“When we are talking about varicose veins, we are talking about patients, all of whom have different patterns of varicose veins,” stated Armando Mansilha (University of Porto, Porto, Portugal), responding to the argument of Thomas Proebstle (University of Mainz, Mainz, Germany) that “If currently available guidelines would even partially penetrate […] healthcare systems, all patients could be happy”.
The debate, on whether current international guidelines are accurate to define the best interventional technique for varicose veins, was held at the Controversies and Updates in Vascular Surgery 2020 meeting (CACVS; 23–25 January, Paris, France), with Proebstle and Mansilha arguing for and against the motion respectively.
Taking to the stage first, Proebstle summarised the history of varicose vein interventions, explaining that “in the last century, treatment was just high ligation, stripping, sclerotherapy, and compression, which did not change for 50 years or so”. However, he also discussed more recent developments, highlighting that “since 2000, we have seen the development of several new technologies by a number of creative people”.
Turning his attention back to the question at hand, he posed a tripartite question: “Do we have enough international guidelines to define the best treatments, are they up to date, and do these guidelines penetrate international healthcare systems?” According to the presenter, guidelines have not changed in the last decade, with 2011 guidelines from the Society for Vascular Surgery (SVS) and American Venous Forum (AVF) “still telling the whole story”.
“If you look at this recommendation,” Proebstle pointed out, “it still favours thermal ablation over surgery, and nothing has changed here. Furthermore, sclerotherapy is not recommended for the saphenous vein because it has a higher rate of recanalisation; there are plenty of other recommendations like this in the paper.”
Other guidelines were also highlighted by the speaker, who acknowledged the success of Alun Davies et al in evaluating the impact of National Institute of Health and Care Excellence (NICE) recommendations on the UK’s National Health Service (NHS), ahead of their publication in 2013. As Proebstle noted, this led to an increase in endothermal procedures and a reduction of surgery, in line with the guidelines from SVS and AVF.
“Endothermal procedures are always favoured over surgery then, and if this option does not work or is unsuitable, foam should be tried. If foam is not possible as well, surgery is the next option: this is very clear,” he emphasised. “Two-year data from the Europeans are also the same: again, there is a strong recommendation for endothermal ablation, in preference to surgery.”
Given the consensus of European, SVS/AVF and NICE guidelines, Proebstle pondered what else would be needed in order to determine the best interventional technique for varicose veins. He said: “Venous specialists should also keep in mind that scientific evidence should always be combined with a physician’s clinical experience and patient’s preference. In addition, we also have to face the fact that parts of the world cannot afford all of the latest, newest technologies.”
While these recommendations set a framework for practice, the presenter was eager to underline the reality of their current implementation in developed countries. He posited: “In the UK, the Netherlands, and Switzerland, current guidelines are fully adopted and in action. In Germany or France, though, where patients with private insurance have had access to endovenous treatment for more than 15 years, the majority of patients with public insurance—90% in Germany, for instance—still undergo high ligation and stripping. This shows that the national societies active in phlebology were not able to implement this information, and these guidelines, into public healthcare.”
Proebstle concluded: “For the well-trained, specialised physician, current available international guidelines are accurate enough.”
Interrogating the accuracy of international guidelines
Following the talk by Proebstle, it was the turn of Mansilha to consider why existing guidelines may not be useful enough in determining which are the best interventional treatments for varicose vein patients. Hinging his case on the notion that all patients are different, and therefore require a different approach, he said: “Not all of them are symptomatic, not all of them are dependent on the saphenous trunk, and not all of them are only treated for cosmetic reasons.”
“My question today is this: if I read the different international guidelines, can I find the right answer to treat all of these patients?” Mansilha asked. Profiling the interventional options currently available in daily clinical practice, the speaker asserted how selection of treatments is dependent on several factors, including the existing evidence-base, skills of the specialist, national healthcare system reimbursement policies, and finally the patient’s preference.
With these variables in mind, Mansilha questioned whether it is possible to use the same method for all varicose vein patients. “Is only one technique for all of them enough? I do not think that this is true. If you analyse the different guidelines, Thomas [Proebstle] has already shown that. The AVF’s guidelines of 2011 favour endothermal procedures over surgery with a 1B grade of recommendation,” he said.
“The EVF, in 2014, gave thermal ablation a grade of 1A, sclerotherapy 1A, and open surgery 1B. The ESVS guidelines followed one year later, with a 1A recommendation of thermal ablation in preference to surgery, and a 1A recommendation of thermal ablation in preference to foam sclerotherapy. The Latin American Venous Forum gave a 1A recommendation to thermal ablation, 1B to foam sclerotherapy and 1B to open surgery.”
Interrogating the accuracy of these various guidelines, Mansilha continued: “For small saphenous veins, again we treat different patients with different varicose veins; even in the same anatomical area, the patterns are different. Is it possible then for us to choose the right answer for all of these patients by reading the guidelines?” No, he continued, because these different international guidelines gave a 1A or 2B level of evidence for this question, and a grade of recommendation which is “absolutely not the same”.
Summarising his thoughts on the matter at hand, Mansilha commented further that “when choosing between interventional modalities to treat patients, with different patterns of varicose veins, one must always take into account the mechanism of action and limitations of different devices, the operator skills required for different techniques, mid- and long-term results, as well as reimbursement policies and cost-effectiveness”.
On that final point of cost-efficiency, Mansilha said: “We must have, in our department, people with enough skills to treat different patients with different techniques. On the subject of cost-effectiveness, we should always take this into account. Currently, the differences between treatments are negligible in terms of clinical outcomes, so the treatment with the lowest cost appears to be the most cost-effective.”