You are in: eMedicine Specialties > Dermatology > DISEASES OF THE VESSELS Varicose Vein Treatment With Endovenous Laser TherapyArticle Last Updated: Nov 7, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 14
  Author: Steven E Zimmet, MD, RVT, FACPH, Consulting Staff, Zimmet Vein and Dermatology Clinic; North American Editor, Phlebology: The Journal of Venous Disease; President, American Board of Phlebology Steven E Zimmet is a member of the following medical societies: American Academy of Dermatology, American College of Phlebology, American Venous Forum, Australasian College of Phlebology, and Texas Medical Association Coauthor(s): Robert Min, MD, Director of Cornell Vascular, Assistant Professor, Department of Radiology, Cornell University Weill Medical College; Craig F Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group Editors: Smeena Khan, MD, Private Practice, Adult and Pediatric Dermatology Associates; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic; Jeffrey J Miller, MD, Associate Professor, Department of Dermatology, Penn State University, Milton S Hershey Medical Center; Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: varicose vein treatment, vein treatment, laser vein treatment, endovenous laser ablation, endovenous laser therapy, EVLA, EVLT, saphenous ablation, vein stripping, varicose veins INTRODUCTIONSection 2 of 14
  Significant advances have occurred in the understanding, diagnosis, and management of venous insufficiency over the last decade or so, mostly owing to the use of duplex ultrasound (DUS) technology. DUS is essential prior to treatment in all patients with CEAP C2 or higher venous disease in order to identify reflux and establish the pattern of disease. (CEAP is a varicosity classification method, in which C is clinical severity, E is etiology, A is anatomy, and P is Pathophysiology.) The Union Internationale de Phlebologie (UIP) has reviewed the objectives and technique of DUS for venous insufficiency.1 An individualized treatment plan is developed based on the history and physical examination, findings of the evaluation, and goals of the patient. Venous insufficiency from superficial reflux through varicose veins is a serious problem that usually is inexorably progressive if left untreated. Saphenous vein reflux is the underlying primary abnormality in many patients with superficial venous insufficiency. Stripping of the great saphenous vein (GSV) has been widely agreed upon as essential to minimizing recurrence due to redevelopment of incompetent communication with the saphenofemoral confluence and/or thigh perforator incompetence. Formerly, stripping of the entire saphenous vein from ankle to groin, along with stab avulsion of varices, had been practiced because it was assumed that reflux extended to the ankle in most patients. However, it was recognized that stripping from the groin to the knee would detach thigh perforators. This fact, along with a high prevalence of saphenous neuralgia associated with groin-to-ankle stripping, explains recommendations for “short” stripping of the GSV from groin to just below the knee that began in the 1980s. One duplex study on more than 500 legs found the most common pattern to be saphenous reflux from the groin to the knee (43.4%), with reflux reaching the ankle in only 1%.2 Endovenous laser ablation (EVLA) is a less invasive alternative to vein stripping. EVLA is routinely performed in an office setting using dilute local anesthesia. EVLA and other minimally invasive techniques, such as radiofrequency ablation and chemical ablation, are increasingly being used instead of surgery to treat incompetent segments of the GSV, small saphenous vein, anterior accessory saphenous vein, and perforators. Outcomes from EVLA appear to be equal to or better than stripping, with better quality-of-life scores in the postoperative period. EVLA has been shown to correct or significantly improve the hemodynamic abnormality in patients with chronic venous insufficiency (CVI) with superficial venous reflux. Early reports suggest that endovenous ablation techniques, in contrast to surgical stripping, are associated with a low prevalence of neovascularization. See Media Files 1-2 for before-and-after images of EVLA treatment of varicose veins. The Medscape Dermatologic Surgery Resource Center and Aesthetic Medicine Resource Center may be of interest. TECHNOLOGYSection 3 of 14
