Varicose Veins

For Members:

What is Varicose Veins?

• A vein is a blood vessel like an artery which carries low in oxygen blood from all parts of the body to the heart and lungs.
• The legs have rungs (valves) that pushes blood back toward the heart, step by step, without slipping back down. When those valves weaken or collapse, blood and fluid can start to pool in the lower legs, leading to visible veins.
• Veins will bulge with the collection of blood when the blood is not being circulated properly. Enlarged, visible, bulging veins resembling a road map with uncomfortable legs is called Varicose Veins.
• In severe cases, varicose veins can rupture, or can form ulcers on the skin. The most common affected sights are the legs, thighs, calves, ankles, and feet.
• Varicose veins can occur in men or women of any age, but most frequently affecting women of childbearing age and old.
• The possibility of Varicose Veins increases with aging, prolonged standing or immobility (gravity), family history, blood vessel disease, water retention, or pregnancy.
• If you are noticing prominent veins on your legs or thighs with or without pain and discomfort, it is advisable to discuss the problem with your Physician.

What are the recommended treatments?

1- Sclerotherapy is a proven medical procedure used to eliminate varicose veins.

• When sclerotherapy is indicated? Procedures medically necessary for treatment of varicose veins when the following criteria are met:
  • Great saphenous vein or small saphenous vein ligation / division / stripping, radiofrequency endovenous occlusion (VNUS procedure), and endovenous laser ablation of the saphenous vein (ELAS) (also known as endovenous laser treatment (EVLT).
  • Treatment of veins < 3 mm that remain after surgery.
  • Treatment of perforator veins with incompetence or reflux in when surgery is not suitable.
  • Treatment of bleeding varicose veins.
  • Treatment of large varicose veins hidden below venous ulcers.

• What happens during the procedure?
  • During the sclerosing solution (salt or an irritating solution) is injected through a very fine needle directly into the vein, which irritates the lining of the blood vessel, causing it to swell and stick together and the blood to clot. Over some period of time, the vessel turns into scar tissue that fades from the view. Sclerotherapy is performed by a dermatologist or a surgeon, and the procedure itself takes approximately 15 to 45 minutes. Avoid taking drugs like aspirin or ibuprofen for 48-72 hours before sclerotherapy and lotion should not be applied to the legs before the procedure.

• What are the common risks/complications of Sclerotherapy?
  • Itching at the site (lasting for 1 or 2 days after the procedure).
  • You may experience raised, red areas at the injection site, which disappear within a few days.
  • Bruising that can last several days or weeks.
  • Larger veins that have been injected may become lumpy and hard and may require several months to dissolve and fade.
  • Brown lines or spots may appear at the vein that disappear within 3 to 6 months.
  • New, tiny blood vessels may occur at the site of sclerotherapy treatment. These tiny veins can appear days or weeks after the procedure, but should fade within 3 to 12 months without further treatment.
  • Rarely, allergic reactions to the injection fluid may occur at the time of the procedure.
  • After the procedure, you might be instructed to wear support hosiery to “compress” the treated vessels.
  • Inform your Physician immediately if you notice, an inflammation within five inches of the groin, a sudden onset of a swollen leg or formation of small ulcers at the injection site.

• When sclerotherapy is NOT indicated?
  • Spider veins, telangiectasia, reticular veins or small varicose veins (less than 4mm)
  • Treatment of incompetent varicose veins when Radiofrequency ablation or Endogenous laser treatment are suitable.

2- Phlebectomy

Larger varicose veins (>6 mm) are best treated with excision called Phlebectomy. After the excision, once bleeding is controlled, duplex examination will be performed to identify any underlying complications.

3- Laser ablation:

Laser therapy is most effective for small varicose veins and spider veins. Laser therapy applies light energy from a laser onto a varicose vein to shrink it and fade away. For veins to be treated successfully, several sessions may be required, usually at six week intervals.

4- Ligation/stripping:

Vein ligation and stripping is a minor surgery. It is used to remove a damaged vein and prevent complications of vein damage. If several valves in a vein and the vein itself are heavily damaged, the vein (or the diseased part of the vein) is removed (stripped). An incision is made below the vein, a flexible instrument is threaded up the vein to the first incision, and the vein is grasped and removed.

During this surgery, one or more incisions are made over the damaged veins, and the vein is tied off (ligated).

For Healthcare Providers:

• All Sclerotherapy sessions or treatments for Varicose Veins require pre-approval from Nextcare.

NICE Guidelines identified the following as priorities for intervention:

• For people with confirmed varicose veins with reflux: Offer endothermal ablation (Radiofrequency ablation or Endogenous laser treatment).
• If endothermal ablation is unsuitable, offer ultrasound-guided foam sclerotherapy.
• If ultrasound-guided foam sclerotherapy is unsuitable, offer surgery.
• If incompetent varicose tributaries are to be treated, consider treating them at the same time.
• Interventional treatment should be avoided during pregnancy.

Varicose Veins Evaluation:

Evaluations determine the type of treatment that needs to be administered. The CPT codes used for those determinations include one radiology code and two codes categorized under Extremity Venous Studies:

Varicose Veins Treatment:

References:

• https://www.webmd.com/skin-problems-and-treatments/spider-and-varicose-veins#1
• https://www.webmd.com/skin-problems-and-treatments/sclerotherapy#1
• https://www.aapc.com/codes/webroot/upload/general_pages_docs/document/sur104.pdf
• https://www.uptodate.com/contents/overview-of-lower-extremity-chronic-venous-disease?search=phlebectomy&source=search_result&selectedTitle=3~9&usage_type=default&display_rank=3
• https://www.uofmhealth.org/health-library/hw113736#:~:text=Vein%20ligation%20and%20stripping%20is,)%20is%20removed%20(stripped).
• NICE Clinical guideline [CG168] Published date: July 2013.
• European guidelines for sclerotherapy in chronic venous disorders April 2013.
• Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) 2015.
• Sclerotherapy for Venous Disease -American venous forum 2016.
• NHS choices – Varicose veins last reviewed 23/03/2017.
• NICE Interventional procedures guidance [IPG557] Published date: May 2016.
• Ultrasound-guided foam sclerotherapy for varicose veins NICE Interventional procedures guidance [IPG440] Published date: February 2013.
• Mayo Foundation for Medical Education and Research (MFMER) 2018.