Incorporating Phlebology into a Vascular Surgery Practice

by Cristobal G. Alvarado, M.D.

Most young surgeons learn quickly that surgical practice as an attending surgeon is quite different from the practice they were exposed to as residents. While many of us were exposed to many complex arterial reconstructions, very few training programs give much exposure to proper care of wounds. In particular, care for wounds caused by venous insufficiency syndromes are in many cases ignored, as they do not threaten life or limb, as arterial lesions can. A busy clinical practice quickly reinforces that venous pathologies are not only much more prevalent than arterial pathologies, but that they cause a significant decrease in quality of life for our patients.

Incorporating a thorough understanding of phlebology into a vascular surgery practice will achieve three major goals:

  • To relieve suffering of patients
  • To increase self satisfaction for the surgeon
  • To become a previously unrecognized source of revenue for a practice

It is estimated that the incidence of venous disorder is perhaps an order of magnitude greater than that of arterial disorder. Varicose veins alone have been estimated to occur in 15-20% of the population depending on gender. Aging of the population and increase in the rate of obesity may only increase this prevalence. Chronic venous insufficiency syndromes are a major cause of lost time from work and decrease productivity, and engender significant amounts of direct and indirect health costs.

Until recently, there were few good treatments for these problems. Ulcers were treated with application of UNNA boots over several months; congestive symptoms were controlled with long term use of graduated compression stockings; and surgical treatment was limited to the somewhat inelegant technique of vein stripping, which was prone to intermediate and late term failure secondary to recannalization. Within the last 5-10 years there has been an explosion of interest in phlebology as newer treatments have more widely accepted. Paving the way for acceptance of these treatments has been the greater comfort all surgeons have experienced with ultrasound technology. Ultrasound has been gradually incorporated into all aspects of surgical practice, from FAST scanning in initial evaluation of trauma patients to office diagnosis of breast lesions to the use of endoscopic ultrasound in examination of the tracheobronchial tree and foregut. Use of ultrasound technology has been revolutionary in many aspects of vascular surgery, from surveillance of arterial bypasses to localization of vessels to the more recent development of IVUS (intravascular ultrasound).

This overall greater facility with ultrasound gives all surgeons the critical tool needed to introduce phlebology into their practice. A large amount of information can be gleaned quickly with a fairly simple ultrasound survey of the legs as can be performed in the office. Working diagnoses can be confirmed with studies done in accredited vascular labs. The most common problem of varicose veins and chronic venous insufficiency can be diagnosed reliably and treatment performed with ultrasound-guided ablation of refluxing and dilated greater or lesser saphenous vein trunks. Ablations can be performed in an office setting with a variety of radiofrequency or laser techniques. The procedure is performed completely with local anesthesia and has no significant recovery time, as patients are encouraged to walk immediately afterward.

Once refluxing superficial vein systems are closed, extremities are de-pressurized and congestion disappears. We have found that the worst pathologies have the most dramatic improvements. In particular, severe venous stasis ulcerations close in an accelerated manner, and future development of ulceration is effectively pre-empted. Significant decreases in symptoms such as aching and heaviness in the legs can create a positive feedback loop, leading to greater ability to exercise, higher energy levels and overall dramatic improvement in quality of life. Many of our most grateful patients are those who have been treated for venous disorders. It is not uncommon to treat patients who have suffered for many years because of an inability to effectively diagnose and treat these disorders.

Ablation procedures are generally reimbursed well by most insurance, including Medicare. As a practice matures, additional patients are usually encountered who benefit from phlebectomies (direct excision of dilated superficial veins) and/or sclerotherapy (directed injection of superficial veins). Those vascular surgery practices with accredited vascular labs may also capture the reimbursements associated with diagnostic procedures. Most practices find the added revenue and patient referral to be well worth the cost of equipment and the effort to gain expertise. The American College of Phlebology has an excellent website ( and hosts a number of educational conferences each year at sites throughout the country, highlighted by the Annual Congress in November. Many vascular surgery practices will find a significant crossover of patients from treatment of venous disorders to arterial disorders and vice versa, as many patients exhibit dual pathologies.

Dr. Alvarado received his undergraduate degree in molecular biology at Haverford College in 1987 and then graduated with Honors in Research from the New York University School of Medicine in 1991. He completed residencies in general surgery and in cardiothoraicic surgery at New York University Medical Center/Bellevue Hospital. In the midst of his surgical training, he pursued a two year research fellowship at Duke University as an NIH Scholar in Academic Surgery. Following residency, he completed a one year fellowship in thoracic transplantation at the University of Pittsburgh. Dr. Alvarado is now a partner in Surgical Associates in Dover, DE as a general thoracic and vascular surgeon.