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262 Chapter 28/Powered Phlebectomy in Surgery of Varicose Veins
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curve. Indeed, as previously described, comparison of our
fi rst twenty patients with our second 20 patients revealed a
signifi cant reduction in hematoma (17 vs. 6, p = 0.0005).”
8
Shamiyeh et al. recognized that in comparing 1000 conventional phlebectomics to his fi rst 41 TriVex procedures, a
signifi cant learning curve existed and that it was somewhat
unfair to make the comparisons. They also heralded some
technique changes to minimize complications. In summary,
a learning curve of 10 to 20 cases was acknowledged.
TriVex can and has been used to treat other conditions
such as venous stasis ulceration.10 It also has been shown to
have a positive effect on incompetent perforating veins.11 It
is one of the tools of minimally invasive vein surgery.
12
In conclusion, results tend to be consistent: fewer incisions, shorter operative times, more complete removal of
varices. These results all are accomplished with complication rates comparable to traditional procedures. All the
reported results, whether they be safety and effi cacy trials,
randomized trials, or prospective randomized control trials,
have come to similar conclusions.
FIGURE 28.9 TriVex II System.
LESSONS LEARNED: THE
TRIVEX MASTERS MEETING
resector. This overcomes one of the main shortcomings of
Even with the very consistent and acceptable results, it
was the consensus of surgeons with signifi cant experience
that improved results could be attained. A meeting of the 15
most experienced TriVex users was convened January 2003.
Field testing of the second generation TriVex device had
already occurred at a few centers. The goal of this meeting
was threefold: standardize new techniques, standardize new
technology, standardize the training of these two. What
evolved from this meeting was a new technique and technology that attained signifi cantly improved results from what
was already an acceptable procedure.
The technique issues of hematoma, hyperpigmentation,
bruising, and subcutaneous scarring were addressed. Technology issues such as infusion rates and pressures, blade
size, blade speed, drainage, tumescent infusion level, and
compression were standardized. Training, teaching, and
proctoring were other issues discussed. The following is the
most up-to-date method for TriVex vein resection, which is
the standard at the time of this writing. Much is similar to
the original technique developed by Spitz. The changes and
added features will be highlighted.
TRIVEX II: NEW TECHNIQUE
AND NEW TECHNOLOGY
The signifi cant changes to the technology consisted of
the TriVex II system (see Figure 28.9). This system has
peristaltic infusion pumps for both tumescence and the
the original system: lack of adequate pressure and fl ow rate
for tumescent infusion. The variability in infusion led to
some early centers not obtaining enough clearance of subcutaneous blood leading to hematoma and pigmentation. A
brighter light source was included, which allowed better
visualization and more complete vein removal. Minor ergonomic changes were incorporated into the resector and illuminator/irrigator.
The recommended technique changes evolved during the
consensus meeting of the TriVex Masters. Spitz had laid
much of the groundwork. Others had come to similar conclusions. The changes in technique addressed issues of
bruising, hematoma, pigmentation, and subcutaneous scarring. Trauma to the tissue was further minimized with the
utilization of a larger blade (5.5 mm) and slower blade
speeds (300–500 rpm) in a pulsed manner. At fi rst it seems
counterintuitive that larger blades and slower speeds cause
less trauma. The larger aperture of the blade and slower
speeds allow more time for suction to be applied to the
veins. Therefore, suction does much of the resecting rather
than the shaver. This causes less subcutaneous trauma and
scarring. The concept of enhanced drainage was introduced.
Instead of closing incisions to contain tumescence (and
residual blood), wounds are left open. Additional drainage
sites were made with either a #11 blade or 2–3 mm dermal
punch (see Figure 28.10). The concept of enhanced drainage
is a 180-degree switch from the original technique. It has
solved the hematoma and pigmentation issues (see Figure
28.11). Patients recover sooner with less discomfort.
