Phlebology Training – Preceptorships, Videos, and Weekend Courses Aren’t Enough

Phlebology Training – Preceptorships, Videos, and Weekend Courses Aren’t Enough

Varicose Vein Treatments Simplified – A Contradiction in Terms?

Varicose Vein Disease and Treatments Are Complex

Sorry, but understanding varicose vein disease isn’t simple. The words, varicose veins and simple, are contradictions in terms.

Likewise, treating varicose veins is not simple either. Attempting to treat varicose veins without the proper training is practicing outside of the doctor’s scope of practice. It’s not fair to unsuspecting patients.

That’s why it takes a true vein specialist expert whom you can trust to guide you through the maze of treatment options and deliver superior results.

Varicose vein treatment options are expanding faster than new versions of the I Phone. When medical options get complicated, you need the expertise of an experienced professional.

The newest varicose vein treatments include glue, proprietary foam, mechanics-chemical treatments and even less well-known options like steam and freezing veins have been tried.

Let me start by taking this opportunity to dispel the lifestyle changes myths as self-treatment options.

No matter what you do with the exception of maintaining a healthy weight, it isn’t going to improve or prevent your varicose veins.

Conservative Care Myth and Insurance

This is propagated by phony regulations not supported by medical evidence.

The biggest offender is the requirement by insurance companies to try conservative measures including wearing heavy compression support stockings before minimally invasive treatment are considered.

Exhaustive review of these conservative medical treatments in both the United States and Great Britain have proven that they are unnecessary.

The most cited vein article of the care of patients with varicose veins states that the three-month trial of conservative medical treatment with compression support stockings is unnecessary and even wrong.

Natural remedies for treating varicose veins are not effective either.

Like conservative medical management, they do not address the underlying problem which is venous insufficiency caused by faulty valves within the veins.

Different Strokes for Different Folks

People often assume that everyone with varicose veins gets the same treatment. Like with heart disease, not everyone needs the same treatment:

  • Some require stents
  • Some need a bypass
  • Some need a valve replacement
  • Some need medication
  • Some a need pacemaker
  • Some a need heart transplant

Allow me to give a few examples of the diversity of vein problems that I see on a typical consultation day.

  1. Phlebitis in a man with large neglected veins
  2. Spider vein resistant to laser treatments tried elsewhere
  3. Recurrence after stripping
  4. Bleeding for veins (usually while taking a shower)
  5. Skin ulcerations from venous hypertension
  6. Cosmetic spider veins
  7. Painful large bulging varicose veins
  8. Restless legs
  9. Swollen legs

Treatments Vary Depending on the Vein Extent and Anatomy

Treating abnormal veins is not so simple.

There are a multitude of procedures available for the treatment varicose veins. Many have recently been cleared by the FDA and are awaiting insurance codes for billing purposes.

Here of a few of the todays most commonly performed procedures for varicose veins.

  • Saphenous Vein Ablation
  • Saphenous Vein Glue
  • Mechanico-chemical Ablation
  • Phlebectomy
  • Sclerotherapy

Different Varicose Vein Training for “Vein Doctors”

Few cardiovascular trainees fully appreciate the breadth and depth of vascular medicine. Because vascular disease is so vast, there are significant academic deficiencies in their vascular training.

At the Massachusetts General Hospital, the invasive cardiology program does not mention varicose veins or venous disease at all.

In just one year, the MGH cardiovascular fellows must master all of the following procedures:

  • Coronary angioplasty
  • Stent deployment
  • Atherectomy of arteries
  • Mechanical thrombectomy
  • Percutaneous treatment of peripheral arteries
  • Catheter management of congenital heart disease
  • Transcatheter closure of intracardiac communications
  • Balloon valvuloplasty
  • Intravascular ultrasound
  • Laser atherotomy
  • Alcohol septal ablation for hypertrophic obstructive cardiomyopathy

Varicose vein treatments are not on their radar screen.

At Yale, the invasive radiologists are trained in some aspects of vascular disease and many non vascular diseases including:

  • arterial and venous revascularizations (balloon angioplasty, thrombolysis, and stenting),
  • trans catheter embolotherapy,
  • percutaneous inferior vena cava filter placement
  • management of stenotic and occluded hemodialysis accesses
  • percutaneous creation of intrahepatic portosystemic shunts
  • interventional oncology
  • placement of a variety of venous access devices

No varicose vein training on that menu either.

Point being, invasive cardiologists and invasive radiologists have little or no training in varicose veins and venous disorders over the course of their one year fellowship. They are too busy learning other things.

In contrast, vascular surgeons specialize and are trained in vascular disease only.


If you dropped a dime on the street at night, but had no flashlight to look for it, would you walk to the next block where there was a street light to look for it?

Of course not.

Similarly, many doctors have tunnel vision when it comes to where their efforts in practicing medicine should be focused.

Unfortunately, not limiting the scope of practice to the field in which the doctor was trained is currently allowed when treating varicose veins.

Varicose veins are now treated exclusively in the office where no credentials committees exist like in a hospital. In the office setting, there is no oversight.

Varicose vein treatments are not simple nor intuitive to perform.

Since varicose veins and venous disease is complex, the training must be more intensive than what is being offered at invasive cardiology and radiology fellowship programs.

The following facts are beyond dispute. Varicose vein treatment can’t be learned during three-day weekend conferences. Similarly, a one day preceptorship is not adequate to become competent in practicing phlebology. Just passing a test doesn’t qualify or certify a doctor either. Unfortunately, this is the continuing trend in varicose vein training in the United States.

You don’t want a doctor who dabbles in treating varicose veins “on the side” and who has been trained in a different specialty. Avoid vein franchises.

If you have varicose veins, it’s essential to choose an experienced and well-trained board certified vascular surgeon who specializes exclusively in varicose veins and venous disease to get the best results possible.

Call us at 724-969-0600 to learn more about your varicose veins from the most experienced vascular surgeon vein expert in Pittsburgh, Dr. John Happel MD.

About The Author

Dr. John Happel

Dr. John Happel has been in practice as a surgeon since 1986 in the Pittsburgh region. He specializes in vascular surgery and has subspecialized in the treatment of varicose and spider veins since 1999. Dr. Happel is board certified in vascular surgery and recertified in vascular surgery in 2012. He was chosen in 1985 to fulfill the position for the vascular surgical fellowship at the world renowned Mayo Clinic.