Endovenous laser treatment
Encyclopedia
Endovenous laser treatment (ELT) is a minimally invasive ultrasound-guided technique used for treating varicose veins
using laser
energy.
in which an optical fiber
is inserted into the vein to be treated, and laser
light, normally in the infrared
portion of the spectrum
, is shone into the interior of the vein. This causes the vein to contract, and the optical fiber is slowly withdrawn. Some minor complications can occur, including thrombophlebitis
, pain, hematoma
, edema
and infection, which can lead to cellulitis
.
EVLT (Endovenous Laser Treatment) has the same meaning as ELT but is a trademark name owned by Diomed and used as the name for their 910nm laser treatment unit for ELT. The 810nm laser is the original laser fibre wavelength as pioneered by Dr Robert Min of New York USA. Subsequently, various other fibres with different wavelengths have become available. The varying wavelength each aim to maximise local damage to a component of the varicose vein or the blood contained in it while minimising damage to adjacent tissues.
During the procedure, a catheter
bearing a laser fibre is inserted under ultrasound
guidance into the great saphenous vein
(GSV) or small saphenous vein
(SSV) through a small puncture. The catheter is then advanced (also under ultrasound guidance) to the level of the groin or knee crease. Dilute local anesthesia is injected around and along the vein (perivascular infiltration) using ultrasound imaging to place the local anesthetic solution around the vein, mostly in a sub-facial location. This technique derives from the Tumescent Local Anesthesia ( TLA) method long used and proven safe and effective for some methods of Liposuction
. The laser is activated whilst the catheter or laser fibre is slowly withdrawn, resulting in obliteration of the saphenous vein along its entire length. The treatment, which is performed without sedation, usually takes between 1 and 2 hours and the patient walks out under his or her own power. The leg is bandaged and/or placed in a stocking that the patient wears for up to 3 weeks afterwards.
Foam sclerotherapy
or ambulatory phlebectomy
is often performed at the time of the procedure or within the first 1–2 weeks to treat branch varicose veins. However, some physicians do not perform these procedures at the time of the ELT because the varicose veins can improve on their own as a result of reduced reflux from the great saphenous vein.
(7.4%), induration (46.7%), and a sensation of tightness (24.8%). More serious complications include skin burns (0.5%), deep venous thrombosis (0.4%), pulmonary embolism
(0.1%), and nerve injury (0.8%). These rates of complications are derived from the Australian MSAC review of all available literature on the procedure.
Retinal damage is a serious but rare complication (<1%) that can occur during the use of laser energy. If the fiber breaks or if the laser is activated when the laser is outside of the body, reflected laser light may cause a focal permanent retinal deficit or "blind spot" or scotoma. The nominal hazard zone (NHZ) or space within which the level of direct, scattered, or reflected laser radiation exceeds the maximum permissible exposure(MPE)ANSI Z-136.1, varies by the wave length of the laser and is shorter (17in) with the newer 1470nm laser. Use of appropriate protective eyeware specific to the wavelength laser being used may prevent accidental injury.
Robert J. Min, MD Neil M. Khilnani, MD - Department of Radiology Weill Medical College of Cornell University New York, NY, USA
In 2005, Doctors Min and Khilnani published their results of 1,000 limbs treated over a 5 year period with EVLT. 98% of the treated vessels at up to 60 months follow-up remain closed. Complications and side effects like temporary parasthesia and DVTs are reported at less than 0.5%.
The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins." It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". A study of 516 treated veins over 69 months by Elmore and Lackey reported a success rate of 98.1%.
Vascular Web - Varicose Veins
Varicose veins
Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards . Leg muscles pump the veins to return blood to the heart, against the...
using laser
Laser
A laser is a device that emits light through a process of optical amplification based on the stimulated emission of photons. The term "laser" originated as an acronym for Light Amplification by Stimulated Emission of Radiation...
energy.
Methods
Endovenous laser treatment is a treatment for varicose veinsVaricose veins
Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards . Leg muscles pump the veins to return blood to the heart, against the...
in which an optical fiber
Optical fiber
An optical fiber is a flexible, transparent fiber made of a pure glass not much wider than a human hair. It functions as a waveguide, or "light pipe", to transmit light between the two ends of the fiber. The field of applied science and engineering concerned with the design and application of...
is inserted into the vein to be treated, and laser
Laser
A laser is a device that emits light through a process of optical amplification based on the stimulated emission of photons. The term "laser" originated as an acronym for Light Amplification by Stimulated Emission of Radiation...
light, normally in the infrared
Infrared
Infrared light is electromagnetic radiation with a wavelength longer than that of visible light, measured from the nominal edge of visible red light at 0.74 micrometres , and extending conventionally to 300 µm...
portion of the spectrum
Spectrum
A spectrum is a condition that is not limited to a specific set of values but can vary infinitely within a continuum. The word saw its first scientific use within the field of optics to describe the rainbow of colors in visible light when separated using a prism; it has since been applied by...
, is shone into the interior of the vein. This causes the vein to contract, and the optical fiber is slowly withdrawn. Some minor complications can occur, including thrombophlebitis
Thrombophlebitis
Thrombophlebitis is phlebitis related to a thrombus . When it occurs repeatedly in different locations, it is known as "Thrombophlebitis migrans" or "migrating thrombophlebitis".-Signs and symptoms:...
