Around 1900 the "stripping" operation was introduced for varicose veins. Its popularity has waxed and waned throughout the 20th century.

When the operation was first performed, it was hoped that it would provide a permanent cure for varicose veins. That hope proved to be premature. By 1920, there were so many surgical cases whose veins had grown back that the method was scrapped almost completely.

From about 1920 to 1940, nearly every case of varicose veins in the United States was treated by injection! This may come as a surprise to people who think that injection treatment of varicose veins (sclerotherapy) is a "new miracle treatment from Europe". It's not new at all !

But by 1940, after 20 years of vein injections in America, there was a multitude of patients whose veins had grown back. So the surgeons went back to surgery. They changed the operation a bit, and the new, improved stripping operation worked somewhat better than the old one.

But then a veritable war began, between injectionists and surgeons. The subject of the war was this question: "Which treatment (i.e., injections vs. surgery) is the one which really cures varicose veins?"

This question was not answered until 1956, when H.I. Biegeleisen (the author's father) published a statistical study proving that varicose veins are never cured! All patients, whether they are operated on or injected, eventually grow new veins.

But the war continued. The new question was this: "OK; we can't permanently cure varicose veins. But whose treatment (i.e., injections vs. surgery) keeps bad veins away longest?". The medical term here is "remission", i.e., "Whose treatment gives the longest remission?".

This question was batted around for around 25-30 years, when it ran head-on into the era of bypass surgery. With ever-increasing frequency, Americans with the heart disease called angina were getting their coronary arteries bypassed (this is described in more detail presently). In angina, the coronary arteries (which carry the blood supply to the heart muscle) become blocked. In the bypass operation, a leg vein is spliced into the coronary circulation, to bring in more blood.

The leg vein they usually use is the greater saphenous vein. This is the same vein which is usually diseased in varicose veins! All of a sudden, vascular surgeons started to ask a new question: "Should we save the saphenous vein, just in case the patient needs a bypass operation later?".

Injections for varicose veins go back to at least 1840. They did not become popular until this century, but around 1900 surgery also became popular. Most of the surgeons stopped injecting, and began operating. Injections almost disappeared from the practice of venous medicine.

Around 1920, however, the tables turned. As I explained earlier, it had become apparent that surgery (at least as it was done back then) had a poor long-term outcome. Consequently, injections gradually replaced surgery as the treatment of choice for varicose veins. In vascular clinics from coast-to-coast, all the surgeons were injecting veins.

Injections became so popular that the medical literature published insulting commentaries on surgery, going so far as to call any surgeon who ever operated on varicose veins a "barbarian"!

Injections reigned supreme for about 20 years, but by the time World War II was over, vein surgery was back. At that point people had finally realized that the problem of re-growth of varicose veins had not been solved by injections. In fact, many surgeons claimed that veins grew in even faster after injections than they had after the old surgery.

So, as pointed out earlier, new forms of stripping surgery were developed, and these became widely used, once again, for the treatment of varicose veins.

Injections, for the second time in the 20th century, became scarce.

Starting in the 1970's, new forms of injection therapy were devised in Europe, and they were very gradually introduced to the United States. But it was not until about 1990 that injections had grown sufficiently in popularity that they were once again well-known in this country.

It is not seriously controverted that I am the inventor of laser and RF ablation of large varicose veins, although, oddly enough, I do not practice these methods at this time. The history of these technologies is reviewed in several other places on this web site.

After injections, the varicose vein shrinks. If the leg was ugly because of the vein, then it will look better! If it ached, it will feel better also.

If the vein was interfering with the normal flow of blood, as indicated by instrumental tests, then the blood flow will be corrected, and the tests will revert to normal.

How do the injections work? The medicines don't actually make the veins shrink themselves. Your body makes the veins shrink. The medicine is merely a catalyst -- a thing which starts a process going, but does not actually do the work itself.

The essence of how the treatment works is this: The medicine irritates the sensitive inner lining of the vein. Once your body "sees" that the vein has been injured, a process called "resorption" takes place. This simply means that the body itself begins to dissolve and remove the vein. It's a gradual process, which often takes months to complete. The medicine is the "trigger" which starts the process off, but it's your own body which actually removes the vein.

