L'information qu'on ne veut pas dire sur les varices et pourquoi le traitement actuel des varices importantes est un scandal

1)   Hello. I am writing under the pseudonym “Cash Cow”. I have the Nutcracker Syndrome and I have had varicosities as of the age of 11 years of age and notable varicose veins as of 15 years of age. I have had 5 phlebology interventions (3 “phlebectomies” and 2 deep vein sclerosis treatments) and 2 “CHIVA” vein ligatures in addition to the “under study” ligature at the groin of my heavily refluxing “Point I” (Franceschi, Bahnini, 2005). All of these vein interventions, without exception, were requested by me purely in the sole and unique goal of improving the cosmetic aspect of my legs and all were reimbursed by the French Sécurité Sociale. Indeed, I no longer have any significant varicose veins on the surface of my legs, but less than ten years after my last phlebology intervention I have instead a myriad of highly disgraceful varicosities, longstanding edema and enlarged calves by the fibrosis that is inevitably caused by chronic edema. To improve much needed patient feedback, ever since my “Point I” ligature I have had notable digestive and increasing food intolerance problems. My personal critique of the long-term result of all my phlebological interventions is that my legs look like ****. This is my blog: i) my story, ii) the rectification of the commonly accepted mis-information regarding the Nutcracker Syndrome and the phlebological treatment of significant varicose veins, iii) in a nutshell, the scandal of the current treatment of the 2%-3% of the population who have varicose veins as of adolescence and the existing medical recommendations, iv) the life-long health risks and problems associated with Chronic Venous Insufficiency (this is the full and true cost of the Nutcracker Syndrome), v) why the current treatment of significant varicose veins is an enormous medical and economic scandal, vi) the abridged listing of the principal sources for this blog. Upon request, I will post a fully annotated version with the totality of the sources indicated (due to the quantity of sources, this might be section by section). Comments are not just welcome; they are needed: both the Nutcracker Syndrome and all the treatments for significant pelvic reflux are highly controversial and the only way to resolve the controversy is by open commentary.

 2)   The Nutcracker Syndrome is NOT a rare disease. In urology, gross hematuria and renal impairment due to the Nutcracker Syndrome are rare. In vascular surgery however varicose veins, a well-noted symptom of the Nutcracker Syndrome as well as of the Pelvic Congestion Syndrome, are exceedingly common. From the numerous estimates for venous malformations of the renal vein (in fact the three manifestations of the Nutcracker Syndrome), the prevalence rates are as high as even 9%. Furthermore, the Nutcracker Phenomenon (an imaging finding of left renal vein entrapment or compression with no symptoms), which is distinguished from the actual Nutcracker Syndrome (an imaging finding of left renal vein compression with noted symptoms), is exceedingly widespread: the Nutcracker Phenomenon is estimated to be found in as many as seventy-two percent (72%) of abdominal CT scans (Buschi et al, 1980). With no surprise, the reported prevalence rates for leg varicose veins are as high as 73% for women (Beebe-Dimmer et al., 2005). The actual Nutcracker Syndrome can cause significant pelvic reflux which in turn can cause significant varicose veins in the legs. 2%-3% of the population has varicose veins as of adolescence (Bertrand, 2008).

A history of vein surgery and/or ligature has been noted to be significantly associated with venous ulceration (Margolis et al., 2004). Venous ulceration predominantly affects women with up to three times more women affected than men. When varicose veins are surgically removed (or ligatured, lasered or sclerosed) they are in no manner whatsoever “repaired” in the sense of being put in good condition again and being put back in place: they are removed or destroyed. It is a physiological fact that veins (vessels with valves) do not grow back. Even in a perfectly functional venous system, by reducing the quantity of veins with an ever constant amount of blood to circulate, the reduced quantity of veins can only accommodate proportionally by dilating. The surgical removal, ligature, lasering or sclerosing of varicose veins in the presence of a significant pelvic reflux will inevitably transfer any non-corrected significant pelvic reflux onto the rest of the venous system (the deep veins, the perforating veins, the remaining superficial veins and the venules in the metabolically important capillary bed). Proportionally, the more large caliber varicose veins are removed, the more small caliber veins must dilate to take over the venous return of blood and potentially thereby become smaller varicose veins in the process. The risk of venous ulceration is in proportion to the severity of the varicosities and the severity of the insufficiency of the venous return of blood. 75% of venous ulceration is caused by long-standing primary progressive reflux. In the close to 100 photos of legs with varicose veins and then of legs with venous ulceration in Google Images and Bing Images respectively, on the one hand the legs with significant varicose veins have no ulceration and on the other hand the legs with venous ulceration all look as if they have been “cleaned up.”  Reference to this can be found in the medical literature, notably that i) voluminous as well as lifelong varicose veins can be asymptomatic; ii) for the majority of cases, large varicose veins are not with concomitant skin problems whereas there are skin problems with varicosities; and iii) the majority of patients with venous ulceration do not have any on-the-surface varicose veins (keeping in mind that 75% of venous ulceration is caused by long-standing primary progressive reflux).

