FAQs

Do you have questions about the services that we offer? Below is a list of frequently asked questions, but feel free to call our office if you need additional information. We are always pleased to assist you. Click on a question below to view the answer:

Why did I get a vein problem in the first place?

Sometimes it’s easy to determine what causes the veins to develop. The known factors include heredity, pregnancy, female hormones (especially progesterone), obesity, and standing all day at work (hairdresser, sales, etc.) Often we don’t have a clue. Varicose veins develop more frequently on the left for reasons unknown.

How can I tell if I have a spider vein problem or a varicose vein problem?

Shut your eyes while you are standing, and feel your legs. If you cannot feel the veins, you have a spider vein problem. If you can feel the veins, and they push in easily but bounce right back out, you have varicose veins. Reticular (net-like) veins are intermediate sized veins which look like varicose veins but don’t bulge.

Can you do anything for the ugly veins I have on my hands? Breast? Face?

Yes. Sclerotherapy  can remove unwanted veins anywhere.

Why can’t lasers be used for all problems?

Zapping veins with a laser is poor treatment for spider veins. Lasers only destroy what they “see.” To prevent new veins from forming, the deeper high-pressure veins that feed the surface veins have to be eliminated, and those veins are usually invisible to the laser. If they are not eliminated, new veins readily form around the old ones, and you’re back to where you started. Laser treatment of spider veins is actually more painful than injections.

Although the traditional role for lasers has been to eliminate the very smallest surface veins (spiders) too small for injections, I have assigned that role to thermocoagulation (VeinGogh) because of its effectiveness and relative freedom from pain. On the other hand, for treating the larger varicose veins, I use lasers (along with the VNUS® ClosureFast device) to close the saphenous vein without open surgery. In my experience, the results are excellent either way and the newest lasers, such as the ThermaLite 1470, are virtually pain-free and less expensive for both patient and doctor. Unfortunately, lasers cannot be used to obliterate the actual bulging varicose veins that brought you to the doctor in the first place. That takes microphlebectomy or injections.

What are microphlebectomies?

Microphlebectomies are tiny incisions through which varicose veins are carefully teased out. The needle-hole sized incisions are spaced about every 2-3 inches or so, so the procedure can be tedious and time-consuming if veins are scattered over a wide area. Stab avulsion is another name for this technique. I usually don’t need to place stitches to close the cut and six months later most patients don’t even know where the cuts were. The simplicity, minimal expense, and rarity of complications with microphlebectomies give this technique an important continuing role in varicose vein treatment.

What if I don’t want to be put asleep for treatment?

In my practice varicose vein procedures are all done with local anesthesia and, if needed, a little sedation by mouth for the ultra-nervous. I have recently added the option of laughing gas (nitrous oxide) for the extremely needle-phobic patient.  If you want to be completely “out” with pain medicines and sedatives given into your veins (conscious sedation), you must employ the services of an anesthesiologist, which I no longer offer. Even extensive, large veins can be removed without general anesthesia.

How long do I need to stay off my feet?

All procedures are done on an outpatient basis. You are encouraged to walk and drive immediately after the procedure. There is no need to elevate your legs. Individuals with desk jobs can return to work immediately. I believe it is prudent to avoid truly vigorous lower body workouts (Stairmaster, heavy weights, ten mile runs, etc) for a day or so, but many patients ignore this guideline because they feel so well.

Are all patients with varicose veins candidates for endovenous laser closure (ELAS, EVLT, ELVeS) or VNUS® ClosureFast of the saphenous vein?

Patients who cannot be treated with endovenous closure of the saphenous vein include those with:

  • Recurrent varicose veins (after previous saphenous vein stripping);
  • Varicose veins that are unrelated to saphenous vein reflux.

This still leaves well over nine out of ten patients with large varicose veins as candidates for laser or VNUS® closure of the saphenous vein.

What’s to choose between laser closure and radiofrequency (ClosureFAST) closure of the saphenous vein?

Successful saphenous vein closure approaches 100% with either (1) the latest lasers (those with a wavelength of greater than 1200) or (2)  radiofrequency catheters. Patients treated with lasers complain of slightly more pain after treatment, but radiofrequency can’t be used when the saphenous vein is very short or small, but neither condition is common. Most insurance companies approve both technologies. Since I have and use both laser and radiofrequency catheters, I can tailor the use of each technique based on the specific needs of the patient.