If you understand this, then you will understand that the goal of treating varicose veins by injection is to selectively irritate the inner lining of the varicose vein, without doing any harm to nearby veins that are normal. This goal is not at all difficult to achieve. Substances as harmless as ordinary salt (called saline when in solution) will suffice.

Now, there's nothing toxic or irritating about ordinary salt -- at low concentrations, that is. Your own blood stream happens to contain about 1% salt, from the minute you're born to the moment of your death. So you can't irritate a blood vessel by injecting 1% salt into it -- that much is in it all the time! But, if you inject 20 times that much (i.e., 20% saline) into a blood vessel, you will most definitely irritate it. Recall the expression "rub salt in a wound" -- at high concentration, ordinary salt is very irritating to living tissue. So, at a concentration of 20%, salt becomes what doctors call a sclerosant -- a medicine capable of irritating the sensitive inner lining of a vein, and consequently triggering its shrinkage and resorption.

But as soon as the 20% saline is injected, it mixes with blood. Before it has moved even a few inches, its concentration has dropped greatly, so that it's no longer capable of triggering sclerosis. Therefore, the saline only works at the exact site of the injection. In order to treat veins safely with saline, you need to give a series of small doses, up and down the vein. Each dose affects only the local portion of the vein immediately adjacent to the injection site.

In the discussion so far, we have referred exclusively to saline, or concentrated salt solution. That means sodium chloride, the same chemical used for ordinary table salt.

In case you're wondering, kitchen-grade salt is not acceptable for this treatment. To be suitable for medical use, the salt must be highly purified, and approved for intravenous injection in human beings. That means that it's a lot more expensive than table salt.

There are many other medicines used besides salt. In fact, salt, by itself, is rarely relied upon exclusively in treatment of large varicose veins (although it has recently been successfully combined with other drugs).

Most of the many medicines used for vein injections fall into one of two different categories:

1. Salts other than sodium chloride
2. Fatty acids

In the early 20th century, salts were the mainstay of vein therapy. That is no longer the case, but several of them remain popular today. On a world-wide basis, the salt (other than sodium chloride) which has been most frequently used has been sodium iodide (which is usually combined with pure iodine to give a dark brown solution). The use of this product is generally associated with the name of the famous Swiss Phlebologist, Karl Sigg. The Swiss product, called Variglobin, was, in its day, the most powerful sclerosant in the world. Unfortunately, is it no longer manufactured, and current iodine sclerosants are less concentrated. These less-powerful iodine solutions are not used in this office.

There are numerous other salts which have been used, or proposed. Next to Variglobin, the most popular of them is sodium salicylate (a close relative of aspirin). It is not approved for vein injection in America. In fact, none of the non-sodium-chloride salts are approved for the treatment of veins in this country.

The second large class of sclerosants is the fatty acids, which, on a world-wide basis, are considerably more popular than salts. In the course of the 20th century, fatty acids have become the mainstay of injections everywhere.

The first drug of this sort was sodium morrhuate, an extract of cod liver oil. Its efficacy in varicose veins was discovered in 1930, quite by accident, in tuberculosis patients. Back then, tuberculosis therapy included injections of cod liver oil. A pair of observant British physicians, named Higgins and Kittel, noticed that the veins into which cod liver oil was injected often shrunk and withered away. They proposed, in the British journal Lancet (the approximate equivalent of our Journal of the American Medical Association), that an extract of cod liver oil be prepared for the treatment of varicose veins.

The active ingredient in cod liver oil was then extracted by a pharmaceutical company. It proved to be not the vitamin A (which was the reason for cod liver oil injections in the first place), but rather the fatty acids. Cod liver oil, which, incidentally, is very similar to human liver oil, is a mixture of hundreds of fatty acids, many of which are well-known and well-studied, but others of which have never even been fully characterized by chemists.

What's a "fatty acid"? The closest thing to fatty acids in everyday life is soap. In fact, it would be possible to sclerose a vein with soap, but household soap is a very crude, impure mixture which would cause devastating reactions if injected. You could think of morrhuate as being a very, very highly purified soap. But it would cost a fortune to wash with it!