 3)   In a nutshell, the current treatment of the 2%-3% of the population who have varicose veins as of adolescence is a truly a scandal because:

-     On the one hand safe, effective minimally invasive pelvic surgery exists, for a little more than the cost of surgical vein stripping, to correct if not completely eradicate the compression of the left renal vein which is the cause of the significant pelvic reflux and consequent varicose veins as of adolescence so typical of the Nutcracker Syndrome. With the eradication of the significant pelvic reflux, there will also be the eradication of the significant varicose veins that normally otherwise would have been created by it and, if done in adolescence, the life-long health risk and expense of the Nutcracker Syndrome can effectively be limited to this 1 pelvic surgery and no more.

-     On the other hand, If there is no corrective surgery for the compression of the left renal vein and hence the continuation of significant pelvic reflux, the life-long health risks and potential expenses of the Nutcracker Syndrome (which will become, unless corrected, a life-long chronic disease) are MULTIPLE and SIGNIFICANT: non-corrected life-long significant pelvic reflux inevitably will cause life-long significant venous insufficiency (Chronic Venous Insufficiency) for which repeated vein interventions especially by women can be sought, for which the associated health risks and problems are multiple and significant and for which there is notably a greatly increased risk of venous ulceration which in turn can cause multiple and  significant treatments lasting many years. 4% of people 65 years and older in the USA have active venous ulceration which is caused in 75% of cases by longstanding primary progressive reflux. Venous ulceration often co-occurs with diabetes.

As specifically stated in the American Medical Association Family Medical Guide of 1994: “If you have both deep and superficial varicose veins, surgery is not recommended. Instead your physician will recommend that you wear elastic bandages on your leg and avoid prolonged standing.” From a French teaching module, there is only the indication of surgery for superficial venous insufficiency (Boccalon, Fauvel, 2001). Keeping in mind that associations of vascular surgeons have a vested interest to promote their livelihood, it is notable that for the healing of venous ulcers the American Venous Forum recommends compression as the primary treatment.

In the U.K., on the basis of a policy of evidence-based medicine, the reimbursement of varicose vein treatments is limited for the most part to only venous ulceration or when there are skin problems with oftentimes restrictive criteria. In France however, the surgery for varicose vein stripping is 100% reimbursed by the Sécurité Sociale without any restrictive criteria; it is also the second most common surgical intervention in France.

4)   The life-long health risks and problems associated with Chronic Venous Insufficiency (CVI) are multiple and significant. CVI is associated with lower leg edema, fibrosis and progressively worsening venous insufficiency for which repeated varicose vein treatments, especially by women, can be sought. From several studies, the re-occurrence for varicose veins is »65% after five years. CVI is associated with pathological levels of inflammation. CVI is associated with excessive free radicals and increased oxidative stress. CVI puts an evident circulatory strain on the heart. An association has been noted between varicose veins and cardiovascular disease. Varicose veins are indissociable from endothelial dysfunction, which in turn is indissociable from arteriosclerosis. A history of vein surgery and/or ligature has been noted to be significantly associated with venous ulceration. 4% of people 65 years and older in the USA have active venous ulceration which is caused in 75% of cases by longstanding primary progressive reflux. From a 12month study, the average total medical costs per venous ulcer treatment were close to $ 10 000 (excluding the costs incurred for recurrent or prolonged treatment after the end of the 12month study). More than half of venous ulcers require prolonged treatment of more than one year; re-occurrence can be as high as 67%; a subset has venous ulceration for more than five years and ≈15% never heal. Repeated treatments are oftentimes necessary (vein ligature or sclerosing, wound debridement, hospitalization, skin grafting, …). Actual total costs have to include lost work days and early retirement. The average lifetimecost per patient of venous ulceration is estimated at over $ 40 000. Venous ulceration often co-occurs with diabetes.

