PHLEBOLOGY

Phlebology is a medical discipline devoted to diagnosing, treating, and studying various venous disorders. Therefore, a phlebologist is a doctor specializing in venous disease. The term phlebology is derived from Greek words phléps, “vein”, and logos, “science”. As a separate discipline, phlebology is a rather young specialty in the U.S. However, researching venous disorders has a long and rich tradition.

History of Phlebology

Phlebology in Europe


For a long time, venous disorders were researched and discussed mostly as a part of a number of different medical disciplines, such as hematology, vascular surgery, dermatology or general medicine. The research was lead separately without international cooperation, and thus it lacked benefits of combining multiple approaches. In the 1980s there were some major breakthroughs. Considerable improvements in managing the condition were made when international cooperation was intensified. But it was the advances in the venous laboratory that truly increased understanding of venous physiology and pathology. Many investigative techniques very majorly improved and successful treatment of various venous conditions stopped being just a dream.

It was clear from the very beginning that treating venous disorders requires a multidisciplinary approach. Because of it, many societies and forums were made involving physiologists, radiologists, pathologists, hematologists, dermatologists, nursing staff, physiotherapists and all the medical and paramedical disciplines which might have a contribution to make in the understanding and treatment of venous disorders.

As it usually happens, coincidence brought phlebology to life. Discipline originated in Paris and Tübingen (Germany) where Jean Sicard and Paul Linser accidentally discovered the possible ways for the sclerotherapy of varicose veins. The second component in the treatment of lymphovenous insufficiency is ambulatory compression described already in the 18th century. It is only recently that reasons for its efficiency have been understood, with the study of fibrinolysis (which is counter-thrombotic), in England. The next step was the medical treatment of arterial affections, developed notably by Henri Reboul in Paris, with the aid of intra-arterial injections. This is how non-surgical disorders entered into the realm of Phlebology. In 1947, the French Phlebological Association (Société Française de Phlébologie) was founded by Raymond Tournay, Jean Sicard, and Jean Marmasse. This society developed fast, attracting every year more and more researchers. Its counterpart was founded in 1957 in Benelux by Van der Molen, Van der Stricht, and Zoller, and in Germany by E. Krieg, F. Jäger, M. Ratschow, P. Matis, U. Ellerbroek, and F. Olsen.

In modern times, there are numerous phlebology associations throughout Europe and the rest of the world. In some parts of the world, phlebology sections of dermatological associations are still prevailing. Evaluation devices (such as Sonar-Doppler, plethysmography etc.) improved diagnosis, made even more objective by the use of radiology. The modern development of medical technologies simplifies and improves diagnosing and treating methods every day.

 

 

Phlebology in America

Formally, the field of phlebology in the USA was established when The North American Society of Phlebology (NA SP) was founded on August 4, 1985, by Anton Butie, MD, a Swiss Angiologist, along with 13 other members and other dermatologic surgeons.

The North American Society of Phlebology is known today by the name of American College of Phlebology. Before phlebology became as eparate discipline, physicians from a variety of medical backgrounds including plastic surgery, vascular surgery, dermatology and family practice treated varicose and telangiectatic leg veins in a variety of ways. Often mystical concoctions of different osmotic and hypertonic agents were used as a medicine. There was very little research when it comes to treatment techniques and outcomes, and this fact contributed greatly to the abundance of dubious medical techniques.

It was one man who in 1985 realized that was a big void in American medicine that needed to be filled. At that time, a young intern at the University of California, San Diego, Veterans Administration Hospital earning his medical license, Anton Butie, followed the European model of phlebology training. In addition, he strived to educate others in the treatment of venous disease. He served as the society’s first president until 1988.

In only three years, the size of the society grew impressively. In 1987, from February 20th to 22nd, a formal Symposia occurred with the first Annual Congress in San Diego, California. This  symposium was a great opportunity that invited European French colleagues, Frederic Vin, Michel Schadeck, Andre Cornu-Thenard, Claude Guarde, and JJ Guex to educate their American friends on the newest approaches to treating venous disorders. In years to come, international congresses showed undoubtedly the size of interest in phlebology. Cooperating with colleagues coming from different countries turned out to be the best way to further promote the discipline and make some important medical breakthroughs.

