Dr. Garth Rosenberg is a co-founder of the Maryland Surgical Care Center in Frederick, Md. Dr. Rosenberg is a board certified General Surgeon and fellowship trained Vascular Surgeon. He received his medical degree from Case Western Reserve Medical school and completed his residency at The Medical College of Virginia. He then completed a Vascular Fellowship at Scripps Clinic and Research Foundation in San Diego. Dr. Rosenberg provides comprehensive care for patients suffering from a range of vascular diseases, with a special interest in vein disease.
Dr. Rosenberg talks with Veins1 about a revolutionary new procedure for treating venous reflux in the saphenous vein, the VNUS closure procedure. Superficial venous reflux develops when the valves that keep blood flowing in the proper direction through the saphenous vein become damaged or diseased. Patients suffering from this condition can experience pain, swelling, and varicose veins in the affected leg. Traditionally, this condition has been treated by surgically removing the saphenous vein. While saphenous vein stripping is still widely used and is successful in treating superficial venous reflux, there is often a lot of pain and disability associated with the procedure. The VNUS closure procedure is a new, minimally-invasive alternative that closes the vein rather than removing it and accomplishes the same end results.
Veins1: What areas do you specialize in at your practice?
Dr. Rosenberg: Maryland Surgical Care was started in January 2000 by Dr. Paul McNeill and myself. We are board certified in general surgery and fellowship trained in vascular surgery. We specialize primarily in vascular, arterial and venous disease, and we also do some general surgery such as gallbladder surgery, appendix surgery, and colon cancer surgery. About 95 percent of what we do is vascular work.
Veins1: With such a strong focus on vascular surgery, do you see a large number of patients suffering from superficial venous reflux? Which symptoms are common in these patients?
Dr. Rosenberg: We frequently see patients with superficial venous reflux of the lower extremities. The reflux primarily occurs in the saphenous vein and tributaries from the saphenous vein. Patients suffer from a broad range of symptoms. Some patients have very mild or almost no symptoms at all. These people come in with cosmetic issues but no pain, burning or discomfort. Then there are patients at the other extreme. These patients have disabling pain and chronic ulceration of the ankles caused by the varicose veins. Some of the common symptoms for the people in the middle range are burning and itching along the veins, heaviness of the legs, discomfort when the veins are touched or bumped, and ulcers of the ankles.
Veins1: When a patient comes in suffering from one or more of these symptoms, how do you evaluate their level of the disease?
Dr. Rosenberg: When patients first come in, we do a comprehensive history and physical examination. Next we will do a simple bi-directional Doppler to assess valvular incompetence and direction of blood flow in the veins. Many times we will proceed with a duplex scan of the symptomatic leg(s). The duplex scan looks at the deep veins and the superficial veins to see where the reflux is occurring.
Veins1: When did you first start using radio frequency endovenous ablation and the VNUS Closure procedure to treat superficial venous reflux?
Dr. Rosenberg: This past summer. We discovered it at a national venous meeting in New York. Several of the nationally recognized speakers were commenting on the benefits of the VNUS closure procedure. That is when we decided to investigate it further.
Veins1: What procedure does the VNUS closure replace?
Dr. Rosenberg: It primarily replaces saphenous vein stripping.
Veins1: What are the advantages of the VNUS closure over the old procedure?
Dr. Rosenberg: The VNUS closure will achieve the same end result as the stripping will: It eliminates any flow through the greater saphenous vein. Where stripping actually removes the vein from the leg, closure does not remove it, but seals it off so there is no more flow going through the vein. Functionally, the end result is the same, with much less patient discomfort and disability. The revolutionary treatment with the VNUS closure eliminates a hospital or surgical center and it eliminates spinal and general anesthesia. It is done through one small incision in the lower leg and there is no bruising or discomfort in the thigh because the vein is not physically removed from the leg. The vein remains in place and is basically destroyed by the radio-frequency heat that is generated. So the patient can get up off the exam table and go about normal routine daily activities the same day.
Veins1:What factors do you consider when determining whether the closure procedure is right for a patient?
Dr. Rosenberg: First we determine if the patients have any co-morbid conditions, that is any other disease that the patient may have that would be an influencing factor. Usually, there are not many of these. We find out about any previous surgery the patient has had in the leg, whether it is vein surgery or any other type. We look at the anatomy of the saphenous vein. These factors are then weighed with the duplex examination. The duplex is really the road map that guides us to determine if 1) the VNUS closure procedure is possible and 2) what difficulties we may encounter along the way.
Veins1:How does the closure procedure work?
Dr. Rosenberg: The duplex ultrasound technician will first map the vein, and see from the groin to the lower leg the exact position of the saphenous vein as well as any branches coming from it. Then the nurse will prep and drape the leg and a portion of the inner thigh is exposed. Then under duplex ultrasound guidance, we will numb up the leg right near the knee and make a small (less than 1inch) incision near the knee. The saphenous vein is brought up from the leg into the incision itself with a small hook device. The whole process is painless. We make a small incision in the vein itself and then put a sheath followed by a catheter. The catheter travels up the saphenous vein from the knee to the groin. This is all mapped out on Duplex scanning so we can see what is going on throughout the whole procedure.
