by Monika Lecomte Gloviczki, MD, PhD; Imre Bihari, MD, PhD; John A. Chuback, MD, FACS, RPVI, RVTY, RPhS; Claudine Hamel-Desnos, MD; Pauline Raymond-Martimbeau, MD; and Jacqueline Sasek, B.S., RVT, RPhS.

This article helps to discover vein practice around the world. We have gathered information about the health care systems and vein care deliveries from three countries, Canada, France, and Hungary, and compared them to current vein care in the United States. It is far from a complete world tour, but we bring real-world examples of how different countries have developed and provided medical care to patients with chronic venous disease (CVD). Learning what others do around the world helps us improve our practice and is another good reason to attend the upcoming World Congress of the International Union of Phlebology (Union Internationale de Phlebologie, UIP), being held in Miami, FL, September 17-21, 2023. UIP embraces the international spirit that stimulated us to write this report.

CANADA

Historical Perspective

The first clinicians in the field of vein practice started in the mid-19th century. In the mid-1800s, Canada became the first country in the world to set up unified vein clinics. These clinics were meant to help diagnose and treat vein-related conditions and began to gain popularity in the country as the technique of vein ligation, and stripping became well known.

During the first half of the twentieth century, vein clinics continued to expand, with specialized practitioners and further development of diagnostic and treatment methods. Later, the use of non-surgical techniques, such as sclerotherapy and cutaneous laser technologies, started to flourish. Many practitioners visited their French colleagues in Paris to learn sclerotherapy. By 1981, Pauline Raymond-Martimbeau introduced duplex ultrasound in Canada to diagnose superficial venous disease more accurately. The foam sclerotherapy practice was firmly established by the end of the twentieth century.

Present Time

The Canadian healthcare system is renowned for ensuring that all Canadians have access to basic medical services regardless of their ability to pay. The Canadian healthcare system is one of the most comprehensive healthcare systems in the world, providing universal access to medically necessary services.

Despite its success and strengths, many challenges still exist. One of these concerns is that varicose vein treatments in Quebec, for example, are not covered by the provincial government and are ultimately the patients’ financial responsibility. Varicose veins are a common condition estimated to affect 20-40% of the adult population in Quebec.

The Quebec government considers varicose veins treatment as medically non­essential, disregarding associated symptoms such as heaviness, aching, fatigue, leg swelling, interference with daily activities, and negative impact on quality of life.
In addition, private health insurance in Quebec is often prohibitively expensive and may provide limited coverage of varicose vein treatments.

Consequently, many Quebecers do not have access to affordable varicose vein care, making them more likely to suffer from CVD symptoms and complications, with marked quality of life declining as their condition progresses.

Sclerotherapy was believed to cause deep vein thrombosis and was forbidden until the end of the ‘80s. This situation changed with the democratic evolution of the country when sclerosing agents from Western firms became available.

The standard therapy for varicose veins in Quebec includes sclerotherapy, radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and medical adhesive ablation. Because of its cost-effectiveness, sclerotherapy is the most common. RFA, EVLA, and medical adhesive ablation are outpatient procedures reserved for a minority. While these treatments are effective, the financial burden can be difficult for the patient.

Vein practice in Canada is an important and growing field. Numerous vein clinics and specialists focus on diagnosing, managing, and treating vein-related conditions. Many have a multidisciplinary medical team to provide the best possible patient care.

Future Perspectives

The future of vein practice in Canada looks very promising, with new technologies and treatments being developed and introduced. Since 2021, physicians (vein specialists or phlebologists) have been obliged to follow a mandatory training program established by the Quebec College of Physicians and Surgeons to practice phlebology.

These programs cover visual sclerotherapy, guided foam sclerotherapy, phlebectomy, endovenous laser ablation, and radiofrequency ablation. Any new procedure must be declared to the College in view of a training preparation.

Phlebologists must be proficient in duplex ultrasound to perform varicose vein treatments. The ongoing development in venous disease treatments is expected to result in the opening of more vein clinics throughout Canada, facilitating patients’ access to specialized vein care. As technology continues to evolve with advancements in imaging and diagnostic tools, the vein practice is expected to grow to be even more effective and accurate. New safe, and effective therapy will reinforce the place of vein clinics as an important part of the Canadian medical system.

