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410 Percutaneous laser therapy of telangiectasia and varicose veins
https://t.me/med1917
Table 34.1 Causes of leg telangiectasia
Primary telangiectasia
Nevus flammeus
Klippel–Trenaunay syndrome
Neavus anemicus with telangiectasia
Angiomas and angiokeratomas
Angioma serpiginosum
Hereditary hemorrhagic telangiectasia (Osler–Weber–
Rendu syndrome)
Ataxia telangiectasia (Louis–Bar syndrome)
Generalized essential telangiectasia
Hereditary benign telangiectasia
Spider telangiectasia
Bloom’s syndrome
Secondary telangiectasia
Causes associated with chronic venous disease
Idiopathic telangiectasia (C1 according to CEAP
classification)
Dermatitis/capillaritis alba (C4 according to CEAP
classification)
Exogenous causes
Toxic exposure to infrared radiation, ultraviolet light or
X-rays
Exposure to toxic or allergenic chemicals
Microbiological agents (e.g., acute [red] and chronic
[bluish] Borrelia infection)
Blunt tissue trauma
Cutaneous drug reactions (e.g., corticosteroids)
Autoimmune disease
Lupus erythematosus
Dermatomyositis
Progressive systemic sclerosis
Morphea
Cryoglobulinemia
Causes with genetic background
Xeroderma pigmentosum
Goltz’s syndrome
Congenital poikiloderma (Rothmund–Thomson
syndrome)
Congenital neuroangiopathy (Maffucci syndrome)
Cutis marmorata telangiectatica congenital
Dyskeratosis congenita
Unilateral nevoid telangiectasia
Angiokeratoma corporis diffusum (M. Fabry)
sometimes require dierent treatment approaches. Several
classications have therefore been proposed to provide a
more detailed view of them.
Initially, leg telangiectasias have been described mor-
phologically by naming their pattern as linear, arborized
or Besenreiser-type, spider or star-like, and punctiform or
papular.
5
is morphologic view frequently helps to identify
Table 34.2 Classification of leg telangiectasia according
to Duffy
Type 1 Telangiectasia, spider vein
Type 1A Telangiectatic matting
Type 1B Communicating telangiectasia
Type 2 Mixed telangiectatic/varicose veins without
Type 3 Non-saphenous varicose veins (reticular veins)
Type 4 Saphenous varicose veins
11
and Goldman
0.1–1.0 mm diameter, color red to cyanotic
0.2 mm diameter, color red
Type 1 veins in direct communication with
varicose veins of the saphenous system
direct communication with the saphenous
system
Diameter 1–6 mm, color cyanotic to blue
Diameter 2–8 mm, color blue to blue–green
Usually diameter above 8 mm, color blue to
blue–green
12
the origin of the telangiectasia, where it may be connected
through a feeder vein with the more deeply located parts of
the venous system, and where any treatment would probably be most eective.
6,7
When laser treatment of telangiectasia was introduced,
the concept of the thermal relaxation time and selective
photothermolysis,8 the diameter of the vessel became the
most important parameter. Telangiectasias were separated into three groups: diameters below 0.2 mm, between
0.2and 1 mm, and between 1 and 2 mm. Veins with diameters greater than 2 mm are named reticular veins.
Additionally, the color of the vessel provides important
information. Due to general properties of light reection
and scattering, otherwise identical vessels appear more bluish if located deeper in the skin than those that are more
supercial.9 Furthermore, it has been demonstrated that red
and blue telangiectasias dier signicantly in their oxygen
saturation,10 implying that red vessels contain more arterialized blood than blue ones.
More recent classications of telangiectasias and visible
11,12
varicose veins
combine dierent aspects of the abovementioned criteria to be most helpful in daily clinical use
(Table 34.2).
34.4 PRE-TREATMENT DIAGNOSTICS
ANDREQUIREMENT
Before starting treatment of any venous disorder, a diagnostic workup including a physical examination, a patient
interview, and a duplex Doppler ultrasound should be
performed. During such a workup, the sources of pathological venous reux in the deep veins, in perforators, and
in the saphenous systems need to be identied, as well as
regions of hemodynamically relevant obstruction, if there
are any at all. Additionally, other reasons for the development of telangiectasias or visible varicose veins as listed in
34.6 Fundamentals of light–tissue interaction 411
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Table 34.1 need to be identied to prevent harm from laser
treatment.
Aer understanding the pathology of the leg’s venous
hemodynamics, if present, saphenous and perforator reux
need to be corrected rst before small supercial vessels
are addressed by any treatment modality. is strategy is
based on the frequent connections of visible varicosities and
deeper located incompetent veins,
6,7
and addresses venous
hypertension in the potentially laser-targeted telangiectasia.
