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272 Chapter 29/Endovenous Laser (EVL) for Saphenous Vein Ablation
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A B
FIGURE 29.4 Thrombus protrusion detected 4 weeks after endovenous laser treatment of the Great Saphenous vein
(A) showing marked retraction 3 weeks later (B).
into the common femoral vein. It was recently reported in
three of 54 limbs (5.6%) after endovenous laser cases but
resolved without further complications under anticoagulation.23 Remarkably, despite regular duplex scanning after
endovenous laser from the very beginning, in fi ve years we
recorded only one case of thrombus protrusion. This single
patient, remarkably, stopped his low molecular weight prophylaxis two days after the procedure. Thrombus protrusion
was detected four weeks after the procedure and showed
retraction three weeks later under anticoagulation with
phenprocoumon (see Figure 29.4).
ENDOVENOUS LASER COMBINED WITH
OTHER TECHNIQUES
Endovenous laser treatment of saphenous vein can be
combined with any other technique to the discretion of
the phlebosurgeon. These techniques include Muller’s
phlebectomy, sclerotreatment of any kind, perforator surgery,
SEPS, and endovenous laser occlusion of incompetent perforators. No need to mention that any other pathological
refl ux in the groin, like refl ux in the anterior accessory Great
Saphenous vein must be treated concomitantly to ablation
of the saphenous vein. Certainly, this also can be done by
endovenous laser treatment. However, some surgeons are
convinced by the role of subtle ligation of the Great Saphenous vein and all other superfi cial inguinal veins at the
saphenofemoral junction. Therefore they perform a crossectomy in conjunction with endovenous laser treatment of
the Great Saphenous vein. In the meantime some examples
can be found in the literature for such a strategy.
results of larger comparative trials randomizing endovenous
6,8
However,
laser against endovenous laser plus crossectomy would be
of great help in future discussions.
CONCLUSION
In conclusion, endovenous laser of saphenous veins has
left the stage of an experimental procedure, and many details
have become obvious, which helped to optimize treatment
results. However, prospective randomized trials of endovenous laser treatment versus traditional surgery, versus high
ligation performed at the same treatment session, or against
other endovenous techniques like radiofrequency closure or
sclerotreatment are still missing but urgently needed.
Acknowledgment
Thanks to Drs. Sylvia Herdemann, Doendue Guel, and Thomas Moehler
for providing tremendous amounts of follow-up data of endovenous laser
patients.
References
1. Navarro L, Min R, Boné C. Endovenous laser: A new minimally
invasive method of treatment of varicose veins—Preliminary observations using an 810 nm diode laser, Dermatol Surg. 2001. 27: 117–
122.
2. Proebstle TM, Gül D, Kargl A, Knop J. Endovenous laser treatment of
the lesser saphenous vein with a 940 nm diode laser—Early results,
Dermatol Surg. 2003. 29: 357–361.
3. Mundy L, Merlin TL, Fitridge RA, Hiller JE. Systematic review of
endovenous laser treatment for varicose veins, Brit J Surg. 2005. 92:
1189–1194.
4. Proebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge
S, Knop J. Endovenous treatment of the greater saphenous vein with
References 273
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a 940 nm diode laser: Thrombotic occlusion after endoluminal thermal
damage by laser generated steam bubbles, J Vasc Surg. 2002. 35:
729–736.
5. Gerard J-L, Desgranges P, Becquemin J-P, Desse H, Melliere D. Feasibility of ambulatory endovenous laser for the treatment of greater
saphenous varicose veins: One-month outcome in a series of 20 outpatients, J Mal Vasc. 2002. 27: 222–225.
6. Chang CJ, Chua JJ. Endovenous laser photocoagulation (EVLP) for
varicose veins, Lasers Surg Med. 2002. 31: 257–262.
7. Roggan A, Friebel M, Dorschel K. Optical properties of circulating
human blood in the wavelength range 400–2500 nm, J Biomed Opt.
1999. 50: 532–539.