The first large-scale clinical trial of the new drug, sodium morrhuate, was done by my father, Dr. H.I. Biegeleisen, in 1933. It established sodium morrhuate as the drug of choice in varicose veins, a distinction which the drug maintained until 1946. The publication of his study, in the journal Surgery, Gynecology & Obstetrics, also launched his own career as a vein specialist.

Between 1930 and 1946, a fairly large number of other plant and animal extracts were marketed by the pharmaceutical industry. Most of them were fatty acid in nature (there were also a few salts). There were so many of them that the competition for sales drove most of these companies into bankruptcy.

Furthermore, all plant and animal extracts shared a common disadvantage: They all caused allergic reactions in some patients. On occasion, these allergic reactions were life-threatening.

It is now known that the allergies were due to protein impurities, and not to the fatty acids themselves. Therefore, in order to avoid allergies, it was necessary to aggressively purify the product. That has since been done with morrhuate, but the modern, non-allergenic morrhuate is considerably weaker than the old-fashioned "dirty" morrhuate used to be. That's apparently been the "price" of purity.

But there was another approach to avoidance of allergies: creation of a synthetic fatty acid. The composition of such a man-made medicine could be rigorously controlled, and a product nearly 100% protein-free could easily be made. This proved to be the method of choice for creation of an "ideal" fatty acid sclerosant. In 1946, the pharmaceutical industry released a new synthetic, "sodium tetradecyl sulfate", under the trade name Sotradecol, for the injection treatment of varicose veins.

Sotradecol, a man-made medicine, was the second-strongest sclerosant in the world at the time of its discovery (Variglobin was stronger). It had significant advantages over existing products. Unlike Variglobin, it was painless on injection. Unlike morrhuate, it rarely produced allergic reactions.

Sotradecol has been the most widely-used sclerosant in the world since 1946, although it is currently getting slowly "edged out" by newer drugs from Europe. Nevertheless, for reasons which you will understand shortly, Sotradecol remains the main medicine used in this office.

Asclera is a trade name for a German drug whose generic name is Polidocanol. It was originally created, probably as early as the 1950s, as a local anesthetic, but it was found to be capable of sclerosing varicose veins. Therefore it was marketed as a sclerosant (i.e., a medicine for varicose veins), under the trade name Aethoxysklerol.

Aethoxysklerol became very popular in Germany. When my father went to the European vascular meetings in the 1960s, he brought back samples of Aethoxysklerol, and tested them on his patients. His conclusion: Aethoxysklerol is a safe and effective medicine, but has no advantages over our domestic Sotradecol. Furthermore, it was not FDA-approved, and the market for it in America was so small, no American pharmaceutical company was willing to spend the $100 million dollars necessary to push it through the F.D.A.

In the 1980s, when I first went into practice, I too brought back samples of Aethoxysklerol from Europe, and, like my father before me, I tested them. Also like my father before me, I concluded that Aethoxysklerol was a perfectly good drug, but had no special advantages over domestic drugs. It was useful to have around, however, because there are always occasional patients who have allergies to domestic drugs, and they can be treated with Aethoxysklerol.

In the 1990s, decades after my father first tested Aethoxysklerol, American dermatologists suddenly became interested in spider vein injections, and began to bootleg Aethoxysklerol from Europe. Why? That is, why would they bootleg in a non-approved drug when we have, right here in America, approved drugs that are just as good?

Here's why. Aethoxysklerol was sold at a strength of 0.5%, which is appropriate for spider veins, whereas American Sotradecol was sold at a strength of 1%, which is too strong for such tiny vessels. Knowledgeable American practitioners of spider vein injections understood that Sotradecol had to be watered down to make it safe for spider vein injection, but the new dermatologists of the 1990s didn't know this. So they used it straight out of the bottle! All their patients got chemical burns!

