The Origin of the word varicose comes from the Greek word, “grapelike”. It was thought to be first used as a medical description by Hippocrates in 460 BC. For over 2000 years mankind has suffered from varicose veins and has been experimenting with many ways to treat the medical problem. For many people it is also a cosmetic issue. Below is a summary of the history of varicose vein treatments and how they evolved through the years in different parts of the world.
The ancient Egyptians described varicose veins as ‘Serpentine Windings’ which were not to be surgically worked on because patients would be ‘head to the ground’. This was the first written account describing a failed attempt at surgery on varicose veins implying that the use of incisions lead to fatal hemorrhaging.
Hippocrates wrote some of the earliest medical descriptions of varicose veins. The Hippocratic Treatises, written in 460 BC took Varicose Vein treatments one step farther. He did not recommend excision but rather compression following multiple punctures. He also believed in cautery. Paulus Aegineta (AD 625-690) favored ligation of the long saphenous vein 200 years before Trendelenberg.
In a medical treatise De Medicina, a Roman physician named Celcus (25 BC – AD 14) described the ligation and excision surgeries, as well as possible complications. Galen (AD 131 – 201), also provided a description of varicose veins and promoted the use of severing the connection of the arteries to veins in order to reduce pain and avoid spreading gangrene. Celsus and Galen were possibly the first to describe ‘phlebectomies’, a technique still used today. Celsus made multiple incisions 4 fingerbreadths apart, then touched the vein with cautery, grasped it and extracted as much of the vein as possible, double damping and dividing the vein between ligatures. Galen described making 3-6 incisions with a hook and then bandaging the leg. Roman surgeons used to carry scalpels with blunt handles that could be used for dissecting varicose veins, a procedure that was done without any form of anesthetic.
The Roman Caius Marius, who was known as a tyrant, had the varicose vein surgery of his time. After treatment on one leg he declined surgery on the other leg saying ‘I see the cure is not worth the pain’. Obviously having this surgery without anesthetic was not comfortable by any means for the patient.
Oribasius of Pergamum ( 325-405), a Byzantine physician, devoted 3 chapters of text to varicose veins. He described the details of the surgery for varicose veins of the legs included shaving and bathing the leg, followed by marking with small incisions and excising the varicose veins with 1 or 2 hooks along the leg through the small incision.
The University of Cordoba in the Arabs produced one of the most famous surgeons. He was known to the western culture as Albucasis (930 AD to 1313 AD). He became a prominent surgeon during that era. He was appointed as the Court-Physician of King Abdel-Rahman III. Besides his practice of medicine he also did a lot of medical and surgical writings.
He wrote thirty volumes of a digest of vast medical knowledge called Tasrif. He is also known for writing the best medieval surgical encyclopedia on record. It dealt with all aspects of surgery and was the first textbook of surgery to include illustrations of instruments to be used in surgery. It became very famous as it was the standard textbook of surgery used up to the 17th century in prestigious western universities. His medical and surgical expertise was evident in his writings of exact details of clinical and surgical procedures. His writings described the binding of the arteries long before any other physicians. His descriptions of varicose vein stripping are almost like our modern day surgeries for the veins.
The progress of medical science and surgery stalled for about 350 years after 13th century when barber surgeons routinely performed surgeries. In 16th century, the ligation at the site of the varix became the preferred varicose vein surgery. A century later, the combination of bleeding, diet and application of bandages to the legs was recommended by a German surgeon, Lorenz Heister, to avoid varicose vein surgery.
In the mid 1600’s intravenous drugs were first introduced. Opium was put into the vein of a dog using a metal tube and was successful. The hypodermic syringe did not appear until 1851. The introduction of anesthesia and antiseptics, delivered by the hypodermic syringe, brought about great changes in the treatment of varicose veins. In the 1850’s injections really took off and the treatment of veins by injection was becoming popular. The injections were either perchloride of iron or iodine. The perchloride of iron seemed to cause inflammation and swelling. In order to help correct this, the use of compression was advised in order to prevent dilation of the veins. In 1894, due to the high numbers of complications from this treatment, treating varicose veins by injection was abandoned.
The methods of stripping Varicose Veins with strippers or Keller wire and open surgical approaches at the beginning of the 20th century were still very crude and not procedures that people looked forward to having. Some of the surgical procedures led to cosmetically undesirable outcomes.
Crossectomy was introduced back in 1916. Crossectomy has been considered the standard procedure for varicose veins. It consists of making a small incision in the groin crease and the saphenofemoral junction is identified and divided between dips. All of the tributaries are identified and dissected back to their first branch before ligation. Ligation can be done in many ways. There is not a technique that has been proven to be better than the other. Failure of varicose vein surgery and the development of recurrent varicose veins are most common at the level of the groin due to inadequate groin dissection.
Using endovenous electrosurgical devices for venous wall denaturation is not new as these methods have been used off and on over the past few decades (1970s to 1980s). Since 2000, more advanced method, Endovenous obliteration with radiofrequency (RF) device or laser, has been becoming a very popular method and the preferred methods of vein specialists and surgeons. The original idea behind using electrosurgical device was to shrink the veins as to make valves competent again, but the observed result of venous obliteration with RF lead to the new ablation method. Endovenous Laser Ablation (EVLA) can be performed in the ambulatory setting under local anesthesia, and it allows for the ease of the catheter to pass through the vein without too much discomfort to the patient. The catheters are able to obliterate veins from 2mm to 12mm. This technique is minimally invasive and yet provides results that are immediately visible and will last long term.