You are in: eMedicine Specialties > Dermatology > DISEASES OF THE VESSELS Varicose Vein Treatment With Endovenous Laser TherapyArticle Last Updated: Feb 15, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Craig F Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group Craig F Feied is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Phlebology, American College of Physicians, American Medical Association, American Medical Informatics Association, American Venous Forum, Medical Society of the District of Columbia, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society Coauthor(s): Robert Min, MD, Director of Cornell Vascular, Assistant Professor, Department of Radiology, Cornell University Weill Medical College; Steven E Zimmet, MD, FACPH, Consulting Staff, Zimmet Vein and Dermatology Clinic 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; Director, Division of Dermatology, Scott and White Clinic; 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; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System Author and Editor Disclosure Synonyms and related keywords: endovenous laser ablation, EVLT, internal laser therapy, laser vein stripping, varicose vein laser therapy INTRODUCTIONSection 2 of 9
  Venous insufficiency from superficial reflux through varicose veins is a serious problem that usually is inexorably progressive if left untreated. When the refluxing circuit involves failure of the primary valves at the saphenofemoral junction, treatment options for the patient are limited, and early recurrences are the rule rather than the exception. In a traditional surgical approach, ligation and division of the saphenous trunk and all proximal tributaries is followed by stripping or by avulsion phlebectomy. Proximal ligation requires a substantial incision at the groin crease. Stripping of the vein requires additional incisions at the knee or below the knee and is associated with a high incidence of minor surgical complications. Avulsion phlebectomy requires multiple 2- to 3-mm incisions along the course of the vein and can cause damage to adjacent nerves and lymphatic vessels. Ablation of the vein by endovenous laser therapy (EVLT) is a newer procedure that is less invasive than surgery and has a lower complication rate. The procedure is well tolerated by patients and produces good cosmetic results. Excellent clinical results are observed at 2-4 years, but the long-term effectiveness of EVLT is not yet known. The varicose recurrence rate is less than 7% after 2 years, a rate comparable or superior to that reported for surgery, US-guided sclerotherapy, and radiofrequency ablation. TECHNOLOGYSection 3 of 9
EVLT works by means of thermal destruction of the venous tissues. Laser energy (most commonly from an 810-nm diode laser) is delivered to the desired location inside the vein through a bare laser fiber that has been passed through a sheath to the desired location. When the laser is fired, it deposits thermal energy in the blood and venous tissues, causing irreversible localized venous tissue damage. The laser is repeatedly or continuously fired 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. Many laser sources are available for medical applications, and many lasers may be effective for endovenous ablation. The Diomed 810-nm laser is the system that has been used in most published studies to date, with a 940-nm diode laser also demonstrating good results in a smaller number of patients. TECHNIQUESection 4 of 9
EVLT is of value in the treatment of truncal varicose veins (eg, greater saphenous vein) in patients with saphenofemoral incompetence. This procedure is also effective in the treatment of large branch veins and other large tributaries. Laser introducer catheters can be passed along small and crooked veins, but they cannot be passed along an extremely tortuous vein with ease. For treatment of the greater saphenous vein and the saphenofemoral junction, ultrasonography is used to confirm and map all areas of reflux and to trace the path of the refluxing greater saphenous trunk from the saphenofemoral junction down the leg to the upper calf. An appropriate entry point is selected just above or just below the knee at a point that permits cannulation of the vessel with a standard or micropuncture needle introducer. The course of the vein, the saphenofemoral junction, and the anticipated entry point are marked on the skin with a surgical marker. The leg is prepared and draped, and a superficial local anesthetic agent is used to numb the site of cannulation. Ultrasonography is used to guide needle puncture of the vessel. The Seldinger technique is used to place a guidewire into the vessel, and the guidewire is passed proximally to the saphenofemoral junction and into the femoral vein. A long introducer sheath (25-45 cm) is passed over the guidewire, which is removed. A 400- to 1000-µm sterile, bare-tipped laser fiber is measured and advanced through the sheath until it protrudes 1-2 cm from the tip of the sheath. To prevent the laser fiber from slipping back into the sheath, the fiber is secured to the introducer by using Steri-Strips. With ultrasonographic guidance, the introducer and laser fibers are slightly withdrawn until the tip can be clearly observed at the level of the subterminal valve of the saphenofemoral junction. Under ultrasonographic guidance, a dilute local anesthetic agent is injected into the tissues surrounding the greater saphenous vein within its fascial sheath. An anesthetic is injected along the entire course of the vein from the catheter insertion point to the saphenofemoral junction. In most patients, 60-120 mL of lidocaine 0.25% is sufficient to anesthetize and compress the vessel. Delivering the anesthetic in the correct interfascial location with a volume sufficient to compress the vein and dissect it away from other structures along its entire length is important. Some practitioners prefer a local anesthetic with epinephrine, whereas others prefer not to use