About Venous Disease:
Understanding Superficial Venous Reflux

Frequently Ask Questions

The Closure® procedure

Q1) How does it work to treat superficial venous reflux?

Since valves can't be repaired, the only alternative is to re-route blood flow through healthy veins. Traditionally, this has been done by surgically removing (stripping) the troublesome vein from your leg. The Closure procedure provides a less invasive alternative to vein stripping by simply closing the problem vein instead. Once the diseased vein is closed, other healthy veins take over and return the blood to back to the heart.

Q2) How is the Closure procedure different from vein stripping?

During a stripping procedure, the surgeon makes an incision in your groin and ties off the vein, after which a stripper tool is threaded through the saphenous vein and used to pull the vein out of your leg through a second incision just above your calf.

In the Closure procedure, there is no need for groin surgery. Instead, the vein remains in place and is closed using a special (Closure) catheter inserted through a small puncture. This may eliminate the bruising and pain often associated with vein stripping (i.e., that may result from the tearing of side branch veins while the saphenous vein is pulled out). Vein stripping is usually performed in an operating room, under a general anesthetic, while the Closure procedure is performed on an outpatient basis, typically using local or regional anesthesia.

Three randomized trials of the Closure procedure vs. vein stripping, including the most recent multi-center comparative trial, show very similar results. In the multi-center comparative trial, the Closure procedure was superior to vein stripping in every statistically significant outcome. In the study, 80.5% of patients treated with the Closure procedure returned to normal activities within one day, versus 46.9% of patients who underwent vein stripping. Also, Closure patients returned to work 7.7 days sooner than surgical patients. Patients treated with the Closure procedure had less postoperative pain, less bruising, faster recovery and fewer overall adverse events.1

Q3) How long does the Closure procedure take?

The Closure procedure typically takes about 3-5 minutes, though patients normally spend 60-90 minutes at the medical facility due to normal pre- and post-treatment procedures.

Q4) Is the Closure procedure painful?

Patients report feeling little, if any, pain during the Closure procedure. Your physician will give you a local or regional anesthetic to numb the treatment area.

Q5) Will the procedure require any anesthesia?

The Closure procedure can be performed under local, regional, or general anesthesia. Local anesthesia is the preferred method for the outpatient/physician’s office setting.

Q6) How quickly after treatment can I return to normal activities?

Many patients can resume normal activities immediately.2 For a few weeks following the treatment, your doctor may recommend a regular walking regimen and suggest you refrain from very strenuous activities (heavy lifting, for example) or prolonged periods of standing.

Q7) How soon after treatment will my symptoms improve?

Most patients report a noticeable improvement in their symptoms within 1-2 weeks following the procedure.

Q8) Is there any scarring, bruising, or swelling after the Closure procedure?

Patients report minimal to no scarring, bruising, or swelling following the Closure procedure.

Q9) Are there any potential risks and complications associated with the Closure procedure?

As with any medical intervention, potential risks and complications exist with the Closure procedure. All patients should consult their doctors to determine if their conditions present any special risks. Your physician will review potential complications of the Closure procedure at the consultation, and can be reviewed in the safety summary. Potential complications can include: vessel perforation, thrombosis, pulmonary embolism, phlebitis, hematoma, infection, paresthesia (numbness or tingling) and/or skin burn.

Q10) Is the Closure procedure suitable for everyone?

Only a physician call tell you if the Closure procedure is a viable option for your vein problem. Experience has shown that many patients with superficial venous reflux disease can be treated with the Closure procedure.

Q11) Is age an important consideration for the Closure procedure?

The most important step in determining whether or not the Closure procedure is appropriate for you is a complete ultrasound examination by your physician or qualified clinician. Age alone is not a factor in determining whether or not the Closure procedure is appropriate for you. The Closure procedure has been used to treat patients across a wide range of ages.

Q12) How effective is the Closure procedure?

