Skip to main navigation Skip to main content

Advancements and Evidence in the Management of Chronic Venous Insufficiency

Welcome to this evening's Advancements and Evidence in the Management of Chronic Venous Insufficiency webinar.  My name is Dr Trish Kahawita and I will be your host for the evening.  Before we get started, I would like to acknowledge the traditional owners of the lands from where each of us is joining to this webinar today.  I wish to pay my respects to the elders past, present and emerging.  Just a few housekeeping notes, this webinar is being recorded and you will receive a copy in the coming week.  If you cannot see the control panel on your screen, move your cursor over the bottom of your screen and the panel will appear.  The control panel provides you with the audio tools for adjustment and is where you can ask questions via the Q&A module.  We have put everyone on mute to ensure learning will not be disrupted by background noise.  If you need assistance, please use the Q&A feature to raise any technical issues and to submit your questions throughout the presentation.  We will be addressing questions throughout and after the presentation in the dedicated question and answer time.  You can upvote questions by selecting the tick icon on a question, this will assist in reducing the amount of same or similar questions being submitted.  Tonight’s webinar is proudly supported by Medtronic and our presenter this evening is Mr Chris Brooks.  Mr Chris Brooks is a highly experienced vascular, endoavascular and renal transplantation surgeon.  He has a special interest in the treatment of all arterial and venous disorders.  Chris is focused on improving the outcomes of patients requiring vascular surgery and where appropriate, employs minimal invasive procedures to achieve the best results possible. His modern approach incorporates advancements in medical technology to treat patients.  The minimal invasive procedures to treat varicose veins, blocked and narrowed arteries or arterial aneurysms results in shorter hospital stays and the reduced risk of complications of patients.  In 2000, Mr Brooks received his Bachelor of Science Biomedical from Monash University.  He then went on to earn his medical and surgical degree in 2005 from the University of Melbourne.  Following this, Chris spent time working throughout specialist hospitals in Victoria and interstate to further broaden his skills and expertise.  His dedication to his academic studies and ongoing surgical research have earned Chris a number of awards.  We will get started now and I hand over to you Chris to commence your presentation.
4:03
Welcome everyone.  So, I am going to talk on varicose vein surgery more than the stripping.  So, what are the purpose of veins.  Essentially to bring blood back from the heart.  So, as you all know, arteries pump up blood to all parts of the body and the veins have to find their own way back.  As you are aware, there is no heart per se between the blood, and particularly in the lower legs where the legs are usually below the heart, the blood has to act against gravity to flow it back up into the heart.  So, this is why even an SAS soldier often collapses when standing at attention.  Why do they collapse even though they are super healthy and fit?  And the answer is that the blood struggles to get back to the heart from their legs and they get reduced filling of their heart and then they get a reduced blood pressure and they faint.  They are, however, embarrassed and get into trouble when they wake up because they haven’t been wiggling their toes.  So, how is this augmented?  It is augmented through the calf pump and the deep veins in the lower legs.  So, when you walk your calves contract, they squash the deep blood, the veins in the calf and they squirt the blood up to the heart.  Small one-way valves are there to stop the blood from coming down and veins on the surface drain into the deep system usually by the two main veins, the great saphenous and the short saphenous vein.  Obviously, any disruption to the function of these veins will affect venous function.  So, normal venous function requires an intact calf pump function.  So, the patient’s calf needs to work.  If the patient’s calf is not working then even if all the venous is patent and functioning properly, the patient is likely to have severe venous disease.  We commonly see this in patients in wheelchairs, as patients get older and become immobile and unable to walk actively or shuffle or use walking sticks or walking frames.  All these are strong indicators that the calf pump is unlikely to be working well.  We also need patent venous system, so, if it is a DVT or clot, then the venous return is grossly affected.  Also, some patients may not have a deep system in some conditions such as Klippel Trenaunay or other malformations as well.  In addition to this, functional valves are important to stop the blood from leaking back down the leg once it has been pumped up with the calf pump.  So, varicose veins.  So, causes of varicose veins tend to be incompetent valves, particularly in the superficial venous system, but also things that augment this are poor calf pump function and central obstruction.  So, patients who are heavily overweight, pregnant, or even getting pressure from the SMA onto the left renal vein can cause pelvic congestion and hence varicose veins in the pelvis.  And this could also happen on the left common iliac vein, so called May-Thurner syndrome, where the right common iliac artery imprints on the left common iliac vein and which is why we see DVTs more common in the left leg.  We also see that varicoceles in the testes 98% on the left side as well as well as left ovarian vein more likely to be incompetent.  But obviously things to watch out for are DVTs, vascular abnormalities and Klippel Trenaunay syndrome.  So, I will start with a quiz question.  A patient with moderate varicose veins in a 30-year-old female and some haemosiderin stain is a cosmetic issue with no treatment recommended.  A cosmetic issue, surgery only if the patient can afford it, medical issue that would benefit from medical and surgical treatment or an urgent issue that needs immediate referral.  Long pause.  Very good.  Okay, as you can see, 78% chose C, a medical issue that would benefit from medical and surgical treatment.  We often see this in my practice, quite a few GPs feel that varicose veins is a cosmetic issue only.  But as you can see, in this particular situation, you have a 30-year-old female who has also got some haemosiderin staining and the haemosiderin staining is basically pointing to a more damaging chronic venous insufficiency, and so, I personally think that a 30-year-old with varicose veins and haemosiderin staining does warrant some treatment and the reason being twofold, one is, they will classify as a type 4 venous insufficiency with haemosiderin deposits, but on a practical level a 30-year-old female with varicose veins is likely to get worse over time and so, I am practicing for 30 years, and maybe another 35 depending on how things go, I am likely to see this person down the track and with worse veins progressively getting worse, heaviness, ache.  With haemosiderin deposits you get scarring and changes inside the tissue in the lower legs and this could later also predispose to ulcers and things.  Obviously, a 30-year-old female is likely to present to you with concern about cosmesis more than the medical side of things and so, that is often the reason that they present, is they are concerned of the look of their veins. I would say that while a lot of, particularly older people, have varicose veins for many many years report no symptoms, when they have been corralled or pressured by, often their wife or husband to get treated, they often report that the legs are much better even though reporting no symptoms beforehand.  They say they don’t feel tired, their legs feel great like they are a lot younger.  We often do get urgent referrals which in the setting of varicose veins and so, I would caution to consider varicose veins as an urgent issue.  I would say that it is something that should be seen, but it doesn’t require the immediate phone call to the surgeon generally speaking, if it is uncomplicated.  Often these are associated with spider and reticular veins, which we will talk about the treatment as we go forward, but spider and reticular veins can also be accompanied with the varicose veins themselves.  