Thus the myth arose that Aethoxysklerol was "safer and more effective" than Sotradecol, and American dermatologists in great numbers began to bootleg it and use it in their offices. At first the F.D.A. protested, but in the process of time, legal cases persuaded the courts that, in the interest of "patient safety", the F.D.A. should "look the other way", and allow dermatologists to continue importing Aethoxysklerol.

What followed was a never-ending series of ridiculous press releases and television interviews by ignorant, publicity-hungry dermatologists, each proclaiming that he was offering a "new treatment for spider veins" employing a "miracle wonder-drug from Europe: Aethoxysklerol!"

"Miracle wonder drug?" Remember, we're talking about a drug which my father had tested and rejected 30 years earlier!

This ridiculous situation persisted for 20 more years until 2010, when, after over a half-century of being an "underground" medicine, Polidocanol i.e., Aethoxysklerol, suddenly and miraculously passed the F.D.A., and became an "approved" drug! How it finally got past the F.D.A. is anyone's guess. My guess is that money was involved, because the public can always be fooled by calling something a "new miracle wonder-drug from Europe", and where there's money, even massive barriers have a way of "magically" melting away.

The new American Polidocanol, however, was not called "Aethoxysklerol". It was marketed here under a brand-new trade name: Asclera.

But guess what. "Asclera" is made by the very same German company, Kreussler, as Aethoxysklerol. In fact, it is Aethoxysklerol, simply shipped to America in bulk and re-packaged with a different name!

I was just as interested in Asclera as the other American Phlebologists, but when I found out what they were planning to charge for this stuff, I balked. Get this: The cost of American Asclera is eighty times more expensive than domestic sodium tetradecyl sulfate. That's "80" times more expensive, not "8"!

I, for one, will not spend 80 times more than a medicine is worth, without good cause.

Therefore, if you come to my office, and insist on "The new miracle wonder-drug from Europe, Asclera", I'll cheerfully administer it, but I'll have to charge you over twice what I charge my regular patients, to cover the cost of this ridiculously over-priced old medicine from mid-20th century Germany.

All three medicines have been around longer than penicillin. Therefore, if you've ever been afraid of getting your veins injected because you had concerns about medicine toxicity, forget it. Provided that you are not allergic, these medicines have no known chemical toxicity. Like the prototype, ordinary salt, they act by a mechanism which is completely dependent upon high concentration, not upon chemical toxicity.

And, like salt, they only work at the exact injection site. As soon as they mix with blood, they get diluted and neutralized. So it is extremely unlikely that they will ever cause damage to any vein other than the one into which they are injected.

There are other ways to bring about sclerosis in varicose veins.

In France, cryotherapy with liquid nitrogen was attempted. A cold probe, with liquid nitrogen flowing through the inside, was inserted into the vein, to freeze it. When the procedure was completed uneventfully, the result was good. Unfortunately, sometimes the cold probe got stuck, causing frostbite to the surrounding tissue. Therefore, this approach has remained experimental.

In England, veins were sclerosed by applying electric shock through intravenous wires. This also worked well, but the electrocautery machine used was originally designed to burn out bladder tumors; a procedure which required high voltages and currents. Such an instrument was too powerful for routine use in veins. It worked, but it was unnecessarily painful. If a better instrument could be designed, it would have promise for the future.

Throughout the 20th century, surgeons and vein injectionists have been at each other's throats. The surgeons used to say that the only way to permanently eliminate varicose veins was by surgery, and that any failed operation was due to faulty surgical technique. If you listened to any one of them, he would tell you that his operations never failed! It was always the other surgeons, who were "less skilled", whose poor surgical technique was the cause of all the treatment failures.

As for injections, the surgeons were unanimous in claiming that they always failed!

The injectionists, on the other hand, claimed that their method was just as good as vein stripping, and that all vein surgery was therefore unnecessary and greed-motivated. In chorus with their surgical rivals, however, the injectionists all proclaimed that treatment failures were the result of faulty technique.

The beginning of making sense out of this occurred in 1953, when my father, H.I. Biegeleisen, published a 20-year study showing that no one was ever cured of varicose veins! Whether they were injected or operated upon, the inevitable result was the same: recurrence. The extent of the surgery, or the number or type of injections, were all irrelevant. If you followed the patient long enough, sooner or later, new veins always appeared. No one was permanently cured!