FRANCE

Importance of Varicose Veins

In France, varicose veins of the lower limbs affect approximately 20 million people, an estimated 20 to 35% of a general population of 67 million inhabitants. Leg ulcers affect 2% of the population over the age of 70.¹

The treatment of varicose veins represents an annual cost of 264 million euros to the community. This cost includes 36 million euros for work stoppages, with an average of 26 days of stoppage per patient after conventional surgery (high ligation & stripping, HLS).²

Vascular Physicians

Vascular physicians (VP) manage the diagnostic, pre-treatment assessment, and follow-up care of CVD and varicose veins. For the therapeutic part, VPs mainly perform sclerotherapy (one million sclerotherapy sessions per year), while endovenous thermal ablations (ETA) are shared by VPs and vascular surgeons (VSs) and represented almost 60,000 procedures in 2019 (and 46,300 in 2021). Both vascular and general surgeons perform HLS; its practice is declining but remained at least equal to ETA in 2019 (and 32,000 in 2021) for total HLS on great and small saphenous veins.

There are about 2000 VPs in France, where they perform arterial and venous duplex scan in the vast majority of cases; they delegate little to assistants or ultrasound technicians, who are still very few in France.

Vascular Medicine and Vascular Surgeons

Vascular medicine became a full university specialty in 2017, and the four-year training course after the general curriculum includes teaching phlebology. However, as the practice of phlebology has historically been mainly carried out in private practices, the implementation of university teaching will have to be adapted gradually.

Parallel courses (university diplomas or European diplomas delivered by centers accredited by the UEMS-European Union of Medical Specialists) have been set up for young (and not so young) VPs, for this transitional period, which could last a few more years.³ They offer e-learning platforms for theoretical courses and practical training in Ultrasound-Guided-Foam-Sclerotherapy (UGFS), and ETA in private and public training centers. However, they are not validating for the vascular medicine specialty.

There are just under 500 Vascular Surgeons; in the face of the arterial field, phlebology is often “sacrificed” in their training curriculum.

Varicose Veins Treatment

The national health insurance reimburses endovenous treatments of varicose veins by sclerotherapy, endovenous laser (EVLA), and radiofrequency (RFA). Still, treatment of saphenous veins is subject to compliance with “choosing wisely”(CW) instructions published in 2018 by the National Professional Council of Vascular Medicine (CNPMV).^4,5

The ten CW instructions concern the treatment of saphenous veins and their recurrence. They aim to provide a framework for good practice, assist in dialogue with the patient, and make the most appropriate therapeutic choice possible. They recommend using duplex ultrasound at all stages of treatment by UGFS, EVLA, or RFA: in the pre­treatment assessment, during the various stages of treatment, and in post-procedure.

For UGFS, a precise report must include the indication for treatment, the target vein, its diameter, its reflux, the type of sclerosing product used, its form (foam or liquid), its concentration, and the volumes injected at each injection site. In addition, photographic documentation must accompany the report. The procedure is reimbursed at 94.64 euros for one session of a saphenous vein UGFS. If necessary, two sessions are reimbursed for a great saphenous vein (GSV) and one for a small saphenous vein (SSV). And 129.69 euros are reimbursed for a session of UGFS for an inguinal or popliteal fossa recurrence (several sessions are allowed).

Sclerosing foam is manufactured manually with polidocanol or sodium tetradecyl sulphate, with 1 to 3% concentrations approved.

Sclerotherapy is performed in the consulting room with available medical first aid equipment and oxygen. The AED defibrillator is recommended but not mandatory.
EVLA and RFA are the first-line treatment for saphenous veins. However, for the SSV, only EVLA is recommended and reimbursed (not RFA) due to its greater maneuverability and a much higher number of publications than RFA for this indication.

For EVLA, as for RFA, strict local anesthesia by tumescence, under ultrasound guidance, is recommended. General anesthesia, spinal anesthesia, or anesthesia by femoral block are discouraged, with some exceptions. The patient must remain “alert” to a potential neurological risk during heating.

There are no specific guidelines or recommendations concerning treating tributaries during endothermal ablation (ETA) of saphenous veins. Thus, the choice of technique (sclerotherapy or phlebectomy) and of concomitant or deferred treatment are left to the operator’s discretion, in consultation with the patient, according to the principle of shared decision-making (SDM).