Today, phlebologists in the USA are recognized around the world as great experts. A number of World Congress Meetings are held in the USA on a regular basis. One of the basic values that the modern American College of Phlebology is trying to nurture is placing a great deal of importance on cross-discipline approach. A variety of specialties allows comprehensive care and the best possible outcome for anyone suffering from venous disorders.

Education of a phlebologist

There aren’t many phlebology teaching centers, and many of the existing ones have a surgical and clinical emphasis, and the neglect polyclinical work. Besides the existing Phlebological Associations in other countries (Canada, Australia, South America) the Collège de Pathologie Vasculaire founded by Cl. Olivier in Paris is very active. It offers the most comprehensive theoretical and practical teaching. Other phlebology centres in Hamburg (Ellerbroek, Stegmann), Tübingen (Schneider, Fischer), Essen (Klüken), Zurich (Bolliger, Brunner), Vienna (Santler), Terwolde, Holland (Van der Molen), Bad Nauheim (Dembowski, Hach), Strasburg (Stemmer), Lille (Huriez, Merlen), Rouen (Ouvry, Davy), Louvain (Haven, De Greef), London (Hobbs), are engaged in spreading knowledge of phlebology, whose social significance is very important, since it deals with very widespread illnesses. A whole series of reviews and papers specializing in peripheral vascular disorders are published in all the main languages the world over.

With the purpose of improving the standards of medical practitioners and patient care in the field of diagnosing, studying and treating various venous disorders, The American Board of Venous & Lymphatic Medicine (ABVLM), formerly the American Board of Phlebology, was established. One of the main roles this Board is establishing initial and continuing qualifications for certification and maintenance of certification as physician specialists in the practice of phlebology, to examine physician candidates for certification and maintenance of certification in the practice of phlebology, to establish educational standards for teaching and training programs in phlebology, and to maintain a registry of individuals who hold certificates issued by the Board.

For a long time, many techniques that aren’t testified scientifically were used in treating venous disorders. Unfortunately, there are still plenty of uncertified venous care providers. In addition, treatment of cosmetic concerns without taking overall health and venous health of the patient into account is a common consequence of the ease of today's modern treatment. In order to treat the patient properly, a full understanding of both vein health and pathology is absolutely necessary. Wrong treatment options can cause more damage to the venous system and overall health. Hence, the need for having certified trained phlebologists who can provide professional medical care and is committed to their overall health.

How to become a phlebologist

If one wants to become a phlebologist, certain steps need to be followed. Firstly, one must obtain a medical degree from an accredited medical school and pass all necessary examinations.

The second step is comprised of compulsory internship where the student is exposed to all different medical areas.

Finally, future phlebologists needs to go through a 3-year residency program. This is where he or she will gain vein related clinical experience and focus on venous disorders.

Responsibilities of a phlebologist

In understanding and treating venous disorders, there are few pre-requirements. The primary physician's role for correct diagnosing is out of immense importance. In order to redirect the patient to a vein specialist, the primary physician needs to do and know the following:

  • Know the risk factors for venous disease.
  • Know the population most at risk.
  • Ask patients about their symptoms.
  • Inform patients with symptoms of venous disease about treatment options.
  • Inform patients who may be at risk about their options for screenings, prevention, and treatment.
  • Tell patients how to prevent or alleviate venous symptoms and how to decrease their risk of deep vein thrombosis.
  • Inform patients who may have had previous treatment, or those who have been dissatisfied with traditional, more invasive approaches, about today's treatment options.
  • Maintain a current knowledge base of venous risks, symptoms and treatment as well as advances in venous care.
  • Provide an information sheet to patients with risk factors or symptoms of venous disease.
  • Refer patients to a certified vein specialist.
  • Contact the Vein Healthcare Center with any questions about vein health or to learn more about venous disease.

The responsibilities of a vein specialist include having specific knowledge about venous disorders, treatments and care options. The mechanism behind these disorders is comprised of structural and biochemical abnormalities of the vein wall that with progression, lead to varicose veins, pain and swelling, clots, vein bleeding and ulcers. If varicose veins aren’t treated in a long time this can lead to vein failure in the "bridging" or perforator veins. Finally, patients with varicose veins are more likely to develop advanced symptoms such as increased pain, skin changes, and ultimately, ulcers. As a complex and progressive illness, venous diseases require comprehensive care by a specialist.