, pain, hematoma
Hematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
, edema
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
and infection, which can lead to cellulitis
Cellulitis
Cellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters,...
.
EVLT (Endovenous Laser Treatment) has the same meaning as ELT but is a trademark name owned by Diomed and used as the name for their 910nm laser treatment unit for ELT. The 810nm laser is the original laser fibre wavelength as pioneered by Dr Robert Min of New York USA. Subsequently, various other fibres with different wavelengths have become available. The varying wavelength each aim to maximise local damage to a component of the varicose vein or the blood contained in it while minimising damage to adjacent tissues.
During the procedure, a catheter
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
bearing a laser fibre is inserted under ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
guidance into the great saphenous vein
Great saphenous vein
The great saphenous vein , also long saphenous vein, is the large superficial vein of the leg and thigh.The terms "safaina" and "el safin" have both been claimed as the origin for the word "saphenous."-Path:The GSV originates from where the dorsal vein of the first digit...
(GSV) or small saphenous vein
Small saphenous vein
The small saphenous vein , is a relatively large vein of the superficial posterior leg.-Path:Its origin is where the dorsal vein from the fifth digit merges with the dorsal venous arch of the foot, which attaches to the great saphenous vein...
(SSV) through a small puncture. The catheter is then advanced (also under ultrasound guidance) to the level of the groin or knee crease. Dilute local anesthesia is injected around and along the vein (perivascular infiltration) using ultrasound imaging to place the local anesthetic solution around the vein, mostly in a sub-facial location. This technique derives from the Tumescent Local Anesthesia ( TLA) method long used and proven safe and effective for some methods of Liposuction
Liposuction
Liposuction, also known as lipoplasty , liposculpture suction lipectomy or simply lipo is a cosmetic surgery operation that removes fat from many different sites on the human body...
. The laser is activated whilst the catheter or laser fibre is slowly withdrawn, resulting in obliteration of the saphenous vein along its entire length. The treatment, which is performed without sedation, usually takes between 1 and 2 hours and the patient walks out under his or her own power. The leg is bandaged and/or placed in a stocking that the patient wears for up to 3 weeks afterwards.
Foam sclerotherapy
Sclerotherapy
Sclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations...
or ambulatory phlebectomy
Ambulatory phlebectomy
Ambulatory phlebectomy is a treatment for superficial varicose veins. The procedure involves the removal of the varicose veins through small 2–3 mm incisions in the skin overlying the veins. The procedure may be performed in hospital or outpatient settings...
is often performed at the time of the procedure or within the first 1–2 weeks to treat branch varicose veins. However, some physicians do not perform these procedures at the time of the ELT because the varicose veins can improve on their own as a result of reduced reflux from the great saphenous vein.
Complications
Complications of endovenous laser treatment can be categorised as minor, or serious. Minor complications include bruising (51%), haematoma (2.3%), temporary numbness (3.8%), phlebitisPhlebitis
Phlebitis is an inflammation of a vein, usually in the legs.When phlebitis is associated with the formation of blood clots , usually in the deep veins of the legs, the condition is called thrombophlebitis...
(7.4%), induration (46.7%), and a sensation of tightness (24.8%). More serious complications include skin burns (0.5%), deep venous thrombosis (0.4%), pulmonary embolism
Pulmonary embolism
Pulmonary embolism is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream . Usually this is due to embolism of a thrombus from the deep veins in the legs, a process termed venous thromboembolism...
(0.1%), and nerve injury (0.8%). These rates of complications are derived from the Australian MSAC review of all available literature on the procedure.
Retinal damage is a serious but rare complication (<1%) that can occur during the use of laser energy. If the fiber breaks or if the laser is activated when the laser is outside of the body, reflected laser light may cause a focal permanent retinal deficit or "blind spot" or scotoma. The nominal hazard zone (NHZ) or space within which the level of direct, scattered, or reflected laser radiation exceeds the maximum permissible exposure(MPE)ANSI Z-136.1, varies by the wave length of the laser and is shorter (17in) with the newer 1470nm laser. Use of appropriate protective eyeware specific to the wavelength laser being used may prevent accidental injury.
Clinical evaluations
Journal for Cardiovascular Surgery 2005 - Vol. 46Robert J. Min, MD Neil M. Khilnani, MD - Department of Radiology Weill Medical College of Cornell University New York, NY, USA
In 2005, Doctors Min and Khilnani published their results of 1,000 limbs treated over a 5 year period with EVLT. 98% of the treated vessels at up to 60 months follow-up remain closed. Complications and side effects like temporary parasthesia and DVTs are reported at less than 0.5%.
The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins." It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". A study of 516 treated veins over 69 months by Elmore and Lackey reported a success rate of 98.1%.
Postoperative instructions
Patients are usually fitted with Class 2 graduated compression stockings and/or bandages for up to 3 weeks. Duplex ultrasound is used during follow-up to assess the success of treatment and if there is a need for additional sclerotherapy or phlebectomy of branch veins.External links
Vascular Web - Varicose Veins