BlueCross BlueShield of Tennessee Medical Policy Manual

Varicose Vein Treatments for the Lower Extremities


Varicose veins are enlarged, dilated, tortuous vessels and a common clinical manifestation of chronic venous insufficiency. These veins can be found anywhere on the body but occur most often in the lower extremities. Symptoms range from pain, burning, and itching to edema, skin discolorations, and painful ulcerations.

During the past decade, new venous terminology has been developed and adopted by vascular societies around the world. The main superficial veins of the lower extremities are the great saphenous veins (GVS) and small saphenous vein (SSV). All previous names used to describe these vessels (greater, long, and lesser) should be discouraged. There are posterior and anterior accessory saphenous veins in the calf and the thigh. The intersaphenous vein (formerly the vein of Giacomini), which runs in the posterior thigh, connects the SSV with the GSV. The deep system includes the popliteal, femoral, anterior, posterior tibial and peroneal veins. Perforator veins, not considered part of the superficial system, connect the superficial veins to the deep veins where they drain. One way valves are located in both the superficial system and the perforator veins, which aid the return of venous blood. Typically varicosities are related to incompetence of these valves which lead to increased pressure in the superficial venous system and result in an accumulation of blood and expansion or bulging of the veins.

Telangiectasias (i.e. spider veins, spider bursts, web veins, thread veins, dilated venules) are permanently dilated blood vessels that create fine, thread-like veins. Usually, they are limited to the dermis and are small (≤1 mm in diameter). The treatment of telangiectasias is most commonly performed for cosmetic improvement.

The treatment of varicose veins depends on the severity of the problem. Asymptomatic varicose veins and those with mild to moderate symptoms are treated with conservative measures such as exercise, elevation of leg(s), supportive stockings, the avoidance of tight clothing, and prolonged standing.

A variety of treatment modalities are available to treat severe symptoms of varicose veins/venous insufficiency, including surgical approaches, thermal ablation, and sclerotherapy. The application of each of these treatment options is influenced by the severity of the symptoms, type of vein, source of venous reflux, and the use of other (prior or concurrent) treatments. Surgical techniques include ligation (tying off a vein), stripping (removing a long segment of vein with a special instrument), ambulatory phlebectomy (removal of a vein through tiny incisions also called stab avulsion, hook phlebectomy or transilluminated powered phlebectomy), endoluminal radiofrequency ablation (e.g., VNUS® Closure™ System), endoluminal laser ablation (e.g., EVLT™ procedure kit). Radiofrequency energy and/or laser therapy is designed to damage the intimal wall of the vessel, resulting in fibrosis and ultimate obliteration of the vein.

Sclerotherapy is a less invasive procedure involving the injection of a chemical agent; liquid, foam, or more recently, microfoam directly into the vein resulting in changes to the lining of the vein wall. If successful the vein is occluded and no longer able to serve as conduit for venous blood flow. The success of the treatment depends on accurate injection of the vessel, an adequate volume and concentration of sclerosant agent. Historically, larger veins were not considered to be good candidates for sclerotherapy due to dilution of the agent in the blood volume of the larger veins and potential migration of the chemicals into the larger vasculature. Technical improvements in sclerotherapy have included the use of ultrasound to target refluxing vessels, and the development of a proprietary microfoam sclerosant (i.e. Varithena ®) that is dispersed from a canister with a controlled density and more consistent bubble size.

Emerging techniques and technologies that use mechanochemical ablation (e.g., ClariVein® Infusion Catheter), cryoablation (e.g., Erbe Erbokryo®), surgical adhesive (e.g., VenaSeal™ Closure System), microwave ablation, or steam injection have not been proven to be superior and/or have no long term studies that address the issues of recurrence, healing, neovascularization, thrombus formation, thrombophlebitis, wound infection, or transient neurologic effects.

Note: Liquid sclerosing agents (e.g. Asclera®) can be foamed at the bedside with CO2 or room air, this does not constitute an ‘off-label’ use of the product. While the literature refers to this as physician-compounded; BCBST’s Administrative Services policy Compounded Drug Products would only apply if components other than CO2 or room air were added to the manufacturer’s product.





2013 FDA approval of microfoam sclerotherapy (i.e. Varithena®) indications for use are ‘for the treatment of incompetent great saphenous veins (GVS), accessory saphenous veins and visible varicosities of the GVS system’.

The CEAP classification, developed by the American Venous Forum, is a method commonly used to document the severity of chronic venous disease and is based on clinical presentation (C) - defined below in class 1-6; etiology (E) - congenital, primary, secondary; anatomy (A) - superficial, perforator, deep; and pathophysiology (P) - reflux or obstruction, basic or advanced:


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