NICE - NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE

NICE Guidelines on Varicose Veins in the legs were published in July 2013 and a Management Pathway in Aug 2014. Although long overdue we are pleased that at last the Endovenous Laser techniques Veincentre introduced to the UK over 10 years ago have been officially recognized as the treatment of choice for varicose veins.

Veincentre was the first company in the UK to be established specifically to provide Endovenous Laser (we were ahead of the game and those who started with RF have mostly now moved over to Laser). It is a shame though that these NICE guidelines are still largely being ignored by the NHS and indeed some insurance companies who have the nerve to include advice on their website on how best to manage varicose veins but have a general policy of refusal to pay for recommended treatment!
Aviva Solutions policy update April 2013 & Varicose vein treatment is now non-invasive

The guidance by NICE established 3 key recommendations:

1. All patients with Varicose Veins and Symptoms should be referred to a Vascular Service.
   
   
2. Assessment should include full Colour Duplex Ultrasound scanning
   
   
3. Treatment should be by Endovenous Thermal Ablation and if this not possible or required Foam Sclerotherapy. Surgery should only be undertaken if both these fail. 
   In expert experienced hands surgery is in fact never required.

Veincentre has been doing all this for the last decade.

NICE defines a vascular service as “a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and provide a full range of treatment.” This is precisely what we have at Veincentre. We, as of Oct 2014, have a total of 9 consultants with a specific vein interest and 4 specialist nurses supported by an experienced team of managers, healthcare assistants, and admin assistants. See the full Veincentre Team. We are careful to appoint a good mix of Interventional Radiologists and Vascular Surgeons who complement each other’s skills.

All our consultants and some of our nurses are highly skilled in Colour Duplex Ultrasound Scanning. This is an essential part of the patient’s assessment in order to define exactly what is causing the problem and determine what treatment is required and precisely where.

We have seen rather disparaging and misleading comments by another company claiming that doctors are not capable of undertaking quality Duplex Ultrasound assessment! This is arrant nonsense and must be challenged.

Vascular Interventional Radiologists have extensive experience throughout their training in Duplex Ultrasound and historically undertook all such diagnostic scanning. As demand for these procedures increased the radiologists started training technicians (sonographers) to undertake these scans and most ultrasound scanning departments are still led by a consultant radiologist. To suggest that the vascular radiologists are somehow less skilled than the sonographers they trained to help with the increasing workload is ridiculous. (This is not to knock the sonographers, who do a fine job, but to expose the spin from those who did not possess the necessary skills and relied totally on sonographers undertaking the scanning, and who now try to claim that use of sonographers is the gold standard and doctors cannot perform their own scans).

The truth lies elsewhere. Surgeons who wanted to undertake Endovenous Ablation had no training in ultrasound and were forced to rely on the sonographers or radiologists to undertake the scanning for them; and many still do. This is not the best way to plan treatment. In our view it is far better for the person undertaking the treatment to also undertake the scan so that they have a perfect picture in their head of what the scan shows. To rely on a written report from a third person to plan treatment is less than ideal. Judgments need to be made as to the relevance of what is detected on the scan. To treat all abnormalities that a sonographer may detect without assessing their importance and relevance to the condition the patient is complaining of will lead to unnecessary overtreatment. Following such a policy may be great for the finances of a company, but is certainly not in the best interests of the patient’s health, comfort or bank balance.

Fortunately most doctors, be they surgeons or radiologists, who undertake Endovenous treatments in the UK now do perform their own scans and are perfectly capable of so doing.

The involvement of sonographers gets more intriguing! Some doctors without a natural background in ultrasound scanning and its use in guiding interventions also use sonographers to guide them during the procedures. The sonographer holds the ultrasound probe and the surgeon places the needle. This is not only highly inefficient (two persons rather than one to do one task) but also illogical. One brain operating two hands (right hand with the needle left hand with the ultrasound probe) is, in our opinion, far better than two brains operating two different persons’ hands! The latter is what a well publicized trademarked “protocol™” advocates. Another reason why it costs a fortune!