Cigna varicose vein policy

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Swiss German. The authors noted that although procedure seems. A position statement issued by the Society of Interventional Radiology in December calls the use of. The statement reports that. Lower rates of recurrence may be the result of the fact that imaging. The society. Endomechanical Ablative Approach: Minimally invasive treatment methods for treatment of varicose veins. One method under current investigation is the endomechanical ablative approach to.

This approach involves the use of a special. FDA approved liquid sclerosant, sodium tetradecyl sulfate to enhance venous occlusion. This mechanicalchemical. Currently evidence in the peer-reviewed published scientific literature supporting safety and.

Incompetent perforator veins result in pooling of blood in the lower extremity area, leading to. An alternative to open subfascial perforator vein surgery i. Linton procedure has been associated with a high incidence of postoperative wound healing complications. Townsend, Direct visualization through endoscopy has been suggested as a more desirable approach. During SEPS, an endoscope is inserted in an incision located away from the ulcer. The veins are ligated with clips and subsequently dissected,.

Authors claim that stasis ulcer healing rates and maintenance of healing at five years after. The overall goal of SEPS in treating chronic. Evidence in the form of randomized clinical trials and both retrospective and prospective case series support the. In contrast, SEPS performed for the treatment of post-thrombotic syndrome is controversial. NICE specialty advisors noted that based on the evidence reviewed, efficacy of the procedure is unproven and. Reported complications include nerve injury and deep vein thrombosis.

There was evidence to support lower wound infection rates compared to the open procedure. Length of stay. The rate of primary ulcer healing and cumulative ulcer recurrence rates was comparable.

Although SEPS has been used for individuals with post-thrombotic. In summary, the advisors noted careful patient. Although not allinclusive,. The etiology of varicose veins is multifactorial and may result in a variety of symptoms and complications. Several treatment options are available, including minimally invasive surgical methods.

The two main treatment. While varicose vein surgery is a very. The treatment of varicose veins is covered only when coverage is available under the plan for varicose.

Benefit exclusions and limitations may apply. Invasive treatment of varicose veins is. Prevention or reversal of deep venous insufficiency by aggressive. Alaiti S. Sclerotherapy: Treatment. Updated May 16, Accessed October 2,. Radiofrequency ablation and laser ablation in the treatment of varicose veins. American Academy of Cosmetic Surgery.

American College of Phlebology. Guidelines for varicose vein surgery. Angermeier MC. Treatment of facial vascular lesions with intense pulsed light. J Cutan Laser Ther. Angle N, Freischlag JA.

Venous disease. In: Townsend CM Jr. Sabiston textbook of surgery. Philadelphia, PA: W. Saunders Co. Prospective randomized. J Vasc Surg. Microfoam ultrasound-guided sclerotherapy of varicose.

Minimally invasive treatment for varicose veins: a review of endovenous. Int J Low Extrem Wounds. Eur J Vasc Endovasc Surg. Sclerotherapy of reticular and telangiectatic veins of the face, hands, and.

Surgical management of varicose veins:. Clinical and technical outcomes. Treatment of primary venous. Endovenous laser photocoagulation EVLP for varicose veins. Lasers Surg Med. Ultrasound-guided foam sclerotherapy for treating incompetent great. Dermatol Surg. Powered phlebectomy TriVex in treatment of varicose veins. Ann Vasc Surg. Randomized clinical trial comparing multiple stab. Br J Surg. Corabian P, Harstall C. Sclerotherapy for leg varicose veins.

Alberta Heritage Foundation for Medical. Technology Assessment. Ip Information paper. May Creton D, Uhl JF. Foam sclerotherapy combined with surgical treatment for recurrent varicose veins:. Ultrasound-guided foam sclerotherapy for the treatment of varicose veins.

Medium-term results of ultrasound-guided. Randomized clinical trial. Subfascial endoscopic perforating vein surgery as treatment for. Endovenous nm laser treatment of saphenous. Randomized clinical trial comparing endovenous. Five-year results of a randomized clinical trial. Duffy DM. Sclerosants: a comparative review.