Is Asclera (polidocanol) better than Sotradecol (sodium tetradecol) for sclerotherapy?

Both Asclera (the “European drug”) and Sotradecol are safe medications that were used in both Europe and the USA for decades before the FDA withdrew licensing for both about fifteen years ago. Sotradecol received re-approval before Asclera did. They now compete again both here and in Europe. Randomized control studies show no difference between the medications if they are used in the appropriate concentration.

Generally, it takes twice the concentration of Asclera to achieve the same effect as Sotradecol. The bottom line, however, is that it makes little difference in either efficacy or complications which solution the doctor prefers.

What counts most is the doctor’s experience and comfort level with the medication she chooses. I now use Sotradecol rather than Asclera for the simple reason that I became very comfortable with the concentrations of Sotredecol I was using when only Sotradecol was approved. I would switch back to Asclera in a second if I thought it were the better drug. Concentrated (hypertonic) saline is painful and is associated with more complications than Sotradecol and Asclera – good enough reason not to use it.

What is the VeinGogh and how does it fit into the grand scheme of vein treatments?

The VeinGogh device delivers a small electric current at the end of a miniscule needle. Because both the needle and current are tiny, patients experience much less pain than when they receive laser treatment for the same vein. The VeinGogh is especially effective on tiny discrete facial veins (thread veins) — the kind that appear on the side of the nose, in the nose, on the upper eyelid, and everywhere following face lifts (N.B. I inject  blue veins under the eye.) The device can also be used for leg veins, but usually only when sclerotherapy fails to eliminate the very smallest veins because they are either too small to be injected or because they are just plain stubborn. Most leg spider veins respond best to injections.

Where will my treatment be provided?

Treatment of major varicose vein problems is possible in any facility with the appropriate equipment. All procedures are done in my office.  I have closed the saphenous vein with a laser in a 13 year-old girl and a 98 year-old man, and neither flinched in the slightest.

Will insurance pay for my treatment?

Blue Cross, Blue Shield, Aetna and other PPO insurance companies usually cover varicose vein treatments (including laser and radiofrequency closure of the saphenous vein and microphlebectomy), but each has a different pre-approval process, and each has a different reimbursement policy.

Some Cigna policies do not cover varicose vein procedures. I have chosen to contract with several PPOs (including Medicare, Blue Cross, some but not all of the innumerable Blue Shield policies, Aetna and Cigna, among others), so my professional fee reimbursement follows their contractual obligations.

I am a non-participating provider for a small number of PPOs (such as Healthnet, which often did not pay anything even when they approved procedure), which means those patients must pay my surgical fee at the time of service. Patients are usually reimbursed a variable amount by their insurance company.

I am not contracted with any HMOs, so those patients are in a difficult position, because they must first persuade their gatekeeper (physician or nurse) that their problem is worthy of treatment. HMOs may authorize treatment, but seldom with any of the newer techniques, or in the surgicenters or hospitals in my community.

Some insurance companies pay a small amount for treatment of spider veins (telangiectasias), even though they are fundamentally a cosmetic problem.

I do sclerotherapy exclusively on a cash basis, although you are welcome to persuade your insurance company to reimburse you. Take lots of pictures. Within reason, our office will assist patients in researching their insurance benefits.

Two benchmarks to tell if your PPO doctor is up to speed are:

  1. Does the doctor do a color flow (Duplex) ultrasound study in the office by either himself personally (best) or a technician (a close second), or does she send you out to a vascular laboratory and discuss the findings later? Innumerable variations and subtleties of varicose vein disease often get lost if the doctor provides treatment based solely on an outside report, without the benefit of a hands-on look at the actual anatomy and behavior (reflux) of the veins. Walk away if the doctor proposes a major procedure without the benefit of a color flow test. This is substandard care.
  2. Does he belong either or both of  the two societies that are dedicated to the treatment of varicose vein disorders, namely the American College of Phlebology (www.phlebology.org ) and the American Venous Forum (www.veinforum.org)? Their annual meetings, newsletters, and journals will keep any dedicated physician up to date on the latest in varicose veins (and this is a surprisingly rapid moving field).

Finally, a contracted physician working exclusively at a hospital remains unfazed by hospital, anesthesiologist and laboratory co-pays. They can really add up (20%-30% of a lot of money is still a lot of money!)

Bottom line: As a dedicated phlebologist, I believe I can provide superior results at a competitive price.



Contact us at (310) 277-4868 to learn more or to schedule an appointment.