Summary of Present Technique 263
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The third change in technique is the installation of thirdstage tumescence in the subcuticular tissue above the level
of resected veins. This adds to the external tamponade of
compression wrapping (see Figure 28.12). The tumescence
is infused with #18 spinal needle attached to the same pump
of the TriVex II System. Much more tumescence is utilized
during these procedures (1–1.5 liters), with most being used
as irrigation to clear the resected vein channels of residual
blood and not absorbed by the patient. Thus, most tumescence is washed out prior to completion.
SUMMARY OF PRESENT TECHNIQUE
1. Pre-Op
• Doppler evaluation
• Mark around areas of resection
2. Preresection
• Infuse fi rst stage tumescence below levels of veins
• Patient in Trendelenberg
• Tumescence partially exsanguinates veins and fi xes
veins
3. Resection with Transillumination
FIGURE 28.10 Drainage sites.
• Larger blade (5.5 mm)
• Slower resector speeds (300–500 rpm)
FIGURE 28.11 Post-op result.
264 Chapter 28/Powered Phlebectomy in Surgery of Varicose Veins
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DISCUSSION
TriVex has evolved. The present technique yields
extremely acceptable symptomatic and cosmetic results.
As already mentioned in the results section, most patients
and surgeons are happy. These studies were done with
original technology and original technique. The majority of
surgeons now use new technology and new technique.
Results are better with the new method. As of this time,
studies have not been done to quantitate this impression.
What are some of the questions currently asked about
TriVex?
• What is a learning curve? One can learn to resect veins
after one or two cases. The key question is how many
cases will it take to attain cosmetic results equal to an
experienced TriVex surgeon? Approximately 10 to 20
cases are necessary to optimize your results.
• Can TriVex be used to resect the Great or Small
Saphenous vein? No, these veins are too deep and
cannot be visualized. More importantly, signifi cant
saphenous or sural nerve injury is possible.
• Can I use TriVex with other vein procedures? Yes,
FIGURE 28.12 Third-stage tumescence.
• Pulsed (on/off) resection
• Keep skin taut with free hand
• Targeted resection—no shearing, directed
subcutaneous channels
4. Post-resection: Second Stage Tumescence
• Transillumination visualization
• Place illuminator/irrigator in channels of resected
veins
• Irrigate residual blood
• Place further drainage sites—2–3 mm dermal punch
or #11 blade
• Obtain clear effl uent
5. Third Stage Tumescence with Transillumination
• #18-gauge spinal needle
• Place in subcuticular plane
• Obtain peau d’orange effect on skin
6. Post-Procedure
• Wrap with compressive dressing
• May use ABDs, Kerlex, Ace, Coban, etc.
• Ambulate immediately
• Unwrap two days post-op
• Compression stockings for two to three weeks
whatever procedures you would normally perform in
conjunction with traditional varicose vein excision can
be done with TriVex (e.g., laser or radiofrequency
endovenous ablation, stripping, SEPS, etc.).
• What about diffi cult areas such as the knee, ankle,
pudendal? These are all good candidates for TriVex
after experience. The initial fi rst stage tumescent
hydrodissects the veins away from the underlying
bony area.
• Is placement of incisions critical? Yes and no. With
experience one can better “hide” incisions. For example,
varicose veins over the anterior thigh or shin can be
resected by incisions placed medially on the inner
aspect of the thigh, thus hiding them. With traditional
techniques, incisions must be placed directly over the
veins, making them more visible.
• Are there any varicose veins for which TriVex cannot
be used? TriVex works well for all varicose veins
regardless of size or location. In fact, postsclerotic
friable varicose veins are better removed with the
suctioning and morcellating effect as compared to
the hook or clamps of traditional procedures. The
tumescence helps to partially exsanguinate large veins,
size does not matter. Large veins are removed as easily
as smaller veins.
• Does TriVex require general or regional anesthesia? No.
This author and other experienced TriVex users perform
most procedures using local tumescent and mild
intravenous sedation. Since late 2004 we have
performed almost all procedures with local anesthesia
and sedation. When learning TriVex it is preferable to
References 265
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begin with laryngeal mask airway or short-acting
regional since these patients should ambulate soon after
procedure completion.
• What are the contraindications to TriVex? These are
the same as those for any venous surgery: acute DVT,
active thrombophlebitis, inability to ambulate, and so
on. There are no specifi c contraindications relative to
TriVex.