So, this is what we typically see often, as you can see this is a fairly older gentleman, he was probably 30 with those small varicose veins and has left it for many many years.  As you can see there are quite large varicose veins in his calf.  You may also see the reticular and spider veins on his lower leg as well, and he was actually a patient of mine, who came and saw me after some considerable pressure from his family and his wife to come and see.  He said, look they haven’t bothered me.  Obviously you can see here that they are starting to become quite superficial as well and puts them at a risk of bleeding, but he reported very little symptoms from this.  So, what we often find is that the level of patient concern is often unrelated to the disease that we see, and in fact I had a lady who had had over 40 treatments for her spider veins and told me that her veins were so bad that she was unable to find a husband.  She was 35, and when I looked at her veins she had very minor scattered spider veins on both legs that were difficult to see at a distance.  Other things that patients may complain about if you ask them specifically or sometimes they volunteer it, is ache, itch is quite common, venous eczema and people with generalised eczema often have it exacerbated by venous hypertension.  Swelling is one that is talked about a lot, we do often have to think about other causes of swelling such as heart failure, et cetera, but swelling definitely is contributed by varicose veins.  Particularly in the older population if they have left it for a long time, the veins tend to superficialise and often get knocked and bleed.  This can often be reported as quite a lot of bleeding, particularly when white towels are used.  It usually will stop with point pressure and can take a long time.  More commonly though we see heaviness in the legs, so people get tired legs in the day, often they just put that down to hard work.  So, I have a few patients who said, I always work hard, that’s why my legs are tired in the day, but once their veins are treated they say, you know what, I can do a 12-hour shift and my legs feel great.  You often see patients coming home and lying down and putting their legs on the wall and that is often just part of the day.  Now if things are left, they get worse, ulceration can form, usually this isn’t just a result of varicose veins, it’s often a mix of other causes such as heart failure and obesity.  The visual appearance, there can be very marked discolouration with the haemosiderin deposits and fibrosis of the lower leg, so-called inverted champagne appearance, and tiredness.
15:45
I am sorry Chris, anonymous has asked can there be haemosiderin pigmentation only without varicose veins?
15:48
Absolutely.  So, haemosiderin deposits are a sign of quite severe venous congestion and so, yes, you can have quite severe venous problems without obvious varicose veins and this typically occurs in patients with obstructive ... such as occlusions from DVTs, post-thrombotic syndromes, central obesity is classic, poor calf function in patients in wheelchairs and so, they can typically have very normal-functioning veins even sometimes, but if you don’t have a calf pump or you have got quite large central obesity, you will often get quite marked haemosiderin deposits.  The haemosiderin deposits here, what it actually is, is I would like to call it is rust basically, so it is the red blood cells that have got iron in them, and they are forced outside the veins into the tissue, and when the red blood cells are forced outside the veins, the tissue, they get gobbled up by ______ , and what’s left behind is the iron, so it really is rust, so you get rusty leg.  It also causes fibrosis in the tissues and the inverted champagne, lipodermatosclerosis is the medical term, and then after that you see these typical ulcers, and this is a very typical ulcer, it is a shallow ulcer, so it’s often reported as not painful even though it looks painful, and so, patients or family members will say, oh Mum has got this painful ulcer, but if you actually ask them, they are not actually in that much pain, it’s part of the family assumed it is painful and then so complained it is painful, but typically without infection, the venous ulcers are not painful, and can be quite extensive so it can cover the whole leg around the leg, but they tend not to be very deep, and they take usually months, sometimes 18 months plus to heal.  So, there are several categorisations of varicose veins, I thought I would just talk on the C classification.  So,  A is we have no symptoms, C0 is asymptomatic, C1 is we have reticular and spider veins, C2 is varicose veins which we are talking mostly about today, C3 is swelling, but usually there is some other compounding factor.  C4 is haemosiderin deposits and lipodermatosclerosis.  And once you get to C4, you start heading towards the _____ ulcer and active ulcer.  It should be noted that several of the public hospitals,  particularly in Victoria, have stopped treating varicose veins unless they get to C4.  So, from that question before, the 30-year-old did have some haemosiderin deposits, so in every hospital in Victoria they would qualify for a public stripping if that’s what they wanted.  Some of the hospitals are doing more newer techniques, which I will talk about shortly, but once you get to that C4 level you tend to have a more serious issue on your hands than just the varicose veins themselves.  So, what about location?  So, here it is in the leg obviously and you can probably see, as this photo shows, you can see the suggestion of the great saphenous vein that’s having the incompetence, which is of course leading to the varicose veins lower down, but you could also have testicular varicose veins, labial varicose veins, this is vulva, often the patients will not volunteer it, at least they don’t volunteer it to me very often, they are quite embarrassed, usually it’s worse during pregnancy and that can often point to an ovarian vein cause as well.  You can get it in the upper limb, but we will save that for another day, that’s our thoracic outlet sort of talk, but most of the varicose veins are in the lower legs.  So, as mentioned, the common cause of varicose veins is incompetency, but as I was talking about before, calf pump function is a very important factor and we often see, as these patients get older their calf pump naturally doesn’t pump as hard, and this is why young children tend not to get DVTs. I have a 2 year old and he does not sit still, he is moving around, grabbing stuff, pushing buttons and you can understand why his calf pump is just pumping non-stop all day every day.  If you see someone in their 70s or 80s, invariably they are sitting, often quite quietly without moving or fidgeting and general mobility and movement actually reduces with age, and so we often see more symptoms even with the same varicose veins or same venous issues _____ down the track.  We do occasionally see young patients who have had some very nasty accidents or trauma to their lower legs.  So, anything that affects the calf pumps, ankle fusions are classic, so if the patient has got a fused ankle, you can be sure their calf isn’t pumping very hard at all, and so what they often don’t expect is actually quite profound venous congestion, because their calf doesn’t work in the same way with a fused ankle and we often see this with multi-trauma as well with pins and rods and fasciotomies and all the rest, and these are often young, usually men, who have profound symptoms and often their legs have only just been saved, but they have spent months and months and years in rehab trying to ensure that they save the leg, but the leg often ... one guy called it his ‘gammy’ leg, and they struggle with that throughout their life.  Central obstruction is often overlooked, so, weight . you often see very obese patients with that marked haemosiderin staining in the legs in the supermarket and I often spend quite a long time discussing weight with them.  Pregnancy obviously is a major issue.  As mentioned, the left renal vein is often impinged on by the superior mesenteric artery and that’s why the left ovarian vein and the left testicular vein are definitely more likely to have incompetence, and in fact in the testicular situations it is 98% on the left ... and we mentioned venous occlusion.  