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Endovenous Laser Therapy

Introduction

Indications

Before The Procedure

Procedure

Postoperative Instructions

Risks

Treatment Alternatives

Related Information

Introduction 

At The Vein Centre we use the ELVeS® Radial Fiber with the Endo Laser Vein System. This is the first radial (360⁰) emitting fiber used worldwide for endovenous laser treatments of the great and small saphenous veins (superficial veins). 

This fiber applies energy faster and more accurately than any other fiber available in the endovenous market. The radial energy ensures consistent destruction of the vein wall as light energy is converted to heat energy when absorbed by water in the vein wall allowing safe closure of the vein. This also avoids any damage of the vein wall and associated heat irritation of the surrounding tissues, minimising pain and bruising during and after the procedure. Because the light energy is emitted from the tip of the fiber at 360 degrees ie as a circle/doughnut, only 1/9 of the energy is required for successful vein closure compared to cheaper end emitting fibers.  Pain and bruising is 20 times less compared to the cheaper end emitting fibers Schwarz et al J Vasc Surg 2010.  This means the procedure can be performed without sedation nor general anaesthetic. The average pain score during treatment is 2.5/10. The procedure does not require that you interrupt your professional nor domestic activities and 75% of patients require no analgesia post procedure.

An alternative way to heat seal a vein is use of radiofrequency ablation (RFA).  This involves direct delivery of an electric current to the vein wall.  When compared to the old low wavelength lasers and cheaper end-emitting fibers it was found to have slightly less pain and bruising than laser.  However, we now know the radial fiber has 20 times lower pain and bruising compared to the cheaper end-emitting fibers. Patients who undergo RFA almost always require a general anaesthetic or strong sedation.  RFA is only suitable for small diameter veins.  We also know the failure rate of RFA is far higher than laser. The probability of the GSV being ablated was about 10 times more likely when the mechanism used to treat the original ablation was laser 1320 (modern high wavelength laser) as opposed to RF"   R. G. Bush, P. Bush, J. Flanagan, et al., “Factors Associated with Recurrence of Varicose Veins after Thermal Ablation: Results of The Recurrent Veins after Thermal Ablation Study,” The Scientific World Journal, vol. 2014, Article ID 505843, 7 pages, 2014. https://doi.org/10.1155/2014/505843.

 

Indications

This procedure is an effective treatment for varicose veins, also referred to as superficial vein reflux, superficial venous insufficiency and superficial venous incompetence. Varicose veins are caused by the pooling of blood as a result of veins that are overstretched and cannot properly return blood back to the heart. Over time the vein may bulge and twist and become unsightly. Problems in larger underlying veins cause venous hypertension or increased pressure in the in the legs.

EVLT is suitable for veins that are relatively straight, as it involves passing a long fiber inside the vein. Veins that are very tortuous or twisted are better suited to other procedures such as Ultrasound Guided Sclerotherapy and Ambulatory Phlebectomy. Most patients have a combination of straight and tortuous veins, and therefore require a multifaceted approach to treatment. The superficial venous system is like a tree, there are trunks (straight veins) and branches (tortuous veins).  EVLT is for the trunks.

 

Before The Procedure

  • Patients must avoid long flights and general anaesthetics for four weeks prior to and post the procedure. Long flights are classified as four hours or more. For a three-hour flight, the requirement is three weeks and for a two-hour flight the requirement is two weeks. There are no restrictions on a one-hour flight.
  • Wear below knee compression stockings in the days leading up to the procedure. This will reduce the venous pressure in your legs, and may also reduce sensitivity during the procedure.
  • Take a bath or shower just before the procedure, as you will not be able to wet the leg(s) until the day after the procedure.
  • Mapping of the veins to be treated will be performed prior to your procedure.  This involves application of texta marks to your legs.  These will need to be maintained with the texta provided until a nurse advises you to wash them off. These generally stay on well but should be checked daily and reinforced as required. Do not apply moisturiser as the marks will come off. 
  • Please do not apply artificial tanning products for one week prior to the procedure to ensure that visible veins can be easily identified throughout the treatment process. 
  • Fasting is not required for the procedure. Please have a light breakfast or lunch prior to your procedure. Be well hydrated.
  • Wear loose-fitting clothes and comfortable shoes.
  • You should take your normal medications on the day of the procedure. The procedure can be done while taking blood thinning medication, although it is important to notify the doctor if you are taking any blood thinners such as Warfarin, Apixaban, or Clexane. Please bring a list of your current medications with you, if not already provided.
  • You can drive home after the procedure. If you require sedation for the procedure, you must arrange for someone to drive you home. Less than 0.5% of patients require sedation, such as those who have a needle phobia or suffer from anxiety. If your drive home involves an extended period of driving, please stop after each hour of sitting and walk for 15 minutes to promote blood circulation.
  • You will need to wear thigh length Grade 2 compression stockings after the procedure. If you have stockings at home, please bring them with you so the nurse can confirm if they are suitable. Otherwise, you will be fitted and supplied with Grade 2 compression on the day of the procedure (as listed in your quote).
  • Finally, make sure to be relaxed. Both the local anesthesia and the procedure are very well tolerated. 

