Phlebectomy as a treatment for venous disease goes back more than two millennia and remains an important component of therapy for patients. Progressive decreases in reimbursement over the past two decades, and more recently this year, necessitates a review of how it is performed, reported, and potentially reimbursed.
History of Phlebectomy
It has been suggested that humankind has been suffering from varicose veins ever since we started walking on two legs. Venous disease has similarly been recognized for a long time with the first documented case of varicose veins recorded around 1,550 BC in the papyrus of Ebers.1 The first phlebectomy by mini-incisions was reportedly performed by Celsus (26BC – 50AD) but it was so painful that the patient refused any further treatments. In 1884, Madelung proposed longitudinal incisions to perform phlebectomy but a less traumatic stripping technique was described by Charles Mayo in 1904. The hook phlebectomy, the basic technique for ambulatory phlebectomy still in use today, was introduced by Muller in 1967. Endovascular techniques using radiofrequency and laser ablation revolutionized superficial venous treatment in the 1990s as a less painful alternative to stripping and with a much quicker recovery. However, along with modern sclerosants with ultrasound guidance which provides effective therapy for both truncal veins and branch varicosities,2 ambulatory phlebectomy continues to play an important role in the treatment of patients with venous disease with about 28,000 Medicare procedures per year.3
Multi-society clinical treatment guidelines recommend phlebectomy for patients with symptomatic varicose veins and ultrasound-proven reflux (CEAP classification C2), particularly tortuous and non-truncal varicose veins as well as the tributaries of ablated saphenous veins, either as a simultaneous or staged procedure.4 Ambulatory phlebectomy (also known as stab or hook phlebectomy, mini-phlebectomy) is most frequently used for the treatment of non-truncal varicosities. The technique utilizes multiple stab incisions and removal of the diseased veins using a hook or hemostat (Figure 1). The varicose veins are usually marked preoperatively and local or tumescent anesthesia injected at the site before the incision is made. Post-procedural compression therapy with either stockings or bandaging is employed by most clinicians although its usefulness is not well established.5 Clinical efficacy is excellent as there is no recurrence of the excised veins although other varicosities may develop over time. Reported complications vary significantly, depending on the involved vein and number of phlebectomies performed, and includes ecchymosis, hematoma, superficial phlebitis, paresthesias and nerve injury, and hyperpigmentation.1
American Vein & Lymphatic Society (AVLS) recently completed a review of phlebectomy procedures utilizing the AVLS PRO Registry which included 187 providers and 229,093 patients.6 A total of 3,689 phlebectomy procedures were reported, either alone or in combination with other venous interventions, in 2,862 patients between the years 2015 to 2021. The majority of patients were women (66%) and the group had an average age of 53 + 14 years and a BMI of 30 + 6. The left leg was affected in 51% of cases. The CEAP clinical presentation was C1 in 15%, C2 in 21%, C3 in 34%, and C4/5/6 in 24% (Figure 2). The mean and median VCSS score was 5.6 + 3.1 and 6, respectively. The large majority of patients, 94%, had a phlebectomy procedure done in combination with another venous intervention while a phlebectomy alone was performed in the remaining 6%. The additional procedures were radiofrequency ablation in 66%, laser ablation in 15%, chemical sclerotherapy 15% and cyanoacrylate adhesive in 4%. These additional procedures were most frequently performed in the great saphenous vein (67%), the small saphenous vein (9%) and the accessory saphenous vein (9%).
The mean and median number of phlebectomy sites were 7.7 + 5.3 and 6.0, respectively (Figure 3). However, there was a bimodal distribution with one peak at 3 incisions and another at 10 with very few patients having 20 or more excisions. The peak at 10 incisions may reflect the increased payments received when 10-20 phlebectomies are performed. The majority of the phlebectomy incisions were located below the knee, either in isolation (41%) or in combination with both above and below the knee (41%) (Figure 4).
These results indicated that ambulatory phlebectomy procedures continue to be performed in a large number of patients, most frequently in combination with endovenous ablation of the great saphenous vein. However, there was a broad distribution in the number of incisions performed and the specific location of the phlebectomy sites was not identified, even though such specificity is possible within the registry.
Although it is a well-established procedure in terms of indications and clinical efficacy, there is large variability in how phlebectomy is performed. For some, a small stab incision with a pulling and tearing out of the underlying vein is all that is performed in a period of less than a minute. Other surgeons will undertake an extensive proximal and distal subcutaneous dissection and remove 10cm or more of a segment of vein. This requires both more time and skill. However, reimbursement is based solely on the number of incision sites, independent of effort required or the amount of vein removed. With reimbursement for phlebectomy having decreased by more than 50% in value over the past decade,7 and more cuts in Medicare payments implemented this year, it is reasonable to identify a reporting methodology that better describes the procedure performed and its pathophysiologic association with the underlying venous disease. Pittaluga and colleagues have defined 32 zones of the leg in their pre-operative mapping of venous insufficiency before performing a phlebectomy.8 This appears to correlate well with treatment planning and clinical outcomes. However, 32 zones seem impractical for most clinicians to record pathology and surgical interventions.
