Varicose Vein Procedures: Endovenous Thermal Ablation

Endovenous Thermal Ablation

The first procedure typically performed is the venous ablation. This is where the vein is burned with either laser or radio frequency catheters. During this procedure, the patient is sedated with valium, nitrous oxide, or both. The patient can choose the level of sedation they prefer.

During this procedure, the sonographer will map the vein to be ablated and mark a location that appears to be a good access point. What we look for is whether the vein is straight and has a large diameter, which makes accessing the vein easy. Veins will sometimes spasm or be a smaller diameter early in the morning when the patient hasn’t been standing or active all day, or when the leg is cold. In these cases, we use gravity, a Nitroglycerin patch, and a blanket to help warm up the leg and increase the diameter of the vein.

Once a location is marked, we prep the leg with a cleansing/sterilizing solution and set up the procedure using sterile technique. We ask that the patient not touch the sterile field, so to prevent infection. When the physician enters the room, he will also dress in a sterile gown and will don sterile gloves. We take every precaution to keep the patient safe and infection free.

At this point, the physician will access the vein and start the procedure. Once the vein is accessed, a “guide” wire is inserted and the sonographer will follow the wire up the vein to make sure we are in the vein and not in the surrounding tissue. After that, the catheter, with the heating element, is inserted and once again the sonographer follows the catheter with ultrasound to make sure it is in the vein to be treated.

Once the catheter is an acceptable distance from the deep venous system, we need to numb around the vein. This is two-fold: The first reason is to numb and protect the tissue surrounding the treated vein from being burned. The second is to compress the vein around the catheter so the walls of the vein will be treated.

Once this all complete, the catheter is slowly removed and the vein will be ablated. We close the access point with steri strips and the procedure is finished. The patient is then required to wear a compression stocking for one week.

Insurance Coverage of Varicose Vein Treatment

Getting treatment for varicose veins can be daunting and sometimes frustrating. We hear you and want to help.

Does this scenario sound familiar:
Physician: How long have you suffered symptoms?
Patient: Explains reason for visit.
Physician: Well, I know we can help you with that. What insurance do you have?
Patient: Gives insurance information
Physician: Oh, I’m sorry to tell you that not all these procedures are covered by your insurance.

If this has happened to you then you are not alone. Most insurance companies have complex policies that are difficult for even their own employees to understand let alone the layman. So, what is it that you need to know about insurance coverage for varicose vein treatment and whether or not your insurance will pay? Three things: symptoms, anatomy and conservative measures.

Varicose Vein Symptoms

Insurance companies are not in the habit of paying for cosmetic procedures; therefore, if you simply do not like the way your legs look then you will have to dig deep into those pockets to pay for those treatments on your own. However, many of our patients are not aware they are experiencing symptoms from their varicose veins because they did not know what to look for. Most patients experience aches and pains in their legs, along with heaviness and sometimes swelling. Another symptom commonly associated with varicose veins is itching. The insurance companies like to quantify these symptoms by determining how they affect your life on a daily basis (Activities of Daily Living). Read about Activities of Daily Living.

Vein Anatomy

We know you have no control over your vein anatomy but regardless the insurance companies have limitations on what they will and will not treat. When you come to an appointment at IVC, you will have a complete ultrasound that we call a “vein mapping”. This vein mapping allows us to determine which veins are healthy and which veins are not. It also allows us determine the diameter of the diseased veins and their shape so we know which modality we should use for treatment. You may hear us mention that a vein size is too small to be covered by your insurance. Most of the time, these smaller veins are not causing the symptoms you are experiencing; therefore, it is not detrimental to your health to not proceed with treating those veins.

Conservative Measures for Varicose Veins

Okay, now we have established that you are experiencing the symptoms the insurance wants for treatment and your vein anatomy meets their policy requirements. What are conservative measures and why do you need to do them? The majority of insurance companies are going to require a patient to have a trial period of wearing prescription strength compression stockings for at least three months prior to approving treatment. The styles really have come a long way from when our grandparents wore compression socks, but they still are tight and can be uncomfortable so the three months can sometimes feel like a lifetime. Insurances also like to see that you tried taking anti-inflammatories to alleviate symptoms. Some require these medications to be prescription strength and others require OTC. Either way, the insurance companies want to determine whether your symptoms can be managed by conservative treatment with medications and compression before they opt to pay for other forms of treatment.

