arterial, venous, and lymphatic disorders. Indeed, these principles are incorporated into the original mission statement of The Society of Vascular Surgery,¹ while standard textbooks of vascular surgery or diseases include venous and lymphatic disorders, along with arterial disease. For most vascular surgeons, however, the diagnosis and treatment of arterial occlusive and aneurysmal disease is their principal focus for many reasons. They are, in essence, arterial surgeons, who, by definition, only apply to a segment of a vascular surgeon’s potential patient population. Does the management of venous disease possess the same challenges that draw physicians to the management of arterial occlusive disease? Should the treatment of venous disease, particularly in its chronic form, play a minor or a major role in a vascular surgeon’s practice? Most physicians have chosen a career in vascular surgery because of the unique technical challenges inherent in treatment, either by an open or endovascular interventions. In contrast to cardiac surgeons, vascular surgeons provide the diagnostic work-up of the vascular problem and select the most appropriate treatment from many options. Since there usually is no pat answer for many vascular problems, this intellectual process can be quite satisfying. The goal of vascular treatment is to save limbs and save lives, which is also rewarding to physicians. Although compensation for vascular surgeons is declining in relationship to effort expended, it is considered reasonable. These facts also hold true for the management of venous disease.

Atmospheric conditions. Arterial surgery has changed in the last 10 years. There is less traditional “open” surgery and more catheter-based procedures performed by vascular surgeons, particularly for infrainguinal disease. The shift to endovascular techniques is not without its adverse consequences for the vascular surgeon. Now, we face more competition from other specialties, such as cardiology and interventional radiology, because they possess these important catheter skills. In addition, cardiologists have the captive patient population with atherosclerotic disease. Finally, for vascular surgeons, there has been a progressive downward spiral of reimbursement for arterial procedures.²

While the treatment of arterial disease has changed, so has the treatment of venous disease. The questions are — is it for the better and is it reasonable to devote more time to it? Like many older vascular surgeons, my career has seen a tectonic shift in the management of vascular disease, and particularly venous disease. When I was a senior lecturer over 30 years ago at St. Thomas’ Hospital in London, an institution noted for its treatment of venous and lymphatic disease, there were two operations available for patients with chronic venous insufficiency: (1) ligation and stripping of the great saphenous vein and (2) subfascial ligation of incompetent perforating veins.³ Venous procedures were usually relegated to the most junior of the house staff. As a vascular fellow at the Massachusetts General Hospital in 1975, where the late Robert Linton developed an open procedure for the management of incompetent perforating veins,⁴ venous procedures were usually considered secondary and sometimes left to a Saturday list. The management of venous disease has changed, and this has led to an increase in the volume of venous procedures. Due to my training in the management of venous disease at St. Thomas’ in London and subsequent publications, I have had a strong venous referral practice over the last 30 years, particularly of more advanced cases from other vascular or general surgeons. The adoption of endovenous ablation techniques has increased the volume of more “straightforward cases” (CEAP 2 and 3) in our group, while this less invasive approach has facilitated acceptance of the surgical approach in the prevention of recurrent venous ulcer by our patients. We have seen a 30% growth in our already busy venous practice as a result of endovenous techniques and I now maintain a suburban office/“vein center” for office-based procedures.

Why Has Venous Surgery Increased So Much Over the Last Five to Six Years?

Perhaps the most influential factor is related to a basic tenet of medical care that improved medical technology drives utilization of certain procedures? Is this increased interest in venous disease similar to what has occurred in the management of arterial disease, occlusive and aneurysmal disease? Like arterial disease, endovascular techniques have revolutionized the management of venous disease. This has led to a tectonic shift in patient selection and therapy for the treatment of venous disease, particularly varicose veins. The reason for the increase in venous surgery is not restricted to better and less invasive technology, but also is related to refinements and standardization in diagnostic imaging techniques, especially duplex scanning. These techniques have identified a greater proportion of the patient population who will require treatment for venous disorders.