The role of sclerotherapy in abnormal varicose hand veins. ECRI Institute. Hotline Response [database online]. Varicose Vein s. Evidence Report Issue No. Plymouth Meeting PA :. Available at URL address:. Evidence Report]. Revision of the CEAP. Feied C. Varicose vein treatment and endovenous laser therapy. Diseases of the vessels.

Updated August 11, Accessed October 2, Available at URL. Endovenous laser treatment of varicose veins. Surg Clin North Am. Foam sclerotherapy for the treatment of superficial venous. Endovenous laser treatment of the small. Mid-term results of endoscopic. The North American Study Group. The care of patients with varicose veins. Gloviczki P, Gloviczki ML. Guidelines for the management of varicose veins. Goldman MP. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating.

Endovenous laser and echo-guided foam ablation in great. Laser and. Habif: Clinical Dermatology, 5 th ed, Ch 3. Stasis dermatitis and venous ulceration: postphlebitic. Ultrasound Evaluation of the Lower Extremity Vein s. Radiol Clinic. Great saphenous vein radiofrequency ablation versus. A prospective randomized controlled trial of. VNUS closure versus surgery for the treatment of recurrent long saphenous varicose veins. Eur J Vasc.

Endovenous laser ablation of the small. Systematic review of foam sclerotherapy for. Kahle B, Leng K. Efficacy of sclerotherapy in varicose veins—prospective, blinded, placebo-controlled.

Kalra M, Gloviczki P. Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein. High ligation. Foam sclerotherapy--a possible option in therapy of varicose veins. Randomized clinical trial of the effect. A randomized trial of cryo. Kouri B. Current evaluation and treatment of lower extremity varicose veins.

Am J Med. Long term results of compression sclerotherapy. Comparative trial between sodium tetradecyl sulfate and glycerin in the. Lee BJ. Plast Reconstr Surg. Subfascial endoscopic perforator surgery for venous ulcers. Systematic review of treatments for. Varicose Vein s: Treatment. Updated August 10, Luebke T, Brunkwall J. Meta-analysis of transilluminated powered phlebectomy for superficial.

Prospective randomized study of. Prospective randomised study of. Clinical spectrum of. Conventional stripping versus cryostripping: a. Randomised clinical trial,. Endovenous laser treatment of saphenous vein reflux: long term.

Min RJ, Navarro L. Transcatheter duplex ultrasound-guided sclerotherapy for treatment of greater. Gloviczki P. A systematic review and meta-analysis of the treatments of varicose veins. Development of open-scope subfascial perforating vein surgery:. Endovenous laser treatment of the long saphenous. Radiofrequency ablation of varicose veins.

Subfascial endoscopic perforator surgery, Guidance. Transilluminated powered phlebectomy for varicose. Issued a Jan.

Ultrasound guided foam sclerotherapy for varicose. Issued June Re-issued May Accessed October 10, Available at. Endovenous laser: a new minimally invasive method of treatment for. True long-term healing and recurrence of venous leg ulcers following SEPS. Minimally invasive. J Am Acad Dermatol. A prospective doubleblind. Clinical results of radiofrequency endovenous obliteration.

Ozkan U. Endovenous laser ablation of incompetent perforator veins: a new technique in treatment of. Varicose vein. Vasc Endovascular Surg. Peden E, Lumsden A. Radiofrequency ablation of incompetent perforator veins. Perspect Vasc Surg. Efficacy of subfascial endoscopy in eradicating perforating veins of.

Proebstle TM, Herdemann S. Early results and feasibility of incompetent perforator vein ablation by. Endovenous treatment. Endovenous laser therapy and radiofrequency. Rabe E, Pannier F. Sclerotherapy of varicose veins with polidocanol based on the guidelines of the. Guidelines for sclerotherapy of varicose veins ICD I Efficacy and safety of great saphenous vein sclerotherapy.

Eur J. Radiological Society of North America. Varicose vein treatment Endovenous ablation of varicose vein. June 29, Reviewed July 13, Double-blind prospective comparative trial between foamed and.

