Short Biography Information
I trained at St. Bartholomew’s Hospital in London and, during training, held Academic Posts at the University of Bath and Oxford University. I was appointed as Consultant Vascular Surgeon in 1998 and then performed the first Endovenous Surgery for Varicose Veins in the UK in 1999. Judy Holdstock and I invented the TRLOP procedure to ablate incompetent perforating veins in 2000 – a procedure that has been copied widely since and even “re-invented” as PAPS. Also in 2000, my team started investigating and researching pelvic congestion as we found increasing numbers of patients with recurrent varicose veins secondary to pelvic venous reflux. In 2002, I set up The Whiteley Clinic and in 2005 left arterial surgery to be a full-time Venous Surgeon.
In 2011 I set up The College of Phlebology to promote understanding of venous disease and training in the new techniques, and in 2013 was appointed as a Visiting Professor at the University of Surrey. In 2019 I introduced Microwave Ablation to the UK and also performed the first commercial High-Intensity Focused Ultrasound (HIFU) treatment of varicose veins in the world with the Sonovein machine. We now have 5 Clinics in the UK and have an active research program. My team and I have won multiple international and national research prizes, and have over 150 peer-reviewed research papers published. I have published 4 books and written 15 Chapters for other books. We combine with The College of Phlebology to run training courses and The College of Phlebology Fellowship.
Can you describe a particularly challenging case you’ve encountered in your practice as a phlebology surgeon and how you approached it?
As our understanding of phlebology increases, and phlebology moves away from just thinking of leg veins, the breadth of patients and conditions that I see increases, as do the challenges. Challenging cases come in all forms and severities. However, all need to be addressed by understanding the principles of venous treatments and applying them, rather than trying to use “standard” approaches. So, for instance, one young man with Klippel-Trenaunay Syndrome who has been previously treated with open surgery to ligate lateral thigh perforators and had cutaneous laser for the skin discoloration attended with a very swollen leg that was difficult to use in sport. Duplex showed that all of the incompetent perforators had recurred as had the veins that has been removed by phlebectomy. This is what we would expect if we understand neovascularisation. As such, we performed TRLOP on all incompetent perforators, knowing that thermal ablation would prevent neovascularisation, and then ultrasound foam sclerotherapy for the same reason. He got an excellent result at follow-up – which was maintained at review 3 years later. We published his case at Harrison C, Holdstock J, Price B, Whiteley M. Endovenous radiofrequency ablation and combined foam sclerotherapy treatment of multiple refluxing perforator veins in a Klippel-Trenaunay syndrome patient. Phlebology. 2014 Dec;29(10):698-700.
What new developments or advancements in Venous surgery are you most excited about, and how do you think they will improve patient outcomes?
For leg veins, I am most excited about High-Inensity Focused Ultrasound (HIFU). The Sonovein machine directs HIFU with extreme accuracy at the vein to be treated, through the skin. The vein is closed by thermal ablation which we know reduces the risk of any neovascularisation or recurrence – but unlike endovenous surgery, nothing is placed inside the vein and no tumescence is needed. As the technique advances, it will get quicker and easier and lends itself to be a semi-automated treatment. With regards to pelvic veins, I think that our understanding of pelvic congestion or as many now prefer – pelvic venous disorders – is improving. I think that pelvic vein obstruction is over-diagnosed, but am excited that certain conditions might well become curable if proven to be related to pelvic vein incompetence. This includes men as well as women and I think many patients diagnosed with “endometriosis”, interstitial cystitis and prostatitis will be found to have a venous cause and will end up being curable. I think that the work on erectile dysfunction by Sriram Narayanan in Singapore has been very impressive. Finally, the world of Aesthetic Phlebology seems to be increasing rapidly – not just the cosmetic veins of the legs, but those of the forehead, temples, face, breasts, hands, arms, torso, and feet. Although many are treated by cosmetic practitioners, there is a proportion that do not respond or that are too big for standard techniques. I am very excited by some of the new techniques that we are developing to address these veins and look forward to seeing new developments and studies to prove optimal ways to treat the difficult aesthetic veins.
