Dr. John Happel | May 19, 2018 | 0
Lessons Learned at the Venaseal Varicose Vein Training Program
Varicose Vein Glue vs. Traditional Treatment for Varicose Veins
This article’s target audience is meant for both the vein doctor and the varicose vein patient audience.
I believe it will benefit both.
Medical jargon is explained simply so everyone can easily understand.
Recently, I attended the Advanced Chronic Venous Summit in Minneapolis sponsored by Medtronic, the manufacturer of the Venaseal Closure System.
This was a tremendous introduction to learn a new vein closing technique before treating patients. Included in the Medtronics program were didactic lectures by four acclaimed vascular surgeons who were well versed in the Venaseal system.
Thirty-three vein specialists from around the country shared a unique learning experience which included hands-on experience.
This VenaSeal physician training program also incorporated plastic model training of the system before the actual hands-on experience commenced.
My Take on Venaseal Closure Compared to Radiofrequency Closure and Laser Ablation
The Venaseal procedure is not difficult for a practicing vascular surgeon or vein specialist.
It may be a little faster than the ablation procedures of the saphenous veins done with laser or radiofrequency.
The adhesive is drawn up into a syringe which is screwed into a gun-like device. The trigger needs to be squeezed repeatedly to prime the tubing.
The tubing is introduced into the saphenous vein.
The tip of the tubing is placed under ultrasound guidance five centimeters from the sapheno-femoral junction.
The back table must be set up. The wet side of the table must be separated from the dry side.
If the adhesive accidentally touches water, it could set, harden and become unusable.
The packet comes with 5 cc of adhesive or glue. The average vein requires about 1.2 cc of glue.
Therefore, one package set could close three saphenous veins or 100 cm total vein length.
Normally, that could close two great saphenous veins and one small saphenous vein – if necessary.
Wires must be advanced into the proper position under ultrasound guidance. Sterile blue towels would be helpful to prevent these long wires from springing out and result in them being contaminated.
The cost of Venaseal glue to the doctor is now $900.00 per kit.
Medicare reimbursement for Venaseal (code 36482) is $2,162.00 (national average) to the doctor.
Before the code being established, Medtronics used to charge the vein doctor $1,500 in the U.S. for the entire disposable kit.
The kit includes 5 ccs of cyanoacrylate adhesive or glue. It expires in two years.
Before the code was established and presently if the patient’s insurance company doesn’t reimburse for the Venaseal procedure, it’s recommended that doctors charge the same for the procedure as what is currently reimbursed by insurance companies for an equivalent procedure plus the cost of the Venaseal system.
At the time of the writing of this article in 2017, that charge was at the doctor’s discretion since insurance companies did not reimburse for this FDA approved procedure.
Before the code came out, charges averaged between $3,000 to $3,500 per saphenous vein treated.
It’s not uncommon for a patient to require treatment for more than one saphenous vein.
Treating more than one saphenous vein on the same day is more convenient for the patient.
The code for billing Medicare patients with Venaseal became available in January 2018.
Commercial insurance companies often reimburse at a higher rate than Medicare.
How Is Glue for Varicose Veins Performed?
The glue is applied inside of the saphenous vein a drop at a time. Every three centimeters along its length the adhesive is compressed with the doctor or their assistant’s hands and ultrasound probe.
The probe compression prevents accidental extrusion of the adhesive proximally into the deep venous system. Compression is initially held for three minutes. Thereafter, each drop is compressed for thirty seconds until the adhesive solidifies.
It hardens almost immediately.
Once set, it is permanent.
It can’t be removed.
Therefore, Venaseal adhesive is an implantable device for all intents and purposes.
Experts with this technique recommend not using Venaseal on patients who are sensitive to adhesives, steri-strips or bandages. It has been reported that in about fifteen to twenty per cent of patients, an inflammatory reaction can be seen on the surface of the skin.
It is recommended that anti-inflammatory medication like Ibuprofen hastens the recovery in these cases.
Drs. Nick Morrison and Kathleen Gibson, the most experienced American vein specialists with Venaseal, now recommend Ibuprofen both before and after the Venaseal procedure to minimize this inflammatory process seen after many Venaseal procedures.
Steroids like a Medrol dose pack may be required for inflammatory reactions that do not respond to NSAIDs.
Patients experience similar degrees of pain after and during the Venaseal procedure as when thermal ablations with either radiofrequency and laser are performed.