In practice, according to the Statistical Institute of the Liberal Professions in France, in 2021, 96% of EVLA procedures performed by VPs did not associate phlebectomies, whereas for VSs, 97% of EVLA procedures had concomitant phlebectomies.
The environment imposed by the High Health Authority-HAS for the ETA is the “operating area,”⁶ which complies with the organizational, functional, and technical criteria defined in the decree of January 7, 1993.⁷

Less constraining than the “operating theatre” because it allows the use of a dedicated treatment room; the “operating area” imposes the framework of a public or private health establishment. These procedures cannot, therefore, be performed in a “Vein Center” or a private practice/office-based surgery.

Reimbursements for ETAs in public hospitals, including doctors ‘fees and materials, are approximately 1,800 euros for RFA or EVLA. In private hospitals, doctors ‘fees are approximately 150 euros for ETA without concomitant phlebectomies and 190 euros with concomitant phlebectomies and are separate from material costs.

According to the CW, conventional surgery should be offered only in exceptional situations. Minimally invasive surgery is not covered by the CW; it is in any case very little practiced in France anymore.

Endovenous treatments for varicose veins, such as steam, MOCA, glue, HIFU, etc., are not reimbursed.

Interventional treatments of pelvic varicose veins and deep veins are performed by VSs and interventional radiologists, very few by VPs. Private and public establishments have developed centers performing pelvic venous embolization, but fewer can offer deep endovenous treatments, for which the demand remains limited in France.

In conclusion, vascular medicine specialists and vascular physicians represent a strong and specific network in the management of varicose veins in France. The weak point of the French system is related to the constraints of a health institution for ETAs practice, which keeps costs unnecessarily high and delays the development of these techniques, “Vein Centers” and office-based surgeries.

HUNGARY

Historical Perspective

The history of Hungarian phlebology is not too long and developed slower than in Western Europe. Hungary was marked by the discovery of flavonoids by a Hungarian scientist, Albert Szentgyörgy, Nobel-prize laureate for his research on vitamin C (1937). He demonstrated that both, vitamin C and flavonoids, have some common effects on the capillaries.

Sclerotherapy was believed to cause deep vein thrombosis and was forbidden until the end of the ‘80s. This situation changed with the democratic evolution of the country when sclerosing agents from Western firms became available. The pharmaceutical companies supported several sclerotherapy courses and promoted awareness of venous disease. It’s not by chance that Professor György Acsady organized the 1st European Chapter Meeting of the Union Internationale de Phlebologie (UIP) in Budapest in 1993.⁸

In the socialist era, phlebology belonged to the National Healthcare System (NHS). After the 1989 revolution, more-and-more private vein clinics were created and took over the charge of patients with superficial venous disease.

Present Time

Currently, in state hospitals, only open surgical varicose vein interventions are performed, usually without ultrasound diagnostics. In private practice, duplex ultrasound examinations are routinely done, and minimally invasive interventions for varicose veins are offered to patients. Laser, radiofrequency, glue, and microwave endovenous techniques are available. Foam sclerotherapy is less popular than in the Mediterranean countries. For esthetic indications, sclerotherapy is frequently used, rarely laser or radiofrequency. Procedures performed in the private practice are not supported nor reimbursed by the NHS.

Conservative therapy is available with a large choice of compression stockings and hosieries. All types of compression class II stockings are financially supported by the NHS. A great variety of veno-active drugs is present on the market. Micronized Purified Flavonoid Fraction (MPFF or Detralex) is the most frequently used drug.

Low Molecular Weight Heparin (LMWH) and Direct Oral Anticoagulants (DOACs) are commonly used in the treatment of deep vein thrombosis (DVT). Thrombolysis is indicated in the cases of proximal DVT. Surgical thrombectomy has been abandoned. Thromboprophylaxis follows international guidelines for surgical and internal medicine patients.

Recently a limited number of stent placements for iliac vein stenosis (May-Thurner syndrome) were performed when indicated.

Venous leg ulcers are treated by dermatologists, partly in academic institutions and partly in private practices, in cooperation with vascular surgeons and phlebologists.