• What are some of the more common complications
utilizing the newer technique and technology?
Temporary subcutaneous sensory nerve parastheias
occur, hematoma may still occur but is now in the range
of 1%, and bruising lasting longer than one to two
weeks occurs in approximately 5% of patients. Longterm subcutaneous scarring has almost been totally
eliminated with slower, larger blades. The TriVex
technique also has been used in countries aside from the
United States and Europe.
13,14
SUMMARY
TriVex is a mechanical method to remove tributary varicosities. As with any procedure it has its unique qualities
and quirks. Can TriVex be used for every varicose vein?
Yes. Does this author utilize TriVex for all varicose veins?
No. Personal experience and data elucidated in the results
section indicate that the real statistical advantage occurs
with large extensive veins, smaller extensive veins, extensive veins, and postsclerotic veins. In these clinical settings
the procedure is signifi cantly shorter and always involves
less incisions. For small localized varicosities, I tend to
employ foam sclerotherapy or microphlebectomy.
What studies also reveal is that patients are as happy with
TriVex as traditional techniques. Surgeons tend to be happier
with TriVex for extensive varicosities due to less operating
time, less incisions, and better visualization lending to less
residual varicosities. There is no need to apologize for using
a technique that gives as good a result for patients and is
more advantageous to the surgeons. Our time is important.
The time saved for extensive varicosities outweighs the disposable cost of $210 to $220. Operative time and costs are
also reduced. The facility saves money.
What is the future? Procedures all done with local tumescent and oral/IV sedation in an offi ce setting. Trials are now
under way to address these issues.
In conclusion, TriVex is a method of vein removal that
surgeons should be familiar with. It has its place for certain
clinical settings. This book and this chapter underscore the
variability and complexity of treating vein disease. The vein
surgeon should strive to be as complete as possible in knowledge and ability. It is my hope that this chapter added to
this goal.
References
1. Spitz GA et al. Outpatient varicose vein surgery with transilluminated
powered phlebectomy, Vasc. Surg. 2000. 547–555.
2. Cheshire N, Elias SM, Keagy B et al. Powered phlebectomy (TriVexTM)
in treatment of varicose veins, Ann Vasc Surg. 2002. July, 16(4):
488–494.
3. Ray-Chaudhuri SB, Huq Z, Souter RG, McWhinnie D. A randomized
controlled trial comparing transilluminated powered phlebectomy with
hook avulsions: An adjunct to day surgery? J One Day Surg. 2003.
13(2): 24–27.
4. Aremu M et al. Prospective randomized controlled trial: Conventional
versus powered phlebectomy, J Vasc Surg. 2004. January, 39(1): 88–
94.
5. Scavee V et al. Hook phlebectomy versus transilluminated powered
phlebectomy for varicose vein surgery: Early results, European
J Vasc Endovascular Surg. 2003. May, 25(5): 473–475.
6. Shamiyeh A et al. Transilluminated powered phlebectomy: Advan-
tages and disadvantages of a new technique, Dermatol Surg. 2003. 29:
616–619.
7. Arumugasamy M et al. Technical report: The technique of transillu-
minated powered phlebectomy—A novel minimally invasive system
for varicose vein surgery, Eur J Vasc Endovasc Surg. 2002. 180–
182.
8. Scavee V, Lemaire E, Haxhe JP. Transilluminated powered phlebec-
tomy. Mid-term clinical experience, Int J Angiol. 2005. March, 24(1):
75–79.
9. Mackay DC, Summerton DJ, Walker AJ. The early morbidity of vari-
cose vein surgery, JR Nav Med Serv. 1995. 81: 42–46.
10. Elias SM, Frasier KL. Minimally invasive vein surgery; its role in
treatment of venous stasis ulceration, Am J Surg. 2004. July (suppl to
July 2004), 26s–30s.
11. Mendes RR et al. Treatment of superfi cial and perforator venous
incompetence without deep venous insuffi ciency: Is routine perforator
ligation necessary? J Vasc Surg. 2003. November, 38: 891–895.