34.5 PATIENT SELECTION
Any patient presenting with telangiectasia can receive laser
or IPL treatment as an alternative to sclerotherapy if there
is no contraindications as discussed above (section 34.2) are
present. Laser therapy is a modern, fast, and easy treatment
which oers the patient a treatment without needle injury,
without wound dressing and—in the hands of many physicians—also without post-treatment compression stockings. Unlike with sclerosants, there is no maximum total
dose of laser light. erefore, treatment of both legs in one
session is possible. Laser or IPL treatment of telangiectasia
are treatment options which combine perfectly with endovenous treatments of saphenous veins and are well suited
for patients who seek minimal impairment of quality of life
during and aer treatment.
ere are also indications for laser treatment in patients
who are unable to receive sclerotherapy, and the typical
reasons are:
●
Needle-phobic patients
●
Sclerotherapy-resistant telangiectasia
●
Telangiectatic matting
●
Patients with pronounced hyperpigmentation aer
sclerotherapy
●
Intolerance to sclerosants
34.6 FUNDAMENTALS OF LIGHT–TISSUE
INTERACTION
Successful treatment of telangiectasia with the use of lasers
or IPL sources has to meet a number of conditions which
are imposed by the physics of light–tissue interaction. e
most important parameters and conditions are listed in
Table 3 4.3.
e selection of a wavelength determines principally
whether the light energy can pass through overlaying skin
tissue and thereby reach the target tissue, in this case a
venous vessel of any given diameter at all. Between approximately 600 and 1200 nm, the human skin as a whole has a
so-called optical window, an absorption minimum of the
skin with an average absorption coecient in the order of
5 cm−1. e relevant chromophores of human skin that are
responsible for the absorption of electromagnetic energy in
this part of the spectrum are hemoglobin in the dermis and
melanin in the overlaying epidermis. Water only starts to
contribute at the infrared end of this part of the spectrum at
Table 34.3 Confounders of successful laseror intense
pulsed light treatment of telangiectasia
• Selection of wavelength according to the absorption
characteristics of the target and overlying tissue
• Sufficient dosing of the laser energy in terms of laser
fluence (J/cm
• Selection of laser pulse duration not to exceed the
thermal relaxation time of the target
• Oversizing of the beam diameter to correct the
penetration depth for scattering losses
• Achievement of homogeneous volumetric target
heating with an optimum combination of wavelength
selection, adjustment of laser fluence, and pulse
duration
• Adjustment of pulse duration with respect to the
patient’s pain perception
• Surface cooling for pain reduction and epidermal
rescue
2
) to achieve reliable vessel closure
wavelengths above 1000 nm. Figure 34.1 displays the most
important absorption curves. Two examples of epidermal
light absorption are given for fair skin and moderately
tanned skin with epidermal volume fractions of melanocytes of 3% and 15%, respectively, calculated as described
elsewhere.
13
In the dermis, the baseline absorption is char-
acterized by the absorption prole of hemoglobin. Figure
34.1 shows the curve with an estimated dermal blood con-
tent of 0.2% and a hemoglobin concentration in the blood
of 10 mmol/L. However, along the whole range of wavelengths, this absorption is about 100-fold weaker than the
absorption of blood alone, which is the laser target in any
transcutaneously treated vessel. As is easily seen, the 532nm wavelength is about 100-fold more strongly absorbed
by hemoglobin (231 cm−1) than the 1064-nm wavelength
(2.2 cm−1).14 e same is true of melanin, which absorbs
the 532-nm wavelength about eight-fold more strongly
(~400 cm−1) than the 1064-nm wavelength (~50 cm−1).
Water absorption does not play a role in both wavelengths.
In summary, the 532-nm wavelength penetrates signicantly less deeply than the 1064-nm wavelength in both
blood and bloodless skin (Figure 34.2).
14
e amount of laser energy which nally reaches the
target vessel determines whether the vessel will be permanently closed. When treating supercial veins, a sucient
uence will elicit an immediate visible reaction, such as
shrinkage or thrombosis of the vessel.14 Proper ranges of
uence are wavelength dependent and start from 4 J/cm2
for ashlamp pumped dye lasers when treating supercial
15
vessels of 0.1 mm in diameter
and can reach 580 J/cm2 in
long-pulse neodymium-doped yttrium aluminum garnet
(Nd:YAG) systems.