My father's study was not well-controlled from a rigorous statistical standpoint, but his conclusions were correct, and subsequently came to be universally accepted by the medical profession. Nowadays, no one claims to be able to permanently "cure" varicose veins. You treat the ones which are there, and you inform the patient that eventually new ones will grow in.

The next breakthrough came in 1973, with the landmark study of the British surgeon John Hobbs. Mr. Hobbs (in Britain, surgeons are called "Mr.", not "Doctor") personally injected and operated on hundreds of patients, and did his own 6-year follow up. It was a monumental task, and it stands as the only reliable statistical comparison between injections and surgery which has ever been done, since it's the only one in which the injections and surgery were all done by the same doctor.

It will perhaps come as no surprise that the study proved that both methods work on most cases! But the long-term outcome was not the same for both methods. In some types of varicosity, surgery gave a better long-term outcome, and in other types of cases, injections gave a better long-term outcome.

The quality of the outcome of vein injections is measured according to three criteria:

1. Cosmetic improvement
2. Relief of pain
3. Length of remission time

1. Cosmetic: If the patient is worried about how the leg looks, then the major determining factor in "rating" the outcome is the appearance of the leg. In general, injections work better than surgery! Although there are some exceptions, this is the usual case.

For one thing, surgery does not always work. Relative to a standard operation such as a gall bladder removal, or an appendectomy, vein surgery has a high failure rate. For example, if a person has the appendix out, it's out! Have you ever heard of a person getting their appendix out, and then having it grow back?

But in 10-20% (depending on whom you ask) of vein surgery cases, a new vein will grow in, sometimes almost immediately. The reason is that this is difficult surgery, and most surgeons won't take the time to do it right. Furthermore, this 10-20% failure rate is in the hands of good surgeons! In the hands of average general surgeons, the failure rate has been said to be as high as 50%!

(This last figure cannot be proven, because surgeons with a 50% failure rate neither keep statistics, nor publish papers. You may, therefore, wish to consider it to be "hearsay". But among academic vascular surgeons, such hearsay is both heard, and said!).

2. Relief of pain: If a patient's primary reason for seeking treatment is relief of pain, then it hardly matters which method of treatment is chosen, because they are all highly effective at relieving pain.

3. Length of remission: In length of remission, however, there are significant differences between injections and surgery. Remember that surgery has a relatively high failure rate. But for those patients whose surgery does not fail, there is a relatively long remission.

How long? This cannot be answered for an individual. Only group statistics exist. According to Mr. Hobbs, the British surgeon mentioned above, by the end of a six-year period, 85% of surgical patients will have required further treatment. But in the injection group, that figure is 95%!

While these may not seem to be encouraging statistics, the fact remains that 15% of surgical patients will experience a long-term remission (more than six years) after surgery. This is not a large percentage, but injection patients have essentially no chance of going more than six years without further treatment.

Furthermore, among the patients who do go on to require further treatment, the amount of treatment needed will be greater in the injection group than in the surgical group.

If the differences between injections and surgery had to be summed up in a single sentence, it would be this sentence:

Since the early 20th century, a combined approach, with some surgery and some injections, has been used. In principle, the long-term remission of surgery and the cosmetic advantages of injections could both be had.

In the greater New York area, I know of no surgeons who have first-rate skills at injection treatment, and I know of no first-rate vein injectionists who also operate. Therefore, in New York, the combined approach requires two different doctors.

In our practice, we occasionally refer patients to one or another of a very select group of highly-specialized surgeons who have chosen to devote their lives to vein surgery. For patients in whom surgery is indicated, we will refer them to one of these surgeons for an operation.

It is almost never medically necessary to operate, because veins can almost always be injected. But in the interests of a longer remission time, we will refer patients out, if it is indicated, and if they are agreeable to surgery.