Venaseal is the one of the three newest fixes for varicose veins.
Clarivein and Varithena are the other two latest competitors.
VenaSeal has a similar discomfort and recovery time as compared to the thermal ablation techniques.
About twenty to thirty minutes is the normal procedural treatment time for a doctor familiar with the technique.
Only one anesthetic needle pinch is needed.
No stockings are required before or after the treatment.
Insurance companies normally require a three-month trial of conservative medical management including support stockings.
If insurance companies don’t get involved, the ridiculous three month conservative medical management which includes support stockings is not necessary.
Doctors have conclusively proven that symptomatic varicose veins should be treated with minimally invasive treatments without an initial three-month trial of compression stockings.
Another big advantage with Venaseal is that you can go to the gym right away. Vigorous exercise can be resumed immediately.
As far as pain goes, the reported incidence of discomfort is about the same as with radiofrequency ablation.
Sometimes the glue sticks as the tube is pulled out through the skin at the end of the procedure.
It needs to be sharply snapped off to prevent this discomfort.
Rarely, the a drop of glue could become stuck under the skin at the entry site.
When glue accidentally becomes deposited outside of the vein, painful granulomas may result.
Here is a review of a patient as described on the realself.com web site where this complication occurred.
Had the procedure done September 22nd/20216 and about 6 weeks ago developed a half of a golfball lump near the top of my leg and behind my knee(smaller lump) the top one went into a huge tit like looking thing and then erupted and looked like a gun shot wound for weeks …
The Advantages of Venaseal Treatment
This glue or adhesive treatment is not a permanent solution in the sense that the visible veins don’t always go away.
In 50-80% of patients, there will be an initial improvement in appearance.
The remaining surface veins could enlarge over time if left untreated.
It is recommended by the Venaseal consultants that you should come back in three months to see if further treatment is necessary for the remaining bumps if they remain symptomatic.
Insurance will cover any painful varicose veins that remain which are resistant to conservative medical management and interfere with activities of daily living after a three month trial of conservative medical management.
If you choose glue and pay for the treatment out-of-pocket, you don’t have to worry about these financially driven ridiculous insurance rules that have no medical significance.
It has been proven that a trial of conservative medical management is not necessary before actually treating symptomatic varicose veins.
Therefore, a big advantage of Venaseal – if you choose not to submit the procedure for insurance coverage – is not having to wait to have the procedure done.
However, if you want to have insurance cover it, you must wait three months and wear compression support stockings during that period, try anti inflammatory medication, elevate your legs, exercise and try to lose weight first.
Complications of Venaseal Glue
The Venaseal consultants report that there has not been a reported case of deep vein thrombosis or DVT at the time of this writing.
However, at least one patient had a pulmonary embolism after the Venaseal procedure.
DVT occurs in 1-2% in cases of radiofrequency closure and endovenous ablation of saphenous veins.
No numbness or skin burns is a big advantage with Venaseal vs. a small per cent in laser and radiofrequency procedures that often improves with time.
Hyperpigmentation can occur if the treated vein is very close to the skin with any of these procedures.
The biggest complication is the inflammatory process that occurs in between 5 to 30% of patients after the procedure.
According to Kurtis Kim MD,
I like most of the advantages of the glue, except that it reports upwards of 30% phlebitis rate; while it is non-consequential for the most part, patients experience severe pain for several months if not more. For this reason, I am still “old-fashioned” and use thermal ablation.
This post Venaseal inflammatory response may become very painful in some cases.
Prophylactic anti inflammatory treatment is currently being recommended by Venaseal experts both before and for five days after the Venaseal procedure.
It remains to be seen how serious or common this inflammatory process after Venaseal truly is since the mid term data is only now coming out.
Technology in the field of varicose vein treatments is evolving extremely rapidly.
Venaseal glue is being used in the treatment of varicose veins.
One needle stick, no stockings and immediate return to all activities including heavy leg exercises are the advantages of Venaseal.
Another procedure to get rid of the surface bumps and prevent them from enlarging may often be required just like with the currently practiced saphenous vein procedures including laser.
All vein procedures have advantages and disadvantages.
There is no perfect procedure for treating varicose veins.
Patients need to know all of the facts when presented with treatment options for their varicose veins.
Speak to your vein specialist to find out which procedure is best for you.