Dr. Marius Saines attended Medical School at Brussels University, Belgium, and completed his training in General Surgery at Mount Sinai Hospital, New York Infirmary Hospital and New York University Hospital. He then completed a Vascular Fellowship at the University of Southern California. Dr. Saines has been in private practice for over 20 years and holds three US patents for medical devices he invented. He is a member of the International Society of Endovascular Specialists, and served a two-year term as Chairman of Surgery at Centinela Hospital, Inglewood, California.
Dr. Saines talks with Veins1 about an important new procedure that is now available to treat varicose (abnormally swollen) veins, a condition in which poor circulation produces visible bulging of surface veins on the leg. Generally, defective valves in these veins send blood back into the vein instead of toward the heart, causing dilation and discomfort. The only cure is surgical removal of the affected veins. Traditional surgeries such as "stripping" or the use of "hook" probes are effective, yet time-consuming and invasive. Dr. Saines is one of the first specialists trained in the new, minimally invasive TriVex System, designed for use during a patented, clinically tested surgical technique for varicose vein removal called transilluminated power phlebectomy.
Veins1: Doctor Saines, let's begin with an overview of varicose veins. What causes these swollen vessels, and why in the legs?
Dr. Saines: As you may know, the venous system depends on valves to direct blood flow, while the heart’s muscles act as a pump to move the blood. To maintain the flow of blood in one direction, from the feet up to the heart, there is a system of multiple valves so the blood will not yield to gravity. So when the valves don’t function well, either because they break or because congenitally we were born with weak valves, or after pregnancy, when the baby is pushing on a vein, the flow is temporarily blocked. Then the vein dilates, and the valves lose their competence. The majority of varicose vein patients are women. Women’s valves will become incompetent as a result of pregnancy.
That is one typical mechanism that causes varicose veins. Another is trauma to the vessels brought about by impact-type accidents, or typically a highly vigorous exercise-type situation. We see a dramatic example in paratroopers, who make repeated landings with such force that they risk breaking a leg, not to mention vessels and valves. It’s the repetition of the impact and trauma that leads to the breakdown of the valves in this case. This is another category of patients who have varicose veins, or "varices" as they are called medically – the plural of "varix."
Veins1: Varicose veins are unsightly, as everyone agrees. But what are the actual health risks if they go untreated?
Dr. Saines: When they become prominent, when they can be seen through the skin, and the diameter goes beyond four to five millimeters, varicose veins will create an unpleasant feeling - burning or tingling or dull pain after you’ve been standing for several hours. If the area is left untreated, a condition called induration with hyperpigmentation sets in. In other words, the skin becomes harder and turns darker around the varices. Then, swelling of the calf or thigh occurs. And then, perhaps a year or two down the road, the patient may end up with an ulcer.
Veins1: After veins are removed, how does the surgeon ensure that proper circulation is restored?
Dr. Saines: There are basically two venous systems in the leg. The one that we treat is called the superficial system - the one we can see on the surface. The main system for drainage, which is located deep in the calf, is called the deep venous system. The most important transport returning blood to the heart goes through the deep system. When the superficial system is removed, there is no significant effect; the deep system will continue to do its work. In fact, in a healthy system we often remove the saphenous vein in the superficial system and use it for a bypass for the leg or the heart.
Veins1: So an entire venous system is removed at once?
Dr. Saines: Yes. If the valves are not good in the superficial system, then we just remove the entire system.
On the other hand, there is another secondary system that may be involved. In fact, there are communications between the two systems called perforators, rather like the rungs of a stepladder. A varicose condition that sometimes goes unrecognized is produced when the valves in the "stepladder" don’t work. Then you start having huge varices in the calf, with normal veins above.
If we make the diagnosis that the valves in the superficial system are functioning normally but the system is nevertheless receiving too much reverse blood flow because the valves in the perforators are not working well, then we direct our surgery for that type of pathology. In other words, we go in and block the perforator so that the blood will not go out from the deep system into the superficial system.
It all depends on the diagnosis. In the majority of cases, we remove the superficial system with its clusters of varicosities. If the perforators are involved, then we block the perforators.
Veins1: At what point do you determine that the perforators are involved? Is it during actual surgery?
Dr. Saines: No, we do preliminary testing to find the cause. It may be the valves in the groin, those in the superficial system, or those in the perforators. We use a special form of ultrasound called duplex to make the diagnosis. This ultrasound reading detects reverse flow, and we can determine the cause depending on where this is occurring.
Duplex ultrasound technology is not available in many hospitals. In that case we take an x-ray called a venogram that shows the perforators in a concrete illustration.
Veins1: How do you determine the extent to which the disease has progressed?
Dr. Saines: Basically, we can tell by examining the size of the varicosities and the appearance of the surrounding tissue. If the patient comes in early, I see the large varicose veins and I find that the tissue is still soft. When the patient neglects the condition and waits before coming in, as many do, then if I see a great deal of ulceration I may decide to treat it in stages. First I remove the varices, then allow the ulcer to heal temporarily. Then I go under the ulcer and block the varices there.
Veins1: So obviously you advise patients to come in early if they are showing symptoms.
Dr. Saines: That’s right.
Veins1: Initially in your career, you began with the traditional procedures that are still used to remove varicose veins. Can you characterize "vein stripping" and the use of "hook" probes, for example?