12. Elias SM, Frasier KL. Minimally invasive vein surgery, Mt Sinai J
Med. 2004. January, 71(1): 42–46.
13. Gabibov SG et al. The fi rst experience with minimally invasive phle-
bectomy using the TriVex system, Angiol, Susud Khirov. 2004. 10(2):
60–68.
14. Zhu X, Lin Z. [Transilluminated powered phlebectomy for varicose
veins of the lower limb: Report of one case], Di Yi Jun Yi Da Xue
Bao. 2003. May, 23(5): 413.
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CHAPTER
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29
Endovenous Laser (EVL) for
Saphenous Vein Ablation
THOMAS M. PROEBSTLE
INTRODUCTION
Endovenous laser treatment of saphenous veins developed during the 1990s. However, it took until 2001 when
Min, Navarro, and Bone published their fi rst relevant paper
about endovenous laser treatment of the Great Saphenous
vein1 that brought the technique to the attention of the whole
phlebology community. Endovenous laser treatment of
the Small Saphenous vein was not even described before
2003.2 Today endovenous laser treatment of saphenous
veins offers the patient an outpatient procedure that frequently enables him or her to return to occupational activity
the same day or the day after the procedure. Additionally,
because no relevant injury to the skin happens during endovenous laser treatment, the cosmetic outcome is usually
excellent. In the last few years our understanding about
mechanisms of action, the role of various laser wavelengths,
proper laser energy and treatment effi cacy, and side effects
and complications increased tremendously, and even a systematic review about endovenous laser treatment has been
published recently.
3
MODE OF ACTION OF ENDOVENOUS
LASER TREATMENT
The fi nal goal of endovenous laser treatment is the
ablation of pathological refl ux of blood by durable occlusion of the vein lumen. In general this can be achieved
either by shrinkage of the vein until the vein lumen has
vanished completely, or by substantial damage to the endothelium and inner vein wall leading to secondary occlusion
of the lumen by a clot, similar to the effect of a sclerosing
agent.
Steam Bubbles and Vein Wall Damage
Initially, diode lasers with wavelengths of 810 nm,1
940 nm,
state laser,6 were used for endovenous laser treatment. All
these laser wavelengths are predominantly absorbed by the
oxygenized and deoxygenized hemoglobin of red blood
cells present within the vein lumen. Water absorption does
not play a major role with these wavelengths. Remarkably,
the absorption of hemoglobin in this part of the electromagnetic spectrum is high enough that a blood fi lm of a thickness of only 200–300 microns absorbs more than half of the
emitted laser energy.7 Actually, during endovenous laser
treatment, these absorption characteristics, in combination
with typical values of laser irradiance emitted by the predominantly used fl at tipped laser fi bers of 600 micron diameter, leads to the formation of steam bubbles4 within the vein
lumen. These steam bubbles are not static but they are in
vigorous movement once they start to be produced (see
Figure 29.1). A mixture of hot blood and steam results in a
kind of a bubble-jet stream, responsible for convective heat
transfer to remote parts of the vein lumen, which otherwise
would not be accessible to the direct impact of the laser
beam. To give an easily understandable picture of this
process, this mixture of bubbles and blood can be compared
to the milk foam produced by an Italian cappuccino
machine.
of the fi ber tip was directed straight toward the inner vein
wall, mechanisms of high energy absorption in small tissue
volumes leading to vaporization of tissue are present as well.
This can cause partial or complete perforation of the vein
wall including carbonization of the adjacent parts of the
vein.
wall damage can be observed only in those parts of the vein
1,4
and 980 nm,5 but also a 1064 nm Nd:YAG solid
Certainly, where the laser beam emitted by the fl at end
4
As mentioned already, these types of endovenous vein
The Vein Book
267
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Copyright © 2006, Elsevier Inc.