The average salary for phlebologist jobs is $56,400*.

Venous diseases phlebologists treat

The most common venous diseases that a phlebologist treats are the following: varicose veins, spider veins, venous ulcers, and deep vein thrombosis.

Varicose Veins – Varicose veins, otherwise known as varicoses or varicosities, are manifested on the skin as enlarged visible veins in the leg. They occur as the result of venous insufficiency: appearing swollen and raised, they are blue, purple or red in color. In the majority of cases, this condition is painful. If they appear on the skin, varicose veins are a clear indication of early stage venous disease. Therefore, it is very important to treat them as soon as possible. If left untreated, they lead to worsening conditions.

Spider Veins – Blue or purple veins that don’t rise above the skin level, but they are close enough to be clearly seen are known as the "Spider vein”. From a medical standpoint, spider veins are another early symptom of venous disease. They don’t cause any serious discomfort, but patients tend to be distressed because of their appearance. Even though treatment of spider veins is mostly a cosmetic procedure, it is beneficial for future vein health professionals to treat this problem early.

Venous Ulcers – Venous ulcers, stasis ulcers, stasis dermatitis, or varicose ulcers are different names for the same condition comprised of open leg wounds. These wounds occur as a result of improperly functioning venous valves. The appearance of non-healing venous ulcers is in the majority of cases an unquestionable indication that venous disease has reached an advanced stage. This happens due to the progressive nature of venous diseases, when venous reflux leads to additional valve failure, and as a result, the pooling of blood can affect a larger area. When it comes to the advanced stage of ulcers, even though there are many possible complications, pain, itchiness and utter discomfort, treatment options are available. Many patients, due to lack of proper information, find ulcers incurable and let this condition affect their lifestyle immensely.

Deep Vein Thrombosis – This is one of the potentially most dangerous venous disorders. Deep vein thrombosis is a common term for a blood clot in the deep vein system. If the clot breaks free from the vein wall and enters the blood stream it could travel to the lungs and become a PE (pulmonary embolism), or to the brain and result in a stroke. Regular vein screenings are one way to prevent possible clot making. This procedure can save your life, and it is highly recommendable in case you have a history of high blood pressure and stroke in your family history.

Risk factors for deep vein thrombosis

The science behind developing deep vein thrombosis isn’t completely understood. Why blood clots are formed is a question that still requires a more thorough answer. Practically, blood clotting can occur in anyone at any age but there are some groups that are more endangered.

  • Pregnant women
  • People with prolonged periods of immobility or no mobility at all
  • People with blood-clotting issues (a genetic disorder)
  • Cancer patients undergoing surgical procedures
  • Patients with damage to their vein walls because of surgery or injury
  • Seniors, 60 and older

How to recognize symptoms

First of all, it cannot be stressed enough that deep vein thrombosis is considered as a medical emergency and any symptoms should be regarded as DVT until proven otherwise. Second, these symptoms include following: the affected area will be tender, painful or swollen. Skin can be discolored or unnaturally red. However, DVT in 50 percent of cases has no symptoms at all. Finally, if you’re in a risk category, be alert and check your veins regularly. When it comes to deep vein thrombosis, prevention is the best action to take. This includes the following steps:

  • Talk to your doctor about DVT and determine if you belong to a high-risk group.
  • Avoid getting obese, poor dietary choices and smoking.
  • After prolonged periods of immobility, try to be as active as possible.
  • If your working space requires a lot of sitting, or if you are traveling and sitting for more than four hours, get up and walk around every few hours and exercise your legs while sitting.

Treatment options that phlebologists suggest

Generally speaking, treatments that phlebologists can prescribe are divided into two large groups: modern and conservative treatments. Both groups are comprised of several treatment options, all of which to a certain extent work. The best way, however, would be applying modern solutions, such as laser therapy, to deal with the problem instantly and maintain a healthy lifestyle and exercise as a part of more conservative treatment afterward.

Endovenous laser ablation (EVLA) is also called endovenous laser therapy (EVLT™) or radiofrequency ablation (RFA). This is a procedure that requires minimal invasion to treat large varicose veins in the legs. A procedure itself is painless, and it doesn’t take much time. Small laser fibers thread into the vein at the failure location. Following a local anesthesia, blood flow is obstructed by irritating the vein wall and allowing the vein to close. Closing the vein won’t affect the patient in any troublesome way because blood is diverted to other veins in the leg.