When the catheter is in the correct position, as determined by the duplex scan, we turn on the energy through the catheter and the energy is converted to heat. The heat passes through electrodes that contact the wall of the vein and heat up the vein itself. This destroys the proteins in the vein, causing it to collapse so that it no longer has flow going threw it. The vein will constrict down so that it is almost like a string rather than a tube with blood going through it. All of this is done under local anesthesia. It is very well tolerated with very minimal discomfort by the patient. After the catheter is removed, we image the veins again with the Duplex scanner to be sure that the vein is indeed closed. When it is closed we pull the sheath and the catheter out and put a tiny stitch in the skin at the knee. The patient get up and walks away.
Veins1:Once the diseased vein is closed, what happens?
Dr. Rosenberg: First it is important to understand that the normal blood flow in the vein is from the lower leg to the upper leg and then up towards the upper body and heart. When the valves are not working properly and there is reflux in the veins, the blood will flow in a backwards fashion. When that happens over a long period of time the veins below the diseased vein tend to dilate, causing further varicose veins and the symptoms we talked about earlier. Over a long period of time, vein disease can cause ulcers of the ankle. By closing the saphenous, the origin of the reflux will be eliminated and will decrease the venous pressure in the lower leg veins.
This will do a couple of things. First, if the patient has lower leg varicose veins, it can make them much less symptomatic, much less painful and discomforting so that they may not need treatment down the road. Secondly, if the patient has an ulcer of the ankle it can reduce the venous pressure at the ankle, allowing the ulcer to heal more quickly and also reduce the recurrence rate. Finally, the general fatigue, aching and itching of the lower leg can be markedly reduced by treating the origin of reflux in the greater saphenous vein.
Veins1: Once the greater saphenous vein has been closed, how does the blood circulate through the leg?
Dr. Rosenberg: Once the vein has been closed, the blood circulates through the leg through many other veins in the lower leg which compensate for the diseased vein. The blood is shunted through working veins with competent valves.
Veins1: Is this procedure performed in conjunction with any other procedures?
Dr. Rosenberg: In some cases, although not on the same day. Once the saphenous vein has been obliterated the lower leg veins can often be treated very easily with a procedure such as TriVex for varicose veins. In a majority of patients, not only is VNUS performed but TriVex is performed at a later date. Many patients who have a lot of varicose veins in the leg wonder why the calf veins can’t just be treated because those are the ones that are bulging and cosmetically look the worst. The problem is that a majority of these patients have saphenous reflux Therefore, the effective treatment is to start high and work low.
Veins1: How long is the average recovery period and when can patients resume normal activity?
Dr. Rosenberg: The recovery period is less than a day. Once the patient is off the exam table they are perfectly free to go about normal daily activities such as working, going shopping, go out to eat or anything of that nature. For something that involves heavy leg activities, such as running or lifting weights, we usually tell patients to wait a week to allow the saphenous vein to fully close before jarring it with the pressure of these sports activities. But if someone’s normal activity involves sitting at a desk job, they can go back to it that the same day or, at the latest, the next day.
Veins1: What advice do you give to your patients to help assure a quick and full recovery?
Dr. Rosenberg: We ask patients to wear compression stockings for about a week. After which, depending upon what other venous problems they might have, they made need a support stocking on regular basis. They come back one week after the VNUS procedure for a follow up Duplex scan. The purpose of this is to ensure that the vein is indeed closed and also to ensure that there are no complications such as clots.
Veins1: What feedback have you gotten from patients about this procedure?
Dr. Rosenberg: The patients are thrilled because they know the alternative procedure is saphenous vein stripping. Many patients have family members or friends who have had veins stripped in the past. These people know that while patients recover well from vein stripping, there is usually a lengthy recovery time associated with it as well as pain and disability. This is why patients are thrilled that they do not have to go through the disadvantages associated with veins stripping. They are very happy that the leg is feeling much better after the saphenous reflux is treated. Since we never treat both legs on the same day, the people who need both legs done come out of the first procedure very anxious to schedule the next one and can’t wait to do it because the first procedure was so wonderful for them. There is no hesitancy to undergo the procedure on the second leg.
Veins1: How long do patients have to wait to have the second leg done?
Dr. Rosenberg: Patients can have the second leg done two weeks after the first. This leaves enough time for the first leg to heal completely.
Veins1: Do you foresee VNUS taking over traditional vein stripping once more doctors begin to learn about it?
Dr. Rosenberg: Absolutely. It is just a matter of time until most physicians have abandoned the traditional method of saphenous vein stripping.
About Maryland Surgical Care
The doctors of Maryland Surgical Care pride themselves on providing the best care and compassion for their patients. Their practice is designed around the patient and family, emphasizing convenience, warmth, and communication in every encounter. They also recognize that continued growth and innovation are keys to the success of the practice. That is why Dr. Rosenberg is constantly on the cutting edge of technology, researching and receiving training in the newest products available in surgical care.