Vascular anomalies are treated in the Semmelweis University’s specific center. Professor Lajos Soltesz, vascular surgeon and founder of the first Vascular Surgery Department, began the research and the development of vascular malformations therapy. His work on vascular malformations and also the role of arterio-venous shunts is well known. Professor Geza Tasnadi followed his call and cared for almost every child and adult with vascular anomaly in Hungary.

Treatment of lymphedema also has a strong Hungarian mark. Professor Michael Földi started his career in Hungary and later emigrated to Germany, where he created a unique center for lymphedema patients treated by complex decongestive therapy. His treatment protocol continues to be used in the lymphedema clinics and is performed by special nurses in the maintenance phase.

Hungarian Phlebologists

The Hungarian Society of Angiology, founded in 1966, created a special Phlebological section in 1979. Later, in 1997, the Hungarian Venous Forum was founded by the author, Dr. Imre Bihari. This society is connected to the Hungarian Society of Angiology and Vascular Surgery and organizes phlebology meetings every spring and autumn. Dr. Bihari also launched the official journal of the society, Érbetegségek (Vascular Diseases). Hungarian vascular specialists are prolific writers (e.g., Gy. Vas, A. Nemes, I. Bihari) and are authors of several chapters and books on venous diseases and their treatment.

It is also worth mentioning that our nation gave the world many eminent vascular specialists with great merits in the research and management of vascular diseases: Gabor Nobl, Geza deTakats, Michael Földi, Etelka Földi, Roberto Varnagy, George M Somjen, Peter Conrad, John Dormandy, Zoltan Várady, and Peter Gloviczki. They were trained in Hungary, emigrated, and worked in other countries, but their hearts have always been Hungarian.

UNITED STATES OF AMERICA

Over the course of the last 30 years, we have experienced a paradigm shift in the management of superficial lower extremity venous insufficiency in the United States. This shift is largely represented by three clinical and philosophical changes to managing patients.

Duplex Revolution

First, ultrasonography using grayscale, pulse wave Doppler, and color Doppler imaging has become the diagnostic tool of choice in combination with a physical examination. This remarkably effective tool utilizing sound waves is safe, highly sensitive, and highly specific in defining the pertinent anatomy and pathophysiology of the lower extremity venous system. This essential information is then used to develop a treatment plan that is uniquely tailored to meet the needs of each patient.

This is in extreme contrast to earlier generations of testing, which were much cruder and led to more of a one size fits all approach to therapy. Antiquated technologies such as tourniquet testing (Brodie-Trendelenburg), handheld Doppler, and plethysmography are now almost exclusively of historical interest only. Venography is essentially never used in uncomplicated superficial venous reflux disease at this point. The venogram does maintain its rightful place in the realm of deep venous obstructive disease, but this is beyond the scope of this discussion.

Tumescent Anesthesia and Outpatient Care Shift

The second major change we have seen is that treatment has moved almost entirely out of the tertiary hospital-based arena and has undergone a mass exodus to the free-standing outpatient clinical care environment. This has been possible due largely to the third seismic shift we have seen in venous therapy, namely, the use of local and tumescent anesthesia in place of general anesthesia.

This major modification in patient care has not only led to safer procedures related to inhalation anesthetic agents and their potential for inducing cardiovascular complications, but it has also dramatically decreased intraprocedural blood loss. Improvements in hemostasis are largely attributable to the vasospastic effect of the tumescent anesthetic technique.

Minimally Invasive Ambulatory Procedures

The general therapeutic approach has shifted away from the maximally invasive and much more traumatic surgical high ligation and blind stripping operations of prior decades to minimally invasive ambulatory procedures such as ultrasound-guided thermal ablations (radiofrequency and laser), micro-phlebectomy, ultrasound-guided foam sclerotherapy, and visually guided sclerotherapy of surface veins (reticular and telangiectasia).

Procedures are now much more commonly broken down into several smaller and better-tolerated sessions. We have moved away from the multi-hour surgical tour de force operations that general and vascular surgeons once prided themselves on.

The hope in the proceeding era was to give the patient a comprehensive solution to their problem in one lengthy surgery, but too often came up short of the objective. Now, a staged approach typically yields a far better result, allowing the patient to heal between interventions and for the venous system to decompress somewhat between visits. This approach often yields the least number of procedures required to achieve the best physiological and cosmetic results.