8. Corcos L, Dini S, DeAnna D, Marangoni O, Ferlaino E, Procacci T et
al. The immediate effects of endovenous diode 808-nm laser in the
greater saphenous vein: Morphologic study and clinical implications,
J Vasc Surg. 2005. 41: 1018–1025.
9. Weiss RA. Comparison of endovenous radiofrequency versus 810 nm
diode laser occlusion of large veins in an animal model, Dermatol Surg.
2002. 28: 56–61.
10. Proebstle TM. Energy delivery and pullback rates during EVL: How
does one decide? International Vein Congress, Miami, Apr 14–16,
2005.
11. Proebstle TM, Sandhofer M, Kargl A, Guel D, Rother W, Knop J.
Thermal damage of the inner vein wall during endovenous laser treatment: Key role of energy absorption by intravascular blood, Dermatol
Surg. 2002. 28: 596–600.
12. Labropouplos N, Bhatti A, Leon L, Borge M, Rodriguez H, Kalman
P. Neovascularization after great saphenous vein ablation. Eur J Endovasc Surg. 2006. 31: 219–222.
13. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser
treatment of the incompetent greater saphenous vein, J Vasc Intervent
Radiol. 2001. 12: 1167–1171.
14. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein refl ux: Long-term results, J Vasc Interv Radiol. 2003. 14:
991–996.
15. Proebstle TM, Gül D, Kargl A, Knop J. Non-occlusion and early
reopening of the great saphenous vein after endovenous laser treatment
is fl uence dependent, Dermatol Surg. 2004. 30: 174–178.
16. Timperman PE, Sichlau M, Ryu RK. Greater energy delivery improves
treatment success of endovenous laser treatment of incompetent saphenous veins, J Vasc Intervent Radiol. 2004. 15: 1061–1063.
17. Timperman PE. Prospective evaluation of higher energy great saphenous vein endovenous treatment, J Vasc Interv Radiol. 2005. 16: 791–
794.
18. Bone C, Navarro L. Endovenous laser: A new minimally invasive
technique for the treatment of varicose veins, An Cir Cardiaca Cir Vasc.
2001. 29: 357–361.
19. Proebstle TM, Gül D, Lehr HA, Kargl A, Knop J. Infrequent early
recanalization of the greater saphenous vein after endovenous laser
treatment, J Vasc Surg. 2003. 38: 511–516.
20. Goldman MP, Mauricio M, Rao J. Intravascular 1320 nm laser closure
of the great saphenous vein: A six- to 12-month follow-up study,
Dermato Surg. 2004. 30: 1380–1385.
21. Proebstle TM, Moehler T, Guel D, Herdemann S. Endovenous laser
treatment of the greater saphenous vein using a 1320 nm laser causes
less side effects than using a 940 nm diode laser, Dermatol Surg. 2005.
31: 1678–1683.
22. Timperman PE. Arteriovenous fi stula after endovenous laser treatment
of the short saphenous vein, J Vasc Interv Radiol. 2004. 15: 625–
627.
23. Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous
laser therapy and radiofrequency ablation of the great saphenous vein:
Analysis of early effi cacy and complications, J Vasc Surg. 2005. 42:
488–493.
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CHAPTER
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30
Effects of Different Laser Wavelengths on
Treatment of Varices
LOWELL KABNICK
INTRODUCTION
Varicose veins are a common problem in the United
States, affecting mostly women and those over age 50.1 They
may be benign or painful, disabling, unattractive, and dangerous to patient health. Varices arise when the valves in
superfi cial veins malfunction, causing deoxygenated blood
to refl ux and pool and the veins to swell under increased
pressure, usually in the lower extremities. Insuffi ciency of
the Great Saphenous vein (GSV) frequently is found to be
the cause, although refl ux of the Small Saphenous vein
(SSV), perforator veins, and junctional tributaries also may
lead to varicose veins.
