3 July 2015
By Dr Roger Tok & Prof Dr BJJ Abdullah, Consultant Radiologists, University Malaya Medical Centre
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. The American Academy of Dermatology believes that the new laser technology is more effective with fewer side effects. Although it is not as widely used as sclerotherapy, some doctors feel it may become the standard for treating varicose veins.
EVLT is of value in the treatment of the larger (e.g. greater saphenous vein) in patients with failure of the valves between the larger surface vein and the deep vein at the level of the groin. It also has a role in effectively treating varicosities of large branch veins and other large tributaries.
How does it work?
EVLT works by means of thermal destruction of the venous tissues. Laser surgery works by sending very strong bursts of light onto the vein that makes the vein slowly fade and disappear. Lasers are very direct and accurate, and only damage the area being treated causing irreversible localized venous tissue damage. All skin types and colors can be safely treated with lasers. The laser is repeatedly fired as the laser fiber is gradually withdrawn along the course of the vein until the entire vessel is treated.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.
How is it performed?
Initially the interventional radiologist or surgeon will consult with the patient about the procedure. This consultation will include a physical examination of the leg and a Doppler ultrasound examination to map the vein to be treated. Once the patient is determined to be a candidate for the procedure, an appointment for the procedure itself will be made as an out-patient
There is considerable variation of how this procedure can be performed but generally it is as follows. The patient arrives on the day of the procedure with no meal for 4-6 hours before. Ultrasound is used to confirm and map all areas of reflux and to trace the path of the abnormal large superficial vein (i.e. the saphenofemoral junction) down the leg to the upper calf. The course of the vein, the saphenofemoral junction, and the anticipated entry point are marked on the skin.
An appropriate entry point is selected just above or just below the knee at a point that permits puncture and insertion of the laser fiber. The leg is cleaned and draped, and a superficial local anesthetic agent is used to numb the site of puncture. Ultrasonography is used to guide needle puncture of the vessel. The laser fiber is measured and advanced through the sheath until it reaches the required point. Under ultrasonographic guidance, a dilute local anesthetic agent is injected into the tissues surrounding the vein along the entire course of the vein to be treated. The procedure is generally quick but which takes the most time and may be slightly uncomfortable. Once the position of the fiber is confirmed the laser console is switched on and using the light from the laser the position is confirmed. While the laser is being fired manual pressure is applied to achieve venous wall apposition around the laser fiber tip. The sheath and laser fiber are pulled back slowly and manual pressure is repeatedly applied. This procedure is repeated along the entire length of the vessel to be treated.
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 no postoperative numbness due to the procedure has been reported. When the site of puncture is reached 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.
Laser introducer catheters can be passed along small and crooked veins, but they cannot be passed along an extremely tortuous vein with ease. In such situations the vein will have to be punctured at several points to treat short segments at a time.
As a result of the treatment, the blood re-routes through the remaining normal veins much more efficiently, thereby reducing the abnormal pressure on the remaining veins.
What is the post-procedure care?
Immediately after the procedure, a class II compression stocking (check with the treating doctor) 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. Bed rest and heavy lifting are forbidden, but normal activity is otherwise encouraged.
Compression is vitally important after any venous procedure since it reduces the risk of clot formation in the legs and it is also highly effective in reducing post procedure bruising and tenderness. The patient is re-evaluated 3 to 7 days after the procedure at which time ultrasonography usually shows a clotted treated vein but no clots in the deep veins. If the vessel is not closed by day 7, the procedure may be repeated.
Advantages of Endovenous Laser Therapy (EVLT)
- A simple procedure
- Performed under local anesthetic and is more comfortable for patients
- Minimally invasive, so minimal risk of scarring and postoperative infection
- Less than one hour examination and treatment time
- Rapid recovery with reduced postoperative pain. Normal activities can be resumed immediately
- Excellent clinical and aesthetic results
- Patient satisfaction with the procedure is high
Does EVLT have any side effects?
Only minimal complications have been experienced with the EVLT. Postoperative bruising can be significant after but may be completely absent in patients who wear compression hose continuously during the first 3 days after treatment. Any tenderness after the 3rd day can occur and it may be related to the amount of clotting within the treated veins. Again this is usually not observed in patients who wear compression hose continuously during the first 3 days after EVLT.
When the laser hits the skin, the patient only feels a small pinch, and the skin is soothed by cooling both before and after the laser is applied. There may be some redness or swelling of the skin right after the treatment, but this disappears within a few days. The skin also may be discolored, but this will disappear within one to two weeks. They are temporary and will usually resolve in a few weeks to a few months.
There are a few potential serious side effects that have never been proven, but theoretically, may occur, such as:
- Blood clots
- Perforation of the vein
- Breaking of the fiber inside the vein
- Numbness or tingling
- Skin burns
Am I at risk from the laser?
No. You will be given a pair of special glasses to wear to protect your eyes. However this is just a precaution against accidental firing of laser energy outside the body.
How successful is endovenous laser therapy?
Early results have been extremely favorable with success rates as high as the conventional surgical approach, which is accepted as the ‘gold standard’ treatment. EVLT will normally treat the cause of most varicose veins but additional or complementary (additional) therapy may be necessary in some cases.
Where is it available?
It is increasingly being used by several centres in the country. Check with your treating doctor.
How much would it cost?
This varies widely on the type of equipment, fiber as well on the cost of the supplementary investigations and follow-up required for the complete process. On the average it can cost from between RM 1,500 to RM 2,500.