Increasingly nationwide, some centers are implementing 20-30mmHg graduated compression stockings in combination with 1000mg daily of micronized purified flavonoid fraction (MPFF) in all patients with symptomatic venous insufficiency of the superficial and/or deep systems. The addition of MPFF to compression for a positive synergistic clinical effect has been based largely on the research done by Dr. Monika Gloviczki, and others and is now recommended by the American Venous Forum in their current guidelines.⁹

Venous Caregivers

In addition to these three major clinical advancements, we have also experienced a somewhat unprecedented convergence of many medical subspecialties taking part in interventional venous disease. We now see interventional cardiologists, interventional radiologists, general and vascular surgeons, and physicians from innumerable fields (internal medicine, OBGYN, anesthesiology, etc.) treating patients with venous insufficiency in the outpatient setting where very little regulation and oversight exists outside of hospitals.

This highly varied group of physicians each brings their own training, experience, background, and clinical skill set to the field. This has naturally led to some disagreement amongst the different groups regarding acceptable and standard approaches to managing this challenging patient population.

To bring a sense of uniformity and evidence-based care to patients in the United States, the American Venous Forum has published guidelines in the Handbook of Venous and Lymphatic Disorders.¹⁰ Edited by Drs. Peter and Monika Gloviczki, et al., this book has rapidly become recognized as an invaluable textbook on the treatment of venous diseases in The U.S. and beyond. The guidelines are now coming into their fifth edition (anticipated publication in late 2023).

The American Vein & Lymphatic Society (AVLS) has also been at the forefront of venous and lymphatic education in the United States since its inception as the North American Society of Phlebology (NASP) in 1985 under the initial leadership of Dr. Anton Butie.¹¹ The NASP became the American College of Phlebology (ACP) in 1997. The AVLS is now preparing to publish its fourth edition of Fundamentals of Phlebology later this year.¹² This is sure to be another indispensable addition to the library of any clinician dedicated to the contemporary management of patients with vein and lymphatic disorders.

Another major advancement in achieving the highest quality of patient care in the U.S. has been initiated by the Intersocietal Accreditation Commission (IAC). This entity has developed a vein center accreditation process in the U.S., which is meant to serve as a quality improvement and assurance mechanism.¹³ This program has been in place for nearly ten years, and it would seem it has been met with less than enthusiastic response. Unfortunately, at this moment, of an estimated 3,500 independent vein centers in the country, only 215 have achieved IAC Vein Center Accreditation status. It should also be noted that to achieve IAC Vein Center Accreditation, the vein center must either possess or utilize an IAC Accredited Vascular Laboratory for its diagnostic venous studies as well.¹⁴

The IAC “Standards & Guidelines for Vein Center Accreditation” list the standard minimum requirements necessary for superficial venous evaluation and management accreditation and accountability. The guidelines are not requirements but merely helpful descriptions or examples that further highlight and help translate the standards. Accreditation is based on primary categorized procedures; secondary capabilities do not qualify for accreditation and are not considered mandatory practice.

The facility must be capable of providing at least two of the four following primary procedures:

• Sclerotherapy
• Ambulatory phlebectomy
• Saphenous vein ablation
• Wound care

We would be remiss if we did not also mention the importance of the efforts made by the American Board of Venous and Lymphatic Medicine (ABVLM) established in 2007 to “improve the standards of medical practitioners and the quality of venous disorders and all aspects of venous disease.”¹⁵ The Board, not yet recognized by the American College of Graduate Medical Examiners (ACGME), also seeks to:

• Serve the public and the medical profession by establishing initial and continuing qualifications for certification and maintenance of certification as physician specialists in the practice of venous and lymphatic medicine.
• Establish educational standards for teaching and training programs in venous and lymphatic medicine.
• Examine physician candidates for certification and maintenance of certification in the practice of venous and lymphatic medicine.
• Award certifications in phlebology to candidates who meet the established requirements.

