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Varicose Vein Treatment With Endovenous Laser Therapy

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
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
Contributor Information and Disclosures

Updated: Nov 7, 2008

Introduction

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.

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 an 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 prevalence 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.

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. The images below depict before-and-after images of EVLA treatment of varicose veins.

Varicose vein before treatment with endovenous la...

Varicose vein before treatment with endovenous laser therapy.

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Varicose vein before treatment with endovenous la...

Varicose vein before treatment with endovenous laser therapy.


Varicose vein after treatment with endovenous las...

Varicose vein after treatment with endovenous laser.

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Varicose vein after treatment with endovenous las...

Varicose vein after treatment with endovenous laser.


EVLA mechanism of action

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.
 
Mordon et al state "The steam produced by absorption of laser energy by the blood is a tiny fraction of the energy necessary to damage the vein wall and cannot be the primary mechanism of injury to the vein with endovenous laser. The carbonization and tract within the vein walls seen by histology following endovenous laser can only be the result of direct contact between the laser fiber tip and the vein wall."6 Dr Rox Anderson, director of The Wellman Center for Photomedicine at Massachusetts General Hospital, reported that carbon appears to be a secondary but key chromophore that is probably independent of wavelength.7 An ex vivo study on human vein segments supports this concept.8 See the image below.

Carbonization of 600-m m laser fiber tip secondar...

Carbonization of 600-m m laser fiber tip secondary to endovenous laser ablation.

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Carbonization of 600-m m laser fiber tip secondar...

Carbonization of 600-m m laser fiber tip secondary to endovenous laser ablation.


Indications

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.)

Contraindications

  • Allergy to local anesthetic
  • Hypercoagulable states
  • Infection of the leg to be treated
  • Lymphedema
  • Nonambulatory patient
  • Peripheral arterial insufficiency
  • Poor general health 
  • Pregnancy
  • Recent or active venous thromboembolism
  • Thrombus or synechiae in the vein to be treated
  • Tortuous GSV, possibly making placement of the laser fiber difficult

More on Varicose Vein Treatment With Endovenous Laser Therapy

Overview: Varicose Vein Treatment With Endovenous Laser Therapy
Treatment & Medication: Varicose Vein Treatment With Endovenous Laser Therapy
Multimedia: Varicose Vein Treatment With Endovenous Laser Therapy
References
Further Reading
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References

  1. Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg. Jan 2006;31(1):83-92. [Medline].

  2. Mendoza E. To the topographic anatomy of the vena saphena magna: A duplex sonographische study regarding by surgery relevant aspects. Phlebologie. 2001;30:141-4.

  3. Proebstle TM, Sandhofer M, Kargl A, Gül D, Rother W, Knop J, et al. Thermal damage of the inner vein wall during endovenous laser treatment: key role of energy absorption by intravascular blood. Dermatol Surg. Jul 2002;28(7):596-600. [Medline].

  4. Goldman MP, Mauricio M, Rao J. Intravascular 1320-nm laser closure of the great saphenous vein: a 6- to 12-month follow-up study. Dermatol Surg. Nov 2004;30(11):1380-5. [Medline].

  5. Schmedt CG, Sroka R, Steckmeier S, Meissner OA, Babaryka G, Hunger K, et al. Investigation on radiofrequency and laser (980 nm) effects after endoluminal treatment of saphenous vein insufficiency in an ex-vivo model. Eur J Vasc Endovasc Surg. Sep 2006;32(3):318-25. [Medline].

  6. Mordon SR, Wassmer B, Zemmouri J. Mathematical modeling of endovenous laser treatment (ELT). Biomed Eng Online. Apr 25 2006;5:26. [Medline]. [Full Text].

  7. Anderson RR. Endovenous Laser: Mechanism of Action. Presented at the Annual Meeting of the American Academy of Dermatology. San Francisco, California, USA. March 3-7, 2006.

  8. Disselhoff BC, Rem AI, Verdaasdonk RM, Kinderen DJ, Moll FL. Endovenous laser ablation: an experimental study on the mechanism of action. Phlebology. 2008;23(2):69-76. [Medline].

  9. Agus GB, Mancini S, Magi G. The first 1000 cases of Italian Endovenous-laser Working Group (IEWG). Rationale, and long-term outcomes for the 1999-2003 period. Int Angiol. Jun 2006;25(2):209-15. [Medline].

  10. Min RJ, Khilnani NM. Endovenous laser treatment of saphenous vein reflux. Tech Vasc Interv Radiol. Sep 2003;6(3):125-31. [Medline].

  11. Perkowski P, Ravi R, Gowda RC, Olsen D, Ramaiah V, Rodriguez-Lopez JA, et al. Endovenous laser ablation of the saphenous vein for treatment of venous insufficiency and varicose veins: early results from a large single-center experience. J Endovasc Ther. Apr 2004;11(2):132-8. [Medline].

  12. Ravi R, Rodriguez-Lopez JA, Trayler EA, Barrett DA, Ramaiah V, Diethrich EB. Endovenous ablation of incompetent saphenous veins: a large single-center experience. J Endovasc Ther. Apr 2006;13(2):244-8. [Medline].