Endovenous laser ablation (EVLA) works by means of thermal destruction of venous tissues. Laser energy is delivered to the desired incompetent segment inside the vein through a bare laser fiber that has been passed through a sheath to the desired location. A variety of laser wavelengths are in use for this procedure, including 810, 940, 980, 1064 and 1320 nm. When the laser is fired, it deposits thermal energy in the blood and venous tissues, causing irreversible localized venous tissue damage. The laser is most commonly delivered continuously as the laser fiber is gradually withdrawn along the course of the vein until the entire vessel is treated. Although a hole may be created in the vessel wall where the laser beam makes contact with it, permanent ablation of the vein is caused by thermal injury to the entire circumference of the vessel. TECHNIQUESection 4 of 14
Endovenous laser therapy (EVLT) is of value in the treatment of incompetent truncal varicose veins (eg, GSV, small saphenous vein, accessory saphenous veins). Laser introducer catheters can be passed along small and crooked veins, but they cannot be passed along an extremely tortuous vein with ease. TUMESCENT ANESTHESIA FOR EVLASection 5 of 14
Endovenous laser ablation (EVLA) should be performed with the patient under local anesthesia using large volumes of a dilute solution of lidocaine and epinephrine (average volume of 150-300 mL of 0.1% lidocaine without or with 1:1,000,000 epinephrine) that is buffered with sodium bicarbonate. This solution should be delivered either manually or with an infusion pump under ultrasonographic guidance so the vein is surrounded with the anesthetic fluid along the entire length of the segment to be treated. See Media File 3. The benefits of tumescent anesthesia for endovenous ablation include the following:
Although the maximum safe dosage of lidocaine using a tumescent technique for venous procedures is not well studied, a dosage of 35 mg/kg is a reasonable estimate. Using these parameters, tumescent anesthesia in the context of liposuction has been shown to be extraordinarily safe. More information is available through Liposuction.com. EVLA MECHANISM OF ACTIONSection 6 of 14
Vein wall injury has been postulated to be mediated both by direct effect and indirectly via laser-induced steam generated by the heating of small amounts of blood within the vein.3 Some authorities have suggested that the choice of wavelength greatly impacts results.4 The main chromophore of 1320-nm lasers, at least initially, is water, while other wavelengths used for endovenous laser ablation (EVLA) primarily target hemoglobin. Obviously, adequately damaging the vein wall with thermal energy is imperative in order to obtain effective ablation. Some heating may occur by direct absorption of photon energy (radiation) by the vein wall, as well as by convection from steam bubbles and conduction from heated blood. However, these later mechanisms are unlikely to account for the majority of the impact on the vein. The maximum temperature of blood is 100°C. Laser treatment has been found to produce carbonization of the vein wall.5 Carbonization of the laser tip, which occurs at approximately 300°C, is noted following EVLA and seems to occur regardless of the wavelength used. Carbonization of the laser fiber tip creates a point heat source and essentially reduces light penetration into tissue to zero. FOLLOW-UP CARESection 7 of 14
Adequate and proper compression is vitally important after any venous procedure. Compression can reduce the (theoretic) risk of venous thromboembolism, and it is also highly effective in reducing postoperative bruising and tenderness. Note that elastic bandages are not an effective means of compression. Immediately after the procedure, a class II compression stocking (ie, one with a gradient of 30-40 mm Hg) is applied to the treated leg. Thigh-high– or panty-hose–style stockings are used. The stockings are worn for at least 1 week; they are kept in place continuously for the first 72 hours, but they may be removed for showering thereafter. Bedrest, hot baths, heavy lifting, and long travel are generally forbidden for approximately 1 week, but aerobic activity is encouraged. Two preliminary reports from 2007 explore the utility of thigh compression after endovenous ablation.9, 10 The mean pressure of a class II compression stocking is approximately 15 mm Hg at the thigh level, while short-stretch adhesive bandages achieved a pressure of greater than 40 mm