By Lilly Manske and Janelle Mallett, Veins1 staff
As many as 30 percent of women and 20 percent of men suffer from some form of venous disorder. In addition to being unsightly, varicose veins often cause leg pain. Dr. Gregory Spitz, a vascular surgeon in Aurora, Illinois, has developed Transilluminated Powered Phlebectomy using the TriVex system. This surgical innovation allows surgeons to remove varicose veins quickly, permanently, and with only a few, very small incisions. The minimally invasive outpatient procedure offers relief of the pain and fatigue of varicose veins; a cause little or no scarring; and usually only requires a brief recovery period.
Dr. Spitz continues to travel throughout the United States and Europe to teach the technique using the TriVex System This system has increased the number of patients willing to undergo a varicose vein procedure as well as providing surgeons an efficient way to remove varicose veins. Traditional surgical methods were tedious, very time consuming and often yielded poor results. Since 1996, hundreds of patients have benefited from Dr. Spitz’s innovative procedure.
Veins1: How did you develop the TriVex System for Transilluminated Powered Phlebectomy?
Dr. Spitz: I developed prototypical equipment on my own, filed patent applications, and then started working with Smith and Nephew. We started developing the TriVex system together in 1997. That union made for a quicker, more efficient process because I was able to get both the equipment and engineers that I needed. The patents were approved in April of 1999. After collecting appropriate patient data, we submitted for FDA approval and received that in November 1999.
Veins1: How did you first become interested in Transilluminated Power Phlebectomy?
Dr. Spitz: It started in about 1996. I had been doing standard vein procedures that were very tedious and time consuming. Because it was essentially a blind procedure, I probably missed a lot of veins. I modified some of the existing equipment that was previously being used in orthopedic surgery and otolaryngology. At first, I tried it just in small areas in which I was using hook phlebectomy anyway. I would put in a device that broke the vein into small pieces and then suctioned the vein out from underneath, and it worked quite well. While still in the early development stages, I would confirm removal of the veins with the conventional procedures. As time went on I found that my new procedure removed the vein both quickly and efficiently and there was no need to do anything else.
I used tumescent anesthesia, a procedure borrowed from liposuction and plastic surgery. It makes the fat (subcutaneous tissue) underneath the skin tense with a local anesthetic and saline. Instilling this solution decreases blood loss, ensures the patient’s post-operative comfort, and helps dissect the vein away from the fat tissue. The final addition was the transillumination. For that, I first used prototypical scopes that went underneath the skin. They are small and go in through one small incision. I put the lighted scope underneath the veins and then put fluid in through another incision; I could then see the vein. The more fluid you put in, the wider the radius of transillumination and visualization of the veins. Finally, we made the tumescent-anesthesia fluid come through the same device that had the light on it and had the vein resector go through the other incision. That is where we are today. We have a relatively easy procedure that only requires two or three incisions (instead of as many as 15 to20). The incisions don’t require a stitch because they are only two to three millimeters in size.
Veins1: What makes your method different from traditional approaches?
Doctor Spitz: Traditional approaches require multiple incisions, long operative times, during which a patient undergoes anesthesia. These operations are frequently incomplete because they are blind. The surgeon blindly hooks for the vein.
Veins1: Who would be an ideal candidate for this surgery?
Doctor Spitz: The good news is that anybody with varicose-vein disease is a candidate for the technique whether he or she has already had a procedure (sclerotherapy or surgery causing a lot of scar tissue). Any person qualifies that has primary varicose veins, which is the first time they are having the procedure done. Any vein ranging from 2 to 15 millimeters is appropriate for surgery. Anything smaller than that is a spider vein. Surgeons make few incisions, and the procedure is always done in an ambulatory surgery setting. Every patient I have performed the procedure on has gone home the same day.
The patient is put under a light general anesthetic, a spinal or an epidural, or it can done with local anesthesia and some sedation. There are many available options, but you go home regardless. The procedure only takes 30 to 35 minutes. In the past, it has taken anywhere from one to three hours, depending on how much vein removal the patient needed. There is less anesthesia and no hospital stays. The patient wears post-operative compression settings for a couple of weeks and returns to normal activity within three to five days depending on how many veins are removed.
Veins1: Are varicose functional? What causes varicose veins? (Any preventive measures one can take?)
