Like many other industries, the shape of healthcare and medicine is being transformed by the emergence of new technologies. Phlebology, as Anelise Rodrigues (Culabá, Brazil) explains, is no different. While there are still concerns with the potential limitations and complications of implementing a new system for treating veins—addressed by Rodrigues in her article—augmented reality (AR) could also represent the future for venous specialists.
In this modern age, technology has become so intertwined with our own lives that we no longer notice how embedded it is in our day-to-day activities. Furthermore, it is accepted that in just a few years, many of today’s jobs will not even exist. When it comes to medicine, the situation is no different; each day there is something new going on, and to row against the stream does not seem to be the best way of navigating the waves of technological change.
My father is a vascular surgeon, and when I was a child I would go to his office after school. I remember being amazed when he would pinch what I would see as pure skin, and all of a sudden those small purple veins would vanish. Sometimes he would miss one spot or another, but in the end the results were very good.
I grew up and became a vascular surgeon myself, and as easy as it was for me to get the needle inside small purple veins, getting to the feeder veins (especially when treating patients with darker skin) was not so easy. The phleboscope came to help me with the struggle of puncturing and marking those hidden veins only he could see, and together with white skin markers it was the top tool of my practice for some time.
Some years later, when I was first introduced to AR in a visit to the Vascular Institute of New York (New York, USA), I kind of hated it; the imaging was different from what I used to get from the phleboscope, and I lost punctures of veins I could see with my naked eye. I was then pretty sure that this “new device” was not useful at all and went back to my comfort zone. After becoming accustomed to it though, during a fellowship at Clinica Miyake (Sao Paulo, Brazil), I knew that I could not run from AR anymore.
It took some work to finally be able to correlate the AR image with the location, size and deepness of the vessels. In the very beginning, before each puncture, I would double check the vein with the phleboscope, and even with an ultrasound, to correlate the AR images to those I was already familiar with. After a while, and with a bit of practice, I realised how amazing it could be.
In 2006, Kasuo Miyake et al published an article entitled “Vein imaging: a new method of near infrared imaging, where a processed image is projected onto the skin for the enhancement of vein treatment,” describing the use of AR for vein treatment. Since that first publication, many improvements have arrived and the tool has been incorporated as part of many phlebologists’ daily routine.
When the work was published in 2006, it was proven that AR could identify veins that were invisible to the naked eye and too shallow for ultrasound detection—in other words, it could easily identify hidden feeder veins. Today, some high frequency US transducers can also identify and measure those veins. The AR devices emit a near infrared light, which is absorbed by the blood and reflected by adjacent tissues. The information is captured, processed and projected onto the skin surface in real time.
Real time imaging is especially useful when performing transdermal laser and CLaCS (Cryo-Laser Cryo-Sclerotherapy). It allows us to observe the vessel’s immediate response, its spasm, and the effectiveness—or not—of our laser settings, and helps us to find the best spot for puncture after lasing, even on darker skin. Moreover, the technology allows us to always select the best projection colour for each skin tone, ensuring that we can see the image in all patients.
There are a few AR devices available, but the better the equipment, the faster its image processing and lesser the parallax effect (the difference we find between the vein’s real position and the projection we get from the device onto the skin). Nevertheless, there are a few easy tricks for punctures, such as aligning the needle image to the vein image, which help us to overcome this drawback.
Some of the main advantages of AR compared to the phleboscope are the possibility of having both our hands free, a larger visual field for treatment and, in addition to these aspects, the fact that it does not get in contact with the skin. That last part is particularly useful when performing sclerotherapy or any procedures that involve vein puncture, where contact with the skin may result in blood contaminating our equipment.
As AR devices are able to show us virtually every reticular vein on patients’ legs, a huge concern among many phlebologists is the unadvised sclerosant injection in normal veins. We have to be reasonable and keep in mind that we cannot inject everything we see, but only the unhealthy veins. To know which veins to treat, we must focus on identifying tortuous veins and feeder veins that might act as sources of the patient’s complaints. Also, you should check the direction of the blood flow of the veins connected to a telangiectasia, thus avoiding drainage veins, while the use of a high-frequency ultrasound is a helpful tool when in doubt. Ultimately, we must know the pathologies we are willing to treat before we do so.
Apart from that which we have already mentioned, patients tend to be very fond of new technologies, and most of them find this imaging amazing, not to mention that every patient (including ourselves) prefers to get their veins catheterised with a single puncture instead of several of them. Suffice to say, happy patients spread the word.
When we talk about implementing new technologies in our practices, the first thoughts we come up with are always the same: “It is too expensive” or “I don’t need to spend so much money on this.” We know that the available AR devices are not cheap. However, if we think of it as an investment that adds value and quality to our practice, and the profit it can bring to our businesses, then the scales will probably shift the other way.
Of course, when deciding whether or not to acquire and implement this technology, the focus of your practice and professional situation must always be taken into account. If you are a vascular surgeon whose main practice is arterial, then perhaps it is not the most appropriate tool to consider. That being said, for those who have thought or are thinking about having phlebology as their main activity, and are looking for the best aesthetic outcomes, I believe the use of AR is highly useful and, at some point, there will be no way to avoid this movement.
We all know that there are many ways of getting good results without AR; we have practiced this way for many years and continue to do so. Nevertheless, we cannot deny all of the developments we are facing; especially the fact that AR can facilitate and optimise our treatments, saving us precious time and helping us to avoid failures that could result from not treating hidden veins.
If it is essential or not may be more of a personal choice, based on each physician’s needs, patients, budgets, and also on the kind of results desired. Even though it may sound superfluous today, I really believe that in the near future every phlebologist will have at least one AR device to call “mine”.
Anelise Rodrigues is a vascular surgeon dedicated to the treatment of varicose veins. She graduated from Campinas State University (UNICAMP; Campinas, Brazil) in 2003 and has been a Brazilian Medical Association Certified vascular surgeon since 2008. Furthermore, Rodrigues is a member of the Brazilian Angiology and Vascular Surgery Society (SBACV) and American Venous Forum (AVF), as well as a former fellow at Barcelona University, Barcelona, Spain.