268 Chapter 29/Endovenous Laser (EVL) for Saphenous Vein Ablation
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A
FIGURE 29.1 Jet-like steam bubble formation during endovenous laser
treatment of the proximal Great Saphenous vein with a 600 micron diameter fi ber and a 940 nm laser set to 30 watt continuous.
that were hit by direct laser beam impact. Other remote parts
of the vein circumference cannot be damaged as severely
during laser treatment; even with up to three times repetitive
treatment of the same Great Saphenous vein, a thermal
damage involving the media layer of the vein can be achieved
only in less than 40% of the vein circumference.
8
Vein Wall Shrinkage and
Thrombotic Occlusion
Substantial heat transfer to the vein wall leads to signifi cant shrinkage of vein wall collagen fi bers and consecutive
reduction of the vein lumen. This fact is well known from
radiofrequency closure of saphenous veins. However, a
comparative animal study between radiofrequency closure
and endovenous laser treatment
shrinkage does not occur automatically with laser treatment.
Within the setting of the previously mentioned experiment
using an 810 nm diode laser in a pulsed fashion, multiple
vein wall perforations and only limited vein wall shrinkage
could be observed. Our own studies10 showed that vein wall
shrinkage directly depends on the delivered linear endovenous energy density (LEED), given in Joule per cm. For
example, a LEED of 80 Joule per cm leads to an immediate
vein wall shrinkage of about 30%. If as much as 150 Joule
per cm vein length were delivered, 50% of shrinkage of the
vein wall can be achieved.
The amount of vein wall shrinkage seems to be important
because the remaining lumen of the vein after laser treatment is subject to occlusion by endovascular clot formation.
This clot later could be subject to recanalization, and it could
be assumed that the larger the clot diameter the higher the
9
showed that this vein wall
B
FIGURE 29.2 Occlusion of the GSV 3 months (A) and 2 years (B) after
endovenous laser treatment (940 nm, 15 watt, stepwise fi ber pullback).
risk for subsequent recanalization. Ideally, such a thrombotic
occlusion of the saphenous vein after endovenous laser treatment is replaced by a fi brotic cord that frequently can be
detected even years after laser treatment (see Figure 29.2).
Laser Wavelength
Laser wavelength actually seems not to be too important
for the success of endovenous laser treatment of saphenous
veins. At least in the range between 810 nm and 980 nm
neither hemoglobin absorption7 nor the resulting steam
bubbles depended on wavelength. Steam bubble formation
was shown to be correlated just to the emitted amount of
energy in Joule.11 The only wavelength in regular clinical
use, which might deserve special consideration, is 1320 nm.
At this wavelength hemoglobin absorption does not play
a role any more and water absorption is the dominant
Selection of Patients 269
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mechanism. As such, the vein wall is gently heated and
shrunken without perforations, translating in less frequent
and also less intense adverse events as described later.
PERFORMING ENDOVENOUS LASER
Performing endovenous laser treatment of saphenous
veins can be split in the sections 1) vein access and fi ber
placement, 2) anesthesia, 3) delivery of laser energy, and 4)
post-interventional care.
Placement of the Laser Fiber
Getting easy vein access starts with a comfortable temperature in the theater room to avoid vein spasm in sensitive,
frequently young female patients. The patient is then cleaned,
draped, and placed on the table in a reverse Trendelenburg
position to additionally fi ll the veins by gravitational forces.
The ultrasound probe and the ultrasound keyboard are also
covered sterile. To preserve the minimal invasive character
of endovenous laser treatment at its most, vein access by
ultrasound controlled puncture is the appropriate way;
however, stab incision and exposing the vein to the skin
surface by use of a phlebectomy hook is an alternative technique. The location of vein access is close to the distal point
of pathological refl ux and can be achieved by using an 18G
venule. A tefl on-coated guidewire and a 5F angiocatheter
used as a sheath help to place the laser fi ber tip between 1 and
2 cm distal to the saphenofemoral junction. In case of treatment of the Small Saphenous vein it is suffi cient to place the
fi ber tip at that point where the small saphenous vein leaves
the fascia toward the popliteal vein. The precise position of
the tip always needs to be controlled by B-scan ultrasound.
Schedules of Laser Energy Delivery
Energy delivery during endovenous treatment of saphenous veins is not standardized. Laser energy can be delivered either in a pulsed or continuous fashion in combination
with stepwise or continuous fi ber pullback, respectively.