So, the natural history of varicose veins is they tend to get worse with age and so, in the old paradigm we would have open stripping, and in fact if we look right back into the Greek times, as the Greek general had varicose veins 2000 years ago, and he got a knife out and he cut open his varicose veins on one leg.  He fixed the varicose veins, but when he looked at his other leg he decided, they are not that bad, and so he left the other leg, and this is often the paradigm we have with varicose veins.  It is unlikely to lose your life or your leg over, but it is likely to give you a background irritation through most of your life, which then gets worse with time.  And when you are doing a general anaesthetic that involves wrapping your legs for six weeks afterwards with all the complications that go with it, then in the past people have been reluctant to come forward.  But I would like to consider varicose veins as not a must operation, and not a could operation, but probably a should operation, particularly with new endovascular techniques with the walk-in walk-out and can often be done without general anaesthetic or even sedation.  So, this patient of mine here, he was in his 70s, he had a procedure without a general anaesthetic.  So, how do we treat?  So, it’s very important to break it up into two sections, one is to treat the cause, because if you just treat the veins themselves that is a short-term fix that’s going to come back, and classically, particularly in shopping centres we have had people do injections of spider or reticular veins, ______ have it in your lunchbreak, you are walking, you do your shopping, you wait for the script, get injections and you go home.  The problem with a lot of these treatment is that they don’t always treat the underlying cause.  If a great saphenous vein is the thing that is leaking or incompetent, then are treating the spider veins below it is just going to cause other spider veins to open up next to it.  It also causes the treatment to be less effective.  So, classically the patient complains, Oh, look, I have had it treated, but they came back, and it just didn’t work.  So, in terms of varicose veins the usual cause is superficial venous incompetency.  You also have to be very careful that the superficial venous system isn’t the only system, you sometimes see that in Klippel-Trenaunay, but also there is sort of deep DVT or other issues deep.  Classically though, one of the main things that makes it worse is weight.  And all these patients are very obese and overweight, but they are not always, not always the case, and pregnancy we mentioned and we have already mentioned poor calf pump function, immobility, so anyone walks in with four-wheeled frame or a walker or walking aids, they are likely to have issues.  Particularly _____ varicose veins or when the veins are in the testes, they need to look at the ovarian and testicular veins.  So, this patient here has got very severe venous congestion, you can see on the right quite marked cellulitis, you can see the swelling on the dorsum of the foot, there’s some lymphoedema and the band is just sort of half done, this is very typical to what we see.  Patients actually in a wheelchair, usually they will say things like, I don’t eat too much, I do lots of exercise, which is clearly not true, and often they sit in the chair all day with the dependent oedema.  You can see how grossly swollen that right leg is.  There is a semi attempt at doing some compression bandage on the left leg, typically these sort of patients don’t want to do it, and then often it’s done short-term and then gross swelling and oedema forms and then they get cellulitis and then they are back to square one.  So, it is important patient education.  I sit down with these sort of patients at depth.  They often have some varicose veins, but the varicose veins in this situation contributes to the problem and I’d like to say that all the different parts is adding up together, actually multiply together, but clearly that last patient….diet, compression, compression, compression, compression.  And we often hear, oh, I don’t eat ____.  Mobility, calf pump activity needs to be maximised. Now compression stockings, generally they are class 2, so that’s 20 to 30mmHg, often it’s whatever we can get on them.  So, TEDs, to give you an idea, are between 8 and 14mmHg, and some Tubigrip is much less.  But anything you get on those patients is helpful.  In pregnancy, we pat on their back and give birth, because I personally don’t want to surgically treat pregnant women with varicose veins. Supportive undies, supportive compression to get them through.  So, in terms of treating the cause surgically, it has really been the two main opposing subsets, that’s open surgical stripping which everyone has heard about, and endoavenous ablation, and that initially started with something like foam sclero, and then progressed to laser, radiofrequency and then later on we were gluing them.  So, stripping is well known, it works, they have several days in bandages, tend to have 6 weeks in stockings, it involves a general anaesthetic almost always, this is significant in the minority of patients who have regrowth of the stripped vein and they need redo surgery.  So, I am 42, I strip a patient today, they may come back in 10-15 years and then have to redo it and then in another 10 or 15 years I will have to redo it again.  Each time when we redo it, the risks of complications go up, the risks of _____, the risks of nerve injury particularly the saphenopopliteal and also the general effectiveness of the surgery diminishes.  Other things that can occur as well is a nerve injury, which is not uncommon particularly in the saphenous nerve.  It could also happen in the sural nerve.  Both these nerves are sensory in nature only, so the mobility tends to be very low, so the patient may end up with a big numb patch on the inside of their calf or behind their calf, but some minority of those patients also get neuralgia associated with the nerve.  The nerve we get most concerned about is the common peroneal nerve, which is uncommon and very debilitating for the patient.  The benefits of stripping is that they are able to ligate all the tributaries around the junction.  So, when you dissect a junction at the top you get all the little side branches that come off and it can be done for the great saph and to accessory saph and the short saphenous veins.  This was traditionally thought to be very important to _____ tributaries and in fact some people go back to second and third order tributaries to make sure that they got far back as they could, but in the end they had a more aggressive reform.  So, what about the endovenous options? Foam sclero has high failure rates around 60-70%, and so tends not to be used these days unless there’s other considerations such as availability or cost.  Laser is a traditional initial way of closing the vein endovenously.  It has a high closure rate over 90%.  It burns the vein, so a catheter is passed up inside the vein, fluid is injected around the vein which is cold, has bicarb, adrenaline and lignocaine in it, and then the laser is turned on and pulled back through the vein and burns it as it goes.  This requires tumescence of multiple needles around the path of the vein and also requires specialised training for laser safety, so laser could be quite dangerous if used incorrectly, and also because it is a burning thing it can actually damage the tissues around it, so if the tumescence isn’t put in properly or below the knee where you have got the saphenous nerve right next to the saphenous vein or the sural nerve near the short saphenous vein, you can get nerve injury as well.  And you will often hear different companies talking about different wavelengths.  I have never been convinced that one wavelength is all that superior to the other, essentially it’s a thermal injury. Radiofrequency ablation has a more controlled burn, it’s a very similar principle, high closure rate is again over 90%.  It burns at a 120 degrees and it can be done in several segments, but it also requires tumescence and can cause thermal injury as well.  More recently, definitely more in my practice these days, is simple gluing, it’s a very similar technique that doesn’t require tumescence or heat.  The downside to endovenous options, they are unable to get all the tributaries around the junction.  They are good for the great saphenous and short saphenous.  A lot of my colleagues have trouble with anterior accessory saphenous vein and you are still able to get nerve injury with the thermal methods, which is laser and radiofrequency ablation.  So, ….
