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Varicose Veins, Laser EVLT

  • Laser EVLT technique:

    This technique can be carried out under local anaesthetic and without any need for surgical cuts. It can be carried out as an outpatient procedure and patients are allowed (and in fact are encouraged) to start walking almost as soon as the procedure is completed.

    Detailed procedure of Laser EVLT ablation

    The laser fibre is introduced into the main leaky varicose vein (at the level of the inner side of the knee) through a very small opening in the skin. The fibre is then passed up the vein in the thigh through the long saphnoeus vein to the level of the junction with the deep vein (sapheno-femoral junction). Local anaesthetic (tumescent solution of 300m of normal saline, 50 ml of 1% lidocaine with 1:100,000 adrenaline ) is introduced around the vein. This has the effect of dissipating the heat produced by the VNUS catheter and reduces pain. The surgeon will then position the closure fibre into the diseased varicose vein under ultrasound guidance. The fibre will deliver laser light (heat) to the diseased varicose vein wall leading to shrinkage and complete closure of the varicose veins. After the diseased vein segment is closed the fibre is pulled back and the cycle repeated all the way down the thigh to the point of entry into the skin. Once the long truncal vein (long saphenous vein) is closed blood flow is re-routed to other healthy veins in the limb. Following the procedure, full length class II compression hosiery (stockings) is applied and worn for 2 weeks, removed only for showering. Immediate ambulation is encouraged and the patients return to normal activities within 24 hours.
    The occluded varicose veins will then be obliterated and slowly removed by the body in the following months.

    Unlike radiofrequency ablation for which there is a standard treatment protocol using a single device, laser ablation can be performed using a variety of laser sources and intensities of energy delivery.
    Most studies describing EVLT have used either 810nm or 980nm diode lasers as this is the range at which red cells absorb red/infrared light (800-1000nm). In fact, the available evidence suggest that the type of laser used is not as important as the laser heat dose in achieving adequate vein occlusion.

    The success of any EVLT procedure is measured by:
    • Effective removal of the varicose veins responsible for symptoms
    • Early complications (such as infection, bleeding, pain, deep vein thrombosis, haematoma)
    • Late complications (numbness, scarring, discolouration, nerve damage, and recurrence of veins)
    • Acceptability by patients

    The occlusion rates (how many of the treated veins remain closed) after EVLT are  in most series over 95% in the short term (about one month) and although this number reduces (some veins re-open) on follow up in good hands this is still between 85%- 95% after 1-2 years. It is unlikely for veins to recur (re-open) after this time.

    Complications of EVLT are similar to open surgery although infection, bleeding, and haematoma are noticeably less frequent. It is difficult to be certain about other complications such as deep vein thrombosis, numbness, or nerve damage because the true incidence of these are not well documented in open surgery and there are wide variation in what is reported.

    The key to successful ablation is adequate closure in the first treatment. In majority of cases of recurrence the vein has either not completely closed off (residual flow persists) or is closed off by thrombosis only. This indicates inadequate laser energy delivery to the vein wall which is crucial for ablation. In this instances laser heat only produces a thrombotic closure (clot in the vein) which can recanalise with time. The required energy for success is reported to be around 60-80 J/cm of vein treated with a laser pulse duration of > 1 second. As well as thrombosis, this also brings about damage to the vein wall by causing structural damage to the protein in the wall resulting in contracture and fibrosis of the entire vein segment treated.

    Other advantages of laser ablation include; no need for general ansaethetic or a cut in the groin, less postoperative pain, earlier ambulation and return to work compared to surgery. Also, available literature indicates better acceptability by patients according to results of quality of life questionnaires filled in by patients after their procedures.

  • What are the comparisons of open surgery and minimally invasive endovenous techniques?

