What is the best minimally invasive technique for the treatment of varicose veins and why?
I had thought that microfoam scleropathy would be the technique that evolved into a painless outpatient procedure. However, home-made microfoam using polidicanol or STD deteriorates within seconds and in my opinion should not be used to treat truncal veins. The more durable product being developed by the British Technology Group (varisolve) has simply failed to get a product licence within a reasonable timescale: surgeons and their patients have lost interest.
Although microfoam is attractive for the treatment of varicose veins in patients undergoing truncal vein ablation by a catheter technique, phlebitis occasionally occurs, resulting in pigmentation. I have never been attracted to laser, even though this is considered by the public to be “sexy”. How do you control temperatures at the tip of a fibre approaching 1400°C? I currently favour fast VNUS as this is incredibly easy to use and almost entirely pain-free for patients. Most of my patients do not even take paracetamol after this procedure. However, I am confident that something even easier will come along within the next few years.
In venous disease, what are the three questions that you would like to see answered in the near future?
- What pressures are required to treat varicose veins, chronic venous insufficiency and venous ulceration? This question could never be answered as we had no way to reliably deliver precise pressures by bandaging or elastic stocking. Now that engineered compression stockings delivering prescribable pressures exist, we are addressing this.
- The big question is how we could reconstruct valves. Vein bypass remains a possibility, but valvuloplasties are difficult procedures with very uncertain results. I fear that creating and repairing valves in the deep veins remains a challenge that will not be addressed before I retire.
- What is the role of clot suction and thrombolysis in the treatment of recent deep vein thrombosis? I am increasingly convinced that we should be undertaking thrombolysis in patients within one month of the diagnosis of significant ilio-femoral deep vein thrombosis. We need a major randomised clinical trial on this topic.
Tell us about one of your most memorable clinical cases...
Although I never remember patients’ names, I never forget a case! I will briefly describe two as the lessons learned in each are remarkable.
The first is a man in his late sixties who was transferred to me when I was reader at Charing Cross from the Royal Free Hospital so that we could place an inferior vena cava filter. He had suffered a deep vein thrombosis and then, despite adequate anticoagulation with warfarin, had a pulmonary embolism while still an inpatient. I placed a Greenfield inferior vena cava filter just below the renal veins and converted him from heparin to warfarin (as had been done at the Royal Free Hospital before his pulmonary embolism). I was already beginning to suspect that patients who suffered an extension of a deep vein thrombosis or a pulmonary embolism while on warfarin would inevitably have disseminated malignancy. I arranged detailed investigation of his gut, liver, lungs and bones; all investigations were negative. We sent him home on subcutaneous heparin only to admit him with severe generalised carcinomatosis with infiltration throughout the lung fields only seven weeks later.
He became increasingly breathless until one evening, after saying goodbye to his wife, he asked me to relieve him of his distress. An intravenous infusion of diamorphine was so effective that when I rang the ward at 23.00hrs to find out whether he was in a coma, the nurses told me that he had taken off his oxygen so that he could cheer the World Cup football on the television despite profound cyanosis. He died in the early hours of the morning, shortly after a nurse had changed the diamorphine syringe pump. There are times when I cannot praise our nurses enough. The lesson from this case has remained true throughout my clinical experience: any patient who has an extension or recurrence of deep vein thrombosis/pulmonary embolism despite adequate anticoagulation will have widely disseminated but usually undetected carcinomatosis.
The second case that I will mention is of a delightful lady in Cheshire, with a painful pulsatile mass in the left iliac fossa. Duplex imaging showed a dissecting aneurysm in the descending thoracic aorta. We performed open surgical repair on a Sunday morning, successfully reperfusing all the visceral vessels and with an excellent initial outcome. Unfortunately, she suddenly ruptured her spleen in the early hours of Monday morning causing substantial blood loss and a period of hypotension.
After 10–14 days on intensive care and 3–4 days in hospital, she was discharged and asked whether she could go and recuperate in the family chalet in a ski resort. When she came back, she wanted to know why she could ski better than she could walk. I remember watching her walk and realising that she had suffered a previously undiagnosed spinal stroke affecting proprioception in her feet. She still skis brilliantly in her late seventies. There were two lessons in this case:
- Unexplained events will often have a history. This lady had stopped on a ski piste in the Alps when hit by two men who came over the brow of the hill. Almost unbelievably, both men had managed to get one ski between her legs so that she was propelled backwards (and still upright) at what she describes as 30mph until she struck a metal pylon supporting a chairlift. This was 24 years before I first met her. She remembers being very ill with severe back pain that could not be diagnosed within the French hospital where she was admitted for nearly two weeks. She had no bone injury. She clearly suffered an aortic dissection then which progressed to near-rupture when I saw her.
- The second lesson was that the proximal part of this dissection was highly fibrotic with a strong aortic wall. I learnt that it was entirely safe to anastomose to a mature dissection and that a lesser procedure is often an option.
What is the most interesting paper you have come across recently?
The long-term results of the EVAR 1 trial recently published are fascinating. This paper’s importance lies in its demonstration that the current fashion for EVAR should not be extended to younger, healthier adults in whom the mortality for open repair is under 4%. Many of our younger colleagues are embracing EVAR with enthusiasm, but the unstable nature of the repair in patients whose aorta will continue to dilate over the next two decades will result in a substantial problem to be tackled in the future. We should be considering long-term survival, not 30-day mortality. In my opinion, patients who die of a cardiovascular event as a consequence of major surgery are likely to have suffered that myocardial infarction or stroke in any event during the course of the next year or so. Patients who survive major surgery are clearly survivors.
Outside of medicine, what other interests do you have?
I enjoy sport, food and good wine. I am an enthusiastic but not highly competent tennis player. I take two skiing holidays a year, always one with my two daughters who are far better skiers than I am. I love my home in the country and thoroughly enjoy country pursuits such as shooting, fishing and stalking. When I retire I intend to take up golf which I gave up aged 16 as I realised there was simply insufficient time in life to play golf as well!
Fact File
Academic and professional qualifications
1972 MB ChB, University of Birmingham, Birmingham, UK
1976 FRCS, London, UK
1976 FRCS, Edinburgh, UK
1981 MD, University of Birmingham
Prizes, awards and honours
1979 Moynihan Prize, Association of Surgeons of Great Britain and Ireland
1983 Patey Prize, Surgical Research Society of Great Britain and Ireland
1983 Geoffrey Holt Award, British Medical Association
1985 Hunterian Professor, Royal College of Surgeons of England
1988 Hahn Prize, European Society of Cardiovascular Surgery
1988 Major grant award, King Edward’s Fund
1995 Patey Prize, Surgical Research Society of Great Britain and Ireland
Summary of positions held
1989–present Professor of surgery, University of Manchester, Manchester, UK
1989–present Honorary consultant surgeon, University Hospital of South Manchester
1988–1989 Reader in surgery, Charing Cross & Westminster, London
1983–1988 Senior lecturer in surgery, Charing Cross & Westminster Medical School
1983–1989 Honorary consultant surgeon, Charing Cross Hospital
1978–1983 Lecturer in surgery, University of Birmingham
Research interests
- Arterial and venous thrombosis
- Cerebral emboli and dementia
- Stroke and cerebral perfusion
- Migraine with aura
- Carotid and extracranial arteries
- Venous disease
- Paradoxical embolism
- Wound healing and leg ulceration
- Risk prediction in surgery
- Blood transfusion therapy
