Frequently Asked Questions

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What are varicose veins?

What will happen if I leave them alone?

Explain the problem with venous blood return from the legs.

What are the risk factors for developing varicose veins?

What are the symptoms of varicose veins?

How can varicose veins be diagnosed?

What are the modern treatment options for varicose
and leaky veins?

How does the closure procedure work?

How will the blood get back after you close this main vein?

I’ve had varicose veins and brown skin for 20 years,
why fix it now?

What can I expect after the procedure?

Which is best for me, VNUS or Laser closure?

Is Varicose Vein Surgery covered by insurance?


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What are varicose veins?

Varicose veins are abnormally enlarged superficial veins
usually seen in the thigh and leg. In many patients they are
a sign of a more serious underlying problem of the venous
system. These veins often are branches of the superficial
set of veins (long and short saphenous veins) which have
leaking valves. As many as 30 million adults in the USA
are affected by significant superficial venous insufficiency
(saphenous vein and branches) and may have an easily
treatable problem. Venous insufficiency is more of an
" umbrella” diagnosis which refers to leakiness of the
one way valves within the veins which results in increased
pressure in the veins. The increased pressure may cause
bulging varicose veins, leg swelling, cramps or achiness
of the calves, restless legs, spider veins, discoloration
and thickening of the skin of the lower leg, and eventual
bleeding or ulceration.

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What will happen if I leave them alone?

Without treatment, varicose veins worsen with time. However,
rather than focus on the varicose veins, it is probably more
important to focus on the fate of the skin of the lower leg in this
group of patients. Venous insufficiency may manifest itself in
other ways as well, such as swollen, achy legs, discolored and
thickened skin over the lower leg around the ankle area and
purple, painful feet.

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Explain the problem with venous blood return from the legs.

Normally there is a series of one-way valves in the leg veins
which allow for blood flow through the veins back toward the
heart during muscle contraction. When functioning properly,
these valves open and close in sequence, preventing blood
from refluxing back down the leg. When the valves become
leaky and open in the opposite direction venous blood begins
to pool in the leg and the pressure rises in the veins below
the knee. Since veins are thin walled, components of the blood
eventually may leak out of the veins into the surrounding tissues.

Initially this may be limited to water and protein, causing
swelling, which worsens as the day progresses and is usually
more significant with standing or sitting. Over time, red blood
cells and white blood cells may also leak out of the veins into
the skin and fat around the ankle leading to discoloration of
the skin and eventually, scarring of the skin and fat to the
underlying muscle. This condition is known as stasis dermatitis
or lipodermatosclerosis (fat and skin scarring), and is a
significant risk factor in the development of venous ulcerations
and recurrent skin infections.

Many unsuspecting patients may seek the advice of a
dermatologist for this condition and be unsuccessfully treated
with a variety of creams. Thus, it is of paramount importance to
investigate varicose veins not only to determine the presence
and severity of underlying venous insufficiency, but also to
perform treatment earlier in the disease process and reduce
the risk of future complications.

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What are the risk factors for developing varicose veins?

Heredity is the most significant risk factor in developing
significant venous insufficiency and varicose veins. The
second most important risk factor is the history of full term
pregnancy. The more full term pregnancies a woman
experiences, the higher the risk of vein related problems.
Other conditions that may contribute to the development
of varicose veins and venous insufficiency include morbid
obesity, prolonged standing or sitting, focal trauma to a vein
(sports injury) and deep vein thrombosis. Varicose veins
are more common in females due to their child bearing
status as well as the presence of estrogen. Despite this
fact, males account for approximately 20-30% of patients
who present for evaluation of varicose veins or other
complications of venous insufficiency.

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What are the symptoms of varicose veins?

Varicose veins and venous insufficiency may cause
symptoms less obvious than the commonly noted spider
veins, bulging lumps, bleeding veins or leg ulcers. Other
symptoms may include swollen achy legs, a feeling of
heaviness or fatigue of the legs, or itchy and discolored legs.
Patients usually complain of increased swelling and aching
toward the end of the day and often note improvement with
elevation of the legs or after a night of sleep. Other patients
may be under treatment for conditions thought to be related
to theheart(congestive heart failure), kidneys(renal failure
or diabetic kidney disease), excess salt intake, lymphedema
(swelling after leg incisions) or for neurologic conditions
such as neuropathy or restless leg syndrome (RLS).
Restless leg syndrome has been strongly correlated
with venous insufficiency, so patients who have been
diagnosed with RLS are encouraged to seek further
vein evaluation.

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How can varicose veins be diagnosed?

Aside from the obvious signs of external varicose veins
found at physical examination, the most accurate method
of diagnosing underlying venous insufficiency is duplex
ultrasound. When performed by a qualified registered
vascular technologist, one can precisely determine the
location of the leaky veins and formulate a logical and effective
treatment plan to cure the problem. In addition to evaluating
the superficial set of veins (saphenous system), the veins
within the muscles (deep veins) are also examined to
determinetheir status with respect to valve function and
presence of clots. In addition, there are a variety of other
types of leg veins which may be leaky and which less
experienced technologists may overlook. These veins
include the posterior thigh vein of Giacomini, the anterior
and posterior medial saphenous veins and a number of
perforating or connecting veins (Hunter’s, Dodd’s and
Cockett’s). The importance of the role of an experienced
registered vascular technologist in performing the venous
insufficiency study cannot be overstated. This is an outpatient
examination which takes approximately 30 minutes per leg,
and is best performed at the direction of the Physician
Vein Specialist who will be responsible for making the
treatment decisions.

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What are the modern treatment options for varicose
and leaky veins?