 5)   Why the current treatment of significant varicose veins is an ENORMOUS medical and economic scandal

-          There is first and foremost the fundamental notion of getting “had”: with anti-depressants, at least the effectiveness is slightly above the placebo level. With the surgical removal (or ligature, lasering or sclerosing) of leg varicose veins caused by significant pelvic reflux, there is no effectiveness whatsoever for stopping a significant pelvic reflux and the Chronic Venous Insufficiency that inevitably results from significant pelvic reflux. For as much as phlebology supposedly would prevent or slow down “venous disease” (a sort of vaccination), the fact that a history of vein surgery and/or ligature is in fact significantly associated with venous ulceration clearly indicates that there is an evident problem with the vaccination.

-          Medically and economically, there is a scandal: Above all, when taking into account that it is possible to correct in adolescence the significant pelvic reflux which is the cause of the Nutcracker Syndrome for a little more than the cost of surgical vein stripping, this effectively means that 75% of people with venous ulceration (which is caused in 75% of cases by longstanding primary progressive reflux), should never even have had varicose veins in the first place. Life-long Chronic Venous Insufficiency is very expensive. Venous ulceration which can last for years is very expensive. On the basis of a policy of evidence-based medicine, as in the U.K., the #2 surgery in France should not even be reimbursed. The fact that the second most frequent surgery in France is reimbursed in totality without restriction is really, in and of itself, an enormous waste of health care expenses of the French Sécurité Sociale. The fact that there are so many health problems, being the potential cause of so many multiple, significant and life-long reimbursed health care expenses, associated with Chronic Venous Insufficiency and in particular venous ulceration and that all could have been avoided if only the significant pelvic reflux had been corrected in adolescence, this is in totality a real black hole of wasted health care expenses.

-          Ethically, there is undeniably less than optimal treatment for women with the Pelvic Congestion Syndrome (of which the Nutcracker Syndrome is a variant): Independently of the associated problems, the Pelvic Congestion Syndrome is not just varicose veins, there is also the major symptom and problem of chronic pelvic pain which in no manner can be treated by the removal of varicose veins. For all the accumulation of inappropriate and inefficient treatments including pain medication and lost work days, the non-treatment of the Pelvic Congestion Syndrome costs a lot more than the appropriate treatment. For all the accumulation of repeated vein interventions and potential problems throughout life, the non-treatment of the Nutcracker Syndrome costs infinitely more than the appropriate treatment. The lack of recognition and of appropriate treatments for the Pelvic Congestion Syndrome and the Nutcracker Syndrome is not at all beneficial medically or economically.

  

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- Weindorf N, Schultz-Ehrenburg U. (Dermatologische Universitätsklinik, St Josef-Hospital Ruhr-Universität, Bochum), [The development of varicose veins in children and adolescents] (article in French), Phlebologie 1990 Nov-Dec; 43(4): 573-7

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-     Olivier  Hartung  “Nutcracker syndrome” Phlebolymphology, 2009; N°63, Vol. 16, N°2: starting page indicated 246

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- Jan T. Christenson, MD, PhD “Postthrombotic or non-postthrombotic severe venous insufficiency: Impact of removal of superficial venous reflux with or without subcutaneous fasciotomy” Journal of Vascular Surgery, August 2007, vol. 46, n. 2, pgs. 316-321

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- Dragan J. MILIC, MD, “Prevalence and socioeconomic data in chronic venous disease: how useful are they in planning appropriate management?” Medicographia, 2011, Vol 33, No. 3: pgs. 253-258

- Abbade LP, Lastoria S, “Venous ulcer: epidemiology, physiopathology, diagnosis and treatment”, International Journal of Dermatology, 2005 Jun; 44(6): 449-56

