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Endolaser surgery: a novel technique for the treatment of superficial varices

An article from the e-journal of the ESC Council for Cardiology Practice

Although “varices” are a frequent finding of a physical examination, in many cases they may signal significant venous regurgitation. High ligation and stripping is the technique of choice for cases with saphenofemoral leaks and vena saphena magna insufficiency.
However, traditional surgery holds a greater risk of complications and recurrence rates than endovenous laser surgery - a minimally invasive method.
Endolaser surgery is suitable for outpatient usage in private office conditions. With less pain, lower costs, and shorter recovery periods, satisfaction is high.



I – Superficial Varices of the lower extremities

a) Epidemiology and diagnosis

The superficial venous system insufficiency of the lower extremities is a common pathology. It occurs in 25% of females and 15% of males (1). Women are affected nearly twice as often as men are. Although “varices” are a frequent finding of a physical examination, in many cases they may be a sign of significant venous regurgitation.
The venous system is comprised of deep, superficial and perforating components. Saphenofemoral and saphenopopliteal junctions, as well as perforating veins, direct the circulation from the superficial veins into the deep veins (2). Failure to one of these parts results in the system’s incompetence as a whole.

Varicose veins are classified as primary – due primarily to congenital pathologies of the vessel wall or valvular structures – and secondary – when valvular damage occurs after recanalisation of the thrombosis or inflammation of the vessel. Obesity, constipation, trauma and occupational factors are responsible for the occurrence of venous insufficiency (3,4,5).

Diagnosis begins with a physical examination in the up-right position. Abdominal and pubic examinations are also necessary. Non-invasive diagnostic tools are gold standard. Duplex ultrasound tests conducted by an experienced physician reveal anatomical and pathophysiological variations which are important factors that help to decide on treatment methodology.

b) Principles of treatment and traditional treatment

Reflux must be annihilated from the most proximal level, and incompetent venous segments need to be ablated. The vena saphena magna and the saphenofenoral junction are responsible for lower extremity venous regurgitation in the vast majority of patients. The aim of therapy therefore is to exclude these structures. High ligation and stripping is the technique of choice for cases with saphenofemoral leaks and vena saphena magna insufficiency. However, traditional surgery holds its own risk of complications and recurrence rate. The need for local or general anaesthesia and hospitalisation for at least two days is one of its disadvantages.

II - Minimally invasive treatments

Electrocoagulation, ultrasound guided sclerotherapy, bipolar radiofrequency and endovenous laser therapy are other modalities, but contrary to traditional surgery, these methods are minimally invasive. Endovenous laser treatment for lower extremity venous insufficiency was first published in 1998. Ablation of the affected vein using radiofrequency, for instance, is the proper treatment method (2,3).

a) Endovascular Laser therapy : methodology

LASER (Light Amplification by the Stimulated Emission of Radiation) is a method using light energy generation. Laser has been in medical application since the 1960s.

For the laser treatment of any pathology, using the appropriate wave length, and selecting the right amount and location of tissue is essential. Tissue energy varies depending on the wave length used - 980 nm is optimal for hemoglobin. For endovenous treatment this wave length is the preferred wave length. The Laser energy is directed through a fiber optic catheter to the site of application. It can be safely used for vena saphena magna and its tributaries, reticular veins, telengiectazias, varicose veins and venous ulcerations (3,4,5,6).

Endovenous laser treatment is a minimally invasive method. It is suitable for outpatient usage in private office conditions. With less pain and shorter recovery periods, satisfaction is high. Its cosmetic and clinical results are immediate and there is a lower risk of intervention-linked infection when compared to surgery. There is no need for hospitalisation and the method is highly cost effective (6,7).
Contraindications of the method are: pregnancy, disturbances of the lower extremity arterial circulation, immobility, a poor general condition, deep vein thrombosis and a tendency to thrombosis or bleeding. Side effects are very rare and most of them are easy to tolerate: deep vein thrombosis, pulmonary emboli, skin burns, indurations, sensitivity and thrombophlebilits(4,5,6,7).

b) Endovascular laser therapy: advantages

The disadvantages of traditional surgery are mainly the advantages of endovenous laser in that they are existant in former and inexistant in the latter : anesthesia induced problems, increased hospitalisation costs, an ineffective use of resources and surgery related complications. In addition, many patients fear “surgery” itself while minimally invasive techniques and mainly endovenous laser offer increased patient comfort and decreased risk and costs. This method can be applied under local and tumescent anaesthesia in private office conditions with no need for hospitalisation, general anaesthesia and there being no lost ability to work. A Doppler ultrasonography imaging is mandatory for initial puncture of the vena saphena magna and visualisation of the appropriate placement of the catheter tip just 2 cm below the drainage of vena epigastrica inferior to the greater saphenous vein. The total duration of the procedure is approximately 30 to 45 min. Vena saphena magna obliteration by laser induced fibrosis can be immediately visualised after the intervention with a Doppler examination. Compressive stockings have to be worn on the table and low molecular weight heparin must be prescribed for 5 days.
There is no reported recanalisation on short term follow up and midterm results are also better than with surgery. Patients return to their normal life on the first post-intervention day without any limitations.

