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What's the best vein treatment?


So, you think you might have a vein problem... should you get it fixed? Wouldn't it be nice if you knew some of the treatment options before going in to see the doctor? Well, this article will provide an overview of vein treatments, and describes some of the considerations that can help determine your best options.

Do you have symptoms?

If you have small veins visible on the skin surface that are not causing any symptoms such as pain, discomfort, leg fatigue, or leg heaviness, then it's likely that your vein issues can be considered "cosmetic" in nature.

Small skin surface veins (less than 1mm in diameter) are called spider veins. If you have spider veins, these are commonly treated with either cosmetic sclerotherapy or cosmetic laser. Sclerotherapy involves injecting medicine into the veins which causes the veins to shrivel, regress, and fade. 

Above: Spider Veins

For most patients sclerotherapy is rated as mildly uncomfortable as the tiny needle punctures the skin, but the procedure can be made more comfortable by application of a topical anesthetic (numbing) spray. At Vascular Solutions, we use topical ethyl chloride spray to numb the area when we perform sclerotherapy.

Above: Sclerotherapy

Another option is for small spider veins is cosmetic laser (sometimes referred to as transcutaneous laser leg vein treatment). This modality of care involves zapping the small skin surface spider veins using a laser light beam. The light beam has a specific wavelength that is targeted at the blood within the spider veins, which results in the elimination of the spider veins. At Vascular Solutions, we use the industry-leading Cynosure ICON laser system with a 1064nm handpiece when treating spider veins.

Above: Spider Veins

If your leg veins are slightly larger than spider veins (eg 1-3mm in diameter) you likely have reticular veins. Reticular veins are slightly larger than spider veins but have not yet reached the size criteria to be classified as varicose veins. Reticular veins are normally relatively benign. Similar to spider veins, reticular veins can be treated with sclerotherapy or laser. In my opinion, sclerotherapy tends to do slightly better for reticular veins, and laser tends to do slightly better for true spider veins. If you are undecided you may be a good candidate for a cosmetic consultation with possible same-day treatment.

If you have large, bulging varicose veins and symptoms of aching, throbbing, leg heaviness, leg swelling, or cramping, then your problem is not cosmetic, and you'll likely benefit from an evaluation with ultrasound. Some people with varicose veins will sustain an episode of phlebitis, where the veins have become red, tender, angry, and inflamed. The purpose of the ultrasound is to see what's going on with your leg veins, and see if there's any evidence of venous reflux (or venous insufficiency), which is the most common underlying condition that causes varicose veins.

Finally, some people can have symptoms related to underlying vein problems, but may not have externally visible spider veins or varicose veins.

Above: Varicose Veins

If you have symptoms, what are they?

Vein problems in the legs can cause a variety of symptoms, including leg heaviness, aching, ankle swelling, leg cramps, and leg restlessness. Some people will get itchy or discolored skin, which is known as stasis dermatitis. Up to 5% of people with untreated vein problems will develop a sore/wound just above the ankle, known as a venous ulcer.

If you have mild or intermittent symptoms any vein problem you have can probably be managed conservatively.

If you have moderate or severe symptoms related to vein problems, you may be better served with procedures. The procedures you may benefit from will be guided by findings on venous ultrasound. 

What do your legs look like?

If you have vein problems the appearance of your leg can vary dramatically depending on the type and extent of the vein problem that you have. People with scattered spider veins require treatments that are quite different from someone with extensive darkening of the skin or wounds on the lower leg.

Vascular specialists commonly grade the severity of your leg appearance of your legs on a 1-6 scoring system (1 is the mild end of the spectrum and represents people with spider veins, whereas 6 is on the severe end of the spectrum and represents people with open wounds or venous ulcer).


Above: Varicose Veins

What does the ultrasound show?

If you have leg symptoms, you'll likely need a vein ultrasound to see what's going on. Venous ultrasound is a painless way of determining whether you have any underlying vein problems that may be causing symptoms or contributing to the appearance of your legs.

More specifically the ultrasound will identify any evidence of venous reflux, where the valves in the veins have ceased to function effectively.

The ultrasound can determine how many veins are affected with venous reflux, and also determine the precise location, depth, vein diameter, and degree of twisting of the problem veins. All of these features help determine the best treatment.

Veins that are close to the skin, really small in caliber, or twisty may be a great candidate for Varithena microfoam treatment.

Long straight saphenous veins are ideally suited for treatment with either Closurefast (radiofrequency ablation - RFA) or VenaSeal adhesive closure.

An ultrasound can determine if there are any blood clots or blockages in the veins that may limit the feasibility of vein procedures.

What does insurance cover?

Vein procedures are not cheap. Most of the time you'll want insurance to cover procedures, if possible. Insurance will not cover purely cosmetic services. Cosmetic sclerotherapy and cosmetic laser spider vein treatment will not be covered by insurance.

If you do have symptoms, then most (but not all) health insurance policies cover vein procedures. Determining whether your plan covers varicose veins and vein treatment can be tricky. Quite often, the "devils in the details" and to determine whether you have coverage for vein care you'll have to assess the coverage guidelines in your policy.