- Peter Gloviczki, MD, Manju Kalra MD, Alessandra Puggioni MD “Venous Ulcers: Pathophysiology” (Third International Vein Congress: In-office techniques, April 14-16, 2005)

- Scottish Intercollegiate Guidelines Network “The Care of Patients with Chronic Leg Ulcer, A National Clinical Guideline” SIGN Publication No. 26 (July 1998)

- M.J. Callum, D.R. Harper, J.J. Dale, C.V. Ruckley, “Chronic ulcer of the leg : clinical history” British Medical Journal, volume 294, 30 May 1987, pg. 1389-1391

- Andrea Cariati, « Investigation of the Leg Lymphatic Function in Patients with Leg Acute Venous Thrombosis and in Patients with Leg Post-Thrombotic Syndrome » The Open Circulation and Vascular Journal, 2010, Volume 3, pgs. 67-71

- Dr. Vesna Karanikolić et al. ”Evaluation of Prognostic Factors Related to Healing of Venous Ulcerations of Lower Extremities” Acta Medica Medianae 2010; Volume 49(1): 22-26

- C.K.Sen, G.M. Gordillo, S. Roy, R. Kirsner, L. Lambert, T.K. Hunt, F. Gottrup, G.C. Gurtner, M.T. Longaker “Human Skin Wounds : A Major and Snowballing Threat to Public Health and the Economy,” Wound Repair Regen. 2009; 17(6): 763-771

- Wipke-Tevis DD, Rantz MJ, Mehr DR, Popejoy L, Petroski G, Madsen R, Conn VS, Grando VT, Porter R, Maas M., “Prevalence, incidence, management, and predictors of venous ulcers in the long-term-care population using the MDS” Adv Skin Wound Care, 2000 Sep-Oct;13(5):218-24

- B.P.M. Schweitzer, J. Doorenbosch, R. Glotzbach, K. Barnhoorn, D.P. Breure, J.R. van der Laan, F.S. Boukes The Dutch College of General Practitioners (NHG) Practice Guideline 'Venous leg ulcer' 2004 (translation of the Dutch NHG Practice Guideline)

- Olle Nelzén, MD, David Bergqvist, PhD, MD, Anders Lindhagen, PhD, MD, “Leg ulcer etiology - A cross sectional population study” Journal Vascular Surgery, October 1991; Volume 14, Number 4: 557-64

- H. Boccalon, J.M. Fauvel “Insuffisance veineuse chronique, Varices,” (Examen Classant National: module 9 arthérosclérose, hypertension, thrombose, thème 136 Insuffisance Veineuse Chronique Varices du Collège des Enseignants de Cardiologie et Maladies Vasculaires, Programme d’enseignement de cardiologie et maladies vasculaires, June 2001)  (Nota: The above document is listed twice in the Catalogue et Index des Sites Médicaux de langue Française” (CISMeF, catalogue of medical sites and documents), under “cours” (courses) and “thérapie” (therapy) and is noted to have Free and Open at the Web site http://www.chu-rouen.fr/ssf/pathol/varices.html )

- Charles B. Clayman, MD (medical editor), The American Medical Association Family Medical Guide, Third Edition (New York: Random House, 1994), pg. 444

- American Venous Forum “New Guidelines Announced for the Evaluation and Treatment of Varicose Veins” dated 5/11/2011 (http://www.veinforum.org/medical-and-allied-health-professionals/news-and-publications/new-guidelines-announced-for-the-evaluation-and-treatment-of-varicose-veins)

- Evans CJ, Fowkes FG, Hajivassiliou CA, Harper DR, Ruckley CV, “Epidemiology of varicose veins: A review” Int Angiol., 13(3) (Sept.1994): 263-70, 

- C.Franceschi and A. Bahnini, “Points de Fuite Pelviens Viscéraux et Varices des Membres Inférieurs” Phlébologie, 2004; vol.57: 37-42 (Nota: for similar article in English: Claude Franceschi and Amine Bahnini, “Treatment of Lower Extremity Venous Insufficiency Due to Pelvic Leak Points in Women” Annals of Vascular Surgery, March 2005; volume 19, issue 2: pages 284-288)

 

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