16
When administering the desired amount of laser energy,
the time in which it is delivered is also crucial. According to
the principle of selective photothermolysis,8 the laser pulse
duration should not reach the thermal relaxation time of the
412 Percutaneous laser therapy of telangiectasia and varicose veins
532 nm
b
Wavelength (nm)
d
Absorption coefficient (cm)
10,000.0
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Figure 34.1 Absorption spectrum of blood with oxygenated and deoxygenated hemoglobin at a concentration of
10 mmol/L. Epidermal absorption of moderately tanned and fair skin is calculated with melanosome volume fractions (f
of 15% and 3%, respectively. Dermal absorption is calculated with a blood volume fraction of 0.2% and oxygenated hemoglobin at a concentration of 10 mmol/L. All curves given in the wavelength range of between 250 and 1000 nm.
target tissue. ermal relaxation describes the time course
of heat transfer, usually by conduction, from the up-heated
target structure to the cooler surrounding tissue. e equation describing this phenomenon is an e-function, with the
thermal relaxation time as its time constant. Practically,
this means that if administering laser pulses longer that the
thermal relaxation time of the target tissue, the advantage
of higher absorption in the target tissue is lost. e magnitude of the thermal relaxation time can be estimated as
follows: its value in seconds is about the square of the target
diameter (e.g., the thermal relaxation time is about 250 ms
in a 0.5-mm diameter vessel or about 40 ms in a 0.2-mm
diameter vessel). Actually, the thermal relaxation times are
a little bit shorter than the estimates above, but in any case,
actual pulse durations should stay below. However, one
Figure 34.2 Semi-quantitative display of penetration
depths of 532 nm and 1064 nm into human skin according to the absorption characteristics shown in Figure 34.1;
a = epidermis, b = dermal layer, c = subcutaneous fat.
1000.0
100.0
10.0
1.0
0.1
0 200 400 600 800
1064 nm
Oxygenated blood
Hb = 10 mmol/L
Deoxygenated bloo
Hb = 10 mmol/L
Medium tanned skin
f
= 15%
mel
Fair skin
= 3%
f
mel
Dermis, 0.2% blood
Hb = 10 mmol/L
1000 1200
)
mel
should not stay below the thermal relaxation time by too
much. For example, for the 1064-nm ND:YAG laser, it has
been shown that longer pulse durations of between 20 and
60 ms consistently produce better clinical results than 3-ms
pulse durations in vessels with a mean diameter of 0.8 mm.16
Histopathology supports these ndings, showing marked
shrinkage of perivascular collagen with longer pulses, while
short pulses of 3 ms were only able to produce a thrombotic
occlusion of the vessel. In conclusion, it seems that substantial heat damage around the target vein, or at least solid heat
damage of the entire vessel wall, is a necessary condition to
achieving instant and durable vein occlusions. On the other
hand, longer durations of laser pulses are more painful than
shorter pulses,14 and therefore patients’ pain sometimes
does not allow for the administration of longer pulse durations; in particular, pulses above 100 ms duration are not
tolerated by many patients.
Additionally, for successful laser ablation of leg telangiectasia, the actual penetration depth of laser light should be
considered. Interestingly, this depth is not only dependent
on the wavelength of the laser light and its absorption characteristics, but also on its scattering behavior. e actual
a
penetration depth, therefore, can be increased by increasing the beam diameter (Figure 34.3). Due to the mentioned
scatter eects, the originally cylindrical laser beam forms
a pencil-like tip before being completely absorbed by surrounding tissue. However, because of the phenomenon of
forward scattering itself, the vanishing of the laser beam
c
takes longer and happens at greater tissue depth with larger
beam diameters.
Aer considering the absorption of skin tissue and
hemoglobin in general, the absorption characteristics of
the target structure, and the geometry of the vein vessel
itself, we need to take a closer look at the volumetric heating
a
b
c
a
532 nm 1064 nm
b
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Figure 34.3 Semi-quantitative display of a penetration
depth of 1064 nm into human skin according to different
beam diameters. Penetration is deeper for larger beam
diameters because of the physical effect of forward scattering (Mie scattering); a = epidermis, b = dermal layer,
c = subcutaneous fat.
34.7 Lasers and IPL for transcutaneous therapy of telangiectasia 413
the administration of cooled gel before laser treatment, or
laser ring through ice cubes are historical methods that
cannot guarantee reproducible results. Today, sophisticated
dynamic spray cooling devices, chilled contact tips, or cool
air generators are available.