Randomized trial comparing. Efficacy and safety of endovenous foam sclerotherapy: meta-analysis for. Treatment of essential telangiectasias with an intense pulsed. Endovascular treatment of venous.

Acta Radiol. Endovenous ablation of. J Endovasc Ther. Surgery for varicose veins: use of tourniquet. Cochrane Database of Systematic Reviews In: The Cochrane Library, , Issue 4. Surgery versus sclerotherapy for the treatment of. In: The Cochrane Library, Issue. Roth SM. Endovenous radiofrequency ablation of superficial and perforator veins. Sadick NS. Advances in the treatment of varicose veins: Ambulatory phlebectomy, foam sclerotherapy,. Scavee V.

Transilluminated powered phlebectomy: not enough advantages? Review of the literature. Eur J Vasc Endovasc Surge. Epub Dec Transilluminated powered phlebectomy. Mid-term clinical experience. Hook phlebectomy versus. Eur J Vasc Endovasc. Transilluminated powered phlebectomy:. Role of endovenous laser treatment in the. Randomized clinical trial of. Singh MJ, Sura C. Endovenous saphenous and perforator vein ablation. Operative techniques in. A Systematic Review and Metaanalysis. Patients with Varicose Vein.

Society for Interventional Radiology. Position statement. Endovenous ablation. Outpatient varicose vein surgery with transilluminated powered. Subramonia S, Lees TA. The treatment of varicose veins. Ann R Coll Surg Engl. Endoscopic versus open subfascial division of.

J Vasc. New approaches for the treatment of varicose veins. Surg Clin N Am. Injection sclerotherapy for varicose veins. Cochrane database of systematic. Radiofrequency ablation of the. The nm diode laser. Uchino IJ. Endovenous laser closure of the perforating vein of the leg.

Single-center experience with foam sclerotherapy without ultrasound. Endovenous therapies of lower extremity. Safety summary. Weiss RA. Accessed October Evaluation of the venous system by Doppler ultrasound and photoplethysmography or light. Transillumination mapping prior to ambulatory phlebectomy.

The Bulletin of the North American Society of. Insurance Advisory Committee Report. J Dermatol Surg Oncol. Controlled radiofrequency endovenous occlusion using a unique radiofrequency. Welch HJ. Endovenous ablation of the great saphenous vein may avert phlebectomy for branch. Primary varicose veins of the upper extremity: a report of three cases. All products and services are provided by or through such operating subsidiaries. Corporation and Cigna Dental Health, Inc. In California, HMO plans are.

In North. Atlantic, Inc. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

In addition, some benefit plans specifically exclude coverage for the invasive treatment of varicose veins. Please refer to the applicable benefit plan document to determine benefit availability and the terms, conditions and limitations of coverage.

Extended embed settings. You have already flagged this document. Thank you, for helping us keep this platform clean. The editors will have a look at it as soon as possible. Self publishing. Share Embed Flag. TAGS varicose vein treatments cigna www. Coverage Policies are intended to provide guidance in interpreting certain standard Cigna benefit plans. Symptoms that have been reported as associated with varicose veins of the lower extremities include pain, cramping, aching, burning, throbbing, swelling and the feeling of heaviness or fatigue in the leg.

Typically, symptoms are exacerbated by standing and warm weather Hamper, et al. Saphenous varicose veins can ultimately result in intractable ulcerations and recurrent bleeding. Chronic cellulitis may also be associated with varicosities. The venous system of the lower extremities is separated into two main systems: the deep venous and the superficial venous system. The deep venous system comprises the popliteal and femoral veins; the superficial venous system comprises the greater saphenous and short saphenous veins formerly called the lesser saphenous vein.

The short saphenous vein is not usually larger than 3 mm in diameter, and connects with the deep veins at the saphenopopliteal junction SPJ in the knee area.

Incompetence of the superficial venous system typically results from failure of valves at the SFJ and the SPJ with resulting pressure that is worse at the more distal area of the vein.

