BlueCross BlueShield of Tennessee Medical Policy Manual

Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis


The relationship between chronic cerebrospinal venous insufficiency (CCSVI) and multiple sclerosis (MS) is a controversial area of research. Correction of CCSVI in patients with MS has been attempted using percutaneous venoplasty. The intent of this procedure, sometimes referred to as the ‘Liberation Procedure’, is to relieve MS symptoms by improving venous drainage of the central nervous system.

The foundation of this vascular theory is that there is abnormal venous drainage from the brain due to outflow obstruction in the draining jugular vein and/or azygos veins. This abnormal venous drainage, which is identified by special ultrasound criteria, is said to cause intracerebral flow disturbance or outflow problems that lead to periventricular deposits. In the CCSVI theory, these deposits have a similarity to the iron deposits seen around the veins in the legs in individuals with chronic deep vein thrombosis. Those studying this theory have promoted the idea that balloon dilatation, with or without stenting, will resolve the CCSVI and alleviate MS complaints.




The association between CCSVI and MS, especially as a causative factor, remains unclear. The evidence is insufficient to determine the effects of the technology on health outcomes.


Baracchini, C., Valdueza, J. M., Del Sette, M., Baltgaile, G., Bartels, E., Bornstein, N. M., et al. (2012). CCSVI and MS: A statement from the European Society of neurosonology and cerebral hemodynamics. Journal of Neurology, 259 (12), 2585-2589. (Level 2 evidence)

Costello, F., Modi, J., Lautner, D., Bhayana, D., Scott, J., Davenport, W., et al. (2014). Validity of the diagnostic criteria for chronic cerebrospinal venous insufficiency and association with multiple sclerosis. Canadian Medical Association Journal, 186 (11), E418-E426. (Level 3 evidence)

Kugler, N., Patel, P., & Lee, C. (2015). Chronic cerebrospinal venous insufficiency in multiple sclerosis: a failed concept. Vascular Specialist International, 31 (1), 11-14. (Level 3 evidence)

National Institute for Health and Clinical Excellence (NICE). (2012). Percutaneous venoplasty for chronic cerebrospinal venous insufficiency for multiple sclerosis. Retrieved November 4, 2013 from 

Siddiqui, A., Zivadinov, R., Karmon, Y., Yu, J., Hartney, M., Marr, K., et al. (2014). Prospective randomized trial of venous angioplasty in MS (PREMiSe) Neurology, 83, 441-449. (Level 1 evidence)

Tsivgoulis, G., Faissner, S., Voumvourakis, K., Katsanos, A., Triantafyllou, N., Grigoriadis, N. (2015). “Liberation treatment” for chronic cerebrospinal venous insufficiency in multiple sclerosis: the truth will set you free. Brain and Behavior, 5 (1), 3-12. (Level 2 evidence)

U. S. Food and Drug Administration. (2012, May). U. S. Department of Health and Human Services. FDA safety communication: Chronic cerebrospinal venous insufficiency treatment in multiple sclerosis patients. Retrieved May 14, 2012 from

Zivadinov, R., Karmon, Y., Dolic, K., Hagemeier, J., Marr, K., Valnarov, V., et al. (2013). Multimodal noninvasive and invasive imaging of extracranial venous abnormalities indicative of CCSVI: results of the PREMiSe pilot study. BMC Neurology, 13, 151. (Level 2 evidence)




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