The History and Present State of Phlebology in the USA: A Personal Perspective

Dr. Mitchel Goldman has pretty much seen it all when it comes to phlebology. As founder and third president of the North American Society of Phlebology (now the American College of Phlebology), a board certified dermatologist and cosmetic surgeon, and president-elect of the American Society for Dermatologic Surgery, Goldman has played a strategic role in the development of the specialty and has observed its progress as an active member and educator in our community. Here, he gives us a retrospective on the beginnings of phlebology in the US and the state of the specialty, in his own words.

The Birth of Phlebology in America

The North American Society of Phlebology (NA SP), founded on August 4, 1985, by Anton Butie, MD , a Swiss Angiologist, along with 13 other members and other dermatologic surgeons – including myself, a vascular surgeon, internist and dermatologist – began the formal field of Phlebology in the USA.

Prior to the NA SP, now the American College of phlebology (AC P), physicians from a variety of specialties including plastic surgery, vascular surgery, dermatology and family practice treated varicose and telangiectatic leg veins in a proprietary, almost trademarked manner. Solutions used were oftentimes secret concoctions of a variety of osmotic and hypertonic agents. Techniques for injection were diverse; compression was haphazardly used and there was very little written in the English medical literature on treatment techniques and outcomes.

Anton Butie, a recent immigrant to the USA in 1985, spent a one year internship with Arnost Fronek at the University of California, San Diego, Veterans Administration Hospital to earn his California medical license. He soon realized that a void needed to be filled. He copied the European model of phlebology training and worked tirelessly to educate others in the treatment of venous disease. He served as the society’s first president until 1988. The Society quickly grew and a formal Symposia occurred with the first Annual Congress in San Diego, California, on Feb 20-22, 1987.

At this Congress, invited European colleagues from France, including, Frederic Vin, Michel Schadeck, Andre Cornu-Thenard, Claude Guarde, and JJ Guex, were very generous with their time and patience to teach their new American friends. Soon thereafter, NA SP (future AC P) congresses brought other European colleagues representing many nations and a who’s who of international phlebology. The need for education in phlebology in the US was striking; and the Americans’ interest to learn new techniques was insatiable. Fortunately, this Hippocratic tradition of sharing knowledge and experience continues with enthusiasm as now even we Americans routinely go abroad to share our knowledge with those who have taught us.

Worldwide recognition that phlebologists in the USA also had an important role occurred in 2003, when the AC P – co-chaired by myself and Robert Weiss, along with John Bergan, Craig Feid, Helene Fronek and Pauline Raymond-Martimbeau as the Program Committee – hosted the UIP Interim World Congress Meeting in San Diego. And next year, the AC P will even host the UIP World Congress in Boston. What a great honor and privilege! The greatest compliment a teacher can receive is when his/her pupil is able to teach and share with the teacher.

The AC P was founded on the principle that all specialties of medicine can contribute together toward the benefit of patient care. The Society was always composed of a variety of specialties and the Society’s officers were always carefully chosen to be composed of not only the best and the brightest, but also those who represented all of the specialties. Sadly, that tradition does not appear to hold any longer. My personal fear is that when any one specialty group is excluded, patient care will suffer.

An example of the benefit of cross-fertilization of specialties is the development of endovenous treatment of varicose veins. John Bergan and I (a vascular surgeon and a dermatologic surgeon) first worked with Neuronavigational Corporation, on February 23, 1995, on the “VN X Monopolar Electrode System,” a radiofrequency treatment to close varicose veins, which later became VN US Closure™. The key to its developmental success was the incorporation of tumescent anesthesia to surround, insulate, anesthetize and compress the vein around the electrode. Tumescent anesthesia was unknown to the vascular surgeon, but routinely used by the dermatologic surgeon.

Further development of endovenous laser treatment was optimized not only by tumescent anesthesia but with the laser surgeon’s knowledge of the optimal laser wavelength to close a varicose vein with minimal perivascular trauma and maximal efficacy, 1320- 1500 nm vs 800 nm. Radiologists and Robert Weiss, the dermatologic surgeon who first trained in radiology, helped in defining optimal approaches to abnormal veins and the selectively placed tumescent fluid within the perivascular sheath. Internists provided expertise to minimize thrombotic complications. Dermatologists helped develop optimal compression systems. And the list goes on…

Now that the ACP has brought phlebology to all physicians with an interest in this specialty, we must ensure that medical ethics prevail.

Far too often I see patients who have been to a “medical spa” under the “supervision” of a physician. Without the physician present, the patient is treated by a nurse with a laser or injection for treatment of leg veins. Patients frequently come in to see me with a variety of scars, recurrent veins or at worse, deep vein thrombosis. These patients have almost never seen the “supervising” physician and, to make matters worse, are usually charged far more than I would charge. The great technique of endovenous ablation is also being utilized improperly with patients presenting to me for a “second opinion” as to the necessity for treating the great saphenous vein (GSV) because they were told that the vein had “abnormal blood flow.” What I find on my examination is a non-refluxing, 3mm diameter GSV.

As Helene Fronek stated in her article “The Opposite is Also True,” which appeared in VEIN Magazine (Spring 2012 issue, page 32), we should stop feeling angry toward the other physician and instead take care of the patient in the best way we know. That is the best way to correct the problem of patient misinformation and potential mistreatment.

The future, however, remains bright for both our specialty and our patients. Together we have disseminated mountains of facts and developed more standardized techniques with far less hocus pocus than seen in the days before the ACP. At our annual congresses, safer and smarter techniques for treating varicose and telangiectatic leg veins are being explored, developed and popularized. The public is becoming increasingly aware that today’s modern treatments are not the painful, scarring treatments that their parents and grandparents had to endure.

Just as the great teacher John Bergan has said, the advances in treatment of venous disease as taught by thought leaders like him is like welcoming Cinderella to the ball. It is time to once again dance together.