Dr. Tarun Grover is a vascular surgeon, practicing at Medanta Hospital in Gurgaon, India. He attended medical school at Gajra Raja Medical College in Gwalior, India. After completing medical school, Dr. Grover did his residency at Sir Ganga Ram Hospital. His interest in vascular surgery developed during his general surgery training as he found vascular and endovascular procedures fascinating because of its newer advances at the time like minimally invasive techniques of angioplasty, EVAR (endovascular aneurysm repair), and TEVAR (thoracic endovascular aortic repair). I was able to do an internship with him over a course of ten days where I scrubbed up and observed some surgeries in the Operation Theatres (OT) as well as seeing patients in the Outpatient Department (OPD). It was a remarkable experience to see the inner workings of a hospital from a surgeon’s perspective, and it was super educational since I was physically able to see many of the surgeries.
One of the first things I saw were varicose veins, which are large dilated veins that occur when the valves become incompetent and allow for backward blood flow. Most of the time, they occur in the legs, and all of the cases that I saw were patients with varicosities in the legs. Normally, veins in the legs push back blood up to the heart when we walk since the calf muscles compress them, leading to the valves opening up. However, with old age usually, these valves become weak, and this causes reflux and a bulging of the vein, which can cause skin discoloration and ulcers among other things. It can cause skin discoloration, medically known as varicose eczema or stasis dermatitis, because sometimes small capillaries may rupture and leak blood into our body tissues. Fibrin, a protein that the body converts from fibrinogen in the blood, forms fibrin cuffs that surrounds the capillaries, causing local cell necrosis since these tissues do not get oxygen as a result (Lights and Reed-Guy). Varicose veins can cause venous ulcers as well when the disease advances because the fluid coming out of the ruptured capillaries breaks down the skin, causing the ulcer. The outpatient treatment for varicose veins mainly consists of compression therapy with the regular wearing of stockings and dressing the wound frequently (if there is an ulcer) and leg elevation when lying down, which both help to improve circulation. In extreme cases where the varicose veins are not responding to therapy and affecting the patient’s quality of life, surgical therapy may be considered. However, surgery can only be done for superficial veins, which are one of two types of veins in our body with the other being deep veins. I saw quite a few varicose vein surgeries such as an endovenous laser ablation combined with sclerotherapy and a radiofrequency ablation, which both have the purpose to burn the vein so that there is no reflux when the patient stands up. Both surgeries are ultrasound guided, and both techniques cause thermal damage to the surrounding tissue; however, there are quite a number of differences between the two procedures. In the endovenous laser ablation combined with sclerotherapy, the surgeon often only ablates above the knee to prevent nerve damage to the nearby saphenous nerve since temperatures can reach up to 800°C. To ablate the rest of the vein, a sclerosant (foam solution where the liquid is combined with air) is inserted into the vein, which causes it to collapse. However, sclerotherapy is not usually done for the entire leg since the chance of recanalization for veins with sclerotherapy is higher than with endovenous laser ablation. In the radiofrequency ablation, the temperature is much lower as it only reaches 120°C, and it ablates the vein seven centimeters at a time. Therefore, radiofrequency ablation is preferred since it is faster and it causes less damage to the surrounding tissues.
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