32:36
Sorry Chris, just before we move on, Amarkie wants to know what the glue is made of.
32:42
Ah, cyanide acrylate. So, the glue is a type of superglue actually, but it sets soft.  So, a superglue traditionally will set hard and this superglue sets soft and that’s why they charge $831 for the glue as opposed to at the hardware store, which you can get very cheap.  It’s a soft setting superglue.  It’s literally a superglue, yeah.  Okay.  So, which technique is recommended by the National Clinical Institute for Excellence ______ Guidelines. Long pause.  Very good.  So, 66 of you said F, which is correct.  So, the National Clinical Institute for Excellence does recommend any sort of endovenous treatment over stripping and foam.  Strangely enough they recommend endovenous first, then if that’s not available, foam sclero to the great saph, and if that’s not available, which I can’t see how that would not be available, they recommend stripping.  So, they have gone definitely very heavy endovenous in the UK.  We don’t have these sort of guidelines here and we still have quite a lot of stripping particularly done in the public hospitals.  So, basically it recommends endovenous techniques.  I will show you a video of the glue, I will just skip it forward a little bit.  So, it uses a glue gun for the glue, a wire is inserted into the vein under local and this is passed up near the junction, a catheter is inserted 5cm from the junction, it can be saphenofemoral or saphenopopliteal, it can be anterior accessory on the top as well.  A sonographer… I use a sonographer as well, ____ 1cm apart and pull it back to 3cm.  And the beauty of this is the patient can sit up and actually watch on the screen if they want.  We push down for 3 minutes ... I used to tell a joke but I am out of jokes now and then it is 0.1ml every 3cm.  And you could work your way down the leg, you can actually do it all the way from the ankle if you want, I tend to do it from the knee. The beauty of this I find as well is because the vein is not stripped, it tends not to grow back, that’s very very uncommon for me to see any veins that opened down the track. I did see that a little bit with the thermal ablation techniques with radiofrequency in less than 1% of people, but with the glue I haven’t see it.  You can see here, there’s usually one injection of local and then that’s the most painful bit and then the veins seem to be treated after that.
36:51
Sorry Chris, Barbara wants to know does the glue dissolve over time?
36:56
No, glue does not dissolve, the glue is permanent.  And there has been concern about whether you can feel the glue, whether the glue is lumpy, but remember this is 0.1 of a mL.  So, you can imagine what a mL is, each drop is 0.1 of a mL, so we may use a whole mL for quite an extended length of the great saphenous vein and some of these veins are 1cm in diameter, so over the length of 20cm, that’s 1cm in surface area squared, you have got 20mL of blood in there, and we are going to convert that to less than 1mL of glue.  No, it doesn’t dissolve, it’s permanent like superglue so, it stays.  So, back to our patient again, so ... we treat the top bit, the great saph, now we are going to treat the veins themselves.  Now, my way of thinking is if you are going to treat the veins endovenous with the top bit, it make sense to treat endovenous in the bottom bit as well.  Some people, however, do inject local _____ even under local, I have always felt that as a bit barbaric, but you can do that, you can mix open and endovascular, I tend to do it all endo though.  So, you treat the veins with avulsions, but you do also have an associated nerve damage, scarring and also the avulsions won’t treat those spider and reticular veins.  This is where sclerotherapy comes in, obviously treating the testicular and ovarian vein will need coiling.  So, what are my secret weapons?  I use a Venolite, I use an ultrasound and I use magnifying loupes, and I find these three things increase my ability to treat underlining incompetence and the varicoseveins themselves.  So, you will see here, this will be a shot of the Venolite and as you can see veins under the skin that you don’t easily appreciate.  You can see the vein, it’s hard to see there, but you can see it with a Venolite very easily, so I will show that again.  So, it’s quite obvious there and these are often the causes of some of these spider veins on the surface.  In terms of sclerotherapy…. so this needle is smaller than a human hair, and what you will see here is the …. as you inject, the vein disappears short term and then later on it will get angry and look worse, so you wear that for the next couple of days, but you often get that sort of immediate response there, and you can see it’s actually affecting these veins here and over here as well, and sometimes you can get quite an extensive injection with it as well.  So, it’s not just each individual vein, so you can see here that’s already inflamed, this will become inflamed and this will be treated as well, where this needs treatment itself.  So what about the big veins.  How do we treat those big sizeable veins on that patient?  So, he has got the great saph here, he has got reticular and spider veins here, which we talked about injecting, but these bigger veins here, how do we treat those.  And what I do with these ones is that I inject with foam, so, use an ultrasound… you don’t really need an ultrasound here, you can see them quite clearly…. but I injected the foam.  You can see there’s a few.  So, I prefer polidocanol.  Someone just asked do I prefer STS or polidocanol, and do I foam or do I not foam.  And so, basically, the polidocanol is another detergent as is aethoxysklerol.  I use aethoxysklerol or polidocanol because that’s what I have always used. You just have to know the concentrations, it’s a 2:1 concentration difference.  The foaming gives you more bang for your buck, so when you foam it it’s more effective, and so in the bigger veins you want foaming, but in the small spider veins you want it to be less concentrated, so it is not as irritating.  So, when would I choose laser over glue, the answer is, I don’t, I think glue is better on a few levels.  I think laser you have to be skilled at using the laser, you have to also be properly taught as well with the laser, all the staff need to wear glasses and also with thermal injury I find is slightly inferior, it is still very good, but the benefit of laser is you can tell people they are having laser, a lot of people like keyhole laser, those sort of terms, where if you say radiofrequency ablation with glue they don’t seem to be as thrilled at that.  So, I have got a few questions here.  So, is the glue available in the public health system.   And my understanding at the moment, I am not sure if this is true, but no, there are some centres like the Alfred Hospital in Melbourne that do some radiofrequency ablation, but generally speaking, a lot of the public hospitals still do open stripping.  In fact 90 to 95% of my public patients, once I go through and discuss all the options with them, actually end up having the veins done in the rooms and so I try and keep the costs as low as I can and that way the patient then doesn’t need to be on the waitlist for two or three years, can come back to the rooms on a Wednesday morning and I will treat both their _____, we have a chat, it’s done without any sedation and they always enter very anxious and the vast majority leave very happy.
43:29
There’s a question about when…..(overlapping)
43:32