For this procedure, patients don’t have to stay in the hospital and they can resume their old lifestyle fast. Many experts claim that this procedure is the gold standard in the treatment of venous symptoms. Previous and more invasive standards of care such as vein stripping were replaced by EVLA.

Compression Therapy – One of the most common forms of compression therapy is the application of compression stockings. Compression stockings function by providing gradient pressure on the leg muscle, which reduces the pooling of blood. In the beginning, stockings may take some adjustment, but they can be a long-term solution to managing symptoms of venous disease, or they can be used in the short term to reduce the likelihood of a clot during long periods of sitting, such as on a long plane ride.

Compression stockings are an alternative to the other procedures in treating varicose veins. Some consider them as a conservative and outdated method in treating venous disorders, but opinions among medical experts are divided. They can be effective in relieving symptoms of venous disease, stopping its progression, and decreasing the likelihood of a clot. Stockings are also a good solution for patients who are not able to move on their own, and, as a result, cannot engage in the activity required for other procedures. However, the drawback to compression therapy is that stockings must be worn daily. Another form of compression therapy is the use of bandages. They are usually worn if there are ulcers or edema.

Sclerotherapy – This procedure is used to treat venous malformations by injecting a medicine, called a sclerosing agent, into the vein’s interior wall. A sclerosing agent makes veins shrink, allowing them to disappear. Blood then finds a healthy path back to the heart. The risk of complication is small, and patients often experience an immediate relief of symptoms.

Sclerotherapy is used to treat veins just below the skin's surface that are either invisible or difficult to see with the naked eye. To ease the procedure, sclerotherapy can be performed either with ultrasound guidance or light assistance. There is no difference between these procedures, and they are both safe and effective. By applying them, we can eliminate the need for traditional surgical removal of veins.

Light-assisted sclerotherapy is normally used to treat veins below the skin's surface that are difficult to see. A small, hand-held light will illuminate the veins and tissue below the patient’s skin. These veins are responsible for feeding the veins that are visible on the surface of the skin. After the veins are shown, the physician can clearly identify the source of the dysfunction and begin sclerotherapy.

Ultrasound-guided sclerotherapy, as the name itself reveals, is performed under the guidance of ultrasound. This is the last resort for the veins that are not visible, and cannot be seen with transcutaneous illumination. This procedure is often used to treat "perforator" veins, or veins that connect the superficial system (above the muscles in your leg) to the deep system (veins under and between the muscles of the leg). These veins, if malfunctioning, can cause venous insufficiency and that can result in skin ulcers, and must be treated at the source of the dysfunction. Due to their position along the artery, a skilled ultrasound sonographer is critical to the success of this procedure.

Conservative Treatments

Elevation – In early stages of the venous disease, elevation of the legs can alleviate the pain or swelling in some cases. Elevating the legs above the heart for three minutes, several times throughout the course of the day, encourages blood flow from the legs and decreases the pooling of blood. A trained phlebologist can guide patients in trying different elevation techniques and finding the one that works best in their particular case.

Exercises – Light exercise is a proven technique that helps in relieving the symptoms and preventing blood clotting. This is done by exercising the feet, toes, and ankles. Tapping the toes and flexing the feet several times a day can help blood move up into the legs. This is particularly recommended to those who sit and stand for long periods.

Medication – In some cases, phlebologists will describe medication as an additional help in treating venous disorders. Ibuprofen, creams, and other non-steroidal, anti-inflammatory medications may be recommended; other medications may be prescribed depending on the severity of the symptoms

References

American College of Phlebology (2017).Retrieved fromhttp://www.phlebology.org/

Goldman, M. The History and Present State of Phlebology in the USA: A Personal Perspective. Retrieved from http://www.veindirectory.org/magazine/article/education/the-history-and-present-state-of-phlebology-in-the-usa-a-personal-perspective

Phlebology: A Journal of venous disease. Retrieved from http://journals.sagepub.com/home/phl

Van der Molen, The development of phlebology in the last 30 years. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/7027281

Venous Ulcer. Retrieved from https://en.wikipedia.org/wiki/Venous_ulcer


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