I should point out that most "vascular surgeons" nowadays do NOT specialize in vein surgery! The public believes that vein surgery is part and parcel of vascular surgery, and that simply isn't true! The specialty of "Vascular Surgery" did not even exist until after the Vietnam War, and it was created to serve the needs of surgeons who specialize in "arterial bypass" surgery. Diseases of the arteries and disease of the veins are NOT the same, and patients with one of these forms of disease usually do NOT have the other.

Therefore, for the first 20 years, Vascular Surgeons operated almost exclusively on arteries. During this period, most of them looked down on vein surgery as being "beneath their dignity", since it had always been considered part of "General Surgery" -- not something which ought to be done by a specialist.

As for training, it was not long ago that Vascular Surgeons had no training at all in veins. Fortunately, things have begun to change, but, on the whole, Vascular Surgery is still heavily concentrated on arterial disease, and remains light on the venous side.

Having said all this about the saphenous vein, I must now report to you that some surgeons are saying it should NEVER be treated; not even when it's varicose! Not by surgery -- not by injections. Not at all!

Why? Because this is the era of bypass surgery, and veins are used as grafts in these procedures.

Bypass surgery is the current favored treatment for blocked arteries. How does this blockage come about? As we age, our arteries gradually get clogged by calcium and cholesterol. Although this happens to everyone, some people clog off faster than others. When it gets really bad, it's considered a disease, called atherosclerosis (or arteriosclerosis, or simply "hardening of the arteries").

As atherosclerosis gets worse and worse, the blood supply to the internal organs can become critically diminished. Although it's a generalized disease, affecting the entire body, all organs do not necessarily deteriorate at the same speed. For example, if the kidneys are the first organs to go, then the patient will require dialysis to stay alive. On the other hand, if the eyes are affected first, the result can be blindness.

The most-discussed of the serious complications of atherosclerosis is the "heart attack", the leading cause of death in America. Most patients destined to get a heart attack will develop warning signs and symptoms years earlier. These begin when the heart's blood supply becomes inadequate to sustain a fast heartbeat. Then, when the patient tries to run or climb stairs, the heart muscle cramps. It's a very painful sensation, and it has a name: angina.

Angina is a sign of severe coronary artery occlusion, and it often progresses to a complete, or near-complete blockage, at which point part of the heart muscle can physically die! This is called a "coronary infarction", which means "heart attack".

A   →   B   →   C   →   D,

but the segment "BC" has become completely blocked by atherosclerosis. So the surgeons splice a vein graft (labeled "G") into the coronary circulation to bring blood around the blockage. It's possible (although not necessarily the method of choice) to use a varicose vein for this purpose.

So, even though varicose veins are not considered a good choice for graft "G" in the above illustration, they are used on occasion. This raises an entirely new question in every interaction between vein doctors and their patients:   Should you ever get your varicose veins treated? Or should you save them in case you need them later, for a coronary artery bypass?

1. If you have blockage of the so-called Left Main Coronary Artery, your chances of dying of a fatal heart attack can be significantly reduced by coronary artery bypass (but see item 1 below). The operation could be difficult or impossible without a saphenous vein to use as a graft.

1. "Left Main Coronary Artery" blockages are relatively rare. In my personal experience as a medical resident, during which time I admitted dozens of patients to the hospital for coronary angiography/bypass, not one had an occlusion of the "Left Main Coronary Artery".

2. Patients with both severe heart failure and significant coronary artery blockages are only a small minority among those who receive coronary artery bypass in the United States. In my personal experience as a medical resident, during which time I admitted dozens of patients to the hospital for coronary angiography/bypass, very few had both severe heart failure as well as significant coronary artery occlusions.

3. The great majority of patients who will undergo coronary artery bypass will NOT derive the main benefit which they think they're going to get: prolongation of life, and prevention of heart attacks. That's right, folks. The operation generally does not work, if the definition of "work" is "prevention of heart attacks". Most of the time, the operation does NOT prevent heart attacks.

When coronary artery bypass was invented, it was hoped and believed that it would prolong life in cardiac patients. But it didn't. Since its origin, the operation has been the most intensely studied medical procedure in history. The statistics which have been compiled are voluminous. It became quickly obvious, at the outset, that the operation did not prevent heart attacks, and that's what I was taught in medical school.