Dr. Saines: Those are the classic methods. Twenty years ago, we were practicing stripping and not much more. Stripping involves inserting a length of wire along the vein and then pulling it out, removing most of the vein with it. Then the "hook" technique was developed. We would still perform the stripping if it was needed, but then also treat the clusters by making multiple skin incisions – little cuts near each varix, through which we grab the vein with a hook and pull it out, cut out the varicose segment, and then tie the remaining vein at both ends.
Veins1: What drawbacks did you encounter in the traditional techniques?
Dr. Saines: The old technique is extremely time-consuming, The patient spends a long time in surgery and the work is very tedious for the surgeon to perform. In addition, the process leaves a great number of scars, which is unpleasant. When the disease is extensive, we’re talking about 20 to 30 incisions. For the patient, recovery is slow and painful. And there’s always the possibility that the removal was incomplete, because these are "blind" processes.
Veins1: You are not only an experienced vascular surgeon, but also an inventor and a certified master instructor. How early in your career did you become involved with using new technologies to cure varicose veins?
Dr. Saines: I always liked to find new devices. About six years ago a new endoscopic device was introduced to treat perforators. I started treating perforators with it instead of the using the classic procedure in which we really have to filet the whole calf in order to get down under the fascia. Today endoscopy is the new technique in surgery, allowing us to make only tiny incisions and practice minimally invasive procedures.
Then almost four years ago, I became interested in the new TriVex system developed by Smith & Nephew. I was fortunate to be contacted early by the company and became one of the first to be trained in it. I performed a large number of procedures among the substantial population of varicose patients whom I treat. As my learning curve progressed, we began to discuss spreading knowledge of the new technique among surgeons.
Veins1: And this professional training is what you now do, in addition to your own practice?
Dr. Saines: That’s right.
Veins1: Could you clarify the interrelation between the new technique itself and TriVex, which is described as a system designed to implement the new technique?
Dr. Saines: The medical name for the surgical technique itself is transilluminated power phlebectomy. "Transilluminated" means that light is passed through the skin and "phlebectomy" means vein removal. TriVex is the commercial name of the equipment that we use to do that kind of procedure.
Veins1: Could you describe how the system is actually used in surgery?
Dr. Saines: Basically, we are using a very small fiber-optic light, no more than four millimeters in diameter. This mini-camera is equipped with a fiber-optic light and a tiny channel carrying a solution containing anesthetic and a medication which produces vasal constriction.
When we place this light beneath the varices, we can see their shape traced on the surface, rather the way that lighting allows you to see silhouette puppets behind a curtain. We can see the location of the varicose veins directly. Then another four-millimeter incision is made on the opposite side, to admit a probe which is tipped with a high-speed turbine. Having located the varices exactly, we place the probe on the varix. The turbine rotates at about 1000 rpm and acts like a Pac-Man, if you remember the old computer game - the little fellow who eats everything in his path. We follow the varix under the skin with the turbine-tipped probe. The turbine grabs the varix wall, morcellates it, aspirates it, and it’s completely gone.
Veins1: What are the advantages of TriVex over the old procedures?
Dr. Saines: To treat a very large amount of varicosities takes an average of approximately half an hour using the TriVex system. That’s about 4 to 5 times shorter than the classic "hook" operation. You have minimal scarring – perhaps four or five tiny incisions on the whole calf and they do not require stitches.
Veins1: How short is a typical recovery period, compared with traditional surgery? How soon can patients resume normal activity?
Dr. Saines: People usually go home the same day and are often able to walk after a period of resting with the leg up. They don’t have much discomfort because the solution under their skin contains anesthetic. After three days, they take off the bandages. For another week, they wear an elastic stocking to reduce swelling. When the stocking comes off, it’s all done! The pain is gone after one to two weeks. It takes two to three weeks for all scarring and bruising to go away.
Veins1: What feedback have you gotten from patients about this procedure?
Dr. Saines: The majority of people are very happy. Many of my patients have volunteered to put their signed testimonials on my web site.
Veins1: How long do patients have to wait to have the second leg done?
Dr. Saines: In cases where there is an incompetent saphenous vein, we still perform the classic "stripping" from the groin to the knee, in conjunction with the TriVex system. If I have to do all that, I prefer to treat just one leg at a time. In cases where I have a simple phlebectomy, because a vein still has good valves and only secondary varices have developed because of weak valves in the branches, then I could do both legs at once.
My preference is to treat one leg at a time, so that the patient can walk using the opposite leg as the main support, and then treat the opposite leg one month later. In cases where I have treated both legs at once, the recovery lasts a similar period but the patient needs to be less ambulatory and keep the legs elevated during more frequent periods of rest.
Veins1: Is the new technology advantageous in treating patients of an advanced age?
Dr. Saines: Basically, our decisions in treating the older population are based on the kind of anesthesia that we would have to give them. Since TriVex employs short-term anesthesia, it’s a big advantage for the older population. TriVex is the procedure of choice for elderly patients.
Veins1: Do you foresee these new technologies replacing traditional treatment as soon as enough doctors learn about it?
Dr. Saines: I think that the majority of people are gradually coming onto the learning curve. First of all, primary care providers need to understand that neglected varicose veins are a disease with complications. Some health care systems might save money by recommending elastic stockings to contain the swelling, but that only brings partial relief of the symptoms, it doesn’t treat the cause. The more doctors and caregivers recognize that this is a disease requiring treatment – and that this new treatment is faster and more efficient – then the new system will be more widely recognized.
On the Web: http://varicoseveindoctor.com