Traditional treatment for varicose veins involves invasive
surgical ligation and stripping of the affected vein; although
effective, this approach carries all the risks and expenses of
surgery and requires prolonged and complicated recovery
periods.
laser ablation (EVLA) and radiofrequency (RF) ablation
have emerged as effective outpatient treatment approaches
that enjoy greater patient acceptance compared to surgical
stripping.
destroy the vein, although their mechanisms of action do
differ.
ing local anesthesia only. EVLA produces excellent cosmetic results and reductions in preoperative symptoms
with no impact on patient mobility and almost no complications.
effective than RF in the short term,10 and is less expensive
than either RF or stripping.
placement of a laser fi ber and the controlled release of
thermal light energy, damaging the endothelium and leading
1,2
In recent years, minimally invasive endovenous
3
Both methods deliver electromagnetic energy to
4
This chapter focuses on EVLA, a short procedure requir-
5–10
In addition, EVLA appears to be slightly more
11
EVLA, fi rst described in 1989,12 involves the intravenous
to thrombosis and resorption of the vessel. In 2002 the FDA
approved EVLA for the treatment of varicose veins,1 and
today lasers of several wavelengths are available for use, all
of which produce excellent results. Nonetheless, some differences have been noted, particularly in terms of short-term
outcomes such as bruising and postprocedural pain. This
chapter describes the basics of lasers and EVLA, then compares results among lasers of different wavelengths, including data from a recent clinical trial.
LASER BACKGROUND
Since the fi rst working laser was made in 1960 at Hughes
Research Laboratories in Malibu, California,13 laser technology has been applied to endeavors as varied as large-scale
engineering projects and microscopic surgical procedures—
depending on its design, a laser can cut through steel or
make incisions smaller than the size of a cell. Today, lasers
are familiar sources of focused light energy, useful in medicine, technology, and meeting presentations.
The word laser is actually an acronym for Light Amplifi cation by Stimulated Emission of Radiation. Light in this
context refers not only to visible light, but to the entire
spectrum of electromagnetic radiation, of which visible light
is only a small part. Each type of light has a specifi c wavelength, which determines its properties (see Table 30.1). For
example, light with a wavelength of 410 nm is seen as violet,
whereas light of 680 nm is seen as red.
of visible light are wavelengths shorter than we can see—
ultraviolet, gamma, and x-rays—and wavelengths longer
than we can see—infrared, microwaves, and radio waves.
The lasers discussed in this chapter emit infrared light with
wavelengths ranging from 810 nm to 1320 nm.
14
Beyond the range
The Vein Book
275
All rights of reproduction in any form reserved.
Copyright © 2006, Elsevier Inc.
276 Chapter 30/Effects of Different Laser Wavelengths on Treatment of Varices
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TABLE 30.1 Spectrum of Electromagnetic Radiation
Type of wave Wavelength (cm)
Radio <10
Microwave 10 to 0.01
Infrared 0.01 to 7 × 10
Visible 7 × 10−5 to 4 × 10
Ultraviolet 4 × 10−5 to 10
X-ray 10−7 to 10
Gamma Ray <10
FIGURE 30.1 Wavelength is the distance between repeating points on
a wave pattern.
15
16
−5
−5
−7
−9
−9
TABLE 30.2 Lasers Used in Endovenous Laser Ablation
of Varice
Diode lasers
EVLTTM FDA Approval: 2002
Manufacturer: Diomed, Andover, MA
Wavelength: 810 nm
Medilas D Compact Diode FDA Approval: 2003
Manufacturer: Dornier MedTech Laser
GmbH, Germering, Germany
Wavelength: 940 nm
ELVeSTM FDA Approval: 2002
Manufacturer: Biolitec, Inc., East
Longmeadow, MA
Wavelength: 810 nm, 980 nm
VenaCureTM FDA Approval: 2002
Manufacturer: AngioDynamics,
Queensbury, NY
Wavelength: 810 nm, 980 nm
Vari-Lase® FDA Approval: 2003
Manufacturer: Vascular Solutions,
Minneapolis, MN
Wavelength: 810 nm
The principle behind laser technology is a quantum
mechanical effect called stimulated emission, which was
discovered by Einstein in 1917.17 During stimulated emission, photons (discrete packets of light energy) are generated
to produce a focused, coherent beam of light consisting of
a single wavelength; in contrast, common light sources such
as lightbulbs produce incoherent light, emitting photons in
many directions over a wide spectrum of wavelengths (see
Figure 30.1). For both types of light the amount of energy
used is measured in joules (watts × sec) and the power (rate
of energy use) is measured in watts (joules per second);
however, a 40 watt laser will appear much brighter than a
40 watt lightbulb, for example. Another difference is that
lasers can emit light either continuously or in pulses of
higher peak powers, whereas regular light cannot be controlled in that way.
