On Vein Problems of the Leg

     Over the last decade, there have been major advances in the minimally invasive approach to vein problems. The key to proper treatment is the correct diagnosis of the root cause of the vein problems of the leg. We start with a careful history and physical examination to identify risk factors along with the signs and symptoms of venous disorders. The next step is the use of noninvasive ultrasound diagnostics to create a road-map of the venous system to identify and locate valve dysfunction. Only then can an appropriate treatment plan be developed. If ultrasound evaluation identifies that the valves of the saphenous vein or perforator veins are not functioning normally, a minimally invasive catheter based treatment can be used. Radiofrequency ablation, the Venefit procedure, is the technique of choice for the NJ VeinCare to treat valve dysfunction resulting in reflux of the long and short saphenous veins along with the perforator veins. This treatment is covered by most health insurance plans!

     Venefit™ is a clinically proven, minimally invasive procedure that treats varicose veins and their underlying cause, venous reflux, with little or no pain. Venefit patients can walk away from the vein procedure and be back to everyday activities – either at home or at work – typically within a day.

     The Venefit procedure is the treatment for venous reflux and varicose veins patients seek when they want a minimally invasive treatment alternative with less pain and less bruising when compared to traditional vein stripping surgery and laser treatment. Using the Venefit system, physicians close the diseased veins by inserting the Venefit catheter and heating the vein wall using temperature-controlled RF energy. Heating the vein wall causes collagen in the wall to shrink and the vein to scar close. After the vein is sealed shut, blood then naturally reroutes to healthy veins with normal valves.

     The Venefit procedure does not involve pulling the diseased vein from the thigh as with vein stripping surgery, or using 700° C laser energy which boils blood to occlude a vein as with endovenous laser (EVL).4   In the RECOVERY Trial, a multi-center head-to-head comparative randomized trial comparing Venefit with EVL, the Venefit procedure was found to have less patient pain and less patient bruising than EVL for the best patient recovery experience available from a minimally invasive vein treatment.2  Additionally, in other randomized comparative studies have shown that patients receiving the Venefit procedure return to normal activity and work significantly faster than those receiving vein stripping.1

     The ClosureFast catheter, which represents the latest advancement in the Venefit procedure, has been shown in a multi-center study to have a 97.4 efficacy rate at one-year.3This shows that the treatment is highly effective.

     Venefit catheters are inserted into the vein via a tiny incision in the lower leg, eliminating the need for groin surgery and general anesthesia. The Venefit procedure is performed using local anesthesia in the office.

     Because treatment with Venefit is minimally invasive and is catheter-based, it results in little to no scarring.

     Venefit can be used for the long and short saphenous veins. In addition, incompetent perforator veins can be treated with excellent success using the Venefit technique. Dr. Nackman presented one of the first series of patients at a national meeting treated with Venefit for perforator disease.5

1. Lurie, F, et al.Prospective randomized study of endovenous radiofrequency obliteration (Venefit procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study), J Vasc Surg 2003; 38(2):207-14.
2. RECOVERY Trial – Data on File – Venefit Medical Technologies, Inc.
3. Dietzek A, Two-Year Follow-Up Data From A Prospective, Multicenter Study Of The Efficacy Of The ClosureFast Catheter, 35th Annual Veith Symposium. Symposium. November 19, 2008. New York.
4. Weiss RA, et al. Comparison of Endovenous Radiofrequency Versus 10nm Diode Laser Occlusion of Large Veins in an Animal Model. Dermotol Surgery 2002; 28: 56-61.
5. Nackman GB, et al. Radiofrequency Ablation of Incompetent Perforator Veins. Presented at the 19th Annual Meeting of the American Venous Forum. Feb. 2007. San Diego, CA.

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On Competency

     What does it mean to be competent at something?  Competency may be defined as the ability to do something successfully or efficiently.  When it comes to determining if a physician is competent in his profession, no one, board, no organization, no government, no residency training program or hospital actually will state that an individual is competent.  There are significant legal ramifications to declaring someone as competent to practice medicine, and a mal-occurence  happens.  Would the organization that states a physician is competent become legally responsible?

     In medical school, residency and fellowship programs, trainees need to demonstrate proficiency in core competencies specific to medicine.  The ability to gather information, interpret the information and form a management strategy along with the ability to perform a variety of interventional tasks are inherent to the role of being a physician.  Medical students must pass national subject exams, national board exams, mock patient interview and physical exams.  Residents and fellow must pass annual inservice exams for advancement and board exams regulated by the American Board of Medical Examiners to become "Board Certified".  To take the board exams, one's residency director certifies that the trainee has completed and met the requirements of the training program. 

     The State mandates that physicians are licensed to practice medicine. One's application includes diplomas from medical schools and residency programs, and a certificate of completion from the national board of medical examiners.  One then is licensed to practice "medicine and surgery".  Most physicians practice beyond the four walls of their office and may have admitting and or operating privileges at a hospital or surgical center.  The assumption is that licensure and having one's "Boards" is a measure of competency, and for the most part it serves well.  

    In 1989, New York State enacted the 405 regulation, limiting resident work hours, as the result of a commission evaluating the causes of the death of the daughter of a prominent journalist at NY Hospital.  The commission blamed resident work hours and poor supervision for the death. This was a controversial finding with little data to support such sweeping changes. I was a junior resident at St. Luke's/Roosevelt Hospital center at the time, and we were very concerned about the impact on our training as surgeons.  A surgeon has to know a lot and do a lot.  Less hours in the hospital meant fewer chances to perform surgery and follow patients.  We worried that  when "on call" were covering far more patients than we normally did. Patients that we did not normally cover , so we were at a disadvantage in providing care.  We used to joke that "405" meant the 4th or 5th yr resident now did all the work, while the intern and junior residents went home.  The choice was between having a tired doctor that knew you vs. a less tired doctor that had never seen you before.

    In 2003, the Accreditation Council for Graduate Medical Education made the cap of an 80 hr work week mandatory nationally. Length of shifts were limited. Time off between overnight shifts required.  In a surgical residency, what had been a full time duty, had become shift work with penalties to the training institution for violation.  As a faculty member of a University, I was concerned that we were making a major change to how we train physicians without first defining how competent our current "product" was and not knowing if the decreased "time on topic" would result in less competent trainees.

     In a recent article in the New England Journal of Medicine (N Engl J Med. 2016 Feb 2), the end points of patient mortality and complications along with resident satisfaction were compared between surgical training programs that adhered to the work hour mandates vs. more flexible policies that waved the rules on maximum shift length and time off between shifts.  The results were that there was no difference in patient outcomes among the groups.  No mention or measurement standard was applied towards assessing resident competency.  Shouldn't the competency of residents be the subject in a training program?