Published data suggests that two years after treatment, 90% of the treated veins remain closed and free from reflux, the underlying cause of varicose veins.3,4,5

Q13) What happens to the treated vein left behind in the leg?

The vein simply becomes fibrous tissue after treatment. Over time, the vein will gradually incorporate into surrounding tissue. One study reported that 89% of treated veins are indistinguishable from other body tissue one year after the Closure procedure was performed.6

Q14) Is the Closure treatment covered by my insurance?

Many insurance companies are paying for the Closure procedure in part or in full. Most insurance companies determine coverage for all treatments, including the Closure procedure, based on medical necessity. The VNUS® Closure procedure has positive coverage policies with most major health insurers. Your physician can discuss your insurance coverage further at the time of consultation.

Q15) What are patients saying about the Closure procedure?

98% of patients who have undergone the Closure procedure are willing to recommend it to a friend or family member with similar leg vein problems.7


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Venous Disease

Q16) What are varicose veins?

Varicose veins – which afflict 10% to 20% of all adults – are swollen, twisted, blue veins that are close to the surface of the skin. Because valves in them are damaged, they hold more blood at higher pressure than normal. That forces fluid into the surrounding tissue, making the affected leg swell and feel heavy.

Unsightly and uncomfortable, varicose veins can promote swelling in the ankles and feet and itching of the skin. They may occur in almost any part of the leg but are most often seen in the back of the calf or on the inside of the leg between the groin and the ankle. Left untreated, patient symptoms are likely to worsen with some possibly leading to venous ulceration.

Q17) What causes varicose veins?

The normal function of leg veins – both the deep veins in the leg and the superficial veins – is to carry blood back to the heart. During walking, for instance, the calf muscle acts as a pump, contracting veins and forcing blood back to the heart.

To prevent blood from flowing in the wrong direction, veins have numerous valves. If the valves fail (a cause of venous reflux), blood flows back into superficial veins and back down the leg. This results in veins enlarging and becoming varicose. The process is like blowing air into a balloon without letting the air flow out again- the balloon swells.

To succeed, treatment must stop this reverse flow at the highest site or sites of valve failure. In the legs, veins close to the surface of the skin drain into larger veins, such as the saphenous vein, which run up to the groin. Damaged valves in the saphenous vein are often the cause of reversed blood flow back down into the surface veins.

Q18) Why does it occur more in the legs?

Gravity is the culprit. The distance from the feet to the heart is the furthest blood has to travel in the body. Consequently, those vessels experience a great deal of pressure. If vein valves can't handle it, the backflow of blood can cause the surface veins to become swollen and distorted.

Q19) Who is at risk for varicose veins?

Conditions contributing to varicose veins include genetics, obesity, pregnancy, hormonal changes at menopause, work or hobbies requiring extended standing, and past vein diseases such as thrombophlebitis (i.e. inflammation of a vein as a blood clot forms.) Women suffer from varicose veins more than men, and the incidence increases to 50% of people over age 50.

Q20) What are the symptoms?

Varicose veins may ache, and feet and ankles may swell towards day's end, especially in hot weather. Varicose veins can get sore and inflamed, causing redness of the skin around them. In some cases, patients may develop venous ulcerations.

Q21) What are venous leg ulcers?

Venous ulcers are areas of the lower leg where the skin has died and exposed the flesh beneath. Ulcers can range from the size of a penny to completely encircling the leg. They are painful, odorous open wounds which weep fluid and can last for months or even years. Most leg ulcers occur when vein disease is left untreated. They are most common among older people but can also affect individuals as young as 18.

Q22) What is the short term treatment for varicose veins?

ESES (pronounced SS) is an easy way to remember the conservative approach. It stands for Exercise Stockings Elevation and Still. Exercising, wearing compression hose, elevating and resting the legs will not make the veins go away or necessarily prevent them from worsening because the underlying disease (venous reflux) has not been addressed. However, it may provide some symptomatic relief. Weight reduction is also helpful.