13
A typical laser consists of three main parts: a laser
medium, a pump source, and an optical resonator.18 The
wavelength a laser produces depends on the type and design
of the medium and also on the alignment of mirrors in the
optical resonator.
• The laser medium (also called gain medium) emits
photons when excited; it can be a solid, liquid, or gas.
• The pump source provides energy that excites the lasing
medium; it may be an electrical discharge, a fl ashlamp,
or another laser.
Nd:YAG lasers
CoolTouch CTEVTM FDA Approval: 2005
Manufacturer: CoolTouch, Roseville, CA
Wavelength: 1320
• The optical resonator (also called optical cavity) is a
mirror or system of mirrors that intensifi es and amplifi es
light emitted from the medium; it does this by refl ecting
light back into the medium, sometimes several times,
before it exits the laser.
LASERS USED IN EVLA
There are many types of lasers available, distinguished
broadly by whether their medium is solid, liquid, or gas. The
lasers used in EVLA (see Table 30.2) are all solid-state lasers
of two types: diode and Nd:YAG.
EVLA Procedure 277
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FIGURE 30.3 With Nd:YAG lasers, the medium is a solid crystal and
the pumpsource is a fl ashlamp or other light source, such as a diode
22
FIGURE 30.2 A diode laser uses a semiconductor and electrical current
to produce a coherent light beam of a single wavelength. (Courtesy of
Biolitec.)
laser.
lasers will be discussed, although the 1064 nm normally is
not used in the United States for EVLA.
Diode lasers (see Figure 30.2) are a common type of
laser, such as you would fi nd in your CD player or laser
EVLA MODE OF ACTION
pointer, that use electrical current as their pump source.
Their medium is a very thin, microscopic chip known as a
semiconductor, which consists of two layered wafers of
semiconducting crystals (e.g., silicon) cleaved at both ends
with smooth parallel edges that act as mirrors.19 The two
wafers each have different electrical properties—one produces electrons and one produces the absence of electrons,
known in solid-state physics as a hole.20 Both wafers are
extremely conductive, but the space between them, known
as the p-n junction, is not. However, applying electrical
voltage to the p-n junction can reduce the width of the junction, thereby making the exchange of electrons and holes
possible and resulting in the emission of photons.
19,20
By
manipulating the p-n junction, diode lasers allow electrical
current to fl ow in one direction, but not the other.
Diode lasers have several advantages, including their
high degree of electrical effi ciency, compact and convenient
construction, and high-speed operation; however, their
output beams can be highly divergent and their peak energies are lower than what is required for some medical applications, although this last point can be overcome by tightly
stacking together many small laser emitters. The diode lasers
covered in this chapter have wavelengths of 810 nm, 940 nm,
and 980 nm.
The other type of laser used in EVLA is the Nd:YAG
laser (see Figure 30.3), the workhorse of solid-state lasers.
The use of lasers to treat varicose veins is a relatively
new application of laser technology, and the mode of action
is not thoroughly understood. In general, the combination of
intense thermal reaction and boiling blood is considered to
be the mechanism of endovenous injury. During the procedure, the intravenously placed laser fi ber emits infrared light
that converts to heat, exceeding the boiling point of hemoglobin or water and boiling the blood.