 

During The Procedure

This treatment is performed at The Vein Centre in our laser procedure room or at the Epworth Hawthorn as a Day Procedure. We use ultrasound to provide direct vision of the vein and to guide the whole procedure. If you have your procedure at Epworth Hawthorn, you will be required to fill in Epworth paperwork and send it through to the hospital prior to the procedure. The hospital will call you leading up to the procedure and confirm that you must arrive one hour before the procedure start time.

When you arrive, you will be asked to change into a gown, removing your lower garments down to, but not including, your underpants. We will then take baseline observations such as your pulse rate, blood pressure and oxygen saturation level. You will be given a small subcutaneous injection into your abdomen with a blood thinner called Clexane (unless already on blood thinning medication). A small amount of local anaesthetic is injected under the skin at the laser fiber entry point, and at 10cm intervals along the vein. Your leg(s) will then be washed with antiseptic solution and covered with sterile drapes.  

A small 1mm incision is all that is required to access the vein. Once the fiber is in position, very dilute local anaesthetic is then injected around the length of the vein. This type of anaesthesia is known as Tumescent Anaesthesia. It is used to numb the vein and tissues around the vein. It also provides a safety buffer for soft tissues around the vein, allowing the dissipation of heat that is created by the laser. The laser machine is then turned on and slowly withdrawn along the length of the vein, directly closing the vein. You will hear the nurse counting at this time as the doctor pulls the laser fiber down the length of the vein at a set rate. As this fiber is pulled out, the vein is heat sealed shut creating immediate vein closure. While the laser is active, everyone in the procedure room will wear laser safety goggles. This is for eye protection, in the unlikely circumstance, the laser is activated outside the vein.

The doctor will apply steri-strips and a small waterproof dressing to the incision. The nurse will apply a small additional pad and Grade 2 thigh length compression stockings before you leave the bed. You will first rest for 10 minutes. You will then walk for 20 minutes and return briefly to the rooms as the nurse will check your dressings and confirm your readiness to go home. The entire stay at the rooms takes approximately two to three hours. You will return within a day or two after the procedure for an ultrasound to monitor closure of the vein and check for the very small possibility of deep venous thrombosis. Should you require Ultrasound Guided Sclerotherapy, your leg will also be mapped for that procedure at this time.

 

After The Procedure

  • Active walking is required immediately after the procedure and on a daily basis. After the procedure you will rest for 10 minutes followed by a 20-minute walk. Walking is the best and most natural way to prevent any complications, although they may occur very rarely with this procedure. You are required to complete a minimum of 20 minutes of continuous walking daily for one week, although we encourage as much walking as possible.
  • Normal daily activities can usually commence straight away, however, there are some restrictions. Do not spend long periods of time on your feet and when seated keep the leg(s) elevated (knees slightly bent) as much as possible during the first 48 hours. Avoid long periods standing still for the next week. Strenuous activity is best avoided for one week after the procedure. Strenuous activity includes, but is not limited to, heavy lifting more than 10kg, running, swimming, yoga, and Pilates. 
  • Compression stockings should be worn overnight for the first night. They can be removed in the morning for showering and immediately reapplied. Take off the padding taped over the dressings prior to showering. The laser markings can now be washed off. Leave the waterproof dressings and steri-strips intact for three to five days. Remove the dressing if they start to leak and leave steri-strips intact. After the first night the compression stockings can be removed at bedtime, but should be worn during the day for a total of one week after the procedure.  If you have a very high in-step, occasionally the compression stockings can become painful overnight with a burning feeling in the heel or top of the foot.  Should this occur, it is OK to remove the stockings for the night.
  • Patients must avoid long flights and general anaesthetics for four weeks after the procedure. Long flights are classified as four hours or more. For a three-hour flight the requirement is three weeks and for a two-hour flight the requirement is two weeks. There are no restrictions on a one-hour flight.
  • Post-procedural pain should be minimal and easily controlled with Panadol. At The Vein Centre our data shows that 75% of our patients do not require analgesia after the procedure. 
  • Avoid excessive sun exposure for two weeks following the procedure. Avoid any direct leg treatments that may affect the skin and risk for pigmentation (e.g., laser hair removal, waxing, and chemical peeling). 
  • Bruising, local swelling, and some tenderness are normal after treatment. This should be temporary. Aching in the leg may persist for up to two weeks.
  • Signs that may be of concern include tenderness associated with redness and warmth. This could indicate infection or a local inflammatory response, known as superficial thrombophlebitis. Infection would generally be accompanied by systemic symptoms such as fever, loss of appetite, and fatigue, and is best treated with antibiotics and drainage where necessary. At The Vein Centre we have only had one minor wound infection in over 10 years and 2000 procedures. A local inflammatory response known as superficial thrombophlebitis is more common. This is not accompanied by systemic symptoms.