Once you have completed your conservative measures trial period, then it is time to submit your clinical for prior authorization and move forward with treatment. Having insurance does not guarantee they will pay so it is very important to choose a clinic that will walk you through the process. Do not be afraid to ask questions to be informed as much as possible because ultimately the buck stops with you.

How long will my treatment plan take?

Every patient at IVC is unique. Therefore, everyone is not going to be the same. Most patients will have a treatment plan that will take anywhere from 6 to 8 weeks up to 14 to 16 weeks depending on how many veins need treatment. The initial plan may change after the first couple of treatments and could be shortened or lengthened compared to the initial plan. Follow-up appointments are how we determine what needs to be done next and if we need to change the treatment plan. Varicose vein treatment is not something that can be treated all at one time so expect anywhere from 8 up to 16 weeks for completion of your treatment plan.

Varicocele Treatment Options

In the United States, varicocele treatment has traditionally involved open surgery, usually performed by a urologic surgeon, or urologist. In recent years however, a safe and effective non-surgical alternative called varicocele embolization is becoming the treatment of choice for many patients and their physicians

Varicocele embolization is an outpatient procedure that is performed without general anesthesia using light sedation. In this type of varicocele treatment, a small tube is inserted into the neck or groin through a small nick in the skin (about the size of the lead in a pencil). The skin is numbed for this procedure and it is not painful. Next a small catheter, or tube, is painlessly guided up into the abdomen and into the varicocele vein under the guidance of x-ray imaging. A dye is injected to create an x-ray map (venogram) of the vein and tiny metal coils or other embolizing substances are inserted through the catheter to block the flow of blood to the vein. The tube is removed and no stitches are needed. Patients are observed for a few hours and go home the same day. Recovery from varicocele embolization typically takes less than 24 hours and patients often return to work the next day.

Advantages of Varicocele Embolization

The majority of men in the United States undergo surgery as varicocele treatment. This is because they are usually sent to surgeons for evaluation, and many do not know about varicocele embolization. The advantages of this alternative, interventional radiology varicocele treatment include:

* It is as effective as surgery, as measured by improvement in semen analysis and pregnancy rates.

* It does not require any surgical incision in the scrotal area.

* A patient with varicoceles on both sides can have both fixed at the same time through one vein puncture site (surgery requires two separate open incisions).

* General anesthesia is not used for embolization (most surgery is done under general).

* There is a lower rate of complications compared to surgery. Infection has not been reported after embolization.

*It requires less recovery time. Post embolization patients are virtually never admitted to the hospital. Even patients with physically demanding jobs may return to work within the next day or two, unlike post surgical patients.

Insurance – it’s the name of the game. Does it mean anything to you?

When it comes to insurance we all have a lot of questions. Do you ever feel that you never get a straight answer? Welcome to the game. For the next few weeks I will be your coach and will provide you with insurance insight that pertains to varicose vein policies. This week I will share general requirements that many of the insurance providers enforce through their guidelines. In the following weeks I will highlight an individual insurance plan.

I’m sure you have questions regarding your deductible and if it will apply to the procedures. You may also wonder what your responsibility will be. All of these questions will be answered during your new patient appointment.

Many insurance companies require conservative measures, such as compression stocking usage. The use of anti-inflammatories and pain meds are required; exercise and being as active as possible is also encouraged. And what about symptoms? Swelling, achiness, PAIN, etc. Ay yi yi. The list goes on and on. I promise I will not leave you hanging. I will address all these things and more in the following weeks and be specific as to which insurances require all or none of these conservative measures and symptoms.

Whether you are playing “Shoots and Ladders” or friendly rounds of fantasy football, all games have rules. I hope to share the rules to the “insurance game” in a way that is easy to understand and help you maneuver through the field of policy madness.

Is it safe to close down veins? Don’t you need those veins?

Often times when we are talking to patients about closing down their problematic varicose veins we will get asked “are you sure you can close down those veins?” or “doesn’t my body need those veins, are you going to make things worse?”

When treating varicose veins we explain to patients that we are treating superficial veins and these veins only return 10% of the blood from the legs. The remaining 90% is returned through the deep system. We are not treating or closing down any deep veins, in addition, there are so many remaining superficial veins that are still working properly that we close down the problematic ones and improve symptoms in you legs.

Another question asked often is “What is the limit to how many veins you can close down without causing a problem?” That is a difficult question to answer, but so far we have not reached an upper limit in treating varicose veins where we would feel that treating anymore veins may create problems instead of solving them.