8,23
The hot blood
delivers extensive, thermal damage to the endothelium,
which in turn becomes thrombotic and the vein occludes.8
Although boiling bubbles and thrombosis are key in the
EVLA mode of action, there appears to be no risk of embolism and a small risk of deep vein thrombosis (DVT) associated with the procedure.
8
Each laser has a target molecule, known as a chromophore, that absorbs light of its particular wavelength (see
Figure 30.4). The chromophore of 810-nm lasers is hemo-
24,10
globin;
and water;
940 nm and 980 nm lasers affect both hemoglobin
24,10
and 1320 nm lasers target water alone.25 To be
effective, the lasers must be able to penetrate hemoglobin,
water, or both to the point where suffi cient energy is absorbed
by the chromophore to generate a thermal reaction releasing
steam bubbles.10 Regardless of the type of laser, the intense
thermal reaction and that boiling of blood is distributed
along the inner vein wall.
10
Nd:YAG is an acronym for the medium used, a crystalline
material called neodymium-doped yttrium aluminum
garnet.
21
The medium is in the shape of a thin rod, which is
EVLA PROCEDURE
fl anked by a pair of mirrors. Rather than using electrical
current as a pump source, Nd:YAG lasers are pumped by
another light source, such as a diode laser or a fl ashlamp,
and are able to build up and release energy to facilitate
focusing on very small areas; however, they are larger, more
complex to operate, and less electrically effi cient than diode
lasers. In this chapter the 1320-nm and 1064-nm Nd:YAG
Although EVLA is applicable to refl uxes of veins other
than the GSV, treatment of this vein is particularly common;
therefore, this chapter describes the procedure using the
GSV as an example.
26
The surgical technique is similar for
both diode and Nd:YAG lasers, with only slight modifi cations necessary when Nd:YAG lasers are used. Regardless
278 Chapter 30/Effects of Different Laser Wavelengths on Treatment of Varices
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FIGURE 30.4 Light is absorbed by different chromophores depending
on its wavelength. (Courtesy of Donier, MedTech, America Inc.)
FIGURE 30.6 The tip of the fi ber is visible using ultrasound.
FIGURE 30.5 A 4-French sheath is inserted into the GSV, just above the
knee.
of the laser, the procedure begins by the patient lying supine
on a surgical table and being draped in the sterile mode.
Local anesthetic is then administered to the skin to provide
anesthesia.
Ultrasound-guided access to the GSV is then obtained,
either at or below the knee, using a 21-gauge micropuncture
catheterization set. A 5 F micro-sheath introducer is inserted
into the GSV (see Figure 30.5). After removing the inner
cannula from the micro-sheath, a .035-inch guidewire is
advanced beyond the saphenofemoral junction (SFJ) into the
common femoral vein, again under direct ultrasound guidance. A 45-cm or 65-cm 4- or 5-French sheath is then
marked at the point of length of insertion, backloaded onto
the guidewire, and advanced to 1.5 cm below the SFJ or just
distal to the epigastric vein.
After the sheath is stabilized, the introducer and guidewire are removed and a 600-micron bare-tipped laser fi ber
is placed into the sheath. The laser fi ber is then advanced to
the end of the sheath by ultrasound guidance and the sheath
is retracted. When using a diode laser, the sheath is retracted
FIGURE 30.7 Tumescent anesthesia should place the vein to be treated
approximately 10 mm from the skin and fi ll an area around the catheter that
is approximately 10 mm in diameter.
to the fi ber’s locking device and married, leaving the tip of
the laser exposed; with the Nd:YAG 1320-nm laser, the
sheath is retracted completely. Final laser position easily is
determined by ultrasound (see Figure 30.6) and can also be
verifi ed directly because the skin becomes luminous where
the laser tip, or aiming beam, emerges from the end of the
sheath. The area around the entire venous segment being
treated is then infused with dilute local anesthesia under
ultrasound guidance; the infusion should create an ultrasound-verifi ed 10-mm hypoechoic diameter around the
vein and a suffi cient amount of tumescent anesthesia to
approximate a 10 mm distance from the skin to the vein (see
Figure 30.7).