If bleeding appears on the stockings, please elevate your leg and apply local compression. Dr Campbell should be contacted via mobile phone 0412 509 504, at the Rooms on 9429 4111, or via the Epworth Hospital on 9426 6666.

Risks

Deep Venous Thrombosis (DVT) 

​​People with varicose veins are 4-9 times more susceptible to DVT. These blood clots can also form in the deep veins as a result of your varicose vein treatment. This is extremely rare and, in fact, we have never had a major deep vein thrombosis at The Vein Centre.  The risk of a minor, calf deep vein thrombosis is 0.1%.  It is important patients follow instructions regarding stockings and walking. If you are unable to perform the required walking please discuss this with the doctor prior to your procedure.  DVT is most likely to occur in patients who have significant risk factors for thrombosis. This includes those who are smokers, overweight, have poor mobility, do not comply with post-procedure orders such as walking and compression, and those patients who have a past history of DVT or a thrombophilic disorder. Your risk of DVT is doubled if you are taking any form of hormone treatment such as the oral contraceptive pill, hormone replacement therapy, or a hormone containing IUD (i.e. Mirena). You may consider ceasing the hormone treatment one month prior to treatment and one-month post treatment to reduce the elevated risk of DVT. However, the consequences of unplanned pregnancy and return of menopausal symptoms must be considered.  There are also potential unquantified risks of treatment during pregnancy.  

Injury to nerves 

Veins and nerves lie close together. These nerves can be stretched when veins are removed or damaged or when exposed to high temperatures. This can result in localised numbness that is usually temporary and recovers within 12 months, although will typically resolve well before that time. Rarely this loss of sensation is permanent or could be painful, however, it does not affect function of the leg and diminishes with time.  It is important you are not B12 deficient.  If you have poor digestion, have taken acid blocking medication for indigestion or stomach ulcers, have inflammatory bowel disease or eat little or no red meat, we recommend you supplement with a soluble B12 supplement prior to the procedure (please discuss this with the doctor or nursing staff for recommendations).  

Infection 

One of the most significant advantages of EVLT is the avoidance of a groin incision. This minimises the risk of infection significantly. Only small incisions are made, and the procedure involves very little trauma to tissues surrounding your varicose veins, hence the risk for infections is very low.

Haematoma 

A haematoma is a collection of blood within the soft tissues. This is usually prevented by compression. This may be felt as a firm lump with associated bruising and discomfort.  Once formed, it would not be expected that it would continue to increase in size. It is not dangerous and almost always dissolves over time. It is best managed with compression and massage and use of Hirudoid cream.

Laser burn 

The laser creates heat when it is active. The tumescent anaesthesia acts as a cool barrier to minimise heat dissipation outside the vein.  The treated vein sometimes lies close to the skin, especially if you are very lean. The tumescent anaesthesia also pushes the vein away from the skin to minimise any chance of skin burn. No patient has ever had the complication of a skin burn in our practice. The laser is never activated outside the vein, also minimising any risk of laser injury to skin and eyes.  

Scarring 

Incisions are very small so scarring is minimised. Please tell the doctor If you have a tendency to develop keloid scarring.

 

Treatment Alternatives

Open Surgical Stripping

Internationally (UK, USA and Europe) open surgical stripping is now considered to be 3rd line treatment and only to be considered if thermal ablation and ultrasound guided sclerotherapy are not available or nor suitable.

Surgical treatment usually requires an operation in hospital under general or regional anaesthesia.  An ultrasound is performed pre-operatively to identify areas of venous incompetence. The procedure usually takes between one to three hours depending on how extensive the disease is. Your legs are marked with texta pre-operatively to identify the superficial veins that also need removal. 

An incision, approximately 5cm in length, is made in the groin and/or behind the knee. A plastic fiber is then inserted into the vein and the vein is stripped out from the groin to just below the knee, where a further 1-2cm incision is made to remove the vein. Further small incisions, 3mm in length, are made to remove the superficial veins that were marked pre-operatively. The incisions are closed using absorbable suture (it does not need to be removed).  

A moderate amount of blood loss can occur. Your legs are then bandaged in soft cotton padding and a firm elastic bandage.  An overnight stay in hospital may be required. The bandages are removed the following day and a thigh length compression stocking is applied. This is worn day and night for the first week then during the day only for one to two weeks. Recovery from surgery takes approximately three weeks. Two to three weeks off work is usually required. The recurrence rate (further varicose veins appearing) is around 20% (great saphenous vein) and 40% (small saphenous vein). Boersma et al J Endovasc Surg 2016.

