By Lilly Manske, Veins1 staff
Dr. Steven Elias travels throughout the United States to teach other vascular surgeons how to utilize new minimally invasive technology to treat vein disease. The two new minimally invasive techniques are SEPS (subfascial endoscopic perforator surgery) for non-healing venous ulcers and TriVex (Transilluminated varicose vein excision) for the removal of varicose veins.
Dr. Elias dedicates his medical career to the overall care of vein disease. As a surgical resident, he gained experience in vein-valve transplant surgery to repair malfunctioning vein valves in the deep venous system. As a practicing vascular surgeon, he utilizes his experience with SEPS to improve abnormally functioning perforating veins. While running a full-time private practice, he also conducts clinical research. He has published his studies aiming to bridge the gap between academic and clinical vascular surgery.
Veins1: How did you first become interested in vein surgery and treatment?
Doctor Elias: As a surgical resident in Buffalo, I worked with one of the surgical attendings who was beginning to do a procedure called vein-valve transplant for people with poorly functioning valves of the main veins in their leg. Working with him as a first-year resident and throughout the next five years, I developed an interest in vein disease and the patients with this chronic, long-standing problem.
Veins1: What is the focus of your private practice?
Doctor Elias: Approximately 75 percent of my private practice deals with all aspects of vein disease, from people with small spider veins or varicose veins, to those who have ulcers and non-healing wounds in their legs.
Veins1: What is SEPS or subfascial endoscopic perforator surgery? Can you explain this procedure?
Doctor Elias: It is a relatively new way (we’ve been doing it for last five or six years) of performing an old procedure on poorly functioning veins. People with this problem had ulcers or non-healing wounds down by the ankles. This operation requires two tiny incisions up by the knee, as opposed to the old method of having a very long incision down by the ankle. The incision used to go through the affected area, which was also much more painful. Now the incisions are higher up in the leg in good healthy skin. We look under the skin (that’s why it’s called subfascial), with an endoscope (a little camera). Perforator refers to the name of the type of vein on which we are working; hence the name SEPS. Normal perforator veins direct blood from the skin to the deep veins inside the muscle and back to the heart. What happens in patients who get these ulcers is that instead of the blood going from the skin to the muscle veins, it flows back out towards the skin and puts pressure from under the skin and continues until the skin ulcerates.
Veins1: What condition is the SEPS procedure used to treat?
Doctor Elias: It treats venous insufficiency. Typically, people will have dark, thickened, tender skin, and/or non-healing sores or ulcers by their ankles. Sadly, the majority of these patients have the sores present on the average for 13 months before they seek treatment. They have been dealing with this wound for over a year.
Veins1: Are the wounds primarily in the ankles, or does it affect all parts of the leg?
Doctor Elias: It really is down by the ankle, the area where gravity causes the most amount of pressure on the skin from the poorly functioning veins. It occurs mostly on the inside of the ankle but it can also be on the outside of the ankle.
Veins1: Is it common for a person with varicose veins to develop ulcers?
Doctor Elias: In a person who has pure varicose veins and normal perforator veins and normal deep veins, the chances are relatively low. Usually a person who develops an ulcer has a problem with the perforator veins as well as varicose and deep veins.
Veins1: How many people suffer from these ulcers?
Doctor Elias: Nearly half a million people have some type of ulcer that develops over the course of their life. Varicose veins are much more common—millions of people have that condition. Varicose veins are not as severe, although their symptoms of aching, heaviness, and swelling, do significantly affect a person’s lifestyle. For varicose veins, I use the TriVex procedure. Ulcers, on the other hand, are at the end stage of vein disease.
Veins1: How does the SEPS vary from the older procedures?
Doctor Elias: It is less invasive and less painful because we are using smaller incisions up by the inner part of the knee where the skin is healthy. Patients are in and out of the hospital in the same day as opposed to two to three days—another advantage. Also, the complication rate is around 1 percent, whereas the old method had a complication rate of almost 30 percent.