After the correct position of the laser is verifi ed, laser
energy is delivered at a determined wattage while the fi ber
is pulled back down the length of the vein. Laser manufac-
810 nm vs 980 nm: A Recent Report 279
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turers provide guidelines on the amount of power that should
be used during EVLA; however, medical practitioners adjust
the standards according to their professional experience
and judgment. Laser energy can be emitted either continuously with constant, gentle pullback of the fi ber, or in a
pulsed mode with energy emitted only when the laser is held
still, not when it is moving.8 Pullback may be performed
either by hand in the case of diode lasers or an automatic
pullback machine in the case of Nd:YAG lasers. In either
case, pullback rate is determined by the watts used and
energy rate (joules/cm) required. With diode lasers, watts
are set in the range of 10–14 and joules/cm are set in the
range of 50–80; with Nd:YAG lasers, watts are between
5–7 and the energy rate is between 50–70 joules/cm (the
automatic pullback device is usually set a 1 mm/sec). After
the entire venous section has been treated with laser energy,
the vein is then checked by ultrasound for closure and any
abnormalities.
The puncture sight is covered with a sterile dressing and
a full-thigh Class 2 compression stocking (30–40 mmHg) is
placed on the leg. There is variation between physicians
regarding how long the patient is told to wear the stocking;
a suggested recommendation is to wear the stocking until
the next evening and while awake for the next 7 to 10 days
after that. The patient is also instructed to take ibuprofen for
pain and to avoid high-impact aerobics.
EVLA CLINICAL OUTCOMES BASED
ON LASER WAVELENGTH
Scientifi c studies on the safety and effi cacy of EVLA are
appearing more frequently in the literature, although to date
there has been only one randomized, double-blind, prospective trial.26 The literature that is available can be diffi cult to
assess, since authors frequently use different measurements
of outcome, and certainly the parameters of treatment vary
between centers. In general authors look for complication
and closure rates, although defi nitions of closure vary among
trials from “no refl ux” to “no fl ow verifi ed by ultrasound.”
In addition, the physician must consider equally important
symptom and quality-of-life outcomes,
jective and nonstandardized in the literature. Nonetheless,
midterm clinical trial results are available and long-term
experience is beginning to accumulate.
There is no scientifi c evidence that wavelength has any
effect on long-term outcome (see Table 30.3), although in
the short term differences can be found for some side effect
rates. Clinical trial experience with the diode lasers has
produced extremely low rates of DVT and paresthesia,
apparently no skin burning, and no documented cases of
7,27,28,29
pulmonary embolism;
both paresthesia and skin burns
have been associated with 1064 nm laser treatment.30 The
most common side effects seen with all laser types are bruis-
4
which are both sub-
ing, localized pain, induration and discomfort along the
treated vein, and superfi cial phlebitis.
One trial has evaluated the parameters associated with
successful occlusion at three-month follow-up.31 Consecutive patients with incompetent GSV received EVLA using a
940-nm diode laser administered continuously with a pullback rate of 5–10 mm/second. Analysis showed that factors
infl uencing whether veins remained closed at three months
were higher laser fl uence (J/cm2), higher energy per vein
length (J/cm), shorter distance from thrombus to SFJ at day
1 after EVLA, smaller proximal vein diameter, and longer
total laser treatment time (see Table 30.4). Obviously
outcome is also dependent on careful patient evaluation,
treatment discussions, and long-term follow-up.
1
810 nm VS 980 nm: A RECENT REPORT
To further determine whether EVLA outcomes are related
to laser wavelengths, a randomized, double-blinded, prospective, single-center trial was undertaken in patients electing EVLA for GSV insuffi ciency.26 Prior to treatment,
patients completed an evaluation of limb pain, rated on a
scale of 1 to 5, where 1 was “no pain” and 5 was “intense
pain”; patients also completed an evaluation of the physical
and emotional impact of their leg problems on their daily
living.
