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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 The laser is most commonly delivered continuously as the laser fiber is gradually withdrawn along the course of the vein until the entire vessel is treated.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.

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

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