    Over the recent years the surgical procedures for varicose vein treatments have been modernised. Examples are smaller incisions, use of ultrasound in ensuring stripping of the truncal vein, and performing the procedure under local anaesthetic infiltration. Successful treatment of varicose veins regardless of method requires meticulous attention to symptoms and removal of all sources of incompetence or reflux. This for example includes ablation of the long saphenous vein down to the lowest point of reflux which in some cases may be well below the knee. Some have also reported combining open surgery (high ligation) and EVLT to the truncal vein although we have no experience of this.

  • We have compared the minimally invasive endovenous techniques with open surgery under the following headings:

    Comparison of VNUS radiofrequency technique and open surgery
    In well conducted studies comparing radiofrequency (RF) obliteration (VNUS)to standard surgery (such as the EVOLVeS study*) the clinical results of VNUS were at least as good as conventional open surgery.

    However, if quality of life outcomes are looked at (loosely equates to patient acceptability), endovenous surgery has the upper hand. In a small randomized study of patients having both legs treated for varicose veins one leg was treated with conventional surgery and the other with laser treatment. Following surgery the patient satisfaction questionnaires indicated that 70% preferred laser to surgery and only 10% reported that there was no difference. These results also reflect the conclusions in the EVOLVeS study with an earlier return to physical activity and return to work in patients undergoing VNUS treatment for their varicose veins. What is more interesting is that the differences between patient satisfaction scores in favour of VNUS persisted even 2 years after initial treatment.

    In another (similarly controlled) trial VNUS took longer to perform compared to surgery but was similarly associated with less post operative pain and earlier return to work and better patient satisfaction scores compared to surgery. In this study although the cost of the VNUS procedure was higher, the advantage of earlier return to physical activity and work meant that the total economic costs involved were in fact less in the minimally invasive technique.

    In a randomised study comparing the VNUS technique with traditional open surgery, patients with bilateral recurrent veins were chosen and were treated in each leg by either of the methods at random and results analysed. Both procedures were carried out at the same time under general anaesthetic. The procedure time was quicker using VNUS technique (25min vs. 40 min) and patients experienced less bruising and pain after treatment compared to surgery.

    *Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up. Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, Sessa C, Schuller-Petrovic S. Eur J Vasc Endovasc Surg. 2005 Jan;29(1):67-73.

  • Comparison of Laser EVLT and open surgery

    In a robust study comparing EVLT with standard open surgery, laser achieved as good a result in terms of continued occlusion of the truncal vein (long saphenous vein) and symptom relief (and patient satisfaction) following treatment 1 year after surgery. Laser treated patients returned to normal everyday activity quicker than surgical patients despite the finding that freedom from postoperative pain was the same between the 2 groups. This is in keeping with results of others reporting shorter hospital stays with EVLT compared to open surgery but comparable outcomes in parameters mentioned above. Another study of similar nature, reported more bruising with open surgery compared to EVLT; however the authors observed no difference in terms of time taken to return to work between the groups (average around 7 days), or patient satisfaction scores, even though the open surgery patients reported higher pain scores compared to EVLT in the first 10 post operative days.

    How do minimally invasive techniques compare to open surgery in patients with recurrent veins?
    One of the indications for minimally invasive surgery is in treatment of recurrent veins. Redo surgery involving reopening of the previous surgical scar is technically more difficult and carries higher risks of complications. With minimally invasive varicose vein therapy, reoperations in the groin are avoided.

    The recurrence rates (reappearance) after endovenous surgery is also probably as good if not better than conventional surgery. In the EVOLVeS trial the recurrence rates following VNUS treatment was 14% compared to 21% in open surgery after 2 years although the differences could have arisen because of the small numbers of patients in the study. In larger series (but not in controlled studies) recurrence rates as low as 1% has been observed after 1 year.  Laser treatment has similar recurrence rates but some have reported rates of 7% at 2 years and others as low as 3% after 3 years. It is thought that the main reason for lower recurrence rates following endovenous therapy is a reduction in the neovascularisation process which often occurs in the scarred tissue of open surgery.