Hg, which is the pressure that has been found to significantly reduce the diameter of the GSV in the thigh.11 The author has measured the mean sub-bandage (pad, short-stretch bandage, 30– to 40–mm Hg stocking) pressure in the mid thigh immediately following EVLA. The mean pressure in active standing position was 55.8 mm Hg (44-68 mm Hg) (Steven E Zimmet, MD, RVT, FACPH, unpublished data, 2008). This is adequate to compress the thigh portion of the GSV and may explain the apparent reduction in pain and bruising that occurs with increased compression. Lugli and colleagues conducted a prospective randomized study to investigate the effect of an eccentric thigh compression technique on postoperative pain after endovenous laser ablation (EVLA).12 They concluded that eccentric compression significantly reduces postoperative pain. Although the concept of increased thigh compression is antithetical to the idea of graduated compression, it may have clinical utility. The patient is usually reevaluated between postoperative days 3 and 7, at which time DUS should demonstrate the treated vein to be incompressible and without flow, with no evidence of thrombus in the femoral or popliteal veins. At 4-6 weeks, an examination should reveal clinical improvement of truncal varices, and an ultrasonographic evaluation should demonstrate a completely closed vessel and no remaining reflux. If any residual open segments or branch veins are noted, sclerotherapy may be performed under ultrasonographic guidance. COMPLICATIONSSection 8 of 14
Reports of major complications following endovenous laser ablation (EVLA) are rare. Rates of DVT, pooled from multiple series, are much lower than 1%.13, 14, 15, 16 One group reported a rate of thrombus extension into the femoral vein of 7.7%.17 However, in that study, EVLA, was performed with the patient under general or spinal anesthesia. The fact that patients were not able to ambulate immediately postoperatively may have contributed to the high rate of thrombus extension. OUTCOMESSection 9 of 14
Proof-of-concept studies, using vein occlusion/ablation as the main surrogate outcome measure, exist for these techniques. Endovenous laser ablation (EVLA) has a successful initial closure rate of 95-100%. The outcomes appear durable, with a persistent closure rate of 94-97%.13, 16, 20, 21 Significant improvements in physician-measured outcomes such as venous clinical severity scores (VCSS) scores22 and air-plethysmography (APG)23 have been reported following endovenous ablation techniques. A fundamental advance in medicine is the recognition of the importance of patient-reported measures of quality of life. Several studies have documented significant improvement in quality of life after endovenous treatment, and, comparing endovenous laser with stripping, results generally demonstrate equal or better outcomes with better quality of life in the postoperative period.23, 24, 25, 26, 27 CONTRAINDICATIONS TO EVLASection 10 of 14
FURTHER READINGSection 11 of 14
Bergan JJ ed. The Vein Book. London: Elsevier Science, 2006. Fronek HS, ed. The Fundamentals of Phlebology: Venous Disease for Clinicians, 2nd ed. London: Royal Society of Medicine Press; 2007. Kabnick LS. Outcome of different endovenous laser wavelengths for great saphenous vein ablation. J Vasc Surg. 2006 Jan;43(1):88-93. Mellière D, Almou M, Lellouche D, Becquemin JP, Hoehne M. [Arterial complications following surgery or sclerotherapy of varices]. J Mal Vasc. 1986;11(1):19-22. Proebstle TM, Gul D, Kargl A, Knop J. Endovenous laser treatment of the lesser saphenous vein with a 940-nm diode laser: early results. Dermatol Surg. Apr 2003;29(4):357-61. Staunton MD. Some complications from surgery in varicose veins. Phlebologie. Jan-Mar 1982;35(1):329-35. Weiss RA, Feied CF, Weiss MA. Vein Diagnosis & Treatment: A Comprehensive Approach. New York, NY: McGraw-Hill; 2001:1-304. Zimmet SE. Endovenous Ablation. In: Ngyugen T, Alam M, eds. Procedures in Cosmetic Dermatology Series- Leg Veins. London: Elsevier Science, 2006. Zimmet SE, Min RJ. Temperature changes in perivenous tissue during endovenous laser treatment in a swine model. J Vasc Interv Radiol. 2003 Jul;14(7):911-5. ACKNOWLEDGMENTSSection 12 of 14
The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article. MULTIMEDIASection 13 of 14
REFERENCESSection 14 of 14
Varicose Vein Treatment With Endovenous Laser Therapy excerpt Article Last Updated: Nov 7, 2008 | ||||||||||||||||||||||||||||