epinephrine. The procedure is quick and does not cause early postoperative pain, thus long-acting local anesthetic agents are not needed. Ultrasonography is used to reconfirm the position of the laser fiber and catheter. The laser fiber tip is placed at the level of the subterminal valve of the saphenofemoral junction, and it should protrude approximately 2 cm from the end of the catheter sheath. Neither the fiber tip nor the laser beam should extend into the femoral vein because injury to the femoral vein may cause deep venous thrombosis. When the laser console is switched on, a red aiming beam is visible through the skin at the level of the saphenofemoral junction. Failure to observe this beam is a reliable indication of malpositioning. For treatment using intermittent pulsation, the console is set to deliver 12 J per pulse in 1-second pulses. The laser can be fired manually, but most often it is controlled by a foot pedal with automatic pulses at 1-second intervals. Manual pressure is applied to achieve venous wall apposition around the laser fiber tip, and the laser is fired. The sheath and laser fiber are pulled back approximately 3 mm; manual pressure is again applied, and the laser is fired again. This procedure is repeated along the entire length of the vessel to be treated. With pulses delivered once per second at 3-mm intervals, an entire 30-cm greater saphenous vein can be treated in 90 seconds. For treatment using continuous energy delivery, the energy delivery is similarly set to 12 J/s (12 W) and the laser fiber is withdrawn at a steady rate of approximately 1 mm/s. If the vein is small, the laser energy may be adjusted to a lower intensity after the laser fiber has been withdrawn 5 cm or more below the saphenofemoral junction. In veins smaller than 0.5 cm in diameter, the laser energy can be reduced to 8 J per pulse, with no apparent change in the outcome. On rare occasions, the patient experiences momentary pain if the laser is fired in an area with an adherent nerve. Subsequent laser pulses immediately below this position usually do not cause the same sensation, and the patient may be reassured that no postoperative paresthesias due to the procedure have been reported. When the red guiding light is 2 cm from the entry point, the procedure is complete. The sheath and fiber are withdrawn from the skin, and pressure is applied to the puncture site for a few minutes. Immediately after the procedure, ultrasonography shows a patent vessel that is in spasm through most or all of its length. Follow-up ultrasonography at 1 week demonstrates nearly 100% early closure of vessels. FOLLOW-UP CARESection 5 of 9
Compression is vitally important after any venous procedure. Compression can reduce the (theoretic) risk of venous thromboembolism in the treated and untreated leg, and it is also highly effective in reducing postoperative bruising and tenderness. Postoperative bruising can be significant after EVLT, but it is much less prominent when lidocaine with epinephrine is used as the local anesthetic. Bruising may be completely absent in patients who wear compression hose continuously during the first 3 days after treatment. Postoperative tenderness after day 3 has also been reported, and it may be related to the amount of intravascular coagulum in the closing vessel. Tenderness is usually not observed in patients who wear compression hose continuously during the first 3 days after EVLT. Except when used by experts, wrapped bandages do not provide a safe or effective means of compression. Bandages may slip spontaneously, or the patient may remove them and reapply them incorrectly. The loss of gradient compression with the development of a tourniquet syndrome can increase the patient's risk for distal venous stasis and venous thrombosis. In the United States, gradient compression is most often applied by using surgical compression stockings. At least 30-40 mm Hg of compression is necessary for effective compression of the superficial veins. 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. Panty hose–style stockings, with compression applied to both legs, are preferred because the risk that the stocking will slip or roll is less. 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 and heavy lifting are forbidden, but normal activity is otherwise encouraged. The patient is re-evaluated on postoperative days 3 and 7, at which time duplex ultrasonography should demonstrate a closed greater saphenous vein and no evidence of thrombus in the femoral, popliteal, or calf deep veins. If the vessel is not closed by day 7, the procedure may be repeated. At 6 weeks, an examination should reveal clinical resolution 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, perform sclerotherapy under ultrasonographic guidance. For patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education article Varicose Veins. COMPLICATIONSSection 6 of 9
Worldwide experience with this procedure is limited because it is relatively new; fewer than 10,000 cases are reported. In this limited population, only a single skin burn has been reported, and no other significant complications of the procedure have been reported to date. Despite the absence of reported complications thus far, no procedure is without risks. Risk is associated with procedural problems such as malpositioning of the laser fiber. Any venous ablation procedure can trigger venous thrombosis in a susceptible patient. OUTCOMESSection 7 of 9
Although the procedure is new, published results show a high early success rate with a low subsequent recurrence rate for as long as 48 months after treatment. Early results are comparable to those obtained with more invasive surgical techniques, but no evidence regarding the long-term effectiveness of the procedure exists. Patient satisfaction with the procedure is high. MULTIMEDIASection 8 of 9
REFERENCESSection 9 of 9
Varicose Vein Treatment With Endovenous Laser Therapy excerpt Article Last Updated: Feb 15, 2007 | ||||||||||||||
