Veins, arteries and the right pressure

Vascular surgeon Dr. Dr. univ. Dominic Mühlberger is an attending physician at St. Josef’s Hospital, which is part of Ruhr University in Bochum, Germany. In this interview with Bauerfeind life, he talks about current trends in his specialist field: treatment methods, the significance of compression therapy and the development of phlebology as a specialist area.

life: We’re in the Vascular Center at Ruhr University Bochum, one of the biggest vascular centers at a university in Germany. What are you treating here?

Dr. Mühlberger: At our Bochum-Gerthe site, we mainly operate on varicose veins. In the interdisciplinary vein center there, we carry out more than 2,000 surgical and another 2,000 non-surgical treatments per year in cooperation with the Dermatology Department. Here at St. Josef’s University Hospital, we perform all the arterial surgeries and major vein surgeries, meaning acute leg vein thrombosis, venous recanalization of the deep venous system as well as pelvic congestion syndrome.
We operate on abdominal aneurysms, carotid arteries after a stroke, we insert dialysis shunts and catheters and prepare ports for oncology.

When do you use compression products for treatment?

Dr. Mühlberger: Compression is a very important part of vascular surgery for us. Patients with varicose veins or edemas, for example, are recommended compression therapy. Let’s look at thrombosis treatment, for example: appropriate compression therapy helps the body to dissolve the blood clot more quickly, resulting in fewer obstructions. That’s important because the remaining vein obstruction is an indicator for possible post-thrombotic syndrome. Or take arterial surgery, for example: when we carry out an arterial revascularization, like a bypass from the groin to the knee, a lot of patients will suffer from post-revascularization edema.

What effects of compression can be noticed following surgery?

Dr. Mühlberger: Postoperatively, we can say that patients benefit from compression therapy after varicose vein surgery. There are fewer hematomas, which is the main aspect for us, and we notice a lower tendency toward swelling. Following sclerotherapy, the incidence of hyperpigmentation is reduced and the treatment success of this procedure is better.

Is there a change in treatment approaches?

Dr. Mühlberger: Yes, absolutely. At the beginning of my professional life, peripheral arterial disease, or PAD, was an absolute contraindication for compression. Studies have now shown that the impaired arterial circulation in the leg is not necessarily a contraindication for compression therapy – or only in cases of advanced arterial occlusive disease. If the ankle-brachial index, for example, is above 0.5 or the absolute arterial pressure at the ankle >60 mmHg, compression therapy can still be used.

How about patient acceptance of compression therapy?

Dr. Mühlberger: Patients are more informed and question more critically. A lot has to be explained to prevent compliance problems. Patients with post-thrombotic syndrome do say though that they couldn’t do without compression. It’s vital to adapt the treatment to the patient. In the past, compression class 2 used to be the standard. Today, treatment is more personalized, and the lowest effective compression class is often used. After all, it’s better if a class 1 product is worn than when a class 3 product isn’t worn. That’s why we really appreciate that manufacturers are very active and improve the knitted fabric and comfort of their products, for example.

Life: You’re currently working on your postdoctoral thesis. What is it about?

Dr. Mühlberger: A purely venous research area. It’s about the anatomy of and functional treatment options for the sapheno-femoral junction. The question is whether the main vein can be saved during varicose vein surgery. Venous valve repair is a procedure where the vein’s diameter is reduced from the outside by encasing it. The vein can be preserved for later use because this vein is the body’s own important bypass material for vascular and cardiac surgeons.
Is it becoming obvious what will be important in phlebology and compression therapy in the future?
Dr. Mühlberger: There are a few things, such as the precise duration of compression therapy following varicose vein surgery, venous thrombosis or arterial revascularization, compression in cases of diabetic foot syndrome and in neuropathic patients. There are a lot of interesting things on the horizon.

You are involved in the German Society of Phlebology. What other topics are important to you?

Dr. Mühlberger: The nice thing about phlebology is that it’s an interdisciplinary specialty involving, for example, general practitioners, specialists in internal medicine, surgeons, dermatologists and vascular surgeons. They all offer different perspectives, which keeps the subject lively. Every year, we host an annual meeting, and we organize continuing education courses, for example about surgical procedures.
One important task is working on guidelines, for example, for varicose veins, lipedema, venous leg ulcers, basically anything where compression plays a role. We do this in cooperation with other specialist societies. Personally, I’m involved in the “Varicose Vein Surgery” working group.

Is there enough new blood coming into phlebology?

Dr. Mühlberger: Yes, we currently don’t have any problems finding new talent. Many young colleagues are involved with “Young Phlebologists”, students, too. We show them exciting cases, we have many research areas, and we actively approach young colleagues, saying: why don’t you submit a presentation for such and such a conference or our annual meeting? Luckily, we’re a growing society.

Images: Katholisches Klinikum Bochum, istockphoto.com/loveguli