Now, over 30 years later, the statistics are even more voluminous, but they still show the same thing: the operation doesn't work!

4. In spite of this, every day in America, angina patients are told that if they don't get this operation, they will die. In the great majority of cases, this is a bold-faced lie.

5. In America, where coronary surgeons can easily make $50,000 per day (that's "per day", not "per year"), massive numbers of coronary bypasses are performed every year. The number is surely in the hundreds of thousands, and possibly as many as a million. In Europe, where many surgeons can earn only a few hundred dollars for doing the same operation, the number of coronary bypasses done is only a small fraction of the number done here in America. Do you think money has anything to do with this?

6. If the operation doesn't save lives, then why is it done? Because it relieves chest pain. The angina, or chest pain of coronary artery disease, is regularly relieved by surgery. But there's an unanswered question: "Why is the pain relieved?". This question arises from the well-established fact that the grafts of one-out-of-seven patients are found to have failed after a year. This means that the bypass in the drawing above (the segment marked "G") has closed off. The coronary circulation, at that point, should have either reverted to its original sick pattern, or maybe even become worse. And yet the majority of these patients still feel fine! Why?

7. It has been proposed that the explanation for the relief of chest pain by the operation may have nothing at all to do with circulation! You see, in order to get to the heart, the surgeon has to cut through the "pericardium", the sheath that surrounds the heart. And that's where all the nerves are. So the theory has arisen that maybe the operation relieves chest pain because the nerves are all cut.

8. It wouldn't be a bad thing to relieve a patient's chest pain by cutting the nerves to the heart, but that doesn't require a prolonged hospital stay -- it could probably be done on an outpatient basis! Moreover, it surely does NOT require "saving" veins!!

9. There is considerable evidence that patients with varicose veins have less chance of needing a coronary bypass than the average American. The statistics supporting this are from this very office. We proved unequivocally that people with varicose veins have lower blood pressure, a disease which is strongly linked statistically with cardiovascular death. We published this in the peer-reviewed medical journal Phlebology (volume 4, pp.191-196, 1989).

In the same study, we showed also that people with varicose veins were much less likely to have angina than age-matched people from the general population. It was not possible for us to prove this as a hard statistic. Nevertheless, the evidence was suggestive of a significant negative correlation between varicose veins and coronary artery disease.

10. The conduit (i.e., "tube") usually used in coronary artery bypass is the saphenous vein. For years, certain observers have been asking "Why?" After all, it's not a good graft!

The best graft is the "internal mammary artery", a small artery which runs down the inside of the rib cage. The internal mammary artery is, or course, an artery, not a vein. And the life-span of arteries, when used as grafts in the arterial system, is much longer than the life-span of vein grafts in the arterial system. The life-span of a vein, when used as a conduit in coronary artery bypass, is in the 5-10 year range. But an artery can last the lifetime of the individual in some cases.

Why, then, are saphenous veins used so much in coronary artery bypass? Because they are easier to get at. It's a matter of convenience! Dissecting free the internal mammary artery from the inside of the rib cage takes longer. And when a surgeon is trying to make $50,000 a day, time is of the essence.

If a patient really needed a coronary artery bypass, and if the saphenous vein was not available, then the surgeon might be forced to use the internal mammary artery. Thus, the patient might actually be better off, not worse!

11. It's a known fact that, compared to healthy veins, varicose veins make poor grafts. They're too big, they're too irregular in shape, and their inner linings are often scarred by phlebitis. There's no doubt that they fail as grafts faster than normal veins do.

Therefore, many vascular surgeons make little or no effort to save varicose veins, when the veins are causing health problems. But others disagree, noting that although they make poor grafts, they can still be used in desperate situations. Are you going to be in a desperate situation?

12. It's a well-established fact that varicose veins invariably recur. That is, new ones always grow in after the old ones are treated. The phenomenon of recurrence has been studied in depth by the British surgeon John Hobbs, mentioned earlier in this report, whose publication on the subject has remained, for 20 years, the standard of knowledge in the field.