34.7 LASERS AND IPL FOR
TRANSCUTANEOUS THERAPY OF
TELANGIECTASIA
Meanwhile, treatment of telangiectatic vessels of the legs
has reached a level which allows transcutaneous treatment
in most of cases. ere was an evolutionary change in laser
parameters, particularly an increase of pulse duration and
uence and a move from visible light to near-infrared wavelengths. Today, a variety of laser and IPL systems are available for the treatment of leg telangiectasia of any diameter
between 0.1 and 2.0 mm.
issue. If using a wavelength which is absorbed too highly by
hemoglobin in vessels of larger diameter, the remote parts
of the vessel do not become suciently heated because the
energy is predominantly absorbed in the part that is rst
hit by the laser beam. In contrast, a wavelength which is
absorbed more moderately by hemoglobin is able to heat up
the vessel as a whole. Figure 34.4 displays this behavior for
a 532-nm laser beam in comparison to a 1064-nm beam.
For this reason, larger vessels with diameters in the order of
1 mm cannot be successfully treated with short laser wavelengths such as 532 nm, 585 nm, or even 595 nm.
To reduce pain and to minimize the risk of the numerous side eects elicited by heat damage of the skin, the use
of skin cooling is mandatory today. Local use of ice cubes,
c
Figure 34.4 Semi-quantitative display of different volume
heating effects of blood vessels caused by either 532-nm
or 1064-nm irradiation. Due to the higher absorption of
blood at 532 nm, larger vessels get heated only at the
most superficial parts, producing a form of shield for
more remote vessel parts, which stay cool. A 1064-nm
wavelength heats the vessel more uniformly due to the
lower absorption coefficient; a = epidermis, b = dermal
layer, c = subcutaneous fat.
34.7.1 532-nm potassium titanyl
phosphateLaser
e frequency-doubled 532-nm Nd:YAG laser system is particularly useful for the treatment of red leg telangiectasias
with small diameters below 0.7 mm. It is most eective if
used on skin types I–III and is problematic in tanned or
dark-skinned patients because of the high absorption of
melanin at this wavelength.
e 532-nm laser was initially used with uences of
between 14 and 20 J/cm2, pulse durations of 10–15 ms and
spot sizes of 3–5 mm in 50 patients with leg telangiectasias
of varying diameters. A total of 83% of patients showed
clearances of 50% or more aer two treatments. With the
abovementioned parameters and a chilled tip for contact
cooling, the 532-nm potassium titanyl phosphate (KTP)
laser proved to be less painful compared to laser systems
with longer wavelengths.17 In another 15-patient study,
clinical results were corroborated on telangiectasias of less
than 0.75-mm diameters. A clearance of more than 75%
was achieved aer two treatment sessions using a uence
of 16 J/cm
the same treatment area each session.18 Another study conrmed the favorable pain and side eect prole, but found
vessel clearance to be inferior to a long-pulse dye laser. e
authors recommended the use of the KTP laser system in
conjunction with sclerotherapy of larger feeding reticular veins.19 However, when using a multi-pulse mode with
three stacked pulses of 100-, 30-, and 30-ms durations (each
separated by a gap of 250 ms), a uence of 60 J/cm2, and a
beam diameter of 0.75 mm, clearance in leg telangiectasias
of 0.5–1.0-mm diameters was 85% aer three treatment
sessions and 93% aer four treatment sessions, most likely
taking advantage of met-hemoglobin formation during the
rst of the three pulses.
KTP laser was found on vessels with diameters of 0.7 mm
or more.
2
with 10-ms pulse duration and three passes over
20
In another work, no ecacy of the
21
414 Percutaneous laser therapy of telangiectasia and varicose veins
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In another study, 79 areas of 20 female subjects (skin
types I–III) were treated using a 532-nm KTP laser.
A5-mm diameter spot, uences from 13 to 15 J/cm², and
a pulse duration of 40 ms were used in two treatment session, 12 weeks apart. Blinded reviewers rated more than
50% improvements of telangiectasias in 69% of patients, and
hyperpigmentation was observed in only 2%.
22
34.7.2 578-nm copper bromide laser
e copper bromide laser is suited for red leg telangiectasia.
In a study of 46 patients, 75%–100% clearance was achieved
aer an average of 1.7 treatments of vessels with diameters
below 1.5 mm. Fluences were in the range of 50–55 J/cm2,
and a contact cooling system with a temperature of between
1°C and 4°C was used.
23
34.7.3 Flashlamp pumped-pulse dye laser
is laser was the rst to take advantage of the concept of
selective photothermolysis and the rst to achieve remarkable results in very small red vessels with diameters below
0.1 mm, like in telangiectatic matting. With a wavelength of
577 nm and pulse durations of 360 μs, this laser was shown
to be suitable for the treatment of infantile hemangioma
or port wine stains. It did not show remarkable eects on
patients with leg telangiectasia.24 When targeting blue leg
telangiectasia with a wavelength of 585 nm and a pulse
duration of 450 μs, it showed only very limited success,
with a clearance rate of 30% and frequent hyperpigmentation thereaer.