Incompetence of the perforating veins also leads to increased pressure in the superficial venous system due to the pump mechanism of the calf. Telangiectases are permanently dilated blood vessels, also called spider veins that create fine red or blue lines on the skin. They are similar to varicose veins, but are limited to the dermis and are not usually more than 3 mm in diameter.

They are not typically associated with symptoms, and treatment is generally considered cosmetic in nature and not medically necessary. Varicose veins may develop during pregnancy, although surgery or sclerotherapy is not typically performed, as the treatment is not medically necessary.

Most varicosities will spontaneously resolve within 4—6 months after delivery. Varicose veins of the upper extremity are rare; still there are a few reports in the published, peer-reviewed medical literature dealing with the management of upper extremity varicosities Welch and Villavicencio, ; Duffy, et al. However, authors have reported successful outcomes utilizing methods of treatment similar to lower extremity varicosities e.

Various ultrasound technologies are used in conjunction with other noninvasive testing to determine the physiological characteristics of the varicosities, as physical exam alone may not be reliable. Duplex ultrasound, Doppler ultrasound and plethysmography may all be used to diagnose varicose veins. In most cases, once the initial vein mapping is performed, it is not essential that follow-up scanning be done for subsequent sclerotherapy sessions. It has not been demonstrated in the published medical literature that repeat Duplex or Doppler studies are essential for the successful outcome of the procedure when performed as part of a series of sclerotherapy sessions.

Also, routine use of any of these tools in the absence of venous symptoms or clinical evidence of venous insufficiency or reflux is not considered a medical necessity. Photographs or diagrams are helpful in assessing the size and extent of the varicosities. The CEAP classification is a method commonly used to document the severity of chronic venous disease and is based on clinical presentation C , etiology E , anatomy A , and pathophysiology P See Table 1.

Each classification can be further defined as follows Eklof, et al. As a result, it is recommended that CEAP classification value be followed by the date of examination. It is also recommended that the level of investigation be included, with Level I representing the office visit, Level II representing noninvasive venous laboratory testing and Level III representing invasive assessment and more complex imaging studies.

In a randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping, all treatments were found efficacious Rasmussen, et al.

Foam sclerotherapy was noted to have the highest technical failure rate but was also associated with a more rapid recovery and less postoperative pain.

Conservative medical practices that may be used in the management of varicose veins include leg elevation, analgesia for symptom relief and avoidance of prolonged periods of standing.

The amount of compression required for treatment of stasis dermatitis or ulceration is between 35 and 40 mm Hg, for varicose veins, for mild edema and leg fatigue the recommended pressure is 20 to 30 mm Hg Habif, When conservative measures fail, treatment options rely on identifying and correcting the site of reflux and on redirecting the flow of blood through veins with properly functioning valves. No single method of treatment is universally employed in the literature; the intervention selected is generally dependent upon the competency of deep and perforating veins, and the site and degree of reflux.

Surgery is commonly used to treat mainstem varicose veins. Many patients require a combination of techniques to correct symptoms associated with venous insufficiency, most of which can be performed in a single treatment session. While staging of procedures is generally not required, repeat sclerotherapy sessions may be required for an unsuccessful vein occlusion. Typically, a treatment plan includes thermal ablation of the incompetent vein segment for greater saphenous vein reflux and associated larger varicosities.

Once this segment is treated, if there are associated varicosities greater than 4mm in diameter phlebectomy is often performed during the same session, and for smaller veins, sclerotherapy is employed as the treatment of choice Kouri, Complications associated with varicose vein treatment vary and are dependent on the type of treatment employed.

Complications that may result from sclerotherapy and phlebectomy include but are not limited to hyperpigmentation, allergic skin reactions, migraine-like symptoms particularly from foam sclerosants , pain at the injection site, superficial and deep thromboembolic events and subcutaneous hematomas. Most complications are transient and resolve with conservative measures.

Subcutaneous hematoma formation is easily managed with warm compresses and nonsteroidal anti-inflammatory medications. Thromboembolic events although rare can be life-threatening and may require anticoagulation Lew, Weaver, ; Alaiti, Complications associated with thermal ablation techniques are usually minor and self limiting; serious events are rare. Invasive Approaches Page 5 of 26 Coverage Policy Number: Sclerotherapy: Sclerotherapy is an invasive procedure used to eradicate small to medium sized varicose veins of the superficial venous system greater and small saphenous veins.