Doctor Spitz: Once veins in the leg become varicose (from the Latin Varix = dilated). They are no longer functional. Because the blood is relatively stagnant compared to normal veins, it acts as a “clog” in the system. Once these clogs are removed, the circulation is better through the hundreds of normal of remaining veins.
You cannot totally prevent varicose veins cannot be totally prevented, but keeping fit (i.e. not overweight), and getting regular exercise can go a long way to keeping the legs in good shape. If heredity is against you, symptoms can be controlled with compression stockings. The best advice I could give someone is to seek advice from a qualified phlebologist (vein specialist) before the problem gets too bad.
Veins1: Is varicose-veins disease more common in women?
Doctor Spitz: In the United States, 30 to 40 percent of people have some sort of varicose vein disease, and 60 to 70 percent of these are women. Men usually seek help in the more advanced stages because they sometimes consider it a woman’s disease. (It certainly is not just a woman’s disease.)
Veins1: Why is it important that varicose veins be treated medically (versus cosmetically)?
Doctor Spitz: Varicose veins are a medical problem. They can lead to poor circulation, phlebitis, clotting and ulceration. If you just treat the cosmetic aspects of the problem you will end up with recurrent veins more scar tissue and may make it more difficult to treat.
Veins1: Could you explain the cosmetic versus the medical need for this surgery?
Doctor Spitz: There is both a cosmetic and medical aspect to varicose vein surgery. Before undergoing a varicose vein procedure, a patient should have a duplex exam—a fancy name for an ultrasound test. It tests the deep-vein system, which is underneath the muscle (the one you can’t see), the superficial vein system (the one you can see) just underneath the skin, and the valves in between them. Usually a person with varicose veins has a valve problem. A doctor detects the valve problem with a pain-free ultrasound. It is then considered a medical condition.
There are cosmetic features to this procedure. Of course, you want to remove the veins and the skin to look good. Previous procedures required small incisions, but there were so many of them that you could see the where the veins had been by following the incisions. Usually we are able to hide the incisions, on the medial (or inner aspect) of the legs, and sometimes on the lateral. As a result, they are small and barely visible.
Veins1: Can a patient undergo this procedure at any age?
Doctor Spitz: We have performed this procedure on patients as young as 17, and as old as 85.
Veins1: What is the expected outcome of a surgery? Is it usually repeated?
Doctor Spitz: When using this technique, recurrences are minimal—usually less than 3 percent. Recurrences in varicose veins frequently relate to a new valve developing from the deep system to the superficial system. If a valve goes bad from the deep to the superficial system, the patients may develop more varicose veins. We try to locate bad valves and to either remove or tie them off during the first procedure.
Veins1: What else should patients know about Transilluminated Powered Phlebectomy?
Doctor Spitz: Many patients deny themselves treatment because they know about the old-fashioned vein stripping that their parents or older family members have undergone. Now we finally have something to offer that has good cosmetic and medical results. Patients are coming out of the woodwork to get treatment.
Veins1: When do see your method as becoming an industry standard?
Doctor Spitz: We just launched it about three weeks ago, but it is catching on quickly. I would think that a surgeon would put this in their armamentarium for varicose vein surgery. We are doing multiple training sessions within the next year or two and expect the procedure to become standard during this time.
Veins1: Where have you been training surgeons in this technique?
Doctor Spitz: I conducted an international clinical trial, which is almost done. We had 20 to 25 patients at each site in the trial. The centers involved London, Dublin, Dusseldorf, Bonn, Vienna, North Carolina, New Jersey, Chicago, and San Diego. Other training will be going on throughout the United States over the next couple of years, and there will be training courses every month. I am also doing a training course with many of the European surgeons, and we hope to have 60 surgeons in London on June 9. We will then be in Germany in September and in Japan in December. After that we go to Australia, and beyond that is hard to tell.
Veins1: Has the Landmark paper on the subject been published?
Doctor Spitz: The journal Vascular Surgery has accepted our paper for publication on using the TriVex system.
Veins1: You are in the Chicago area. Are other surgeons performing this procedure around the country right now?
Doctor Spitz: Yes. The procedure is being done right now by experienced surgeons that were involved in the clinical trials at the University of North Carolina; at Mount Sinai in New York; Holy Name in New Jersey; and in San Diego. We just completed training surgeons in Louisville; Denver; Dallas; Miami; and Philadelphia. We have scheduled more training sessions for the next two years both here and abroad.