In the mid-1990s, dye lasers with 595-nm wavelengths
and pulse durations of 1.5 ms were introduced. One study
with uences of 15 or 18 J/cm2 showed clearance in up
to 65% aer a single treatment when treating vessels of
between 0.6 and 1.1 mm in diameter.26 Another study
reported 100% clearance in leg telangiectasias of below
0.5 mm in diameter and 80% in vessels with diameters of
between 0.5 and 1.0 mm.27 In 10 patients, more than 75%
clearance was achieved aer three treatments every 6 weeks
with minimal side eects using a 595-nm dye laser with
a 1.5-ms pulse duration. Fluences of between 15 and 20 J/
2
cm
were used on leg telangiectasias with diameters below
1.5 mm.28 Wavelengths of 595 and 600 nm were compared
in 87 patients with 257 treatment sites using 1.5-ms pulse
durations and uences of 16, 18, and 20 /cm2. A clearance
rate above 50% in up to 80% of patients was noted aer
a single treatment. e authors found best results with
higher uences on vessels of less than 0.5 mm in diameter.
Pigment changes were noticed in 32% of cases.29 e use
of a dynamic cooling device in conjunction with a 595-nm
wavelength and 1.5-ms pulse duration treatment reduced
patient discomfort without diminishing the average clearance rate of 68%.
pulse durations of 40 ms enabled treatment without or at
least with diminished production of purpuric lesions aer
laser treatment. With the use of an extended pulse width
25
30
e introduction of dye lasers with
of 40 ms and a uence of 16 J/cm2 and administering up to
three passes over the same location during one session, aer
a total of two treatment sessions, 70% of leg vessels showed a
clearance of 75%–100%. A −4°C air cooling system was used
during treatment.31 Aer only one treatment of submillimeter telangiectasia with the 595-nm dye laser at a 40-ms
pulse duration with a uence of 25 J/cm2 and spray cooling,
about half of patients had clearance of 50% or more. In the
same study, 532-nm KTP laser treatment with a 50-ms pulse
duration and a uence of 20 J/cm2 and contact cooling gave
similar results.
32
34.7.4 755-nm long-pulse alexandrite laser
e long-pulse alexandrite laser in the near-infrared at
a wavelength of 755 nm proved to be most eective in a
double-pulse mode (frequency: 1 Hz) at a uence of 20 J/
cm2 with pulse durations of 5–10 ms.33 Small vessels with
diameters below 0.4 mm did not show signicant response,
while larger telangiectasias showed a 63% reduction aer
three treatments at 4-week intervals. Subsequent sclerotherapy improved laser results signicantly. Another study
showed that long-pulse alexandrite laser treatment at 3-ms
pulse durations and uences of 60–70 J/cm2 for the treatment of veins of 0.3–3.0 mm in diameter frequently caused
signicant inammatory skin reactions, purpura, and telangiectatic matting. Despite this side eect prole, only 33%
of patients had more than 75% clearance aer up to three
treatment sessions.34 When using the 755-nm alexandrite
laser with a uence of 90 J/cm2, 15 of 20 patients had a clearance of between 25% and 75% of treated telangiectasias with
diameters of 0.3–1.3 mm. However, in 75% of cases, hyperpigmentation was noted.
35
34.7.5 Diode lasers of between 810 nm
and980 nm
No side eects but also no clearance of leg telangiectasia
were observed in a study using an 810-nm diode laser with
a 5-mm spot size and a pulse protocol of four consecutive stacked pulses (frequency: 2 Hz), each with a uence
of 3–4.5 J/cm
clearing by more than 75% were also reported by another
group using an 810-nm long-pulse diode laser on vessels
with diameters of between 0.3 and 3.0 mm.34 Using a 940nm diode laser with a 1-mm spot size, a pulse duration of
40–70 ms, and uences of between 300 and 350 J/cm2, a
single treatment resulted in a clearance of more than 75% of
treated telangiectasias in 12 of 26 patients (46%).37 e same
authors published the results of an additional 1-year followup with further improvement of clearing rates in 35% of
patients.38 Another group from France using spot diameters
of between 0.5 and 1.5 mm, a pulse duration of between 10
and 70 ms, and uences of slightly above 300 J/cm
clearance rates of superior to 75% aer up to three treatment sessions in only 13% of cases if vessel diameters were
2.36
Inconsistent results of only 29% of sites
2
found
34.7 Lasers and IPL for transcutaneous therapy of telangiectasia 415
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below 0.4 mm, and in 88% of cases if vessel diameters were
between 0.8 and 1.4 mm.39 An 810-nm laser used with a
12-mm spot size, a pulse duration of 60 ms and uences in
the range of 80–100 J/cm2 managed to completely clear 43%
of spider veins aer one session with two treatment passes.40
Acombination of a 915-nm diode laser with 1-MHz radiofrequency energy with up to three treatment sessions
showed more than 75% clearance in 77% of treatment sites
when using 80–140 J/cm2 laser uence and 80–100 J/cm3 of
radiofrequency energy with pulses of 100–300 ms in duration.41 A 980-nm diode laser which was used with a contact
cooling device, with uences of between 300 and 500 J/cm2
and pulse durations of 150 ms achieved up to 50% clearance
in 60% of patients; however, with such long pulse durations,
pain was pronounced in the majority of patients.