Veins1: What age group generally receives this treatment? Does this venous insufficiency primarily affect the elderly?
Doctor Elias: The average age of the first 25 patients I had was actually 59; that has held up in well over the next 100 patients. The age of my patients ranges from the late 20s into the early 80s. It affects all ages.
Veins1: How does this procedure improve the quality of a patient’s life?
Doctor Elias: Patients have had these ulcers for an average of 13 months. Many have had these off and on for five, 10, or 15 years and have had to take care of these ulcers on a daily basis, changing the dressings and dealing with the pain and discomfort. The average healing time is six weeks and, of course, they no longer have to take care of their wounds anymore. There is a big improvement in patient’s quality of life.
Veins1: How would you rate the success of SEPS?
Doctor Elias: With SEPS, we have followed patients for up to five-years. Such a procedure will allow on the average, around 80 percent of the patients have had ulcers during the course of their lifetime to remain ulcer free after surgery. Without surgery, almost all would have a reoccurrence over a lifetime.
Veins1: When do you expect this procedure to become the industry standard?
Doctor Elias: I think it now has become the industry standard because almost no one has performed the older procedures in the last five years.
Veins1: Do you teach other technologies besides SEPS?
Dr. Elias: We hold teaching courses on SEPS and surgeons come to visit to see me perform surgery. Then I go to their hospitals to proctor them with their first cases if they wish. I also teach the new TriVex procedure, or transilluminated powered phlebectomy. In addition, I teach the use of the laser for the small spider veins.
Veins1: How do you think your studies have bridged the gap between academia and clinical vascular surgery?
Doctor Elias: My clinical studies show that you do not necessarily have to be a pure academic to do studies or to utilize new technologies. It allows practicing vascular surgeons to see that someone in clinical, private practice can do these types of procedures and demonstrate that it works in real patients. I have done over 130 SEPS procedures on patients who have come from my private practice.
Veins1: Do you see any new technologies emerging in treatment of vein disease?
Doctor Elias: We are beginning to work on taking care of the deep veins inside the muscle. These veins do most of the work. That’s where I started years ago in terms of doing vein-valve transplant in which surgeons transplant a valve from a person’s arm vein down to their leg vein to get a good functioning valve. We are working on ways to utilize valves or veins from cow veins (similar to a heart valve transplant) and putting those veins into humans again with minimally invasive surgery. We are developing techniques to use tiny wires, instead of incisions, to go down into the valves in those veins and place normal functioning valves.
Veins1: Do you think that the assumption that vein disease is often cosmetic is erroneous?
Doctor Elias: I think it is. Although it can be cosmetic, the majority of times it is a combination. With the very small spider veins, I think it is cosmetic. When you are dealing with larger varicose veins, the complications of veins such as the ulcers and the wounds, it is not a cosmetic problem. Peoples’ legs feel heavy, aching, and swollen at the end of the day. It affects their ability to work. With the exception of spider veins, varicose veins do have some element of symptoms.
Veins1: What is the greatest benefit of these new minimally invasive vein technologies?
Doctor Elias: Physicians erroneously think asking a patient to wear heavy supportive stockings can eliminate vein disease and is the only solution. It is important for the public to know that we now have a number of minimally invasive techniques that will allow them to take care of their vein disease permanently. They will have to wear stockings for a lot less time. I think that even in the general medical community they are not aware of the types of modern techniques. It is important to talk to internists to let them now what is available. Getting the word out is the key. These procedures have relatively low complication rates and very good results. Not perfect, because when you are dealing with the veins it is hard to be perfect, but much better than not taking care of the veins.
Now, people are more active—including older people. Wearing stockings at the age of 70 for the rest of their life does not fit into the lifestyle of many people. Giving them an alternative to compression stockings is a very worthwhile thing especially because it can be done with same-day minimally invasive surgery.