  • Criticisms of minimally invasive procedures

    One of the criticisms of endovenous ablation is that if phlebectomies (avulsion of the varicosed tributaries of side branches) are also required, a more extensive procedure needs to be planned possibly in an operating suite using general anaesthetic. If numerous, the avulsion removal of these varicosed side branches will require multiple injections with local anaesthetic which most patients find unacceptable and therefore more effectively performed under general aneasthetic. Some argue however, that extensive multiple phlebectomies may not be required if they are carried out several weeks after the initial endovenous procedure. Many of these disappear once the pressure within the venous system is reduced by removing the source of reflux i.e.; the truncal vein (long or short saphenous vein). It is a point to bear in mind that the more extensive the varicosities are (specially if tortuous) the less likely that they will be suitable to endovenous methods.

    The costs associated with minimally invasive treatment of varicose veins have also been higher than open surgery relating to the cost of the equipment and the disposable RF catheters or laser probes. Although the treatment is more costly with these techniques, once the economic costs of later return to work (in open surgery) is added on to the operative costs the differences swing in favour of the minimally invasive methods.

  • What is the best method of treatment for varicose veins?

    Each case of varicose veins needs to be considered separately. However, patients who undergo the minimally invasive procedures such as VNUS or EVLT typically:
    • Can have procedure carried out under local anaesthesia.
    • Experience less postoperative pain and bruising compared to surgery.
    • Resume normal activities sooner than surgery.
    • Have better patient satisfaction scores than surgery.
    • Good cosmetic outcome with no surgical scarring in the groin.

    Endovenous techniques of laser (EVLT) and radiofrequency (VNUS) have arguably become the gold standard of treatment for truncal varicose veins, such as long saphenous or short saphenous veins.  These methods hasten patient recovery and have been used for more than ten years with proven safety and efficacy.  However, there are limitations as well as cautions to be exercised in considering these techniques for treatment of varicose veins. Most of the information from the medical literature reports comparable (if not better) short and medium term outcomes with these treatments to open surgery; but until long term data regarding durability and recurrence rates are available open surgery will remain an option in treating varicose veins.  Heat generated from minimally invasive endovenous techniques may cause skin damage or burns in patients with very thin legs or very superficial veins. Extreme tortuousity of truncal veins may prove difficult to negotiate with the laser fibre or the RF catheter.

  • Which of these methods of minimally invasive varicose vein treatments are better?

    Recently, the results of endovenous ablation with radiofrequency Closure FAST (VNUS) catheter have been compared to the conventional laser (EVLT) treatment in a controlled trial (the RECOVERY trial*). The two treatments were compared in terms of post operative pain, bruising, and complications of deep vein thrombosis, numbness, and pigmentation. The results indicated that at one month bruising was less common in patients treated with VNUS. The laser treated patients experienced more pain for up to 2 weeks after treatment but there was no difference in terms of pain levels at one month. There were no differences in terms of successful occlusion of the long saphenous vein (both 100%) , or complications such as pigmentation, deep vein thrombosis, or numbness between VNUS and EVLT. Although study is seemingly well conducted, it must be noted that it was sponsored by the company making the VNUS Closure FAST catheters. Therefore, it would be interesting to know if others can reproduce the findings of this study.

    In an earlier interesting study patients with bilateral varicose veins were treated using EVLT in one leg and VNUS technique in other chosen at random. Although the overall complication rates were the same, a higher proportion of the veins treated by VNUS technique remained closed compared to EVLT treated veins after one year follow up.

    In another (less well controlled) study, the reported complication rates following VNUS technique were 7% compared with 20% in the EVLT technique of varicose vein treatment.