  13. Mozes G, Kalra M, Carmo M, Swenson L, Gloviczki P. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg. Jan 2005;41(1):130-5. [Medline].

  14. Timperman PE. Arteriovenous fistula after endovenous laser treatment of the short saphenous vein. J Vasc Interv Radiol. Jun 2004;15(6):625-7. [Medline].

  15. Dunst KM, Huemer GM, Wayand W, Shamiyeh A. Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein. J Vasc Surg. May 2006;43(5):1056-8. [Medline].

  16. Lugli M, Cogo S, Guerzoni S, et al. Effects of eccentric compression after EVLT of great saphenous vein. Presented at the 19th Annual Congress of the American Venous Forum. San Diego, California. February 17, 2007.

  17. Zimmet SE. Endovenous laser ablation. Phlebolymphology. 2007;14:51-8.

  18. Meissner MH, Eklof B, Smith PC, Dalsing MC, DePalma RG, Gloviczki P, et al. Secondary chronic venous disorders. J Vasc Surg. Dec 2007;46 Suppl S:68S-83S. [Medline].

  19. Lugli M, Cogo A, Guerzoni S, Petti A, Maleti O. Effects of eccentric compression by a crossed-tape technique after endovenous laser ablation of the great saphenous vein: a randomized study. Phlebology. Aug 2009;24(4):151-6. [Medline].

  20. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol. Aug 2003;14(8):991-6. [Medline].

  21. Lu X, Ye K, Li W, Lu M, Huang X, Jiang M. Endovenous ablation with laser for great saphenous vein insufficiency and tributary varices: a retrospective evaluation. J Vasc Surg. Sep 2008;48(3):675-9. [Medline].

  22. Marston WA, Owens LV, Davies S, Mendes RR, Farber MA, Keagy BA. Endovenous saphenous ablation corrects the hemodynamic abnormality in patients with CEAP clinical class 3-6 CVI due to superficial reflux. Vasc Endovascular Surg. Mar-Apr 2006;40(2):125-30. [Medline].

  23. de Medeiros CA, Luccas GC. Comparison of endovenous treatment with an 810 nm laser versus conventional stripping of the great saphenous vein in patients with primary varicose veins. Dermatol Surg. Dec 2005;31(12):1685-94; discussion 1694. [Medline].

  24. Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AI, Gough MJ. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg. Mar 2008;95(3):294-301. [Medline].

  25. Mekako AI, Hatfield J, Bryce J, Lee D, McCollum PT, Chetter I. A nonrandomised controlled trial of endovenous laser therapy and surgery in the treatment of varicose veins. Ann Vasc Surg. Jul 2006;20(4):451-7. [Medline].

  26. Rasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B. Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results. J Vasc Surg. Aug 2007;46(2):308-15. [Medline].

  27. Vuylsteke M, Van den Bussche D, Audenaert EA, Lissens P. Endovenous laser obliteration for the treatment of primary varicose veins. Phlebology. 2006;21(2):80-7.

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Further Reading

Bergan JJ ed. The Vein Book. London: Elsevier Science, 2006.
 
Feied CF. Peripheral venous disease. In: Rosen P, Barkin RM, eds. Emergency Medicine: Principles and Practice. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998:chap 107.

Fronek HS, ed. The Fundamentals of Phlebology: Venous Disease for Clinicians, 2nd ed. London: Royal Society of Medicine Press; 2007.
 
Holme JB, Skajaa K, Holme K. Incidence of lesions of the saphenous nerve after partial or complete stripping of the long saphenous vein. Acta Chir Scand. Feb 1990;156(2):145-8.

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. 
 
Min RJ, Khilnani NM. Endovenous laser treatment of saphenous vein reflux. Tech Vasc Interv Radiol. Sep 2003;6(3):125-31. 
 
Navarro L, Min RJ, Bone C. Endovenous laser: a new minimally invasive method of treatment for varicose veins--preliminary observations using an 810 nm diode laser. Dermatol Surg. Feb 2001;27(2):117-22.

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. 
 
Timperman PE. Prospective evaluation of higher energy great saphenous vein endovenous laser treatment. J Vasc Interv Radiol. Jun 2005;16(6):791-4.

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. Endovenous laser ablation. Phlebolymphology, 2007;14(2):51-58.

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.

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Keywords

varicose vein treatment, vein treatment, laser vein treatment, endovenous laser ablation, endovenous laser therapy, EVLA, EVLT, saphenous ablation, vein stripping, varicose veins

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Contributor Information and Disclosures

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, MD, RVT, FACPH 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
Disclosure: vascular insights Ownership interest Consulting

Coauthor(s)

Robert Min, MD, Director of Cornell Vascular, Assistant Professor, Department of Radiology, Cornell University Weill Medical College
Robert Min, MD is a member of the following medical societies: American College of Phlebology, American College of Radiology, American Society for Laser Medicine and Surgery, and Radiological Society of North America
Disclosure: Nothing to disclose.

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, MD, FACEP, FAAEM, FACPh 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
Disclosure: Nothing to disclose.

Medical Editor

Smeena Khan, MD, Private Practice, Adult and Pediatric Dermatology Associates
Smeena Khan, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

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, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey J Miller, MD, Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center
Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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