When reflux is present at the junction, sclerotherapy should be performed in addition to surgical ligation and division of the junction, promoting control of the point of reflux. Injection of the vein at its junction and of the incompetent perforating veins has been proposed as an alternative to ligation; however, the scientific literature does not support the efficacy of this procedure.

Sclerotherapy has not been shown to be effective as a sole treatment of larger incompetent veins and is often used with other approaches to treat significant varicosities. A recent systematic review Leopardi, et al.

During sclerotherapy, the abnormal vein is injected with a sclerosing agent that irritates the lining of the vein, causing it to thrombose and stenose, ultimately leading to resorption into the surrounding tissue. Echosclerotherapy using either liquid or foam sclerosant, also referred to as ultrasound-guided sclerotherapy and endovenous chemical ablation ECA , employs real-time ultrasound during the sclerotherapy procedure to help locate deep or inaccessible sites.

Echosclerotherapy is indicated for treatment of veins below the surface, such as deep veins and other varices that are difficult to visualize Corabian, et al. According to the ACP, the use of image guided techniques such as ultrasound is essential for the safe and effective performance of endovenous chemical ablation and reflects the current standard of care.

Foam sclerotherapy, which involves the use of a sclerosing solution that has been forcibly mixed with air or gas e. Foam sclerosant forces blood out of the vein and allows for less dilution of the sclerosant and more contact with the endothelium Lew, Weaver, Overall, authors generally agree foam sclerotherapy is a safe and effective method of treating varicose veins Rabe, et al.

As with sclerotherapy in general, the need for repeat treatment sessions when utilizing any of these methods of treatment has been reported in the literature Barrett, et al. Although echosclerotherapy has been investigated as an alternative to traditional saphenous vein ligation and stripping Min, Navarro, ; Bountouroglou, et al. Evidence consists mainly of case series with few comparative trials and mixed reported clinical outcomes.

There is no consensus in the published scientific literature regarding the optimal number of sclerotherapy treatments required to reduce the symptoms associated with varicose veins and the number treatments needed to resolve symptoms varies among patients.

The AACS reports sclerotherapy is the treatment of choice for varicose veins that are 2—4 mm in diameter and large areas of veins can usually be eradicated using two to three treatment sessions. Vessels 4—6 mm in diameter may be treated by sclerotherapy or ambulatory phlebectomy. The primary aims of sclerotherapy are to prevent complications of varicose disease and relieve symptoms; cosmetic improvement in the leg's appearance is an added benefit.

Treatment provided solely for cosmetic purposes is not considered a medical necessity. Sclerotherapy is a palliative solution and cannot prevent the formation of new varicosities. New varicosities may form, either because of an underlying illness or condition, or, in some cases, because of a genetic predisposition. Page 6 of 26 Coverage Policy Number: In compressive sclerotherapy, the most commonly performed method of sclerotherapy, compressive dressings are applied after injection of the sclerosing agent, while the limb is elevated and the vein is drained.

External compression and internal decompression e. Non-compressive sclerotherapy involves injecting a sclerosant into the non-elevated blood-filled vein without applying a compressive dressing.

This method of therapy has not been shown to be effective in producing long-term obliteration of the incompetent veins. Other agents such as morrhuate sodium Scleromate morrhuate sodium although FDA approved are not used as commonly. Nonetheless, there is no evidence-based consensus on the optimal type, dosage or concentration of the sclerosing agent. Used as an alternative to or to complement sclerotherapy in treating small varicose veins and telangiectases spider veins , this type of light therapy utilizes small pulses of light energy which travel through the skin, are absorbed by the blood, are then changed to heat and ultimately destroy the vein.

Successful treatment requires adequate heating of the veins, and several treatments are usually required for optimal results. Transcutaneous laser ablation, also known as transdermal laser treatment, is a type of laser therapy similar to light therapy that involves the use of a laser to treat small varicose and spider veins. Small laser pulses are delivered to the vein, causing heat, which will ultimately lead to destruction of the vein.