Economic factors. In addition, economics have influenced the increase in the treatment of venous disease, particularly through improved reimbursement for the most common venous disorder — varicose veins. Payers have driven an increase in procedure volume by differentially rewarding physicians who shift the site of these procedures to a non hospital-based setting (i.e., their office). Payers have obviously understood that it is more economical for them to provide treatment of saphenous disease in an office-based setting in contrast to a hospital-based setting or an ambulatory operating room. This setting lowers overhead, personnel costs and anesthesia costs. Professionals might be compensated $400–500 for an endovenous procedure (a professional fee comparable to that provided for ligation and stripping), if it is performed in an outpatient operating room or surgi-center. By contrast, if the procedure is carried out in an office site, the reimbursement is on a global basis. Dependent upon the overhead, capital cost of the duplex machine, catheter costs, other disposables, and personnel costs (assistant and/or ultrasound technician), the physician stands to net 2 to 3 times the fee of a hospital-based procedure.

Given the economic/reimbursement strategies of most payers, endovenous ablation becomes an office-based practice. The solution for the vascular surgeons is to move the majority of their venous practice into an office, which avoids conflicts over capital allocation, personnel, and operating room availability encountered in the hospital environment. In an office-based practice, the vascular surgeon has the advantage of totally controlling the operation and managing throughput better, both of which usually result in greater procedural volume. Reimbursement, therefore, can be maximized. Moreover, an office practice is, in general, a warmer, more patient friendly environment. The significant costs of dedicated equipment and personnel for these procedures can be a barrier for adoption of these minimally invasive procedures. Endovenous procedures, however, can be a turnkey operation. There are a number of companies that provide the ultrasound technologist, the ultrasound equipment, and the kits to perform the procedure, so that all the surgeon has to provide is the office space. Although the margin of the individual procedure in the turnkey arrangement is less than if the vascular surgeon owned the equipment, performing four to five procedures in a day is associated with a reasonable compensation.

Competition. Vascular surgeons are not the only physician specialties performing venous procedures. Like the situation in the management of arterial disease by catheter-based techniques, this shift in the technology has facilitated cross-specialty participation. Interventional radiologists, cardiologists, dermatologists, and obstetrician/gynecologists can perform endovenous procedures. Finally, patient awareness of less invasive techniques for the management of venous disease, particularly varicose veins, has made a majority of these patient-driven procedures.

While endovenous ablation has rapidly displaced standard ligation and stripping for varicose veins in most areas of the United States, other minimally invasive techniques have become more refined. Subfascial endoscopic perforating vein surgery (SEPS) has matured, and its application has become more selective. Reimbursement is adequate. Sclerotherapy and its variations have reemerged and are being touted as an across-the-board solution for chronic venous insufficiency. For example, foam sclerotherapy has been proposed as a rival technique for both endovenous ablation of saphenous veins and for the management of incompetent perforating veins.5 Sclerotherapy, however, does not carry the same degree of excitement for a vascular surgeon that an open or endovascular aneurysm procedure provides. Moreover, the mechanism of reimbursement for sclerotherapy with patient self-pay is foreign to most vascular surgeons.

Evidence for the Increase in the Treatment of Saphenous Vein Disease in the United States

The number of ligation and stripping procedures has decreased from 155,000 to 50,000 from 1999 to 2006, while the total number of endovenous procedures has increased from 1000 in 1999 to nearly 150,000 in 2006 — at which time those procedures were 3 times the number of ligation and stripping operations. In 2006, more endovenous laser procedures were performed than endovenous radiofrequency procedures. The availability of a radiofrequency catheter, which ablates the saphenous vein in the same amount of time as a laser catheter does, may have the potential for increasing the number of patients undergoing endovenous radiofrequency ablation. Obviously, adoption of this catheter type is dependent on long-term results with both low recanalization and morbidity rates, particularly thrombotic complications.

Management of incompetent perforating veins. Minimally invasive treatment of incompetent perforating veins has been available for 15 years, employing the laparoscopic approach and laparoscopic instruments.6 Techniques that used standard surgical instruments and mediastinoscopes had been employed several years earlier than when we developed the laparoscopic approach for ligation of incompetent perforating veins.⁷ The laparoscopic approach, which employs both a viewing and a working scope, has been a valuable technique for the management of advanced chronic venous insufficiency (i.e., CEAP clinical classification C4 through C6). While a recent randomized controlled trial failed to show an overall advantage in ulcer-free survival for the SEPS group as a whole, when compared to elastic compression, patients with large or recurrent ulcers did better with SEPS than with compression.⁸ Direct approaches to incompetent perforating veins, which use sclerotherapy has enjoyed success, and there is a flurry of interest in radiofrequency or laser-based endovenous approaches under duplex guidance.⁹ Success rates vary, however, and very little long-term data are available for these later techniques. Moreover, no randomized controlled trials have been conducted to examine the validity of direct endovenous perforator techniques. Certainly, a compelling financial reason for choosing the endovascular approach is related to current physician reimbursement, which appears to allow cost per treatment (CPT) coding of ablation of incompetent perforating veins by the same CPT code that is employed for the endovenous ablation of the great saphenous vein. Moreover, the procedure can be done locally in a physician’s office.

