Dr. Merchant has spent the past 10 years developing a vein practice at the RENO VEIN CLINIC in Reno, Nevada where he focuses primarily on the treatment of vascular diseases of the vein and skin. He launched a comprehensive treatment program called PROREJUVENATION® which is a unique program that emphasizes several key elements in the overall management of venous and vascular skin disorders: accurate diagnosis utilizing modern techniques and providing safe treatments with excellent outcomes. He is recognized by physicians’ worldwide as being a leader in the development of the FDA-approved Radio Frequency Closure procedure as a treatment for varicose veins. This procedure is incorporated in the Reno Vein clinic’s Prorejuvenation® treatment program along with services including Ambulatory Phlebectomy , Sclerotherapy and Laser Therapy.
Dr. Merchant is an active member of the community having served on the Board of Directors for the Nevada Bighorns Unlimited, the Reno Rodeo Association, and the Boy Scouts of America, Nevada Council. He also served on the Washoe County Medical Control Board while it was active.
Veins1: What lead to your interest in venous and vascular skin disorders?
Dr. Merchant: I’m a vascular surgeon, fellowship trained at the University of Arizona, and am a member of various vascular surgery organizations which include the American Venous Forum and the American College of Phlebology. Early in my career treating all aspects of vascular disease, arterial and venous, I developed an awareness of the extent of varicose vein disease in our population. With all its attendant disability, the traditional treatment of Stripping by surgical means left so many of these patients with even worse debility following the severe trauma which accompanied this painful surgery. I decided 10 years ago to limit my practice to treating varicose veins and vascular skin problems to concentrate all my efforts on finding better means to treat these disorders.
Veins1: What is your area of clinical expertise?
Dr. Merchant: Specifically, the treatment of varicose veins with less invasive methods, such as Radiofrequency Closure, limited ambulatory phlebectomies, and sclerotherapy and laser treatments for surface spiders and smaller reticular varicose veins. Here at the Reno Vein Clinic we are unusually good at this because we stress cosmetic principles and techniques which I learned as a surgical resident on the Plastic Surgery program at the University of Arizona, under the guidance of Erle E. Peacock, M.D., an internationally acclaimed plastic surgeon and head of the Surgery program. I am currently board certified by the American Board of Surgery and the American Board of Phlebology.
Veins1: What medical organizations are you active in?
Dr. Merchant: Other than the organizations I have previously mentioned I’m also active in the American Venous Forum’s semi-annual national screening program to identify venous disease in our local community and increase public awareness of the extent of venous disease associated problems, such as venous blood clots and pulmonary embolism. I am also a member of the Society for Vascular Surgery, Western Vascular Surgical Society, and the Rocky Mountain Vascular Surgery Society, as well as the American College of Phlebology.
Veins1: What do you find most gratifying about your work?
Dr. Merchant: The extreme satisfaction of our patients undergoing treatments. We can document 98 percent satisfaction rate for our patients. They are really excited that no one can tell that they had had varicose veins or that any treatment for them had ever been done. It can’t get any better than that!
Veins1: What has helped contribute to your success with patients?
Dr. Merchant: My office staff has been with me for nearly all of the ten years of the Reno Vein Clinic existence. They are thoroughly knowledgeable about the workings of our practice including all insurance issues and the pathways for the patients while they are receiving treatment at the Clinic. They are very friendly and helpful at every step of the treatment, including follow-up of any problems. The quality and continuity of care the patients receive at the Clinic is assured by the nursing staff most of whom have been at the Clinic since 1999. By emphasizing plastic surgery principles in the surgical treatment of venous disease, we can achieve exceptional results and very satisfied patients.
We have a unique approach that we call Prorejuvenation whereby the patient is completely evaluated and treated at the Reno Vein Clinic. A thorough history and physical examination pertinent to venous disease is done at the Clinic. Duplex ultrasound of the lower extremities vein system is performed by the physician at the Clinic, and all treatments, including surgery and post-op sclerotherapy or surface laser for spider veins, are performed at the Clinic. It is a state licensed facility, nationally accredited (AAAHC), where we are authorized to use intravenous sedation as appropriate for the procedure.
Veins1: What is the current standard of care for treating vein disorders?