When the patient will return to work….? Yes…. so, that’s a very good question and I find that there are two types of people in the world, there are ones who work for someone else and there are ones who work for themselves.  So, we have lockdown, a lot of people who work for other people, they go, great I’ll get a holiday, I’ll get two weeks off, I will get paid, perfect.  Then there’s the people with their business who are pulling their hair out, jumping up and down and it is very similar.  So, I have had a patient that I did at the Base Hospital, my nurse calls later in the week and she said, my legs were a bit achy afterwards that night.  I said, what did you do?  She said, I walked out of the base, down the road and did a 12-hour shift as a chef till 4 in the morning.  And so, she owned her own restaurant, so, she wasn’t going to stop working and she did not have a sedation or anything, so she is like, sweet, I am just going to go down and get back to work.  I wouldn’t recommend that.  I normally recommend a week off.  If you are a security guard and you are a standing still, have two weeks off, that’s not a great thing for your veins if you have to stand by a bank or something like that.  It depends what you are doing, but generally speaking, I tend to give a week off work, they walk in, walk out, with stockings, they have stockings for three weeks and I would say the stockings are actually the second part of the procedure, so I do the first part, stockings are the second part.  So, how much glue.  You can use as much glue as you like really because it doesn’t actually travel anywhere, it’s only if you put the glue in the wrong spot.  Are there any complications?  Yes, there’s always complications with anything.  If you glue the common femoral vein shut, you will wish you never did that, I am very lucky that hasn’t happened, but obviously you have to be careful that the glue doesn’t travel in the deep vein, otherwise you are going to have to try and fix it.  What I found with a lot of these things as well, it is becoming “easier” and so a lot of my nonsurgical colleagues and even some GPs have done courses and are now picking it up and doing it themselves.  So, some of the competition I am seeing with, on the vain side, some of my older colleagues who are stuck in their ways, what would this new guy know and do the stripping, it is actually through phlebologists and people who aren’t surgeons, but they have done courses and training and say, look, you know what, I can do this, you glue it, it’s easy, just glue glue glue, and so my main competitor where I am is actually a guy who has never done surgical training, but he has done the _____ and that’s all he does, he does veins, veins, veins, veins, veins, and so he has five days a week doing veins, I have… it’s about a one day roughly for me, and so he is able to do it all the time.  The interesting thing is they tend not to be able to do it in the hospital, so doing it in the hospital is an advantage, because if the patient has got health insurance, the hospital and the health insurance pays for the glue.  So, the glue is $830, so I can get them in ____ fund them and then they walk in walk out and they are really happy, they go to _____ and they show their friends and those friends come down and then I get all their friends to come down to see me, and they say, I heard you are doing veins, you don’t charge 6000 or 7000 dollars, which is sometimes what people get charged and you can do it in the hospital.  It also enables people who don’t have insurance to have it in the rooms and get it done in a timely manner.
47:15
There’s quite a lot of questions, do you want to answer them now or at the end?
47:19
Oh we can keep going.
47:21
Now? Okay.
47:22
I’ll keep going and I might be able to answer some of the questions as I go.  So, complications.  Lumpiness.  So, if you have a big vein like that, it is going to be lumpy.  It doesn’t just disappear.  And if they don’t wear their stockings, which sometimes they don’t, it will get blood in it.  If it gets blood in it, it will be angry and sore and they will get discolouration.  So, they will get the blood that is trapped in there, will come out and it will stain, you will have a brown stain.  Sometimes occasionally you need to aspirate, so like this gentlemen here, I would say look, you are going to have lumpy veins and then I see them at one week, but then I see them at four months.  I see them at four months, because if I see them at four months what happens is, most of it has gone away.  And I find class 2 compression stockings are a must.  _____ forget it, all that stuff and we have really got to encourage now.  I have got a nurse, I call her the bad cop, she calls them and she drills in you got to wear it, you got to wear it, you got to wear it, and I see people cut them, sew them, put straps around their necks, all sorts of strange things.  So, this is the same gentleman I was talking about before.  This is him seven months down the track, he complained bitterly about lumpiness and discolouration and what you can see here is a little bit of residual discolouration.  You might note here, all that purple stuff here is now gone.  And this all happens slowly over those months.  And he asked me, do I think this looks any better.  And clearly from the photos I showed you before, it looks… you would hardly know, you can see the vein he has been treated, the in-flow vein, those big lumpy veins, this is where some of the biggest lumps were and so you are seeing that haemosiderin deposit and yes, in him you don’t notice it, but in a young girl you may. Particularly a young girl who wants to show off her legs, that may be an issue for them.  This was much much worse a couple of months before.  So, this patient actually had an episode of aspiration as well, which helped reduce it, but here it is a very very dark, say a month before. What I found is, I have a lady who could laser the haemosiderin stuff off, I haven’t actually used it yet, because, with time it tends to diminish to the point where most people aren’t concerned by it.  Other sources of incompetency.  So, as mentioned, ovarian veins, testicular veins.  As you may be aware, the ovaries and testes originated in the abdomen and when they migrated down they took their vascular bundles with them.  The ovarian vein, I had a patient who told me that I had done the wrong side, because I went up the right side to do the left ovarian vein, and she was concerned that I had done the wrong side, but that’s how you go, right over left, and as mentioned it’s almost always left side.  There is a picture here, the catheter going up over the left renal vein down the ovarian vein and you can see here this looks like a retractable one where you can pull the coil up.  I don’t use that many coils, so this is one of my cases, and this is a fairly typical sort of picture, it’s often got some sort of venous abnormality here, so you can see this, you have your left renal vein, you have a very large ovarian vein coming off, it is actually some of it is coming off the tributaries directly from the kidney.   What you can see here is an accessory left renal vein, and this actually usually goes behind the aorta, you can see the sort of thing there, and often you almost see an impression there of the SMA compression the renal vein a little bit.  When you inject, the blood tends to go all the way down into the pelvis and then often tracks back up the IVC.  Now, this is not what should normally happen, it should travel back up to the renal vein and then have some coils deployed.  You don’t need too many, though the company will encourage you to put lots in, they are over 1000 dollars each, but you need enough to occlude the vein.  This is a different patient with a very low lying renal vein and you can see here the ovarian vein is coming off and getting coiled as well.  Testicular incompetency in men, you get the bag of worms, which is exclusively left sided, 98%, often they will get quite embarrassed about it and here is another example here.  Interestingly the testicular vein doesn’t go into the pelvis, it goes in the testes and so you can see some coiling here.  I stay away from the inguinal canal, so I will coil a little bit higher.  So, in summary, the natural history of varicose veins is they tend to get worse with age.  Newer endovenous techniques are walk in walk out procedures and can generally be done without a general anaesthetic or even sedation.  Questions?
52:40
Thanks so much Chris.  We have had a few questions come through, so I will just group them together.
52:47
Okay.
52:48
Lots of interest about glue, so I think we have a lot of phlebologists maybe here, budding phlebologists.
53:00