Published schedules include laser pulses of 1–2 sec duration
in combination with stepwise pullback of the laser fi ber of
1–5 mm between single laser pulses. The laser power is set
between 8 and 15 watts with pulsed laser treatment. Specifi c
recommendations of laser device manufacturers may be
more specifi c for individual laser devices. If continuous fi ber
pullback is used it can be performed either manually or by
the use of motorized pullback devices in case of the 1320 nm
laser. In general, typical pullback speeds are in the range
between 0.5 and 3 mm/sec and typical settings of the laser
power range between 5 and 30 watts.
Recent publications suggest, regardless whether stepwise
or continuous fi ber pullback is used, that the LEED value is
around 80 joule per cm vein length.
Post-Interventional Care
Post-interventional care of endovenous laser patients is
variable around the world. Our schedule includes excentric
compression over the course of the treated vein for one day
and graduated compression stockings (30 mmHg) for a total
of eight days. Additionally, low molecular weight heparins
(dalteparine 2500 IU s.c.) were administered, also for eight
days, once daily starting immediately after the procedure.
Patients were advised to return to normal physical activity
immediately after the intervention and nonsteroidal antiphlogistics like diclofenac or ibuprofen were prescribed for
use at the discretion of the patient.
Anesthesia
Endovenous laser treatment can be performed under any
kind of anesthesia. Tumescent local anesthesia, however,
has the advantage of not only providing suffi cient anesthesia
but also forming a heat shield around the vein. It protects
delicate structures like nerves and other perivascular tissue,
and most important in slim patients, the skin. Furthermore,
under tumescent local anesthesia the patient still can bring
pain originating from nerve damage to the attention of the
physician before durable nerve damage can happen. This is
particularly relevant when treating the Small Saphenous
vein running close to the sural nerve.
For tumescent local anesthesia different mixtures are
reported. Either lidocaine or prilocaine are suitable in concentrations between 0.05 and 0.2%. A total volume of 100–
500 cc, depending on the length of the vein to be treated,
is needed for ultrasound-controlled perivenous infi ltration,
most conveniently injected by the use of a motor-pump.
SELECTION OF PATIENTS
Selection of patients for endovenous laser treatment of
saphenous veins is very simple. Any patient foreseen for a
stripping procedure, either of the Great or Small Saphenous
veins, is suitable. Placement of a guidewire and laser fi ber
is at least as easy as placement of a wire-stripper. Patients
with acute disease who therefore would not receive high
ligation and stripping procedures are usually also not candidates for endovenous laser treatment. However, endovenous
laser can additionally be performed in some patients not
really well-suited for high ligation and stripping. Such
patients are those taking coumadin or phenprocoumon for
various reasons. They can be treated without withdrawal of
anticoagulation. Also patients with peripheral arterial disease
or those with a peripheral venous bypass are suitable candidates. They can be treated the same way as normal patients
apart from the point that compression stockings or other
270 Chapter 29/Endovenous Laser (EVL) for Saphenous Vein Ablation
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circular compression bandages have to be avoided after the
procedure. Compression is limited to excentric compression
and inpatient follow-up could be taken into account in such
cases.
Like for surgery there are conditions that make a patient
not, or at least less, suited for endovenous laser. Examples
for these conditions are a prior thrombophlebitis of the
saphenous vein or earlier sclerotreatment of it. In such cases
parts of the vein might be still occluded or have been subject
to multiluminal recanalization, so that the laser treatment
cannot succeed in complete ablation of all parts of the vein
recognized by duplex ultrasound.
Pronounced tortuosity of the saphenous vein or the presence of aneurysmal dilatations generally does not prevent
endovenous laser treatment; particularly, there is no diameter limit for endovenous laser. However, advancement of
the guidewire may be diffi cult in these cases and if advancement of the wire is still impossible with skin stretching
maneuvers, a second vein access may be necessary to allow
treatment of the whole length of the vein.