Until year 2000, the treatment options for varicose veins
and venous insufficiency were limited to compression
stocking therapy on the conservative end of the treatment
spectrum or saphenous vein ligation and/or stripping on
the surgical end of the spectrum. Since VNUS Medical
technologies introduced the radiofrequency catheter based,
endovenous closure technique in 1999, an estimated 25-30
million adults in the USA with significant superficial venous
insufficiency now have an effective, outpatient treatment for
their swollen achy legs, varicose veins and venous leg ulcers.
In the days of vein stripping, more advanced skin changes or
ulcerations were required to justify the invasive procedure.
With endovenous techniques of sealing the leaky veins from
within with a small catheter, under local anesthesia, these
patients can now be treated at a much earlier stage of
their disease, more effectively preventing more advanced
complications from occurring in the future. Since a number
of patients may also have arterial blockages, endovenous
closure should be performed by a surgeon familiar with
arterial and venous disease. Performance of the procedure
in the office setting under local anesthesia offers the
advantages of a less stressful environment, avoidance
of exposure to hospital related risks (infections and IV
medications) as well as avoidance of general or regional
anesthetic risks. The procedure should be performed in a
sterile operating room, under standard surgical protocol
and precautions, using local anesthesia with a mild oral
relaxant. The procedure usually takes less than one hour
to perform, either as an isolated procedure or in conjunction
with removal of varicose veins through small incisions (microphlebectomy).

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How does the closure procedure work?

Under local anesthesia, a small catheter is inserted into
the leaky vein through a needle stick in the mid calf. Either
radiofrequency (VNUS) or light (Laser) energy is delivered
through a small catheter to the inside of the leaky vein which
heats and seals the abnormal vein closed. The catheter is
inside the vein only long enough to seal the vein and is
removed upon completion. The treated vein is gradually
reabsorbed by the body and causes no harm. Over time,
most varicose veins will resolve and limb swelling will
improve within weeks.

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How will the blood get back after you close this main vein?

The function of the leg veins is to return blood from the feet
to the pelvis. This occurs through the pumping action of the
muscles and properly functioning valves. Ninety percent of
blood return from the feet to the pelvis normally occurs through
the deep veins (inside the muscles). As long as the deep set
of veins are working properly, the effect of closing a leaky
superficial vein is actually beneficial. The leg circulation will
be better off with the leaky vein closed rather than left open
and leaking.

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I’ve had varicose veins and brown skin for 20 years,
why fix it now?

The natural history of untreated severe venous insufficiency
is that of progression. Progression to larger varicosities,
clotted varicosities, bleeding varicosities, progressive leg
edema and disability, and brownish discoloration and
thickened skin, with potential for future ulceration. Prior to
the introduction of endovenous closure techniques, it made
sense to be conservative when considering “surgical”
treatment of varicose veins and venous insufficiency.
Although compression stockings offer some symptomatic
relief from venous insufficiency, their use in no way constitutes
a definitive treatment. The underlying problem persists
after removal of the stocking and the process will progress
in even the most compliant of patients. Just as an astute
Internist would not wait for a complication of diabetes, high
blood pressure or high cholesterol to occur before offering
definitive medical therapy for these conditions, we should
be equally proactive in objectively establishing the diagnosis
of venous insufficiency and offering definitive therapy when
appropriate. In this era of preventative medical care, it makes
logical sense to investigate venous problems, institute a
conservative trial of therapy, and when appropriate, offer
definitive treatment prior to the occurrence of irreversible
complications.

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What can I expect after the Closure procedure?

The local anesthetic will wear off within the first 2-3 hours
after the vein closure and only a mild to moderate amount
of discomfort is usually noted with the VNUS Radiofrequency
Closure Fast procedure. Laser endovenous closure may
result in slightly more bruising and discomfort, and thus is
generally applied to those with larger veins, segments too
short for the VNUS catheter or in other special circumstances.

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Which is best for me, VNUS or Laser closure?

Although VNUS closure (radiofrequency based) has enjoyed
excellent patient comfort ratings, both techniques are very
effective in achieving successful long term closure of the
saphenous vein trunks and its branches. Laser endovenous
closure may be more appropriate in cases where there are
segments of veins less than 7 cm in length which need to be
closed, or when the diameter of the vein to be treated exceeds
the recommended limit for radiofrequency closure. Treatment
decisions should be individualized based on clinical and
anatomic factors.

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Is Varicose Vein Surgery covered by insurance?

If a patient has symptoms of leg swelling, pain or
inflammation related to bulging varicose veins, skin
changes predisposing to ulcers or history of superficial
clots or ulcers, most insurance companies will consider
this a medically necessary condition. In general, a
conservative trial of therapy, including 3-6 months of
compression stocking therapy, elevation and anti-
inflammatory medications is required to satisfy Medicare
and most commercial insurance carriers’ inclusion criteria.
Some carriers may also require certain training qualifications
be met by the treating physician to guarantee coverage
(vascular surgeon performing procedure vs. other
specialties). Most commercial insurance carriers will
require a detailed letter of preauthorization to make a
predetermination of medical necessity. This letter must
include patient history of symptoms, types of previous
treatments, results of physical and ultrasound exams,
and photographs of the patient’s legs demonstrating the
clinical findings. Diagnosis codes and procedure codes
must also be included. Thus, it is very important for patients
to keep track of the length of time they have had their
problems and the type and duration of all previous
treatments (surgery, injections and stockings). Injection
sclerotherapy is rarely covered by insurance unless there
has been a history of recurrent hemorrhage or pain directly
related to the varicosities in question.

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