42
34.7.6 1064-nm long-pulse Nd:YAG laser
e wavelength of 1064 nm shows less absorption in melanin compared to shorter laser wavelengths and is less
absorbed by hemoglobin. Because of the relatively low
hemoglobin absorption, laser energy can heat up the larger
vessels as a whole. In 1999, Weiss and Weiss reported a
study on 30 patients using a Nd:YAG laser at a 1064-nm
wavelength with a pulse duration of 16 ms. ey observed
a 75% improvement aer a single treatment in 0.5–3.0-mm
diameter vessels.43 Another study reported 64% clearance
aer a maximum of three treatment sessions using a 1064nm Nd:YAG laser with a contact cooling device. e author
used a 6-mm spot size, pulse durations of up to 14 ms and a
uence of 130 J/cm2 to treat vessel diameters of between 0.2
and 4.0 mm.44 A rate of 75%–100% clearance was achieved
with a dual wavelength approach, when using the Nd:YAG
system only for telangiectasias of 1.0–4.0 mm in diameter,
but treating 0.1–1.0-mm vessels with a 550-nm IPL device.45
Interestingly, in comparison to Sotradecol sclerotherapy,
the long-pulse Nd:YAG laser had equal results in leg telangiectasias of 0.25–3.0 mm in diameter.46 By utilizing a spray
cooling device, long-pulse Nd:YAG treatment of leg veins
of 0.3–3.0 mm in diameter showed clearance of more than
75% in 85% of treated sites aer a maximum of three ses-
47
sions.
is nding was corroborated in vein diameters of
between 1.0 and 3.0 mm. With a single treatment using a
uence of 100 J/cm2 and a pulse duration of 50 ms, a clearance of more than 75% was achieved in 66% of cases.48 In a
highly interesting approach taking advantage of met-hemoglobin formation using a non-uniform pulse sequence, a
French group reported a clearance rate of 98% aer three
sessions. ey used a 2-mm spot, uences of between 300
and 360 J/cm2, and a contact cooling device to treat blue leg
telangiectasias of diameters between 1 and 2 mm.
49
34.7.7 Combination of laser treatment after
injecting telangiectasia
More recently, lasers have been used for combination
treatment modalities aer either a systemic intravenous
injection of a green dye50 or the injection of the target vessel
with a polidocanol-based foam sclerosant.51 Laser energies
of an 810-nm diode or a 1064-nm Nd:YAG laser, respectively, were delivered.
In a prospective randomized trial, telangiectasias of
29 subjects were treated in the rst arm with a 1064-nm
Nd:YAG laser with uences of between 160 and 240 J/cm2,
a pulse duration of 65 ms, and a 5-mm spot size, and in the
second arm with a 810-nm diode laser aer intravenous
injection of 4 mg/kg body mass of an indocyanine green
dye and using an uence of 60–110 J/cm2, a 48–87-ms pulse
duration, and a 6-mm spot size. Blinded investigators and
participants assessed clearance rate, cosmetic appearance,
and adverse events up to 3 months aer a single treatment
session. Both investigators and participants ranked the
clearance rates of the dye-augmented diode laser treatment
greater than those aer 1064-nm Nd:YAG treatment, but
also rated the dye-augmented treatment as more painful.
In a randomized controlled trial in 320 female patients
(skin types II–IV), polidocanol foam sclerotherapy of leg
telangiectasia followed by 1064-nm Nd:YAG laser treatment was compared to polidocanol foam sclerotherapy
alone.51 Each patient received two single treatment sessions
at a 3-week interval, with treatment of both legs occurring
in full in each session. Up to 20 cc of foam prepared from
a 0.3% polidocanol solution were injected per session. In
the laser group, depending on the vessel diameter, a 2-mm
spot size was used with a uence of about 300 J/cm2 or a
5-mm spot size was used with a uence of around 60 J/cm2.