This modality is not generally useful as a primary treatment of spider veins of the lower extremity; instead, it is employed to treat superficial vessels on the face. The treatment may result in superficial skin burns and permanent pigmentation changes. Laser or light therapy has been indicated for the treatment of telangiectasis and cutaneous vascular lesions Raulin, et al.

The vessels in the lower extremities are located deeper and have thicker surrounding tissue. Deeper vessels require a longer wavelength and longer pulse duration to damage the vessel effectively. Additionally, because spider veins and varicosities smaller than 3 mm do not usually cause symptoms, they are considered cosmetic; hence, treatment for them is not medically necessary.

When the GSV and SSV have reflux or incompetence, junction ligation with or without vein stripping is often recommended; in most cases, ligation is followed by GSV stripping. During the procedure, the saphenous vein and other smaller veins are exposed through an incision in the groin, where the veins are then ligated i. A second incision is made just below the knee or at the ankle to allow access for stripping the vein.

When both ends of the vein are free, a wire-like instrument is threaded through the vein, extending up to the second incision in the groin area. Removal of the superficial symptomatic vein restores venous circulation and provides relief of symptoms.

Operative excision of the vein is most often reserved for large varicosities and for those located in the medial or anterior thigh. Cryostripping of the GSV may be considered an alternative approach to traditional ligation and stripping.

During this procedure, a cryoprobe is passed through the GSV, the probe freeze attaches to the GSV and stripping is performed by pulling back the probe. The authors reported significantly improved quality of life scores for both groups, with no difference between the two Page 7 of 26 Coverage Policy Number: groups at six months. There was less bruising in the cryo group but no difference in post-operative pain scores between the two groups. The published evidence is mixed and does not lend strong support to improved clinical outcomes when compared to more conventional methods of varicose vein treatment.

Further studies are needed to demonstrate safety, efficacy and the clinical utility of cryostripping. In ambulatory phlebectomy, multiple small incisions are made, and the varicose veins are grasped with a small hook or hemostat. They are then clamped, divided and finally extracted. Compression therapy has been shown to reduce bleeding and improve resorption following this method of treatment and is thus widely used for that purpose. Effectiveness is dependent on the type of vein treated; the results of a recent systematic review Leopardi, et al.

Transilluminated Powered Phlebectomy TIPP : TIPP, which is similar to ambulatory phlebectomy, is another minimally invasive alternative to standard surgery for the treatment of symptomatic varicosities. Subcutaneous transillumination and tumescent anesthesia help visualize and locate the varicosity, while subcutaneous vein ablation is performed using a powered resector to obliterate the vein.

Tumescent anesthesia involves the infusion of large amounts of saline and lidocaine to reduce hemorrhage and of epinephrine to delay absorption of the lidocaine. During this procedure, the veins are marked with a marker, and a bright light is introduced into the leg through a small incision 2—3 cm to enhance visualization of the veins.

The power vein resector is then inserted to cut and remove the vein through suction. Proponents of this method suggest that the illuminating light allows quicker and more accurate removal of the vein, leading to a more effective yet less traumatic procedure.

TIPP is intended for patients who are suitable candidates for conventional ambulatory phlebectomy, and may also be used as an adjunctive method to other varicose vein treatments e. The individual components of the TriVex system were approved for use by the FDA in , however since that time, several other illumination and powered-resection devices have been approved and are available for use. Evidence evaluating TIPP for the treatment of varicose veins is primarily in the form of published reviews, few comparative trials few involving randomized groups and both retrospective and prospective case series involving small populations and evaluating short-term outcomes Kim, et al.

In addition, the outcomes measured in most studies include operative time, number of incisions, complications, and cosmetic satisfaction with few patient-oriented outcomes being reported.

Generally, the results of these studies demonstrate that TIPP is associated with fewer incisions Luebke, et al. Operative time varies among authors and with experience.