 

The advantages of EVLT over surgery include:

  • Less pain and bruising;
  • Fewer scars;
  • No stay in hospital;
  • No General Anaesthetic;
  • Short treatment time;
  • Excellent medical and cosmetic results;
  • Rapid return to normal activities;
  • Higher success rate;
  • Significantly lower complication rate.

 

 

Ultrasound Guided Sclerotherapy

Ultrasound Guided Sclerotherapy (UGS) involves injection of a sclerosant (vein wall irritant) under ultrasound guidance.  This is considered 2nd line treatment for the trunk veins.  It should only be considered when thermal ablation is not available.  The failure rate is comparable to surgical stripping, however, with lower morbidity compared to surgical stripping.  Please refer to our UGS handout for further information.  At The Vein Centre this procedure is generally reserved for treatment of the branches, not trunks.  It may be considered for trunk treatment if the trunk has previously been ablated in its more proximal extent.  

 

Frequently Asked Questions

Can I consume alcohol before and after the procedure? 

Yes, you can consume alcohol in moderation. Please stay well hydrated with water, as alcohol will dehydrate your veins.

 

Why do I have to avoid strenuous exercise after the procedure?

Once the vein is lasered we recommend allowing the vein time to heal shut. Pressure applied to the veins with strenuous exercise, or indirectly via the abdomen with lower impact exercise such as yoga and Pilates, can reopen the treated veins.   

 

What happens if I get foot pain while wearing my compression overnight?

If patients have a wide foot instep (between the heel and the top of the foot), newly applied compression can be tight and may cut off circulation to the skin. As a result, you may feel a burning pain that begins once you are lying down. If this occurs, please do not hesitate to remove the compression to sleep as your legs will naturally be elevated. The pain will not resolve otherwise. 

 

How long do I need to wear my compression for?

Your compression should be worn one night overnight after the procedure. They can be taken off in the morning for a shower and immediately reapplied. Compression should be worn daily (first thing in the morning until bed) for one week from the date of the procedure. If you have another procedure within the same week, please take note of the aftercare related to compression for that particular procedure (not all procedure aftercare requirements are the same). 

 

Can I wear shoes with a heel? 

Yes, however, you are advised to wear walking shoes for your daily walk.

 

What should I do if my leg still feels numb after the procedure?

Numbness is not uncommon after EVLT.  The numbness should not be bothersome and should gradually decrease in size with time. If you begin to feel any associated nerve symptoms, such as pins and needles, shooting pain, or tingling, we recommend using a topical analgesic cream called Zostrix. This can be a good sign that the feeling is returning.  Zostrix cream is made from chili pepper (capsaicin) and helps to reduce the transmission of pain impulses.  It should be used immediately upon noting any additional nerve symptoms (apart from reduced sensation).   

Zostrix (0.025% strength) can be purchased over the counter at the chemist. Apply a small fingertip amount to the affected area only three to four times per day. It is also recommended to wear gloves and thoroughly wash your hands after application to avoid contact with sensitive areas, such as the eyes. Additionally, if you have preexisting nerve impairment or eat very little red meat, it is advised that you take a vitamin B12 supplement to protect nerve function and aid in the prevention and management of numbness associated with the procedure.  We recommend the Bioceuticals Methyl B12 Chewable tablet which is absorbed through the lining of your mouth.

 

What’s the next step after my treatment is finished?

After you have completed all necessary treatment, we will arrange for a one-month review ultrasound (standard fee with Medicare threshold rebate) to ensure all treated veins remain closed. We will then arrange for a 6 month and then annual review ultrasound to monitor for any new venous insufficiency.   

 

Is this treatment a cure for varicose veins?

Venous disease requires life long care. While we can treat your presenting problems, over time it is possible to develop venous disease in new veins. This is why we recommend annual follow up. We believe that early intervention will generally result in less extensive treatment and prevention of the problems associated with varicose veins such as swelling, tissue damage, ulceration and increased incidence of deep vein thrombosis. Your tendency to develop new superficial venous disease will depend on your risk factors, including heredity and lifestyle. We encourage you to stay active avoiding long periods sitting and standing, maintain a healthy weight, and eat a nutritious diet. Wearing compression stockings or sports wear may also help reduce the progression of new disease. 

 

Please do not hesitate to contact the rooms if any of your questions or concerns have not been addressed above or any symptoms you are experiencing have increased in severity.

 

Questions? Please feel free to document any questions so you don’t forget to ask before the procedure.

 

Dr Claire Campbell
Compression Fitting Service
Ultrasound
Deep Vein Thrombosis
Superficial Thrombosis and Thrombophlebitis
Varicose Veins