Depending on the diameter of the vessel, the pulse duration was chosen to be between 20 and 50 ms. Evaluation
was performed by blinded analysis of photographs taken up
to the 3-year follow-up and patients’ self-assessment in 79
control legs and 517 legs treated with the foam–laser combination. Depending on the vessel diameter, clearance rates
of the combination laser treatment were 89%–95%, while in
the control group, aer foam sclerotherapy alone, the corresponding clearance rates were only 15%–18%.
In a study in 60 patients, laser treatment of leg telangiectasias was evaluated with a unique coupled 585-nm dye laser
and a 1064-nm Nd:YAG laser.
52
A spot diameter of 7 mm
with pulses of 10 ms and a uence of 9 J/cm2 for the dye laser
and pulses of 30 ms and a uence of 80 J/cm2 for the 1064nm Nd:YAG were utilized. e time delays between sequential dye laser and Nd:YAG pulses were 125, 250, and 500 ms
for vein diameters of 4, 3, and 2 mm, respectively. e
patient satisfaction rate was 47 out of 60 patients. Blinded
evaluation of clinical photographs as well as computerized
analysis demonstrated good to very good improvements in
47 and 49 out of 60 patients, respectively.
34.7.8 Intense pulsed light
IPL sources do not make use of monochromatic light or
of coherent light emission. ey emit polychromatic light,
which is dened by lters placed between the IPL source
and the patient. In its initial phase, without concomitant
416 Percutaneous laser therapy of telangiectasia and varicose veins
https://t.me/med1917
use of special cooling devices, side eects such as skin burns
or hyperpigmentation could occur more easily than with
today’s devices. However, even in its early days, IPL was
able to demonstrate excellent results on leg telangiectasia.
In a multicenter trial treating 369 lesions in 159 patients,
a clearance of more than 75% was achieved in 79% of vessels between 0.1 and 3 mm in diameter. e rate of adverse
eects was low.53 Another study showed that IPL is most
eective in small red vessels with diameters of less than
0.2 mm, with an immediate clearance of 82%, while only
60% was achieved with IPL treatment of vessels between
0.5 and 1.0 mm in diameter.54 In a more recent comparative study between Nd:YAG and IPL, the IPL treatment was
judged to be more eective when diameters were below
1.0 mm, while larger veins were more eectively treated by
the Nd:YAG laser.55 Treatment combining IPL treatment for
smaller vessels with diameters below 1.0 mm and Nd:YAG
laser treatment for vessels with diameters above 1.0 mm was
reported to be very successful.
45,56
34.8 COOLING SYSTEMS
Skin cooling is crucial to minimizing thermal side eects
on skin structures apart from telangiectasia. Today, icing of
the skin cannot be judged as suciently reproducible, but
is more reliable than the use of cooled gels. Gels provide a
temperature decrease of only about 5°, can even disturb the
spot geometry of the laser beam, and account for energy loss
of about 35%.29 Reliable and more eective techniques are
contact cooling devices,
dynamic spray cooling
temperature air cooling devices
a collar contact cooling device improved clinical results,
enabling the delivery of higher uences with less pain.
23,32,44
e.g., sapphire hand-pieces and
30,32,47
using tetrauoroethane or low-
23, 31,57
. In addition, for IPL,
58
532-nm KTP devices. Patients with activation of their pigment system aer sunny vacations, or who use sunbeds,
should strictly avoid laser or IPL treatments. Conversely,
sun exposure and use of sunbeds should be strictly avoided
aer laser therapy as long as any skin response is visible,
usually for 3–4 weeks. Dark-skinned patients should be
treated with particular caution, if treated at all.
A less frequent side eect of laser treatment is thrombosis of telangiectasia, which is mostly associated with vessel
diameters above 1 mm. To accelerate the clearing of this
phenomenon, thrombosis should be removed by needle
puncture within the rst week of treatment.
Rare complications of laser treatment include blistering of the skin with or without subsequent scarring. ese
side eects most frequently happen with overdosing of laser
energy. Overdosing of laser or IPL can happen in conjunction with:
●
Administration of too high uences
●
Inadvertent pulse stacking or inadvertent overlapping
of pulses
●
Intended pulse stacking with too small cooling intervals
in between
●
Inappropriate cooling of the skin surface during
treatment
In addition, laser treatment of skin that is covered with
lotions or ointments can result in skin burns and hyperpigmentation. Removal of all of these before laser treatment is
therefore mandatory.