Mobile Phone App
An initiative was therefore begun through an AVLS Phlebectomy Task Force to investigate if fewer zones could be defined that aligned both with a patient’s venous pathology and the phlebectomies performed. Since this detailed data was not available from the AVLS Pro Registry, a software application was developed to be utilized on a physician’s cell phone (Figure 4).9 It included eight web pages describing the involved vein, number and location of phlebectomies, concomitant adjunctive procedures, and the time taken for their completion.
During a 7-month period from December 2021 to July 2022, a total of 1,196 phlebectomy cases were performed by 27 physicians and details submitted via the app. Similar to the Registry data, the majority of patients were women (68%) and the group had an average age of 57 + 14 years. The mean CEAP score distribution was: C1- 0.1%, C2 - 67%, C3 - 20%, and C4/5/6 - 12%.
A total of 21,132 phlebectomy incisions were performed where all the sites were identified with the majority located below the knee (52%) followed by the thigh (39%), knee (8%) and foot (1%). The location of the excisional sites was further localized to 14 anatomic locations along the leg. They corresponded to the distribution of the great saphenous vein in 46%, small saphenous in 7%, anterior accessory saphenous vein in 7%, posterior accessory in 1% and other tributaries in 40%.
The average time to perform the entire phlebectomy procedure was 67 + 40 minutes with a median time of 60 minutes but a wide range of 5 to 255 minutes. This reflected the wide variation in the number of incisions performed. The mean number of phlebectomy incisions or sites per patient was 34 + 25 and with a median of 27 but a range from 1 to 146 incisions. The average operative time per incision was 3.3 + 5.3 minutes with a median time of 2.0 minutes.
The study is on-going with final results to be presented at the AVLS Annual Congress in October. However, this experience demonstrates that a smart phone mobile app can be effective in rapidly obtaining relevant clinical procedural data in a large number of patients. The results will provide a detailed mapping of phlebectomy sites in 14 anatomic locations along the length of the leg.
The results obtained from both the AVLS Registry and mobile app studies demonstrate that there is a large variation in both the number and time needed for performance of a phlebectomy procedure. They also reflect the great clinical variability in how the procedure is performed and suggests that procedural documentation and reimbursement policies should be based on something other than just the number of incisional sites.
This great variability in methodology also suggests a need for a better understanding of current best practices. Proper treatment and procedural documentation of superficial venous disease has never seemed more important and will help lead the way toward better care for our patients. As phlebectomy continues to evolve as a very effective treatment modality, so should the appropriate reimbursement processes.
Figure 1. Phlebectomy being performed with removal of the diseased vein.
Figure 2. CEAP clinical classification of patients.
Figure 3. Phlebectomy incision sites per patient.
Figure 4. Phlebectomy location along the leg.
Figure 5. A. Phlebectomy Tracker cell phone app face page. B. Data entry page indicating the seven levels of the leg and the three regions of the thigh and calf for a total of 14 zones.
- Shchatsko A, Blebea J. Superficial Venous Insufficiency and Varicose Veins. In Nazzal M, Blebea J, Osman M. (eds) LANGE VASCULAR AND ENDOVASCULAR SURGERY: CLINICAL DIAGNOSIS AND MANAGEMENT. New York, NY: McGraw-Hill, 2022 (In Press).
- Cartee TV, Wirth P, Greene A, Straight C, Friedmann DP, Pittman C, Daugherty SF, Blebea J, Meissner M, Schul MW, Mishra V. Ultrasound Guided Foam Sclerotherapy is Safe and Effective in the Management of Superficial Venous Insufficiency of the Lower Extremity. J Vasc Surg: Venous and Lym Dis 2021; 9(4):1031-1040.
- Prabhakar AM, Misono AS, Sheth RA, et al. Changing Medicare utilization of minimally invasive procedures for the treatment of chronic venous insufficiency. J Vasc Interv Radiol. 2017; 28:818-824.
- Masuda E, Ozsvath K, Vossler J, et al. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. J Vasc Surg: Venous and Lym Dis. 2020;8(4):505-525.
- Lurie F, Lal BK, Antignani PL, Blebea J et al. Compression therapy after invasive treatment of superficial veins of the lower extremities. Clinical practice guidelines of the American Venous Forum (AVF), Society for Vascular Surgery (SVS), American College of Phlebology (ACP), Society for Vascular Medicine (SVM) and International Union of Phlebology (UIP). J Vasc Surg: Venous and Lymphatic Dis. 2019;7 (1):17–28.
- Blebea J, Harper K. Ambulatory phlebectomy in the treatment of superficial venous disease. Phlebology. 2022;37(1-Supp): 3.
- Haglin JM, Edmonds VA, Money S, Stone WM, Soh IY. Procedure reimbursement, inflation, and the declining buying power of the vascular surgeon (2011-2021). Ann Vasc Surg 2021; 76:80-86.
- Pittaluga P, Chastanet S, Locret T, Barbe R. The effect of isolated phlebectomy on reflux and diameter of the great saphenous vein: a prospective study. Eur J Vasc Endovasc Surg. 2010;40(1):122-8.
- Blebea J, Harper K, McNeil P, Albert J, Smith N, Meissner M, Moore K, Carr S, Gibson K, Hansen T, Schul M. Ambulatory phlebectomy mobile app in the treatment of superficial venous disease. Phlebology (In Press).