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Varicose Veins - Endovenous Laser Therapy

Endovenous laser ablation has several proprietary names, eg. EVLT, ELVes, VeinSeal, according to the laser manufacturer. In this article we use the general term EVLA for endovenous laser ablation, as all of the various types of laser ablation are essentially the same.

What is EVLA?

EVLA is a new method of treating varicose veins without surgery. Rather than tying and removing abnormal veins, they are heated with a laser. Heat kills the walls of the veins and the body naturally absorbs the dead tissue and the abnormal veins are destroyed. It can be done in a simple treatment room instead of an operating room.

Are my veins suitable for EVLA?

Almost all patients with varicose veins are eligible for EVLA. Those few that are unsuitable (usually those with small recurring veins after previous surgery) can usually be managed with just foam sclerotherapy.

What does the procedure consist of?

An ultrasound is performed and the veins to be treated are marked with a pen. You lie on a sofa and your leg is cleaned and covered with curtains. Depending on the veins to be treated, it can be on your back or front. All these steps are guided by ultrasound.

A laser fiber is passed through the catheter so that its tip is at the highest point to be heated (usually the groin crease). A large amount of local anesthetic solution is then injected around the vein through multiple small punctures. All staff and patient applied laser safety specifications as a precautionary measure. Then the laser is fired and the vein is lowered for about 5 minutes. You will hear a warning buzzer ringing and you may smell or feel burning but will not feel any pain. If you have both legs treated, the process is repeated on the other leg. The laser and catheter are removed and the puncture of the needle is covered with a small dressing.

The treatment lasts about 20-30 minutes per leg. You may also have some foam sclerotherapy or some avulsions and then put on a compression stocking.

What happens after treatment?

Soon after your treatment, you will be allowed to go home. It is advisable not to drive, but to take public transport, walk or ask a friend to take you. You will have to wear the stockings for up to two weeks and you will be instructed on how to bathe. You should be able to go back to work right away and continue most normal activities.

You cannot swim or get your legs wet during the period when you are recommended to wear stockings. Most patients experience a feeling of tension along the treated vein and some feel pain in that area about 5 days later, but this is generally mild. Normal anti-inflammatory medications like ibuprofen are usually enough to relieve it.

Are all lasers the same?

l. Some new types of claim to cause less pain than standard lasers. There seems to be some truth to this, although the degree of pain experienced by most standard laser patients is minimal and easily tolerated. The new lasers have not undergone the same extensive clinical trials, and therefore we are uncertain as to whether they will be as effective, especially in the long term.

Will I need more treatment?

If you are receiving treatment only to relieve symptoms, no further treatment is usually necessary. However, most patients also want to improve the appearance of their veins, and of these, about 80% will require additional treatment. Varicosities usually become less obvious after EVLA, but they rarely disappear completely.

Additional treatment for varicosities may be avulsions or foam sclerotherapy. These additional treatments can be carried out at the time of the EVLA or more generally after a delay of 4-6 weeks. If you have extensive varicose veins in both legs, it is highly unlikely that all further treatment will be possible at the time of EVLA.

Avulsions are performed after local anesthetic solution has been injected around the veins to numb the area. Small incisions are made in the veins and removed with a crochet hook. You may need many small incisions, but they heal easily without stitches and minimal scarring.

Foam sclerotherapy is the most common means of treating residual varicose veins after EVLA and is very effective for them.

What are the complications?

Serious complications after EVLA are very rare.

Thrombophlebitis: EVLA works by heating the vein wall, and an inevitable and deliberate response to heat is inflammation of the vein wall. You may feel that the vein that has been treated becomes hard and tender. Varicose veins that feed on the treated vein can also become hard and lumpy as a blood clot forms inside them. This clot is not dangerous, and your body will naturally absorb it for a few weeks.

Nerve damage: Because the nerves can be next to the veins, they can also be damaged by heat or avulsions, and some patients notice small patches of numbness on the skin. These generally resolve within a few months.

Burns: Although it is possible to burn the skin with the laser in practice, this is very rare.

DVT: a DVT is a blood clot in the deep veins of the leg. It is a recognized complication of surgery and can be dangerous if the clot breaks free and travels to the lungs. The risk of getting DVT after EVLA is very low, but it has been reported.

What procedure is right for me?

Many patients considering EVLA are confused as to which treatment to follow. This is not surprising as there are several options including doing nothing, having an operation, and several new non-surgical treatments such as Foam Sclerotherapy, RFA (VNUS), and EVLA.

Much will depend on the experience of your vascular specialist. Some surgeons still only perform surgery, but most now offer at least one of the new treatment options. Doing nothing is a good option if you are not bothered by the appearance of your veins and are not causing significant symptoms. There is no medical need to treat most varicose veins.

Wearing stockings is a good option for those with symptoms but who are not concerned with the appearance of their legs and are willing to wear stockings for the rest of their lives.

Surgery is rarely required, but some patients prefer it, especially those who wish to receive general anesthesia, those who do not like injections, and those with extensive varicose veins in both legs who want all treatment to be done in one session.

If you want definitive treatment but want to avoid surgery and general anesthesia and return to your normal activities quickly, you should consider one of the following treatments:

• Foam sclerotherapy is good, especially for people with less extensive veins who are willing to accept the possible need for several treatment sessions and the possibility that the veins will reappear in the future and that additional treatment is necessary. It is the least invasive option.
• RFA (VNUS, RFITT) is good for those with a long and wide straight vein segment that requires treatment. Approximately 70% of patients are RFA eligible.
• EVLA is suitable for almost all patients, no matter how short or wide their veins are. The method and results of the treatment are almost identical to those of RFA and EVLA.

note well Foam sclerotherapy, RFA and EVLA require at least two treatment sessions in most patients. Wait at least 8 weeks to see the full effect of the treatment. Consult the information on all the different options and ask for the advice of your specialist before making a decision on the right treatment for you.

Dr. Sridhar Devu has 11 years of expertise in Radio Diagnosis, Image-guided Interventions, Minimally invasive Endovascular Interventions and Daycare Oncology