34.10 ALTERNATIVE TREATMENT
OPTIONS FOR LEG
TELANGIECTASIA
34.9 SIDE EFFECTS AND COMPLICATIONS
To identify patients who are prone to idiopathic hypersensitivity reactions aer laser treatment, a test treatment of a small
area is absolutely necessary before a full treatment session is
administered. Furthermore, an informed consent from about
the treatment-related risks should be signed by the patient.
e most frequent side eects of laser treatment are:
●
Transient or, rarely, permanent hyperpigmentation
●
Telangiectatic matting
●
Incomplete elimination of telangiectasia
●
Treatment-related pain
Restricted to special laser types, particularly to the old
type of ashlamp pumped dye lasers, is the side eect of
purpura. As stated above, the long-pulse alexandrite laser
therapy of leg telangiectasia is associated with pronounced
inammatory skin reactions under certain conditions.
Hyperpigmentation can happen with the use of any laser
or IPL source, but is more likely to happen aer treatment
of telangiectasia with shorter-wavelength lasers, such as
A serious alternative option to light-based systems or some
of the described combination treatments of leg telangiectasia is sclerotherapy with various liquid or foam sclerosants.
e technique of sclerotherapy is presented in detail in a
dierent chapter of this book.
34.11 FUTURE DIRECTIONS
e laser and IPL treatment of leg telangiectasia oers significant potential to evolve. Bimodal wavelength approaches,
longer pulse durations, and improved skin cooling contributed much to more eective laser and IPL treatment of leg
telangiectasia.
Despite a solid theoretical basis, concepts such as the
exploitation of laser-induced met-hemoglobin formation are
still not fully developed.
measurement of vessel and skin temperatures during laser
treatment and subsequent online adjustment of laser uences
and skin cooling are technically possible, but have not yet
been introduced into daily clinical practice. e same is true
of automatic scanner systems which would direct the laser
beam to the previously traced course of the target vessel.
59
49,6 0
Similarly, feedback loops for the
References 417
https://t.me/med1917
Combination treatments consisting of laser treatment
of telangiectatic vessels aer systemic injection of a dye or
a sclerosing foam at the treatment site look promising as
50, 51
well.
However, the scientic exploration of these con-
cepts has only just begun.
34.12 SUMMARY
●
Small leg telangiectasias: for diameters below 0.5 mm
and telangiectatic matting, the ashlamp pumped
dye laser at 595 nm is eective.
at 532 nm is suitable for vessel diameters below
0.7 mm.
18,21
Multi-pass treatment
may improve clinical results.
●
Larger telangiectasias up to 3 mm diameter can be
eectively treated by long-pulse Nd:YAG lasers with
1064-nm wavelengths.
43,46– 48
27,29,31
e KTP laser
18, 31
or pulse stacking20
●
e combination of laser treatment of leg telangiectasia with prior injection of a polidocanol foam seems to
increase clearance rates dramatically.51 Systemic injection of an indocyanine green dye prior to laser therapy
may increase treatment success as well.
●
Eective skin cooling is mandatory to avoid thermal
50
skin damage. Appropriate cooling devices are dynamic
spray cooling,
30,32,47
contact cooling,
23,32,44
or cooled
air.31 Cooled gels do not provide sucient or homogenous skin cooling.
●
In human skin, melanin is the main competing light
29
absorber to hemoglobin13; therefore, laser treatment of
telangiectasia can cause the side eect of long-lasting
hyperpigmentation. An increased epidermal melanin
content aer sun exposure—a so-called tanned skin—
therefore should be regarded as a contraindication to
cosmetic laser treatment of leg telangiectasia.
Guidelines 4.6.0 of the American Venous Forum on the percutaneous laser therapy of telangiectasia and varicose veins
Grade of evidence
(A: high quality;
B:moderate
quality; C: low or
very low quality)
No. Guideline
4.6.1 For telangiectasias with vein diameters below 0.5 mm and for
Grade of
recommendation
(1: strong;
2:weak)
1 C
telangiectatic matting, we recommend the flashlamp pumped dye
lasers at a 595-nm wavelength.
4.6.2 For telangiectasias with diameters below 0.7 mm, we recommend the
1 C
potassium titanyl phosphate laser at a 532-nm wavelength.
4.6.3 For large telangiectasias of up to 3 mm in vein diameter, we suggest
2 C
treatment with long-pulse neodymium-doped yttrium aluminum
garnet lasers at a 1064-nm wavelength.
4.6.4 During laser treatment, we recommend cooling to avoid thermal skin
1 C
damage using dynamic spray cooling, contact cooling, or cooled air.
4.6.5 We do not recommend cosmetic laser treatment of leg telangiectasias
1 A
in tanned skin with increased melanin content after sun exposure.
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