Yeah, I have got a few of them here.  So, is there hope in the future for patients with deep venous insufficiency.  That’s an excellent question, and in fact a colleague of mine in Sydney invented an artificial valve for the deep venous system.  He sold it to a company and he made millions of dollars and it didn’t work.  So, there are all sorts of artificial valves being trialled, but anytime you touch these deep veins, what tends to happen is they occlude.  In patients with extensive occlusive disease, venous bypasses have been trialled, but again often you have to be pretty desperate because they often occlude and the patient is often worse than ever.  So, yes, so any treatment for the testicular varicoceles.  The bag of worms…. by stopping the venous inflow, the bag of worms tend to get treated straightaway, and so some people do inject aethoxysklerol down into the testes, but you can get epididymo-orchitis, which you got to be very careful of.  Nutcracker syndrome.  Okay.  Yes, so that’s a good question, nutcracker, I like that one.  So, you do have to be quite careful with nutcracker syndrome, and there is a lot of controversy about nutcracker as well because surgically you can actually divide the left renal vein completely, and so it is a bit unclear about why the nutcracker would be such an issue with pain on that side, so it’s often a very common suggestion that’s made usually when the patient has got quite a lot of extensive abdominal pain and they almost always get a CT and then someone says, oh, maybe there’s nutcracker.  You do have to be very careful about ligating the tributaries coiling in that situation because if there is a true nutcracker that’s occluded in the left renal vein, if you occlude the outflow of the left kidney, you can actually make it worse, so you do have to be a little bit careful with that if it’s a true type nutcracker.
55:14
A just might read these together, just for the recording as well so they know the questions for people listening.  So, Carlos wants to know, one of the new concerns with the glue as published by the ACP Board is glue migration and granulomatous reactions, have you seen such adverse events?  And anonymous has also asked how long has glue been used, any long-term effects, fibrosis, inflammation, autoimmune or allergic reactions.
55:39
Very good.  So, I have been using glue for about three or four years, and I have seen sort of an inflammatory reaction from it before in two or three patients, and I would have done about 600, and I found that goes away after a couple of days.  Glue can definitely migrate and there is different types of glues on the market, so there’s the glue that I showed you in that film clip where you put a catheter in and then you close the vein under ultrasound guidance and carefully do it like that.  Other people using glue, where you just literally just put in a needle in and you inject it.  And some of these glues aren’t very viscous, so, it depends on how sticky and viscous the glue is.  The Venoseal one is quite viscous, so it tends not to migrate too much, but the way I do it is, I have got a sonographer and a machine that has got very high resolution and when I inject it, I can actually see the glue come out, and so sometimes you will see the glue run and then you just adjust the catheter to avoid it from going the other way, so there is quite a steep learning curve associated and it’s not as simple as radiofrequency, just a push a button, push push a button, push push a button, push.  With the glue, there is a learning curve to make sure that you inject the glue at the right spot.  Also, how the glue has been loaded, so it needs to be loaded just short of the tip, so if people are mucking around with it they can push that inadvertently.  Sometimes ... Medtronic has had a gun that hasn’t worked very well, so you can click and click and click and click and it does not actually squirt the glue out.  So, if you are not careful you might just not put any glue in and not notice and then the thing doesn’t work.  Or alternatively, you might click click click click click and then suddenyl get the plunger to click then you can squirt a whole lot of glue into the vein and then migrate somewhere else.  I haven’t seen that with Venoseal, but there are other glues that are quite thin and viscous and that would be more likely to embolise.  I haven’t seen any autoimmune or stuff like that associated with it.  I would be a bit cautious about doing a short course and then just treating, because there are short courses that are offered, you go do a weekend, oh this is how you do it and then people just go for it, I would be a little bit cautious about that and I think if you want to do something like, you are much better come in under the wing of somebody who has done it a long time and then just go through, see how they do it, help them out, and see if you can partner in that sort of situation, particularly with a busy surgeon who doesn’t necessarily mind losing some of that venous work.
58:34
Anonymous here has asked.  Patient who had injections into her spider veins, now there’s pigmentations from the injections, would these ever go, if not what can be done to remove them.
58:50
Yes, absolutely, so some people do get discolouration, particularly in those ... almost reticular veins usually.  So, the reticular veins are sort of in between the spider and the varicose veins.  I will see if I can show ... I’ll go back a bit.  On that guy I showed you before, the blood can get trapped through it superficially and yes, they can discolour, both with varicose veins and the spider veins, but classically it’s…. so you can see …. I don’t know if you can see that, that group down the bottom there, that would be at high risk of getting discolouration.  The stockings are an important part to try and avoid that, so if you have got a class 2 compression stocking, that’s much more likely to avoid it.  It can still happen though, and it is quite distressing to give a young female who wants to show off their legs. In my experience it goes away over months to years, so, while they might be quite disturbed about it today, but if you wait a year or more, usually it fades substantially and then they can’t see it and they are quite happy then.  There is a minority of patients that still has it even after a year plus, and in those patients you can try all sorts of different things, but you can try lasers, like a tattoo removal type laser, but that is one of the risks of the treatment unfortunately, there is going to be a minority of patients, and usually, it’s actually quite a small minority that are concerned about some discolouration that can occur and that’s part of the consent process as well.
60:47
Helena wants to know, 25-year-old male with left large varicose vein, should we find out a secondary cause or what investigations should be considered before referral.
60:58
Yeah.  So, large varicose veins in a 25-year-old, very happy to get the referral straightaway.  The thing that I am thinking of is Klippel-Trenaunay.  So, sometimes they have massive veins, got a big leg, port wine stain, lateral marginal vein go up the right side, deep venous problems as well.  Hopefully the vascular surgeon you refer to will recognise that because if they don’t they are going to be in trouble.  _____ deep veins absent, but obviously if they are grossly overweight, we see some patients who are like 240kg and they say my legs feel heavy.  Well, guess what, they are heavy, that’s why they feel heavy, and so losing the weight is actually part of a really important thing, so they say look, you know what, I don’t eat too much. You are 240kg, we need a results base, you need to eat so much that you lose weight not gain weight, and if you are gaining weight you are eating too much, and so they need a dietitian, they need all that sort of support as well.  So, I wouldn’t be too concerned, and me personally, I have an ultrasound sonographer that I use and so, a lot of my GPs will refer to me, and I just order the ultrasound before seeing them, so, that way my sonographer looks at it and says, look, that’s suitable for glue.  You are not going to get that at MIA or Capital Radiology.  And a lot of those sonographers actually do general sonography most of the time and occasionally do veins and so the ones that like doing veins get swallowed up by other vascular surgeons who come and grab them, because they are not actually training vascular sonographers anymore, and so, I would much rather have my sonographer have a really good look, check the deep veins, and so if they miss something I can go look, hang on, you missed this, what you are doing, and also I give them a good half an hour to study it, so I wouldn’t be too concerned about trying to get to the bottom of it before, if you send to the vascular surgeon they should sort that out.  I had never experienced an anaphylaxis from glue either.  That would be very bad to happen.
 
