ENDOVENOUS LASER THERAPY
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 are increasingly being used instead of surgery to treat incompetent
segments of the great saphenous vein (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.
Endovenous laser ablation (EVLA) works by means of thermal destruction
of venous tissues. Laser energy is delivered to the desired incompetent
segment inside the vein through a bare laser fiber that has been passed
through a sheath to the desired location. A variety of laser
wavelengths are in use for this procedure. When the laser is fired, it deposits thermal energy
in the blood and venous tissues, causing irreversible localized venous
tissue damage. The laser is most commonly delivered continuously as the
laser fiber is gradually withdrawn along the course of the vein until
the entire vessel is treated. Although a hole may be created in the
vessel wall where the laser beam makes contact with it, permanent
ablation of the vein is caused by thermal injury to the entire
circumference of the vessel.
Endovenous laser ablation (EVLA) is performed with the
patient under local anesthesia using large volumes of a dilute solution
of lidocaine and epinephrine.
Adequate and proper compression is vitally important after any
venous procedure. Compression can reduce the (theoretic) risk of venous
thromboembolism, and it is also highly effective in reducing
postoperative bruising and tenderness.
Immediately after the
procedure, a class II compression stocking (ie, one with a gradient of
30-40 mm Hg) is applied to the treated leg. Thigh-high– or
panty-hose–style stockings are used. The stockings are worn for at
least 1 week; they are kept in place continuously for the first 72
hours, but they may be removed for showering thereafter. Bedrest, hot
baths, heavy lifting, and long travel are generally forbidden for
approximately 1 week, but aerobic activity is encouraged.
The patient is usually reevaluated between
postoperative days 3 and 7. At 4-6 weeks, an
examination should reveal clinical improvement of truncal varices, and
an ultrasonographic evaluation should demonstrate a completely closed
vessel and no remaining reflux. If any residual open segments or branch
veins are noted, sclerotherapy may be performed under ultrasonographic
guidance.
Complications
Reports
of major complications following endovenous laser ablation (EVLA) are
rare. Rates of Deep Vein Thrombosis is lower than 1%.
Endovenous
techniques have largely replaced surgical vein stripping in many
countries as the first-line treatment for saphenous incompetence.
Contraindications to EVLA- 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
