Bruce R. Hoyle, M.D., Medical Director, Advance Vein Center, Orange, Ca., treats a wide spectrum of vein complaints, including facial, breast and hand veins. A graduate of the Unibersity of Western Ontario and an active member of the American College of Phlebology, Dr. Hoyle recently discussed the vein profession with Vein Magazine's Dave DelVal.

What are some of the challenges that come with your profession?

Probably the biggest professional challenges are convincing insurance companies of the medical necessity of treating varicose veins and venous insufficiency. I think insurance companies are often skeptical on this point and tend to regard these vein disorders as primarily cosmetic in nature. I don't disagree there is often an overlap between the cosmetic and medical nature of vein disorders. Insurance companies pay for the treatment of pain. If the condition is not painful, their conclusion is such treatment is cosmetic in nature and therefore not a covered benefit. No insurance company pays for the treatment of spider veins. Such treatment has always been considered cosmetic. The reality is that even spider veins can be symptomatic with complaints such as burning or aching. These complaints will resolve with the treatment of the spider veins.

What are some of the tough recommendations that you have made for certain venous diseases?

Probably the toughest recommendation is telling the patient that there is nothing you can do for them. While the treatment of vein disorders has advanced considerably in the last several years, patients with chronic venous hypertension [reflux or venous insufficiency in the deep veins], have very few options. For the majority of these patients, the best advice you can give them is to wear graduated compression hose as much as possible for the rest of their life.

Is there any one particular case which stands out in your mind?

A middle-age man came to see me from the San Diego area, about 120 miles away. He had a large wound on his lower leg about 4" in diameter. The wound had been present for 3-4 years. He had been part of an HMO and while they recognized this as a manifestation of venous insufficiency, his only treatment had been the prescription of compression hose. He did not have insurance but his leg looked so bad, we decided to treat him pro bono. After about four treatments that were conducted over a period of eight weeks, we had his leg healed. He worked at a bakery so on his last visit he brought us some fresh bread, but it was the smile on his face that made it all worthwhile.

What are some of the new trends that you think will be popular in the treatment of varicose veins in the near future?

One of the newest trends is the treatment of incompetent perforator veins by radiofrequency or laser ablation. Incompetent perforators have historically been a problem. Historically, incompetent perforator have been treated either surgically or by injections of various sclerosing agents using a liquid or more recently a foamed preparation. In the last year or so there has been increasing use of radiofrequency or laser to ablate the perforator.

Which venous diseases may be avoided with persistence and care? How might they be avoided?

Many vein disorders are hereditary. Since we can't choose our parents, there is little to be done in this regard. Spider veins and varicose veins certainly may run ‘in the family.’ These can be aggravated by conditions such as obesity, occupations that involve prolonged standing and in the case of women - pregnancies. However, there are vein disorders that are acquired and some potentially debilitating ones are the long-term consequence of blood clots in the veins. When someone gets a blood clot in a vein, the valves can be destroyed leading to long-term venous insufficiency and if this involves the deep system of veins, there are significant long-term consequences. So, the message is to do all that you can to protect yourself from blood clots. This involves regular exercise, keeping hydrated, use of graduated compression hose and doing leg exercises on long car rides or air flights.

Have you read any recent medical studies which intrigued you? If so, what were they?

I think there is more interest in venous disease than ever before. The cause of varicose veins is still being researched. We know there is a hereditary component involving the type of collagen that supports the vein walls. This may lead to failure of the vein valves. There is also research that suggests inflammation both in the veins and even in the skin around the ankles may be involved in the process.

Gene therapy is an exciting field. It offers the hope of potentially curing many diseases that have an inherited nature. Someday, maybe there will be a drug or treatment that can prevent the development of varicose veins.

For more information about Advance Vein Center, please visit www.advanceveincare.us.