    For these reasons, we recommend VNUS radiofrequency ablation to our patients for the treatment of their varicose veins. It is an effective method and can be combined with the immediate removal of tributaries (side branches) of varicose veins through tiny incisions under local anaesthetic. It offers excellent rates of long saphenous vein closure (main truncal superficial vein) with less immediate post-operative pain and lower incidence of other complications compared to the laser method. We do however, offer the full range of treatments for varicose veins including Laser EVLT, foam sclerotherapy, and open surgery. Details of these can be discussed with you during your appointment.

    *Radiofrequency endovenous ClosureFAST versus laser ablation for the treatment of great saphenous reflux: a multicenter, single-blinded, randomized study (RECOVERY study). Almeida JI, Kaufman J, Göckeritz O, Chopra P, Evans MT, Hoheim DF, Makhoul RG, Richards T, Wenzel C, Raines JK.
    J Vasc Interv Radiol. 2009 Jun;20(6):752-9.

  • How likely are my varicose veins to disappear following minimally invasive treatment?

    VNUS Radiofrequency treatment is our method of choice for treatment of varicose veins where possible. This minimally invasive technique causes an occlusion (thrombosis) of the main truncal superficial vein (long saphenous vein). This along with deliberate damage to the protein structure of the vein wall means that the vein will no longer carry any blood. Over the ensuing months there is a gradual disappearance of the long truncal vein. With the back pressure reduced, the tributaries (side branches) of the main superficial vein (what most people recognise as varicose veins) also reduce in size and in many instances are no longer visible. Those that remain can be removed under local anaesthetic.  This is a very simple procedure which we will explain to you in your appointment.

  • What are the advantages of VNUS Radiofrequency technique?

    The minimally methods (such as VNUS radiofrequency technique) of treating veins are generally less invasive and have the following potential benefits:

    • Procedure can be carried out under local anaesthesia.
    • Patients experience less postoperative pain and bruising than compared to surgery.
    • Resumption of normal activities sooner than surgery.
    • Better patient satisfaction scores than surgery.
    • Good cosmetic outcome with no surgical scarring in the groin.

  • What are the side-effects of minimally invasive endovenous techniques such as VNUS Radiofrequency:

    Any technique for treatment of varicose veins can lead to development of complications and broadly speaking these are similar between techniques; what is different is the frequency with which they can occur.

    The success of any varicose vein procedure is measured by:
    • Effective removal of the veins responsible for symptoms
    • Early complications (such as infection, bleeding, deep vein thrombosis, haematoma)
    • Late complications (pain, numbness, scarring, discolouration, nerve damage, and recurrence of veins)
    • Acceptability by patients

    Endovenous techniques produce as good a results, if not better, than conventional surgery in removing the cause of incompetent reflux (leaky vein valves) in the main superficial truncal veins (long saphenous vein)

    There has been no serious complications in the patients who have been treated with endovenous surgery by our vascular surgeon, who has routinely been carrying out this procedure for a number of years. Very occasionally there might be trouble with transient inflammation of the treated varicose veins (thrombophlebitis) which normally responds well to anti-inflammatory drugs such as Voltarol or Nurofen.

    Deep vein thrombosis is a reported complication of this procedure and might occur in any operation particularly on those which are carried out on the lower limbs. This is avoided by careful techniques and encouraging mobilization after the operation. Minimal bruising does occur but always clears with time. Occasionally patients will develop a few thread veins after treatment but these generally subside with time. If bothersome, they can be dealt with by micro-injection sclerotherapy (not the foam injection mentioned above). Infection of the needle access site can occur very rarely. Numbness in the inner thigh distribution has also been reported.

    With the removal of the head of pressure, thread veins, spider veins, and even reticular veins frequently improve, sometimes even to the point of disappearance. However, those that remain after three to six months will need to be addressed by micro-injection sclerotherapy if they bother the patient. Occasionally, thread veins may appear after the varicose vein surgery (usually just above the knee on the inside of the thigh) – this seems to be the result of blood opening up new routes to return to the heart. These fine thread veins usually settle with time, but may require micro-injection Sclerotherapy if they bother the patient.

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