If there are inflamed areas or an infection, topical antibiotics may be prescribed. If ulcers develop, medication and dressings should be changed regularly.

There are longer-term treatment alternatives for visible varicose veins, such as sclerotherapy and phlebectomy.

Q23) What is sclerotherapy?

Traditional sclerotherapy is the "gold standard" in treatment of reticular and spider vein disease. In sclerotherapy, a nontoxic liquid sclerosant is injected with very fine needles into diseased veins. The medicine irritates the inner lining of the vein and causes it to close down and seal shut. The veins are then absorbed by the body and other veins then take over its work. This may bring only temporary success and varicose veins frequently recur. It is most effective on smaller surface veins, less than 1-2mm in diameter.

Q24) What is ambulatory microphlebectomy?

Ambulatory microphlebectomy is a surgical procedure for treating surface veins in which multiple small incisions are made along a varicose vein and it is removed from the leg using surgical hooks or forceps. The procedure is minimally invasive, uses local anesthesia, and can be done in the physician’s office.

Q25) What is vein stripping?

Vein stripping is a surgical procedure that involves tying off the upper end of a problem vein and pulling it out of the leg. Typically a vein stripping is performed in the operating room with the patient under general anesthesia. The legs are bandaged after surgery and the bruising and swelling may last for weeks.

Q26) When is Closure used?

Closure is used, like vein stripping, to eliminate reverse blood flow in the saphenous vein, but without physically removing the vein. It can be performed with local anesthesia in the physician’s office or outpatient setting. Like other venous procedures, the Closure procedure involves risks and potential complications. Each patient should consult their doctor to determine whether or not they are a candidate for this procedure, and if their condition presents any special risks. Complications reported in medical literature include numbness or tingling (paresthesia) skin burns, blood clots, temporary tenderness in the treated limb.

Q27) What is the main difference between arteries and veins?

In simplest terms, arteries pump oxygen-rich blood FROM the heart, veins return oxygen-depleted blood TO the heart. In order to help blood return to the heart, there are valves in the veins which prevent the back flow of blood as it gets pumped back towards the heart.

Q28) What are the three main categories of veins?

They are the Deep, Superficial, and Perforator veins. Deep leg veins return blood directly to the heart and are in the center of the leg, near the bones. Superficial leg veins are just beneath the skin. They have less support from surrounding muscles and bones than the deep veins and may thus develop an area of weakness in the wall. When ballooning of the vein occurs, the vein becomes varicose. Perforator veins serve as connections between the superficial system and the deep system of leg veins.


Insurance

Q29) Will my insurance pay for treatment of my varicose veins?

VTC is in network with most insurance plans (BCBS, Aetna, Cigna, UnitedHealthcare, Humana, Great West, Tricare/Veterans, and Medicare). Being in network is important to the patient because it means our clinic has agreements with various insurers to use their fee schedule as charges for treatment we render. This means most insurance plans covers most of the cost of treatment other than deductible and co-payments a patient may have. Secondary insurances often cover much of the difference. We file with both primary and secondary insurances for the patient. If you don't see your insurance company listed, please call 423.648.4181 to inquire.

Reimbursement depends on your particular insurance company, as well as, the terms of your individual policy. Each policy is different and the philosophy of each insurance company is also different. After completing your physical evaluation and diagnostic testing, if treatment for your condition is recommended, we will gladly submit a claim for you.

Each insurance company is slightly different. What one company may approve, another one may not - it depends on the agreement you and/or your employer has with the insurance company, and the insurance company particular policies. We will work with you and your insurance company so that you receive the care and treatment that you require.

Q30) What does "medical necessity" mean?

Most insurance require documentation of "medical necessity". This is a way to differentiate between a cosmetic treatment and one that is medically necessary for the patient. Generally patients who have symptomatic varicose veins (those that cause symptoms: such as leg pain, complaints of achiness, heaviness, cramping or swelling) and are inadequately relieved with conservative therapy, will qualify for insurance coverage of treatment.