Within six years after treatment for varicose veins, most patients have required further treatment. The figure for surgical patients is around 85%. For injection patients, it's at least 95%. That means that unless a patient is going to need coronary bypass within the next 6 years, there's almost no chance of there not being another varicose vein to use as a graft.

Therefore, the only patients in whom "saving" the saphenous vein is an urgent consideration are patients in whom the significant possibility of a sudden need for coronary bypass can be foreseen within the next 6 years. On the other hand, if you are a young, healthy person with a normal cholesterol level, no chest pain, a normal electrocardiogram ("EKG"), and no family history of early cardiac death, then saving your varicose veins for use as bypass grafts is probably pointless.

13. Recent studies from our own office have shown that large varicose saphenous veins never completely disappear after treatment. They shrink to a size so small that they can be neither seen nor felt. After they have shrunk thusly, they no longer have any measurable harmful effect on the circulation. And yet, within a year or two, sensitive ultrasound studies invariably show signs suggesting that the shrunken saphenous veins are once again carrying blood. It's a tiny trickle at first. The patient, at this early stage, rarely has any awareness of the recurrence. But by 5-6 years, the vein has grown back, and can again be used as a bypass graft, if the surgeon is inclined to use varicose veins at all.

This would have been regarded as a very negative aspect of injections only a few years ago, but now, in the era of bypass surgery, it has turned out to be a potential advantage! You can get your veins treated now, and years down the line, when they grow back, you can get your coronary artery bypass!

Some surgeons would object, saying that a recurrent saphenous vein will make a poor bypass graft. They're right. But the original one would have made a poor graft also.

14. Worst case scenario: You need a bypass; the saphenous veins have been injected, and, for some reason, they either haven't grown back, or they just can't be used. What do you do?

1. First of all, there's that internal mammary artery, mentioned above.
2. Then, there are other veins. Arm veins are usually too small, but in some patients, they're large enough. There are other leg veins which can be used, principally the "short" saphenous veins behind the knees.
3. There are synthetic grafts which can be used. They work fine, but they don't last as long. It's not the best way to go, but it's something which can be done when no real vessels are available.
4. There's a treatment called "endarterectomy", in which the clogged artery is simply opened up and "cleaned out". No graft is put in. My own mother, who (without consulting with me) got a coronary artery bypass operation, needed 5 grafts, and they only could find 4 vessels. So they did an endarterectomy on the fifth.
5. There's balloon angioplasty, which becomes more popular all the time. In this procedure, a balloon is blown up in the clogged vessels, which forces them open. It's a relatively simple procedure, requiring no surgery. The balloon is at the end of an intravenous catheter, which is threaded in through an arm vein.

Balloon angioplasty doesn't hold up as long as surgery, but it's relatively non-invasive, and can easily be repeated a few years later, if necessary.

6. Finally, there's laser angioplasty, in which the clogs are burned out with a laser. It's otherwise just like the balloon procedure. The laser light is sent through a catheter which is threaded in through an arm vein.

Critics of laser angioplasty say it doesn't hold up as long as surgery, which is true. But, like its cousin, balloon angioplasty, it can readily be repeated in a few years, if necessary. Laser angioplasty is not done in most medical centers. I'm not sure why. In those centers where it is done, its advocates praise its merits highly.

In short, there are a fairly large number of alternatives to the use of saphenous veins in bypass surgery. One of them, the internal mammary artery, is actually better. The others are not as good, but they'll do in an emergency.

But will an emergency arise? In all the years I've been injecting veins, I've heard of no case in which a patient needed a coronary artery bypass (or a leg bypass), and got into any trouble at all because of previous vein injections!

Does this mean that it's never happened? No. It's possible that there have been cases, which have not been publicized. But since such a thing would, in all probability, lead to a lawsuit, it seems likely that there would be some talk of it. And there isn't.

Therefore, it is my belief that the entire issue of "save the saphenous" is a man-made issue which has been blown way out of proportion. It's my opinion that unless a patient has a relatively clear-cut cardiac risk, saving the saphenous vein for bypass surgery is usually pointless.

Obviously, it would not be hard, in a city the size of New York, to find any number of other doctors who either agree or disagree with me.