Another disputable issue is the laser treatment of
extremely superfi cial, immediate subdermally located saphenous veins. This is sometimes the case in slim patients with
a body mass index around 20 or below, or if the saphenous
vein leaves its fascial compartment relatively proximal. In
these cases the deeper located proximal part of the vein can
be treated by laser, the distal superfi cial part can be removed
by miniphlebectomy to avoid the long-lasting presence of a
subdermally located indurated vein that later might cause
secondary hyperpigmentation of the overlying skin.
EFFECTIVENESS OF ENDOVENOUS
LASER TREATMENT
treatment in 39 Small Saphenous veins in which vein access
2
was obtained was 100% at day one.
Also complete occlusion of the Great Saphenous vein at day one or during week
one after the procedure should be natural. However, early
13,14
studies
97%. This was corroborated by our own early studies,
did not report a 100% success rate; it was around
4,15
but
in our hands the problem was overcome when we started to
treat saphenous veins with higher LEED values in the range
between 80 to 100 joule per cm vein length. This was after
understanding that the amount of energy delivered per cm
vein length plays a central role for treatment success.15 With
a setting of 30 watt continuous laser power (940 nm) and a
continuous pullback speed of 3 mm/sec,10 a 100% occlusion
rate of the treated vein segment at day one after laser treatment could be observed.
Recanalization during Midterm Follow-up
Durable occlusion of the treated saphenous vein segment
is certainly a central goal of endovenous laser treatment.
However, recanalization of the Great Saphenous vein can be
observed and frequently it seems to be associated with low
energy delivery during treatment.15 Figure 29.3 displays a
so-far unpublished plot of otherwise published original data
about three months follow-up of continuous laser treatment
of Great Saphenous veins.15 It clearly displays that recanalization is associated with low LEED values, and furthermore that veins with greater diameter require the delivery
of more energy to stay occluded during the fi rst three months
after treatment. The line drawn in Figure 29.3 is the result
of linear regression analysis of open boxes showing a slope
of about 10 joule per cm GSV diameter. This indicates that
Long-term results about endovenous laser treatment of
the Great Saphenous vein are still missing to date; therefore,
success can be reported only with respect to immediate postprocedural ablation of the vein and with respect to recanalization events during midterm follow-up. Other interesting
questions like fi ve-year success rates or questions about
randomized prospective comparison to traditional surgery
cannot be answered today. Also the questions whether endovenous laser treatment is not associated with future neoangiogenesis or if the pattern of future disease progression of
venous disease is generally infl uenced, remain open at
present, even if there is an interesting publication suggesting
one mechanism for recanalization of veins after endovenous
ablation.
12
Immediate Success Rate of Endovenous
Laser Treatment
Published data upon immediate closure of the Small
Saphenous vein is still rare. Success rate of endovenous laser
FIGURE 29.3 Plot of the linear endovenous energy density (LEED)
versus the proximal diameter of the Great Saphenous vein. Dots resemble
veins still occluded, open boxes resemble veins already recanalized 3
months after endovenous laser treatment (15 watt, continuous). The line is
the result of linear regression analysis of the data of open boxes and is
described by the formula y = 9.7x + 10.6.
Complications and Adverse Events 271
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a 15 mm diameter vein requires 10 joule of laser energy
more per cm vein length to stay occluded at three months
compared to a 5 mm diameter vein. Recent publications indicate that the administration of a LEED of 80 joule per cm
vein length helps to reduce the frequency of recanalization
events during short term follow-up.
10,16,17
Relevant studies on short and midterm follow-up are put
together in a recent systematic review.3 Unfortunately, data
on midterm follow-up of at least one year after endovenous
laser treatment are still rare. The largest study reporting on
121 procedures at 24 months showed an occlusion rate of
93.4%.14 Other studies reporting a 12-month follow-up demonstrate occlusion rates of 95.2% (N = 125)18 and 87.9% (N
= 107).19 In our most recent experience, 12-month results
were improved to above 98% occlusion rate (N = 91) after
introduction of 30 watt high LEED treatment.
10
Early recanalization of the Small Saphenous vein is not
reported so far,2 but follow-up interval in this study of 37
followed legs was only median six months.