63:12
So, Fatima wants to know how long do you need to continue anticoagulants for soleal vein thrombosis almost 14cm long.
63:02
Yeah, excellent.
63:23
Or is there any role for this.
63:29
Okay.  You just broke up a little bit there.  But, yeah, so, below-knee clots have always been a bit controversial and the reason that these clots are controversial is that when all these DVT studies were done they were done using venegrams and so, you inject blood in the vein, they were symptomatic and to be seen on a venogram it had to be a huge clot, these are big big clots.  Now, with ultrasound we have got very detailed high-resolution ultrasound that can look at all sorts of these small soleal veins, gastroc veins, these are non-axial veins and so when we see those clots, we go, oh okay we have a clot, and then we assume, okay, let’s look at what the research shows.  The research all looked at the big big clots, they didn’t see these clots, because they couldn’t see them, and so, there has been quite a bit of controversy.  Me, personally, I anticoagulated them for about 12 weeks or three months, because in my experience it can herald something more serious down the track, and you know if you treat a soleal clot then, if it doesn’t extend, which it usually doesn’t after being treated then they are not going to have any problems, where if you want to serial scan them, in theory you can, you can scan today, next week, three weeks, you may as well put them on some blood thinners and if they could tolerate it, because it will stop it progressing and also it will give you peace of mind, give them peace of mind.  Usually, six to three months is enough for that sort of thing, and you can scan at the end, and this is where sonographers are important, is it might be an old clot, so you scan the leg for something and say oh I can see a soleal clot.  What does that mean?  Okay, well has it been there for three years?  Don’t know.  So, having those sonographers who can look at it and go, well that’s an old clot, I’ve seen that, and they have a clot from ages ago, in that case you may not treat it at all. You say, look okay, you have got an old clot and they say, oh yea my leg swelled when I got back from Bali but it’s all fine.  So, it is a bit controversial, I treat myself, particularly with the NOACs now, you can use apixaban or rivaroxaban and give them tablets.  It’s not the same hassle as warfarin, you don’t have to watch how much spinach they eat and that sort of stuff.  So, am I willing to take anyone under my wing?  Yes, I am, because I have a very busy practice and I find it hard to find time to do stuff, so if someone was interested, absolutely; same with assisting, very happy _____ get involved, just let me know.
66:12
You may want to say where you are based (laughter).
66:18
I am based in Frankston, so, yeah, that’s sort of the southeast of Melbourne, but it is a little bit further south than Melbourne per se. I have a question about compression in the acute phase of DVT?  Absolutely.  Yeah, you want the leg compressed and in fact I put them in compression stockings for two years.  So, if you have a big DVT, we are talking a proper DVT, then you want to avoid the complications of chronic venous insufficiency, they should be wearing a class 2 below-knee sock, we actually got socks, black socks, or stockings for two years.
66:58
Anonymous has just asked, do you _____ superficial clots rather than just aspirin?
67:03
Yes.  That’s a very good question as well.  So, a very controversial question actually as well.  So, the question is why they had a superficial venous thrombosis.  Now, historically migrating superficial venous thrombosis was associated with a diagnosis of cancer actually.  So, people go up their arm.  When it is associated with varicose veins it is a little bit less clear, usually ... we tend to pick a figure out of our heads and say look, if it is within 5cm of the junction at the top or the saphenopopliteal junction, we would treat.  Some people just want to be treated anyways, that’s fine.  Sometimes it migrates, so then they go, oh well.   So, most of these people do end up with anticoagulation.  I tend to anticoagulate them and then I tend to treat the veins and the beauty of these minimally invasive techniques is you just keep the anticoagulation going, so once they have settled down a bit you can actually just treat the in-source vein and close off, so you might have say, in this picture here, a localised superficial venous thrombosis here, then what you can do is you could put them on anticoagulation and then treat the vein and then close these other veins off around them and then just treat the problem altogether.  The problem that happens is when it is in the great saphenous vein, so the great saphenous vein is actually occluded with the clot, and sometimes they say, oh my veins are actually looking better, and they sort of auto treated themselves in some way, because the cause of the incompetency is now closed, so the veins have less pressure and they say, oh my varicose veins are better, but in that situation you need to check with them down the track because what often happens is the great saphenous vein then recanalises and then becomes incompetent again and then they get the varicose vein back worse than ever and then they get further clots down the track.
68:57
Excellent.  We have 1 or 2 minutes, Helena has just made an observation of, my recent patient has huge success with coiling.
69:12
Good.  Excellent.
69:15
Anonymous has asked, 25-year-old female with a history of dependent oedema from prolonged standing and sitting, developed haemosiderin pigmentation, what is the chronological order of treatment if differential diagnosis is venous insufficiency plus/minus DVT.
69:34
Yeah.  Okay.  So, obviously it depends a bit on the patient, but sometimes you might have a 25-year-old female who is like grossly overweight, and then you just have to hit them and say, look your weight is an issue, your BMI is 50, your life expectancy is 10 years less.  They often will say, I have been trying.  Well, you actually need to have a strong look at what you are doing and try and fix it.  You do have to think about other things that might be causing that chronic venous insufficiency, so, often the legs are done, that central venous is an issue as well, and if it is one side or the other, sometimes even things like heart failure or some unusual things that are pushing on the veins, sometimes they can have clots obviously centrally as well as in the legs, so they might have an iliac clot and you have just done the lower leg scan, you missed it.  They can have all sorts of abnormalities, they can be pregnant, that’s one that sometimes gets missed.  I had one or two, we even had a surgical registrar, who missed that on themselves, so, sometimes that can happen, particularly if they are not having periods.  Yeah, so there’s a few things that you can look at there.  The time course is important as well, if they have always been swollen or it just suddenly occurred, tumours and things like that can do it as well.  So, I think if it is bilateral and it is swollen, I always think can I check the central veins. Unusual things like heart failure can also cause quite a lot of swelling in the lower legs, even low protein, kidney failure that causes low protein can cause bilateral swelling.
71:24
Yes.  Are you looking at … there are three more questions…
71:30
Yeah, I am looking at… yeah, three more questions.  Alright.  So, treatment for ____ eczema, so, yes.  So, compression, compression, compression.  Weight loss, weight loss, weight loss.  Exercise, exercise, exercise.  So, these classically they come in, and I had this lady come in, she’s huge and she says, I don’t eat too much and I can’t wear compression, and you are like, oh, because I am going to tell you you need to lose weight because you are eating too much and you need compression, and so these are often very long sort of consultations.  The patient is often very unsatisfied.  So, I had a lady who saw someone else ______, she said I have had six venous operations on my right leg, I had three on my left, I can’t afford the other three, can you do the other three.  She is massive, huge, and I said look, you need compression, compression, compression, weight loss, weight loss, weight loss and you need to exercise and get your calf pump working.  And she didn’t like that very much.  She came back three years later and she wasn’t wearing compression, she was 15kg heavier and she wasn’t exercising.  And I said to her, what did you take out of the consultation three years ago, and she said, oh, you didn’t want to operate because somebody else had.  And so, patients want to hear what you can do for them.  They also want to know what can this surgeon do for me.  They can give me script, they can do this, they can do that.  What they don’t like to hear is, you need to stop smoking, you need to stop eating too much, you need to exercise.  Ah, I already knew that.  And the compression is the classic one. They have to wear the compression and they get the venous ulcers, they get their eczema, they get into trouble and then they get the compression on, it goes away, they take it off, it comes straight back again.  Contraindication to glue.  So, I guess, if you are allergic to superglue, I can’t imagine too many people allergic to superglue, sometimes the veins, as you get more skilled you can track sort of very tortuous veins, I would probably say redo vein, so when you have got a regrowth of the vein it can be very hard to track a wire through it, so you can imagine it has been stripped in the past, it is actually very hard then to get a wire to follow-up and so, as a general contraindication I would say that’s one of them, so we do have to be a bit mindful of that. I have actually had some redos that I had glued and you can actually get the glue into the mesh of veins as well, but as a general thing I would consider that a contraindication.  Mechanism of _____.  So, there are other things on the market as well that irritate the vein and just sort of cause it to shrivel up and things like that to occlude it as well.  There was a situation where people would coil the great saphenous vein.  I am always a bit cynical of that because what I get paid for coiling is about three or four times what I do for veins.  So, if I coil, guess what, I get three or four times as much, but the MBS book now says coiling except in the use of varicose veins, so it actually excludes varicose veins from claiming those numbers, and so coiling of the lower leg veins, not the ovarian and testicular veins, was tried for a short period of time, but I think these other techniques are much better.
75:15
Excellent.  Thanks so much Chris.
75:16
My pleasure.
75:29
I am afraid that’s all we have time for this evening.  Thank you very much everyone for attending and we hope you enjoyed the webinar.  A big thank you to our presenter Chris for sharing your knowledge and time this evening, and our webinar partner Medtronic. Thanks everyone.
 