Fifty-one patients underwent the procedure as described
earlier in this chapter; 30 limbs were treated with a 810-nm
laser and 30 with a 980-nm laser. Immediately following the
procedure and again at 72 hours the treated vessels were
confi rmed closed using duplex ultrasound. At 72 hours, three
weeks, and four months patients completed a survey of
physical activity and underwent an examination of
symptoms.
No differences in outcome or in any physical activity or
symptom survey items were apparent at 72 hours following
the procedure. As follow-up continued, patients in the 810nm group experienced more bruising at one week (P =
0.007) and worse pain intensity (P = 0.028) and varicose
vein ratings (i.e., visible varices) (P = 0.004) at four months,
but signifi cantly less itching at three weeks (P = 0.031). Ten
patients in the 810-nm group and three patients in the 980nm group experienced phlebitis of the treated vein, which
was directly related to increased postprocedural pain. At one
year, two legs in each group exhibited refl ux by duplex
ultrasound using the compression and release method, indicative of returned fl ow in the GSV. All other limbs remained
free of fl ow at their one-year follow-up, for a success rate
of 93%.
This trial shows that both the 810-nm and the 980-nm
lasers are effective with no complications or adverse events.
Although there was a short-term trend in favor of the 980nm laser, those differences did not lead to the need for
280 Chapter 30/Effects of Different Laser Wavelengths on Treatment of Varices
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TABLE 30.3 EVLA Outcomes by Laser Wavelength
Diameter of
pretreatment Complete
Veins vein, mm occlusion
Author, treated range rate %
year Design of trial (patients) (mean) Parameters Follow-up (patients/n) Side effects
7
Min, 2001
Prospective, 90 GSV 3–27 (11) 10–12 W, 1 week 97 (87/90) Self-limiting bruising,
nonrandomized, (84) pulse mild discomfort,
consecutive duration 1–9 months 99 (89/90) soreness along
enrollment 0.8–1.0 (6 months, GSV, paresthesia
multicenter seconds mean) in one patient
Min, 2003
32
Prospective, 499 (423) 4.4–29 (11) 55% of limbs 1 month 98 (490/499) Bruising, tightness or
nonrandomized treated with pulling along GSV,
consecutive 14 W 6 months 99 (390/396) superfi cial phlebitis
enrollment continuous of varicose
single center mode, mean 1 year 98 (310/318) tributaries
delivery of
laser energy
123 sec, 2 years 93 (113/121)
1727 J
Min, 2004
33
Prospective, 1000 4.1–38 (10) 14 W <1 year 96 (309/322) Bruising and mild
nonrandomized (925); continuous tenderness
consecutive 811 GSV, mode, 100%
enrollment 80 SSV, success if >3 years 99 (218/219)
single center 96 AASV, treated
13 PASV with >70 J
Proebstle 200234 Prospective, 109 GSV Not available 15 J 1 year 90 (94/104) Pain and induration
consecutive (85) administered along the vein,
enrollment in 1 second symptoms of
pulses thrombophlebitis
Proebstle 20028 Patients 31 (26) 4.0–9.9 (6) 15 W, pulsed 28 days 97 (30/31) Moderate bruising,
selected from (1 second on, slight-to-moderate
phlebology 2 seconds off) local pain,
clinic induration along
the vein
Proebstle, 200328 Patients 41 (33) 2.0–6.0 (3.4) 15 W 1 day 100 (39/39) Pain, bruising,
selected from intended; continuous induration,
phlebology 39 (31) pullback 6 months, 100 (37/37) paresthesia,
clinic completed 0.5–1 cm/sec; median periphlebitis, DVT
or 15 J with in one patient
1-second
pulses
Kabnick, 2002