What advice would you give to patients who are considering Venous surgery, and how can they prepare themselves for the procedure and recovery?
First of all, the patient must be clear about why they are having the treatment. If it is for leg varicose veins that are giving symptoms and/or signs, the research is clear that there is an advantage for those having treatment as compared with those who decide not to get treatment and let the condition deteriorate (REACTIV Trial). This is particularly true for patients with venous leg ulcers (ESCHAR and EVRA trials). Hence this treatment is medical and patients are well advised to proceed, and only need to know that they are choosing the right doctor, facility, and technique. For leg varicose veins without any symptoms or signs, the treatment is cosmetic and there is no firm evidence as to a medical benefit. Thus these cases fall into the same group as patients seeking aesthetic phlebology – cosmetically unattractive veins on the forehead, temple, face, breasts, chest, torso, arms, hands, and feet – as well as thread veins on the legs.
As there is no medical advantage to treatment, but there are risks of complications, it is even more essential for the patient to choose the right doctor, facility, and technique. With pelvic congestion (pelvic venous disorders), treatment might be advised because of symptoms in the pelvis or veins emerging from the pelvis into the intimate areas or legs. The evidence for treatment is becoming clearer but is not completely clear yet. There are a wide range of tests used to look for pelvic vein reflux and, although transvaginal duplex ultrasound using the Holdstock-Harrison technique has been shown to be optimal, many patients still get offered treatment on the basis of trans-abdominal duplex ultrasound, venogram, MRI, CT or IVUS. This can lead to incorrect or incomplete treatments – or even stents where they are not needed. Hence patients being offered pelvic vein surgery need to be very sure as to why they are having the treatment recommended, and if the assessment that they have had is as complete as it should be. They should also check that the doctor, facility, and technique are recognised as being specialists in the field, and if they have any doubts, should think of a second opinion.
Secondly, when the patient is certain that they know why they are going for the procedure (medical or cosmetic), they need to consider the risks and benefits. The risks vary depending on the technique used, the experience of the doctor, the severity of the condition, as well as many other factors. All good doctors will go through the pros and cons of the procedure and go through a consent form with the patient, at least 24 hours before the procedure (and preferably several days or weeks ahead) to enable the patient to be certain that they have gone through any questions that they have and they fully accept the risks and possible benefits. Patients are well advised to check that the doctor they are seeing has their results checked continuously on a registry – such as The College of Phlebology Venous Registry. Such registries follow patients up for years after the procedures, checking for complications and recurrence rates, making sure that doctors are informed if their results are poor, and allowing patients to assess them for themselves.
Many doctors are scared that their results might not be as good as they claim and will not join such registries. Patients should be wary of such doctors and facilities as not only are the doctor’s results unavailable to the patient, but even the doctor does not know their own results! Patients who have bad results and seek help from specialists elsewhere rarely feedback to the original doctor, leading them to think that they are doing a good job. Hence it is sensible to be wary of any doctor who is not part of a registry that has long-term patient feedback such as the College of Phlebology Venous Registry. One note about patient satisfaction websites and reviews (ie: Google reviews, Trustpilot, Doctify, etc). These tend to get the patient’s opinion just once – usually a few weeks after treatment. As venous recurrences and problems are often only apparent 6 months – to 3 years after treatment, such reviews only tell you that the doctor is nice, or the facilities are good – they don’t really give you any information about the success or otherwise of the treatment! Finally, when thinking about recovery, it is sensible to be prepared for discomfort.
Although nowhere as painful as stripping, all ablative surgery will cause inflammation, and hence by definition, will cause some amount of pain. Any medical website or marketing material that says that venous treatments are pain-free should alert the patient to the fact that this is untruthfully – and should raise suspicions as to the honesty of anyone sanctioning such a website or marketing material. Patients should also be clear as to what the out-of-hours cover is should a problem occur post-operatively. There should be a clear route for out-of-hours contact and advice that does not send patients straight to Accident and emergency. In my own clinic, all of our doctors are monitored by The College of Phlebology Venous Registry.