Management of spider veins. To a vascular surgeon the cosmetic treatment of spider veins appears a long way from the challenges of a ruptured abdominal aortic aneurysm. This area has been the general purview of dermatologists or plastic surgeons, but more vascular surgeons who participate in the management of venous disease through necessity have become skilled in this procedure. Vascular surgeons also possess the necessary hand-eye micro techniques for this procedure. While laser has been used for spider veins, the maxim that “anything you can get a needle into is probably best treated by sclerotherapy” holds. Again, third-party Payers do not generally compensate for this treatment, and the procedure is therefore patient self-pay. The physician-patient relationship appears different in this setting, and may be foreign to the vascular surgeon. Despite this, there are powerful economic incentives when reimbursement of sclerotherapy per unit of time is compared to standard reimbursement of some major arterial procedures.

Negatives to venous surgery. Certainly, any vascular fellow has perceived a certain attitude toward physicians who perform venous surgery — it is just not “macho” compared to carrying out arterial surgery. In the past, vascular surgeons feared that a “halo” effect from performing a high volume of venous procedures might label a vascular surgeon as a venous surgeon only, and potentially decrease arterial referrals. This criticism is less frequent today, as more vascular practice groups have realized that based on the economic benefits alone, they should do venous surgery. Endovascular ablation of saphenous reflux rather than ligation and stripping becomes a disadvantage, because it encourages participation from competitive specialties and provides access to this patient population that was generally restricted to vascular surgeons. This competition can be significant and may dictate direct marketing to patients in order to preserve procedural volume.

Positives to the practice of venous surgery. In my 35 years of experience, patients are quite grateful after the treatment of their venous disease. I have received more spontaneous gifts from venous patients than I have from patients undergoing arterial procedures. Since venous surgery is elective and morbidity is usually low, emergencies are rare, as are calls in the middle of the night. Current reimbursement is good for venous procedures and a venous practice provides a unique practice-building opportunity for the entire vascular practice. While the number of venous surgery publications has increased in the last decade, there are a few well-conducted randomized controlled trials which validate the surgical treatment of chronic venous insufficiency. Certainly, the chronic venous ulceration alone versus compression plus surgery in long-term results of compression therapy (ESCHAR) trial stands as an exception to this finding.¹⁰ This trial validated the superiority of surgical treatment of great saphenous vein reflux for C5/6 disease in the prevention of ulcer recurrence over compression. Obviously, clinicians may extend the findings from this open technique to endovenous ablation of the great saphenous vein, but is that appropriate? The previously mentioned Dutch SEPS trial also provided clarification of the indications for SEPS. More trials are needed to prove the efficacy of sclerotherapy versus endovenous ablation of incompetent perforating veins. EBM should stand for evidenced-based medicine not ego-based medicine.

Summary

Why is there an increase in venous surgery and why should an arterial surgeon be interested in this area of vascular disease? The increase in venous surgery is due to a combination of many factors, producing the “perfect storm”: (1) high prevalence of the disease state; (2) a non-invasive imaging technique that is universal in availability — duplex ultrasound; (3) a new catheter-based procedure that can be carried out in the office; and (4) reasonable reimbursement for the time expended. Venous “surgery” has increased for many physicians and may be a part of or the majority of vascular surgeons’ practice. The current economics of physician reimbursement makes it difficult for a vascular practice to ignore the treatment of venous disease. Moreover, this area of vascular disease may be an ideal for a surgeon, particularly in his/her later years. Competition, however, dictates marketing, and in the end, vascular surgeons are the only physicians that can provide full service for all forms of venous disease.