COMPLICATIONS AND ADVERSE EVENTS
Adverse Events
Frequently occurring adverse events after endovenous
laser treatment with wavelengths between 810 and 1064 nm
include ecchymosis, induration, and pain. Ecchymosis
related to endovenous laser is diffi cult to be assessed,
because frequently it is performed in combination with other
techniques, producing ecchymosis like Muller’s phlebectomy. Under these conditions, ecchymosis rates of 100% are
reported most frequently.3 Only laser treatment of the Small
Saphenous vein was associated with a lower rate of ecchymosis of 41%, but in this study phlebectomy was not combined with endovenous laser treatment.
Induration after endovenous laser of saphenous veins is
reported in 34% after treatment of the Small Saphenous
vein, but in 50 to 100% after treatment of the Great
Saphenous vein.
3
Induration frequently occurs a few days
after laser treatment—which is sometimes severely irritating
to the patient—and continues most likely for one to three
weeks thereafter. It frequently is associated with a feeling of
tissue shortening for the patient running along the inner
thigh most irritating at full extension of the leg. This process
most likely is due to the formation and shortening of an inner
scar and its concomitant infl ammatory processes. Nonsteroidal anti-infl ammatory drugs improve symptoms dramatically and are also a good choice for any other treatment
related pain.
Less frequent adverse events related to endovenous laser
treatment of the Great Saphenous vein are phlebitis and
paresthesia. Phlebitis at the treated leg can be observed in 3
3
to 12% of cases
and, in our hands, responds well to nonste-
roidal antiphlogistics and prolonged compression therapy.
2
TABLE 29.1 Adverse Effects—Percentage of Affected Legs,
Median [min–max] Duration in Weeks According to Laser
Schedule
Continuous 30 watt Continuous 8 watt
Laser protocol 940 nm 1320 nm
Number of treated legs N = 136 (100%) N = 33 (100%)
Recanalization rate
(3 months)
partial 0% 3% (n = 1)
complete 0% 0%
No side effects 2% 18%
any time
Ecchymosis 81% 2 [0.2–4] 61% 2 [1–4]
Pain 81% 1.2 [0.1–12+] 50% 1.5 [0.1–2]
Analgesics 67% 0.3 [0.1–4] 36% 1 [0.1–2]
Induration along vein 64% 4 [0.2–12+] 46% 2 [0.5–4]
Phlebitic reaction 13% 1 [0.2–2] 7% 1.4 [0.7–2]
Paresthesia 12% 3 [1–12+] 14% 1 [0.2–3]
Paresthesia is not consistently reported in all studies but
certainly occurs in the range of 1 to 10%.
3
In our observation
paresthesia is most likely to happen at the distal leg and most
likely resolves spontaneously within less than three months.
In only one study the rate of paresthesia exceeded 30%,6 but
in this study extraordinarily high LEED values were delivered along the vein and even skin burns were observed in
conjunction with that.
Interestingly, the 1320 nm wavelength seems to be associated with a lower frequency of adverse events20 even if the
delivered values for LEED are comparable to those delivered with diode laser treatment. Table 29.1, which is extracted
from a more detailed description,21 shows that frequency and
maximum duration are reduced for pain and induration.
However the rate for paresthesia remains unchanged as—
given by their natural course—durations for ecchymosis and
phlebitis are not.
Complications
Relevant complications reported with endovenous laser
treatment of saphenous veins are rare. The most important
complications are deep vein thrombosis and clinically inapparent thrombus protrusion into the deep vein system as a
special fi nding related to endovenous procedures. One anecdotal report exists about the formation of an arteriovenous
fi stula in the popliteal region after treatment of the Small
Saphenous vein.22 The detection of deep vein thrombosis is
related to ultrasound B-scan examinations in regular intervals after endovenous laser treatment, which is not performed with the same intensity in all studies. In our own
series,2 we observed one case of a popliteal vein thrombosis
after laser treatment of the Small Saphenous vein in a patient
with the concomitant diagnosis of polycythemia vera. One
interesting phenomenon of endovenous procedures seems to
be the thrombus protrusion from the treated saphenous vein
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