Other RACGP online events

Originally recorded:

5 August 2021

This webinar will explore Venous Insufficiency by giving an overview of the disease and how it progresses, deep diving into venous anatomy and pathophysiology.

It will discuss the symptoms of chronic venous insufficiency, how to diagnose and patient classification, as well as the available management options for the disease.
 
This event attracts 2 CPD points

This event attracts 2 CPD points

This event is part of Medtronic 12 part webinar series. Events in this series are:

Facilitator

Dr Trish Kahawita

Trish is a new GP fellow who is passionate about digital health, medical education, and doctor wellbeing. She has been practicing medicine for the last ten years and has worked all around Australia, in both urban and remote areas. Her main clinical interests include Women's and Children's Health, Mental Health, Neurology, Geriatrics / Palliative Care, and Tropical Medicine. She has just moved to Sydney where she will work as a medical educator for GP Synergy as well as being a community Palliative Care GP. She also volunteers as a peer support facilitator for junior doctors. She is excited about the future of primary care and the use of innovative health technologies.

Presenter

Mr Chris Brooks
Vascular, Endovascular and Renal Transplantation Surgeon

Mr Chris Brooks is a highly experienced Vascular, Endovascular and Renal Transplantation Surgeon. He has a special interest in the treatment of all arterial and venous disorders. Chris is focused on improving the outcomes of patients requiring vascular surgery and where appropriate, employs minimally invasive procedures to achieve the best results possible. His modern approach incorporates advancements in medical technology to treat patients. The minimally invasive procedures to treat varicose veins, blocked/narrowed arteries, or arterial aneurysms result in shorter hospital stays and the reduced risk of complications for patients. In 2000, Mr Brooks received his Bachelor of Science (Biomedical) from Monash University. He then went on to earn his Medical and Surgical Degree in 2005 from the University of Melbourne. Following this, Chris spent time working throughout specialist hospitals in Victoria and interstate to further broaden his skills and expertise. His dedication to his academic studies and ongoing surgical research have earned Chris a number of awards.

Sponsor

Advertising

© 2021 The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807