Chronic venous insufficiency of the lower limbs, a condition responsible for the so-called "varicose veins", is one of the most frequent diseases of our population, involving up to 56% of men and 60% of women as stated by Robertson in an article on the epidemiology of varicose disease in 2008. The data are confirmed in 2016 by the German Rabe, collecting the European experience reporting an increase of up to 70% in women in the early stages of the disease. From 2% to 5% of the population over 70 reaches the most severe stages of the disease, thus suffering from chronic skin ulcerations associated with venous hypertension, representing as published by Harry in the Journal of Vascular and Lymphatyc disorders in 2014 with data collected from 84 centers in the USA, a very high social cost and destined to increase in relation to the aging of the population.

There is a need to find a fair compromise between prevention and therapy in younger subjects before more severe complications appear; therefore, to intervene to prevent and not only to cure, as the Americans Raju and Mallik affirm, where from the analysis of 44,000 varicose patients they peremptorily affirm that the precocity of the treatment removes more serious problems, also considerably reducing social costs.

But is there an ideal method to treat varicose veins?

Varicose veins were first mentioned in the so-called Ebers papyrus, dating from 1550 BC. it is one of the first medical documents in recorded history. This Egyptian manuscript contained the herbal knowledge of the doctors of the time. The ancients referred to varicose veins as "serpentine coils" and discouraged surgery as it often resulted in a fatal outcome.

In ancient Greece, the father of modern medicine Hippocrates also advised against surgery, but introduced an alternative method of treatment using compression bandages, while another Greek doctor, Galen, described the first phlebectomy, he described making incisions with an instrument sharpened and then forged into a hook, after which it would have extracted as much as possible the affected vein. Roman doctors also practiced a similar procedure around the same time. Practices performed even today, even if at the time there was no anesthesia, so much so as to make the practice too painful. The first venous stripping has an Arabic matrix, and it was a doctor named Albucacis, well ahead of its time, who described this procedure, which is still practiced in many hospitals today.

The main discoveries on veins are entirely Italian: Leonardo da Vinci was the first to map the anatomy of varicose veins in the 15th century when he depicted the anatomy of the leg veins with disturbing precision. Professor Hieronymus Fabricius of the University of Padua first identified the venous valve responsible for ensuring the flow in the veins towards the heart in 1603.

It had to wait until 1900 for general anesthesia to allow removal and invasive techniques, but still decisive in many cases, at the cost of incapacitating scars and long and frequently complicated operative courses.

Fortunately, the aggressive surgical practices of the past have gradually been replaced by quick, painless and less invasive methods.

Many and imaginative are the methods invented to make a reflux vein, potentially a harbinger of future troubles, free of reflux, and as such, however, also unable to bring blood, not even to the heart, the function for which it was created.

These consist in the introduction of an instrument (a fiber, a catheter or a needle) inside the diseased vessel, then proceeding with its elimination by supplying thermal energy and / or occlusive substances.

In particular, among the thermal techniques we recognize the Laser, among the first to propose it the Americans Min and Morrison on the threshold of the second millennium, the Radio frequency then up to the Steam of the French Milleret.

Other non-thermal endovascular methods today involve closing the vein with sclerosing foams, an all-Italian invention of 1999 (Tessari and Frullini), or glues in the form of particular cyanoacrylate gels.

All these methods, however, have the same purpose, that of making a vessel, the saphenous vein in fact, replaced by a fibrous cord without flow, even if as reported by numerous controlled clinical studies, with a result in terms of relapse and recovery of the disease venous at a distance, still too high and no different from the old stripping. Other scholars have proposed more gentle methods, with the aim of repairing the venous circulation by acting with precision in the points where the valves within the vein are no longer able to guarantee the right direction of flow.

They are modern approaches that presuppose a full mastery of the subject, the Chiva technique of the father of venous hemodynamics Franceschi and other illustrious phlebologists, or the Asval method, by his compatriot Pittaluga, both aimed at safeguarding the venous heritage and not at its destruction.

Depending on which valves are malfunctioning, it will be possible to apply different techniques aimed at closing the "vanishing points" of the venous system, thus decreasing the overload inside the previously dilated vessel, bringing it back to a normal caliber, as the vice president recently published. of the International Union of Phlebology.

Today it is possible to treat varicose veins on an outpatient basis, painlessly and without disfiguring scars, most of the time with respect for the main trunks, once deliberately destroyed.

It has been demonstrated that the strategy based on repair instead of demolition leads to better results, as the group of researchers of the American Venous Forum indicate in the guidelines of the American Vascular Surgery Society already in 2011 and also recently taken up by the most famous European companies.

We hope that the future will head on the one hand more and more towards the conservation of venous structures (the saphenous veins) although not vital, and with less and less invasive methods. In this regard, today a new energy is emerging, that emitted by ultrasound, therefore no longer thermal or chemical; an energy that can pass through the skin to hit a target under the skin, leaving it unscathed; here there are still French researchers, or English such as M. Whithley, or from neighboring Austria such as A. Obermayer, who are applying these methods with the aim of minimizing venous damage, a direction that many surgical methods in general are pursuing, such as the gamma knife for brain tumors, or targeted robotic surgery for certain neoplasms, confining aggressive and demolishing methods, increasingly to the history of medicine.

Published on: Gazzetta di Parma 3 March 2021