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Vein Classifications


The treatment of veins in Patients who fall in the 2-6 range on the CEAP classification, is considered medically necessary and are covered by insurance and Medicare.

Vein Classifications

Although we treat spider veins, insurance and Medicare consider treatment of these veins as cosmetic, and are not covered.

Varicose Veins are dilated and ropy appearing blue vessels that look like lumps under the skin. Factors that contribute to Varicose Veins:

  • Heredity (the most common cause)
  • Pregnancy
  • Hormone Replacement Therapy
  • Birth Control Pills
  • Prolonged Standing or Sitting
  • Obesity
  • Increasing Age

Spider Veins are small blue or red vessels visible within the surface of the skin, usually on the leg, face, neck or chest.  There is usually a hereditary component, that is to say if your parents or other relatives have spider veins, you are more apt to have them as well.  Female hormones such as estrogen and progesterone can worsen them.  These may be seen following trauma or sun exposure.  These have little medical significance, other than if they are very dense, and in areas below the knee, they may bleed spontaneous.

The gold standard for treatment, for spider veins on the legs, is sclerotherapy. Lasers may be used, but are generally less effect. The same is true for the Ohmo thermic devices such as the Vein Wave, and Vein Gogh. The Laser and Vein Gogh can both be used effectively on facial spider veins.

Sclerotherapy is performed in an office setting. Numbing cream is usually applied for short period of time prior to treatment.  Sessions are usually 20 minutes. It may take multiple sessions to obtain the results you want. Assignment of a percent improvement is an arbitrary number. Our goal is significant improvement. You should see significant improvement after 2 sessions to a given area, spaced 2-3 months apart. It is important to know that spider veins are treated, but not cured. There are some patients we see yearly, most; however, we retreat 2-3 years or more.

We use 3 solutions. Glycerine is used for the smaller veins. Sotradectal and polidocanol (asclera) may be used for dense clusters of spider veins or reticular veins. Reticular veins are also surface veins. They are green in color. These can grow into small varicose veins. When I use the sotradectal and polidocanol, I mix them with gas to make them frothy or foamy. This is referred to as foam sclerotherapy. The solutions work better in this state. The blood is displaced better, there is more surface area contact, and there is less risk for skin breakdown, if the solution leaks into the tissue around the vein. Although no procedure is without risk, serious complications are complications are rare from sclerotherapy. Potential risks and benefits, will be discussed in detail by Dr. Bardwil during your initial consultation.

The Waterfall Analogue

When it comes to treating the leg veins, the principals involve treat the underlying problem first, then to treat what is any residual veins, and finally any addressing cosmetic issues, if the patient wants these address. Obviously, if there is no underlying problem, the cosmetic issue may be addressed directly.

The best analogy that I have heard, is comparing the absaphenous vein to a large waterfall on the side of a mountain. One can imagine a large waterfall on the side of the mountain with smaller waterfalls down below, most of them resulting from the larger waterfall.

If one attempts to build a dam to block each of the smaller waterfalls, but ignore the large waterfall, then new smaller waterfalls will result, from the water which is still flowing from the large waterfall. If on the other hand, a dam is build to block the large waterfall,  then many of the smaller waterfalls will dry up. Those that are remaining can then be blocked by building individual dams, and will have a much better chance of staying blocked, without forming new waterfalls.

The same is true for the treatment of veins. The long saphenous vein is the superficial vein, which extends from the ankle to high in the thigh, where it empties into the deep vein the femoral vein. There is a one-way valve allowing blood to flow from the saphenous vein into the femoral vein. If this valve is not functioning properly, blood flows back into the saphenous vein, which then influences all of the superficial veins extending all the way down to the ankle.  It is like the large waterfalls. There are tributary veins which empty into the saphenous veins. When the saphenous vein backs up, it backs up into the smaller veins, creating varicose veins, which could be likened to the smaller waterfalls. If these veins are treated by removal but the large saphenous vein is ignored then the recurrence rate will be very high, new varicose veins would form, much like smaller waterfalls, if the large waterfall is ignored. If on the other hand, the saphenous vein is closed first, it wound be like blocking the large waterfall. The result would be, that many of the varicose veins will shrink. Some may disappear. Those that do remain can then be treated and will have a much lower recurrence rate.

When we treat leg veins, all of the procedures are performed in an office setting, using local anesthesia.  If the saphenous vein is abnormal, it is treated first by performing a laser ablation. Following this, any residual bulging veins are observed to see how much they shrink.  If they disappear, or shrink to the point that the patient is content with the results, then no further procedures are performed. If there are residual veins, and the patient prefers to have these addressed, these veins are addressed, by a microphlebectomy. (Removal of the residual bulging veins in small segments through 2mm sized incisions.) This procedure is also performed in the office.

If the patient also has spider veins, which they would like to have addressed, sclerotherapy is performed after the other procedures have healed, usually about a month later.


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