Most insurance companies require that photographs of your venous condition be submitted with the treatment request/claim. We will take these photos on your first visit.

Medical necessity is evaluated at the time of your initial consultation. Ultrasound "maps" and photographs with written documentation are subsequently sent to the insurance company to confirm medical necessity.

Once the claim has been submitted to your insurance company, most allow up to 30 days to complete the approval process/predetermination of medical necessity. Generally, if the ultrasound of your veins is abnormal, and you are having a medical problem or symptoms (tired, achy, heavy, pain, swelling, skin changes, leg ulcers, etc.,) and the symptoms are unrelieved by a trial of conservative therapy, most insurance companies will eventually approve the recommended treatments. Also, treatment claims for more severe conditions, like leg ulcers, may actually be approved more quickly than usual.

A written predetermination of medical necessity is obtained by our office from the insurance company before actually beginning treatment or closure of varicose veins. This means that the insurance agrees that the treatment is medically necessary and should be covered by insurance. Medicare does not require a predetermination.

Q31) What does "conservative therapy" mean?

The insurance companies generally require a "trial of conservative therapy" for 3-6 months prior to approving treatment. Usually conservative therapy means participating in regular exercise, elevation of the legs, weight loss attempts and wearing prescription, surgical grade compression stockings for 3-6 months. While there is no evidenced based medicine to support this, insurance companies have this requirement, and your compliance is required for payment authorization.

Compression stockings are available for purchase at VTC or from local pharmacies and at most medical supply stores. Usually, the patient is responsible for the costs of compression stockings; however, under special circumstances, such as deep vein thrombosis (DVT) or lymphedema, certain insurances companies may offer compression stockings as a covered benefit. Check with your insurance company.

Q32) Will insurance cover any "Cosmetic treatments"?

VTC is not aware of any insurance company that will pay for cosmetic treatments. Though frequently painful, spider veins will not qualify for insurance coverage. While cosmetic treatments may be performed at the time of medical treatment, they must be paid for separately from your medical treatments. We will work with you to receive the treatments and care you require.


Disclaimer: Please note that the description above is meant to be helpful in understanding insurance. The particulars of your individual insurance plan will apply. For the additional information contact your insurance carrier.

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1 Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, et al. Prospective randomized study of endovenous radiofrequency obliteration (Closure) versus ligation and stripping in a selected patient population (EVOLVES study). J Vasc Surg 2003;38:207-14. 2 Goldman, H. Closure of the greater saphenous vein with endo radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: preliminary 6-month follow-up. Dermatology Surg 2000; 26:452-456. 3 Merchant RF, DePalma RG, Kabnick LS. Endovascular obliteration of saphenous reflux: a multicenter study. J Vasc Surg 2002;35:1190-6. 4&7 Weiss RA, et al. Controlled Radiofrequency Endovenous Occlusion Using a Unique Radiofrequency Catheter Under Duplex Guidance to Eliminate Saphenous Varicose Vein Reflux: A 2-Year Follow-up, Dermatologic Surgery, Jan 2002; 28:1: 38-42 5 Whiteley, MS, Holstock JM, Price BA, Scott MJ, Gallagher TM. Radiofrequency Ablation of Refluxing Great Saphenous Systems, Giacomini Veins, and Incompetent Perforating Veins using VNUS Closure and TRLOP technique. Abstract from Journal of Endovascular Therapy 2003; 10:I-46. 6 Pichot O, Sessa C, Chandler JG, Nuta M, Perrin M. Role of duplex imaging in endovenous obliteration for primary venous insufficiency. J. Endovasc Ther 2000;7:451-9.
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Vein Therapies of Chattanooga, PLLC
6031 Shallowford Road, Suite 113
Chattanooga, TN 37421-168
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Phone: 423.648.4181
Fax: 423.648.4183
Email: Info@choochoovein.com

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