Dr. Merchant: Varicose veins, including smaller spider veins and reticular varicose veins, are treated for aesthetic and medical reasons. To establish medical necessity, which is necessary for insurance companies to consider coverage of treatments, the presence of symptoms (typically aching, throbbing, burning, itching, swelling, or nocturnal calf cramping) must be present to a significant degree to alter normal daily living activities, and the presence of significant reflux, or vein insufficiency, must be documented by Doppler exam, usually a duplex ultrasound study. The traditional standard of care has been surgical stripping and ligation of the refluxing saphenous vein and its varicose tributaries. This procedure requires a groin incision, the insertion of cable into the saphenous vein, usually the length of the thigh or to the ankle; the offending vein is then forcefully extracted or pulled out of the leg through the groin incision. The results are dramatically effective, but carry a potentially high and serious complication rate, and there is usually a 50 percent five year recurrence rate as a direct result of the surgical trauma in the groin. A satisfactory risk/benefit ratio must be considered in choosing appropriate treatments, whether or not they are alternatives such as sclerotherapy or aggressive surgical stripping.
Veins1: How has this standard changed with new technology? (For example, how has the development of Radio Frequency Closure changed doctor’s approach to vein treatment and patient care?)
Dr. Merchant: The Closure procedure and its successor, the ClosureFAST©, have revolutionized the way varicose veins are now treated. No longer is it necessary to make a groin incision. The ClosureFAST© catheter is inserted percutaneously under ultasound guidance and threaded up the leg to a point near the junction of the saphenous vein with the deep vein. Controlled segmental heating of the vein for short duration along the length of vein accomplishes reliable and durable closing of the vein. Several randomized controlled trials (the highest level research standard) have established the Closure procedure favorably compared to traditional stripping and ligation. The relative risks of the procedure are minor and rare, and the patient satisfaction is 96 percent or greater. There is very little pain associated with the procedure so that the patient usually returns to normal activity within one day, and to work within 4-5 days. As a result of this, the ClosureFAST© procedure is becoming more widespread as the general population becomes more informed and aware of these successes.
Veins1: What procedures do you most commonly do for vein treatment? Are there treatment options available at Reno Veins Clinic that are not available elsewhere?
Dr. Merchant: You may be surprised by this answer, but the most common treatments we perform are non-surgical. Injection sclerotherapy, simple or advanced techniques, e.g. ultrasound guided or assisted, are done twice as often as surgery. We perform our sugery in office-based ambulatory surgery center which is fully licensed by the State of Nevada to perform procedures done under intravenous sedation, or “twilight anesthesia”. Local anesthesia is used along with lose doses of suitable sedation and analgesia to allow us to perform the ClosureFAST© procedure along with any necessary ambulatory microphlebectomies, or direct removal of large varicose veins through micro-incisions, not to be confused with “stripping”. How it’s done is a Reno Vein Clinic secret (see number two above).
Veins1: Can you share an example of a particularly satisfying case?
Dr. Merchant: There are too many to single out anyone. It is very typical that patients, women and men, may first be seen wearing long skirts or pants at the initial consultation, but to be seen one month subsequent to treatment are wearing shorter skirts or plain shorts.
Veins1: What are some of the issues that interfere with patients obtaining care for their vein disorders?
Dr. Merchant: Probably the most pressing issue is establishing insurance coverage. Insurance has traditionally covered stripping and ligation performed in hospitals or ambulatory surgery centers, but not in physicians’ offices. This can limit the patient’s access to appropriate high quality care as they opt for less expensive alternatives with less satisfying and potentially dangerous outcomes.
Veins1: How is the economic downturn affecting patients getting care for their vein disorders? Do you have any suggestions on improving access for such patients?
Dr. Merchant: We have seen an actual increase in the number of new patient consultations compared to 2008, however, the number of those selecting surgical treatments has not changed (probably because we increased our number of insurance contracts). The number of non-surgical treatments has leveled off during the summer months, as it usually does. We have introduced novel financial options, e.g. Care Credit, attempting to improve patient access; we’ll see if it works.
Veins1: What other advice do you have for consumers with vein disorders?
Dr. Merchant: More and more patients are seeking treatment now as the word is beginning to spread that endovenous (inside the vein) thermal (heat) ablation treatments are less risky and less painful than traditional stripping. In my opinion, the tremendous advantages of thermal ablation techniques, whether Radiofrequency or laser, are such that traditional archaic stripping should be relegated to the dust-bin of discarded medical treatments.
Veins1: Are there any additional comments you would like to add?
Dr. Merchant: With the newer techniques of treating varicose veins reaching such an acceptable risk/benefit ratio, many experienced vascular surgeons are beginning to advocate widespread application to prevent the complications of longstanding untreated venous insufficiency, e.g. blood clots, bleeding, skin breakdown.