We also have Trustpilot and Docotfy reviews as patients look for these, but we do explain the shortcomings of reviews. All patients are given a “preparing yourself for endovenous treatment” booklet and out-of-hours contact information for our on-call doctor. Finally, we encourage our patients to watch the post-operative recovery video so that they know what to expect in a normal recovery (https://youtu.be/Lv5r_zXh7Ao ).
In your opinion, what sets phlebology apart from other surgical specialities, and what drew you to this field?
Phlebology is a fantastic field to be involved in at the current time. Since the introduction of venous duplex ultrasound in the 1980s, we have come to learn that most of what we had thought about varicose veins was wrong. Then, the introduction of endovenous surgery in the late 1990s allowed us to both treat veins successfully with little or no chance of the same vein getting recurrent reflux (IF done correctly!) and also to access any veins in the legs at any point that we wanted to. This has opened up our understanding of venous surgery, and shown us that venous reflux is not just restricted to the two main truncal veins. However, the complete overhaul of how we diagnose and treat leg veins is only a part of phlebology.
Many of us in phlebology research understand that venous disorders are not restricted to leg veins – but veins anywhere in the body. Hence phlebology now includes pelvic veins and all of the conditions associated with those (ie: haemorrhoids, pelvic pain, varicocele, leg varicose veins of pelvic origin) and probably conditions in some patients previously thought to be due to other, or unknown, causes (ie: interstitial cystitis, endometriosis without endometriomas, low back pain, prostatitis, hip pain, erectile dysfunction).
With the advent of Aesthetic Phlebology, and the interest of some in deep vein reconstruction, there are huge areas of the specialty that need research and development and a great many patients who we can now start treating who have previously been told that there was nothing that could be done for them. The two reasons that I went into Phlebology were that it was clear, even before the NICE guidelines in 2013, that treating patients with venous diseases effectively would be beneficial in the long term and hence be cost-effective, and secondly, no-one else seemed to be taking it seriously in the late 1990s.
How do you see the future of phlebology evolving, and what role do you see technology and innovation play in this evolution?
The field of phlebology is expanding rapidly and so there are many aspects to this question. In leg veins, the venous duplex is still the “gold standard” but we all know about the areas where it can miss a diagnosis – such as the “sump effect”. Also, although there are many excellent health professionals performing scans with high-quality machines, there are many doctors or other healthcare professionals who don’t specialise in scanning, and use cheap scanners to look for basic reflux only.
Hence innovations in imaging, whether improving and standardising duplex scanning, or even adding to or replacing this technology, can only be beneficial across the board. For pelvic veins, we need more functional imaging – and less reliance on static pictures – if we are going to improve diagnoses of pelvic conditions. With regard to treatments, we know that thermal or chemical ablation reduces the risks of neovascularisation, and so we need innovation to replace phlebectomy with safe and effective treatments.
Treatments such as the “Total EVLA” treatment for varices need to be studied and compared with other techniques to show their long-term safety and efficacy. Also, we need an innovation to get rid of compression using fabric stockings – either innovating sclerotherapy so compression isn’t needed, or finding new materials that cause much less distress to the patient such as the clear dressings proposed by Johann Chris Ragg. There are other areas of phlebology that I do not practice or research in, such as obstructive lesions and stenting, where I am sure that innovation and technological improvements will benefit patients.
Finally, I think that there is a likelihood that venous disease might be modified by early intervention and the work by Dr Johann Chris Ragg in identifying the possible causes of venous deterioration and the possibility of improving function with simple minimally invasive injections is very exciting. In conclusion, I suspect that many technologies and innovations are being developed that I am not even aware of, and these opinions will be outdated quite soon.
The one thing that I am sure about is that the world of phlebology will continue to expand and, as more doctors and companies get interested in it, and more patients start seeing better results lasting into the long term, it will become more and more of a separate specity with its own sub-specialties.