Endovenous laser treatment (ELT) is a minimally invasive ultrasound-guided technique used for treating

varicose veins Varicose veins, also known as varicoses, are a medical condition in which superficial veins become enlarged and twisted. These veins typically develop in the legs, just under the skin. Varicose veins usually cause few symptoms. However, some indiv ...

using

laser A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The fi ...

energy commonly performed by a phlebologist, interventional radiologist or

vascular surgeon Vascular surgery is a surgical subspecialty in which diseases of the vascular system, or arteries, veins and lymphatic circulation, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty ...

Methods

Endovenous laser treatment treats

using an

optical fiber An optical fiber, or optical fibre in Commonwealth English, is a flexible, transparent fiber made by drawing glass ( silica) or plastic to a diameter slightly thicker than that of a human hair. Optical fibers are used most often as a mea ...

that is inserted into the vein to be treated, and

light, normally in the

infrared Infrared (IR), sometimes called infrared light, is electromagnetic radiation (EMR) with wavelengths longer than those of visible light. It is therefore invisible to the human eye. IR is generally understood to encompass wavelengths from around ...

portion of the

spectrum A spectrum (plural ''spectra'' or ''spectrums'') is a condition that is not limited to a specific set of values but can vary, without gaps, across a continuum. The word was first used scientifically in optics to describe the rainbow of colors ...

, shines 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 This causes the vein to contract, and the optical fiber is slowly withdrawn.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 is a phlebitis (inflammation of a vein) related to a thrombus (blood clot). When it occurs repeatedly in different locations, it is known as thrombophlebitis migrans ( migratory thrombophlebitis). Signs and symptoms The following ...

, pain, hematoma, edema and

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dis ...

, which can lead to

cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of ...

. EVLT has the same meaning as ELT, but it is a trademark name owned by Diomed and used as the name for their 910 nm laser treatment unit for ELT. The 810 nm laser is the original laser fiber wavelength as pioneered by Dr. Luis Navarro, Dr. Carlos Bone and Dr. Robert Min, at the Vein Treatment Center in New York, New York. Subsequently, various other fibers with different wavelengths have become available. The varying wavelength each aim to maximize local damage to a component of the varicose vein or the

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the cir ...

contained in it while minimizing damage to adjacent tissues. During the procedure, a

catheter In medicine, a catheter (/ˈkæθətər/) is a thin tubing (material), tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgi ...

bearing a laser fiber is inserted under ultrasound guidance into the

great saphenous vein The great saphenous vein (GSV, alternately "long saphenous vein"; ) is a large, subcutaneous, superficial vein of the leg. It is the longest vein in the body, running along the length of the lower limb, returning blood from the foot, leg and thi ...

(GSV) or

small saphenous vein The small saphenous vein (also short saphenous vein or lesser saphenous vein) is a relatively large superficial vein of the posterior leg. Structure The origin of the small saphenous vein, (SSV) is where the dorsal vein from the fifth digit (sma ...

(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 Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...

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 fiber 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 two 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 three weeks afterwards. Foam

sclerotherapy Sclerotherapy (the word reflects the Greek ''skleros'', meaning ''hard'') is a procedure used to treat blood vessel malformations (vascular malformations) and also malformations of the lymphatic system. A medicine is injected into the vessels, wh ...

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.

Complications

Complications of endovenous laser treatment can be categorized as minor, or serious. Minor complications include

bruising A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur clos ...

(51%), hematoma (2.3%), temporary numbness (3.8%),

phlebitis Phlebitis (or Venitis) is inflammation of a vein, usually in the legs. It most commonly occurs in superficial veins. Phlebitis often occurs in conjunction with thrombosis and is then called thrombophlebitis or superficial thrombophlebitis. Unlike ...

(7.4%), induration (46.7%), and a sensation of tightness (24.8%). More serious complications include skin

burn A burn is an injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or ultraviolet radiation (like sunburn). Most burns are due to heat from hot liquids (called scalding), solids, or fire. Burns occur ma ...

s (0.5%),

deep venous thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...

(0.4%),

pulmonary embolism Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream ( embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathin ...

(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.

Retina The retina (from la, rete "net") is the innermost, light-sensitive layer of tissue of the eye of most vertebrates and some molluscs. The optics of the eye create a focused two-dimensional image of the visual world on the retina, which then ...

l damage is a serious but very rare complication (<1%) that can occur during the use of lasers. 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 A scotoma is an area of partial alteration in the field of vision consisting of a partially diminished or entirely degenerated visual acuity that is surrounded by a field of normal – or relatively well-preserved – vision. Every normal mam ...

. The nominal hazard zone (NHZ) or space within which the level of direct, scattered, or reflected laser radiation exceeds the maximum permissible exposure (MPE), varies by the wavelength of the laser and is shorter (17 inches) with the newer 1470 nm laser. Use of appropriate protective eyeware specific to the wavelength laser being used prevents accidental injury.

Clinical evaluations

A 2005 report from one practice, summarising results of 1,000 limbs treated over a 5-year period with EVLT showed that 98% of the treated vessels at up to 60 months follow-up remained closed, with complications and side effects such as temporary paresthesia and DVTs below 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 Nerve injury is an injury to nervous tissue. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Seddon introduced a classification of nerve injuries based on three main types of nerve f ...

and paresthesia, post-operative infections and hematomas, 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%. Endovenous thermal ablation (EVTA) by radiofrequency or laser is a safe and effective treatment of refluxing great saphenous veins (GSVs) and has replaced traditional high ligation and stripping in official recommendations of various leading Vascular Societies in the United States and the United Kingdom.

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.

References

External links