In the Carolinas, Medicare covers most vein procedures, including Radiofrequency ablation (Closurefast procedure), VenaSeal closure, Varithena, and Phlebectomy. If sclerotherapy is performed with the intent of alleviating symptoms (as opposed to being performed for cosmetic reasons) then sclerotherapy can be deemed "medically necessary" and is a covered service.

Commercial health insurance plans, eg Blue-Cross Blue Shield, United Healthcare, Cigna, and Aetna all have available plans that cover vein care, however, even the plans that cover vein care have various restrictions. For example, some of the Blue Cross Blue Shield plans in North Carolina have a policy limitation, that limits coverage of saphenous vein treatments to one vein per limb, per leg, per lifetime. This is not ideal, given that many people may require 2 (or sometimes even 3) different saphenous vein treatments per leg.

Some commercial health insurance plans require abnormal saphenous veins to exceed (arbitrary) minimal diameters to be eligible for insurance coverage. For example, United Healthcare requires the saphenous veins to be a minimum diameter at certain locations (eg. great saphenous vein must be at least 5.5mm in diameter, and small saphenous vein must be at least 5.0mm in diameter). Also, United Healthcare requires documentation that symptoms of vein problems are interfering with your quality of life or activities of daily living.

Aetna, Cigna, and most Blue Cross plans in North Carolina require that you trial wearing medical strength (20-30mmHg) compression hose for at least 3 months before being eligible for insurance coverage.

How much do vein procedures cost?

The cost of vein services depends on several factors. If you're getting cosmetic services, like cosmetic sclerotherapy or cosmetic laser leg vein treatment, then you'll have to pay for the service. The charges for cosmetic services are set by the individual practice you're attending. Currently (in 2020) Vascular Solutions charge $450 for a 30-minute session of cosmetic sclerotherapy. We charge the same amount for a 30-minute session of cosmetic laser leg vein treatment.

If you require saphenous vein treatments, such as ClosureFast, VenaSeal, Varithena, or phlebectomy the charges for these services are significantly higher; often in the order of several thousand per treatment.

The whole issue of how medical practices charge and receive payments from insurance companies is complex. Payments to medical practices are based upon contractual agreements between individual insurance companies and the medical practice. The amount paid by insurance company A for a specific service is likely different than the amount paid by insurance company B for the same service, which is likely different than the amount paid by insurance company C, etc. The lowest paying payor tends to be Medicare. To allow for this variable payment most practices set their "charges" or "fees" on the high-end of the range, which allows capture of full payment from the highest payor. In North Carolina medical practices are not permitted to balance-bill, meaning the difference between a service charge and allowable rate has to be accepted as a negative "adjustment". When you review an invoice, EOB (Explanation Of Benefits), or claim from a medical practice, the "charge" is often significantly higher than the payment received. The payment a practice receives from the insurance company is called the "allowable" rate, which is the amount the insurance company will pay, regardless of the submitted charge. Any patient-responsible deductible, copay, or co-insurance is subtracted before paying the medical practice.  

From a patient perspective, all of this complexity makes it hard to know what the deal is. Most of us are not versed in the nuances of charges, allowable rates, deductibles, etc.

At Vascular Solutions, we try to make it simple. We provide a simple price quote, which clarifies the following information:

* Name of Procedure 
* Code of Procedure
* Allowable Charge (total service payment due)
* Insurance Company Responsibility
* Patient Co-pay Responsibility (if applicable)
* Patient Deductible Responsibility (if applicable)
* Patient Co-insurance Responsibility (if applicable) 
Finally, if you have symptoms and are planning on getting procedures covered by insurance, it’s hard to calculate how much vein treatments are going to cost, until you know exactly how many veins need to be treated. Price estimates become a lot more accurate once diagnostic ultrasound has been completed. If you only require only one saphenous vein to be treated the cost of this service will be less than if you need several veins in both legs to be treated.

What is a vein doctor called?

Doctors that specialize in veins will commonly have different backgrounds and training, but commonly have baseline training in surgery, dermatology, radiology, or internal medicine.

Doctors who work in the field of vein care sometimes use the title phlebologist (a doctor that specializes in vein-care) to highlight that this doctor focuses his/her practice on veins.

A doctor that has completed a surgical residency in General Surgery is commonly called a general surgeon. If a surgeon has completed advanced training (fellowship) training in vascular surgery (diagnosis and treatment of blood vessels) then this doctor is called a vascular surgeon.

A great resource to gain additional information about vein doctors and resources for finding a vein specialist in your area is the website hosted by the American Vein & Lymphatic Society.


Nearly all modern-day vein treatments are leaps-and-bounds ahead of procedures that were performed 20 years ago. Determining the best vein treatment for a vein condition depends on a variety of factors, as described above. 

At Vascular Solutions, we carefully analyze each of these data-points and make recommendations about your best options. Dr. Ford is the best vein specialist in Charlotte. We carefully review the pro's and cons of each option and provide you with guidance, based upon our experience and expertise.

Contact our practice today to set up your new patient evaluation.




Peter Ford MD FACS RPVI Peter Ford, MD, FACS, RPVI, is a board certified vascular surgeon who works at Vascular Solutions in Charlotte, North Carolina. Dr. Ford specializes in the management of varicose veins and venous disease.

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