Expansion of Minimally Invasive and Outpatient Treatment for Venous Disease

The treatment of superficial venous insufficiency in the U.S. has exploded in the last 20 years as minimally invasive and outpatient treatment has opened the field to physicians from various training backgrounds. In some ways, the impact of this expansion has been great, as many more patients in need of venous care are receiving it. On the other hand, this care must somehow be monitored. An evidence-based standard of care and quality assurance measures must ultimately be put in place to protect patients and ensure that proper treatment remains the rule rather than the exception.

Conclusions

We hope you have enjoyed this virtual visit to selected vein practices worldwide. If this journey gave you some ideas, or inspired reflections on your own experiences in venous patient care, then we accomplished our mission. We found several common points in these comments. Venous medical practice worldwide is currently almost exclusively in the hands of private practitioners.

This shift brought the issue of the educational system adaptation, as the academic institutions that that have traditionally provided medical education and training are left with little or no expertise in chronic venous disease. Another issue that arises is the need for quality and quantity control of the booming network of vein clinics. Ultimately, this question is at the forefront: How can the best care be provided to patients with venous disease? In this era of rapid development of phlebology, we should be able to find the correct response adjusted to the specificity of each country.

References:

1. HAS. Occlusion de veine saphène par laser par voie veineuse transcutanée. Actualisation de l’évaluation conduite en 2008. Mis en ligne le 21 décembre 2016. www.has-sante.fr https://www.has-sante.fr/upload/docs/ application/pdf/201612/rapport_laser_endoveineux_vd.pdf
2. Rapport de l’assurance maladie sur les charges et produits pour l’année 2013. Constats. Page 22; http://www.securite-sociale.fr/Rapport-de-l­Assurance-maladie-sur-les-charges-et-produits-pour-l-annee-2013
3. Guex JJ, Mariani F, Maleti O, Hamel-Desnos C, Vasdekis S, Staelens I, Urbanek T, Traber J, Vuylsteke M, Klitfod L, Mansilha A. European training requirements in phlebology. Int Angiol; 2019 Oct;38(5):345-364. doi: 10.23736/S0392-9590.19.04188-9.
4. Hamel-Desnos C., Miserey G. Varices saphènes et récidives. Traitements d’occlusion chimique ou thermique dans l’insuffisance des veines saphènes et des récidives. Phlébologie 2018, 71 (3):1-8
5. Hamel-Desnos C. Choosing Wisely in France, for the Treatment of Saphenous Vein Insufficiency and Recurrences. Phlebologie 2022; 51: 183–186
6. See 1
7. Arrêté du 7 janvier 1993 relatif aux caractéristiques du secteur opératoire mentionné à l’article D. 712-31 du code de la santé publique pour les structures pratiquant l’anesthésie ou la chirurgie ambulatoire visées à l’article R. 712-2-1 (b) de ce même code. https://www.legifrance. gouv.fr/ affichTexte.do?cidTexte=LEGITEXT000006080858
8. Sandor T, Bihari I: The development of phlebology in Hungary. International Angiology 32(1):102-109 (2013)
9. P Gloviczki et al. Handbook of Venous and Lymphatic Disorders. Guidelines of the American Venous Forum. Fourth Edition 2017
10. See 9
11. Goldman, M. P., MD. (2017, October 26). Mentors who made me: Anton Butie, MD, founder and first president of the American College of Phlebology. Vein Magazine, A Publication of VeinDirectory.org. https://www. veindirectory.org/magazine/article/featured-doctor/mentors-who-made­me-anton-butie-md-founder-and-first-president-of-the-american-college­of-phlebology
12. Forrestal, M., MD, FACPh, & Neuhardt, D., RVT, RPhS (Eds.). (2014). Fundamentals of Phlebology (3rd ed.). American College of Phlebology.
13. Intersocietal Accreditation Commission. IAC Standards & Guidelines for Vein Center Accreditation: Superficial Venous Evaluation and Management. October 2013
14. IAC website. Intersocietal.org/programs/vascular-testing/standards
15. Overview. (n.d.). ABVLM, The American Board of Venous & Lymphatic Medicine. https://www.abvlm.org/about_us.php

Acknowledgement from Dr. Claudine Hamel-Desnos: The author thanks P Goffette, former president of the National Union of Vascular Physicians (SNMV) and the ISPL (Statistical Institute of Private Health Professionals) for providing data on national statistics.