The disadvantages of traditional surgery are mainly the advantages of endovenous laser in that they are existant in former and inexistant in the latter : anesthesia induced problems, increased hospitalisation costs, an ineffective use of resources and surgery related complications. In addition, many patients fear “surgery” itself while minimally invasive techniques and mainly endovenous laser offer increased patient comfort and decreased risk and costs. This method can be applied under local and tumescent anaesthesia in private office conditions with no need for hospitalisation, general anaesthesia and there being no lost ability to work. A Doppler ultrasonography imaging is mandatory for initial puncture of the vena saphena magna and visualisation of the appropriate placement of the catheter tip just 2 cm below the drainage of vena epigastrica inferior to the greater saphenous vein. The total duration of the procedure is approximately 30 to 45 min. Vena saphena magna obliteration by laser induced fibrosis can be immediately visualised after the intervention with a Doppler examination. Compressive stockings have to be worn on the table and low molecular weight heparin must be prescribed for 5 days. There is no reported recanalisation on short term follow up and midterm results are also better than with surgery. Patients return to their normal life on the first post-intervention day without any limitations.

The disadvantages of traditional surgery are mainly the advantages of endovenous laser in that they are existant in former and inexistant in the latter : anesthesia induced problems, increased hospitalisation costs, an ineffective use of resources and surgery related complications. In addition, many patients fear “surgery” itself while minimally invasive techniques and mainly endovenous laser offer increased patient comfort and decreased risk and costs. This method can be applied under local and tumescent anaesthesia in private office conditions with no need for hospitalisation, general anaesthesia and there being no lost ability to work. A Doppler ultrasonography imaging is mandatory for initial puncture of the vena saphena magna and visualisation of the appropriate placement of the catheter tip just 2 cm below the drainage of vena epigastrica inferior to the greater saphenous vein. The total duration of the procedure is approximately 30 to 45 min. Vena saphena magna obliteration by laser induced fibrosis can be immediately visualised after the intervention with a Doppler examination. Compressive stockings have to be worn on the table and low molecular weight heparin must be prescribed for 5 days. There is no reported recanalisation on short term follow up and midterm results are also better than with surgery. Patients return to their normal life on the first post-intervention day without any limitations.

Conclusion

For all the advantages that endovenous treatment of varicose veins and superficial venous insufficiency presents, we think that this treatment method, for this common but underestimated pathology, will win the interest of the community (6,7).

References


1. OH CK, JUNG DS, JANG HS, et al. Endovenous Laser Surgery of the Incompetent Greater Saphenous Vein With a 980-nm Diode Laser. Dermatol Surg 2003;29:1135–1140.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14641341&query_hl=1
2. Gérard JL, Desgranges P, Becquemin JP, et al. Peut-on traiter les grandes saphénes variqueuses par laser endoveineux en ambulatoire. J Mal Vasc 2002; 27: 222-285.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12457128&query_hl=3
3. Navarro L, Min RJ, Boné C. Endovenous laser: A minimally invasive method of treatment for varicous veins – Preliminary observations using an 810 nm diode laser. Dermatol Surg 2001; 27: 117-122.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11207682&query_hl=5
4. Min RJ, Khilnani NM. Lower extremity varicosities: Endoluminal therapy. Seminars in Roentgenology 2002; 37: 354-360.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12455132&query_hl=7
5. Proebstle TM, Gül D, Kargl A, et al. Endovenous laser treatment of the lesser saphenous vein with a 940 nm diode laser: Early results. Dermatol Surg 2003; 29: 357-361.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12656813&query_hl=9
6. Proebstle TM, Sandhofer M, Kargl A, et al. Thermal damage of the inner vein wall dur,ng endovenous laser treatment: Key role of energy absorption by intravascular blood. Dermatol Surg 2002; 28: 596-600
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12135514&query_hl=12
7. Zimmet SE, Min RJ. Temperature Changes in Perivenous Tissue during Endovenous Laser Treatment in a Swine Model. Journal of Vascular and Interventional Radiology 2003; 14: 911-915.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12847199&query_hl=14

VolumeNumber:

Vol4 N°10

Notes to editor


Öztekin Oto1, Kivanç Metin2, Murat Çelik3, Murat Aygün4
1 Dokuz Eylül University Faculty of Medicine Department of Cardiovascular Surgery, Izmir, Turkey
2 Ege Saglik Hospital Department of Cardiovascular Surgery, Izmir, Turkey
3 Ege Saglik Hospital Department of Anesthesiology, Izmir, Turkey
4 Ege Saglik Foundation Department of Radiology, Izmir, Turkey
Past-Chairman of the ESC Working Group on Cardiovascular Surgery

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.