Despite reports in the published literature of a reduced number of incisions, an increase in bruising, postoperative pain and decreased quality of life during the early postoperative period has been reported. Moreover, it has been reported in the literature that technical complications may be associated with inexperience. The published, peer-reviewed, scientific literature does not lead to strong conclusions that TIPP results in clinical outcomes e.

Furthermore, long-term safety and efficacy of the procedure has not been adequately demonstrated. According to the report, the available data are promising for demonstrating the safety and efficacy of TIPP relative to hook phlebectomy and stab avulsion to treat varicose veins. However, ECRI also reported that the available evidence is inadequate to draw firm conclusions about its relative short- and long-term effectiveness, or its purported advantages over existing methods in terms of complications, operating time, pain, varicose vein recurrence, and cosmetic outcomes.

The advisory committee indicated that, although the evidence suggested that the procedure is effective, the data are too limited to be conclusive. In addition, there are no long-term follow-up data NICE, a.

Endoluminal Radiofrequency Ablation RFA : Radiofrequency ablation, also known as endovascular occlusion, is a treatment for symptomatic varicose veins that involves delivery of controlled radiofrequency RF energy through a catheter inserted into the affected vein.

The heat generated by the RF energy causes the vein to contract and become occluded. The treatment is intended as a minimally-invasive alternative to standard surgery for symptomatic varicosities located mainly below the saphenofemoral or saphenopopliteal junction. RFA has also been investigated as a treatment of incompetent perforator veins Singh and Sura, ; Uchino, ; Roth, et al. Next, the closure catheter is inserted into the vein, and electrodes are implanted in the venous wall.

The temperature is maintained for 30 seconds; then the catheter is slowly retracted, causing the entire length of the vein to collapse on it. If the assessment following treatment indicates any areas of steady flow, those areas may be re-treated, as long as the catheter is reinserted immediately Chandler, et al.

Possible complications include vessel perforation, pulmonary embolism, phlebitis, hematoma, infection, paresthesia and skin burns Chandler, et al. Evidence in the peer-reviewed published scientific literature supports the safety and efficacy of RFA for the treatment of symptomatic varicose veins.

Most early studies were small case series with short-term follow-up Ogawa, et al. RFA has been shown in a prospective nonrandomized trial to be more effective than foam sclerotherapy for closure of the GSV at one year follow-up Gonzalez-Zeh, et al. Compared to EVLT, at one month following treatment, RFA was significantly superior for measures evaluating post procedure recovery and quality of life parameters. When performed with and without ligation, at two years post procedure, there was no difference in outcomes recurrence, degree of ablation and venous clinical severity scores from adding the ligation procedure.

The short-term results of several other studies have demonstrated that the procedure effectively occludes incompetent veins following RFA treatment Proebstle, et al. This group of authors collected data to evaluate the long-term treatment outcomes of endovascular RFA and to determine risk factors that affect treatment efficacy. In their study, the authors reported on five-year follow-up results of patients limbs treated with radiofrequency obliteration RFO.

Immediate vein occlusion was achieved in The vein occlusion rate at six months, one, two, three, four and five years was Over a five-year follow-up period, anatomical failure was identified in limbs, 19 of which received reintervention. RFA also resulted in improved pain and less bruising compared to ligation and stripping in some studies Hinchliffe, et al.

Early studies, in addition to the more recent studies cited above, do support the safety and efficacy of RFA for the treatment of symptomatic saphenous varicosities, and is considered an appropriate alternative to conventional procedures. After reviewing the available evidence ECRI concluded that RFA Page 9 of 26 Coverage Policy Number: offered a less invasive alternative to surgical stripping and ligation for patients with symptomatic varicose veins.

Nonetheless, the benefits of RFA compared to surgery were supported on follow-up periods that were short term and consisted of a few days to one month posttreatment. In NICE issued an Interventional Procedure Guidance for RFA and reported that safety and efficacy appeared adequate to support use of the procedure as an alternative to sapheno-femoral ligation and stripping. EVLT is performed by threading a catheter through the greater saphenous vein and inserting an optical fiber through the catheter.

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