35
Patients with 20 GSV Not available 12 W, Immediate 100 (20/20) Bruising, discomfort
GSV refl ux (15) pullback rate or pain, superfi cial
confi rmed 10–12 cm/min phlebitis
by duplex
ultrasound
Oh, 20039 Patients of 15 GSV Not available 10–12 W in 1, 4, and 100 (15/15) Bruising, mild
phlebology (12) pulsed 12 weeks tenderness,
clinic chose fashion with induration,
either traditional 1–2 seconds superfi cial
surgery or thrombophlebitis
EVLA in one patient
Kabnick, 200429 International 7611 Not available Not available Not 96 Bruising, paresthesia,
Registry limbs, available burns 0.5%, DVT
7061 GSV 0.3%
810 nm Wavelength
940 Wavelength
980 nm Wavelength
Conclusion 281
https://t.me/med1917
TABLE 30.3 (continued)
Diameter of
pretreatment Complete
Veins vein, mm occlusion
Author, treated range rate %
year Design of trial (patients) (mean) Parameters Follow-up (patients/n) Side effects
26
Kabnick, 2005
double-blind, laser: continuous 93 (28/30) bruising, itching
single-center 30 GSV pullback at
980 nm 50 joules/cm 1 year 980 laser:
laser: 93 (28/30)
30 GSV
Chang, 2002
10-second (19 bruising, lower pulse duration months, limb swelling,
mean) dyschromia,
superfi cial burns
and phlebitis,
hematomas
Goldman, 2004
consecutive (22) second months bruising not
automatic (8 months, mentioned
pullback mean)
W = watts; J = joules; GSV = Great Saphenous vein; SSV = Small Saphenous vein; AASV = anterior accessory saphenous vein; PASV = posterior
accessory saphenous vein; LSV = lesser saphenous vein
Randomized, 810 nm Not available 10 W, 1 year 810 laser: Phlebitis, pain,
30
Not available 252 (149) Not available 10–15 W, 1–2 years 97 (244/252) Local paresthesia,
2
Prospective, 24 GSV 0.5–1.2 5 W, 1 mm/ 6–12 100 No pain or phlebitis,
810 nm Vs 980 nm Wavelength
1064 nm
1320
TABLE 30.4 Parameters and EVLA Outcome at Three
Months Using a 940-nm Laser
Median value of
parameter
Parameter Closed veins Open veins P value
Laser fl uence (J/cm2) 13.2 7.2 <.001
Energy per vein length (J/cm) 23.8 19.3 .004
Distance thrombus to SFJ 1.1 2.5 .004
at day 1 after EVLA (cm)
Proximal vein diameter (cm) 0.64 0.90 .002
Total laser time (seconds) 91.0 72.3 .046
31
additional treatment or to any difference in long-term outcomes between the two treatment groups. This study confi rms earlier published reports showing few complications
associated with the 810-nm and the 980-nm lasers in
EVLA.
ONGOING RESEARCH BY THE AUTHOR
A clinical trial is under way comparing EVLA using 980nm or 1320-nm lasers and RF ablation. To date, no trial has
adequately compared these three treatment methods,
although discussion abounds as to the advantages and draw-
TABLE 30.5 Signifi cant Differences between 810 nm and
980 nm Outcomes in EVLA
810 nm 980 nm
Outcome parameter Mean (n) Mean (n) P value
Bruising at 1 week* 2.4 (30) 1.55 (3) .0047
Itching at 3 weeks† 0.167 (30) 0.50 (30) .031
Pain intensity at 4 months† 1.5 (30) 1.21 (30) .028
Varicose vein rating at 4 months† .97 (30) .31 (30) .004
Phlebitis 10 (30) 3 (29) .08
*Based on a 5-point scale, where 0 = no visible bruising and 5 = extreme
bruising.
†Based on a 4-point scale ranging from absent to severe.
26
backs of each. The trial is a randomized, double-blind, prospective trial with methods similar to the trial described
earlier; it is expected that results may help further differentiate these noninvasive treatment methods for varices.
CONCLUSION
Although clinical trial experience is limited and there is
no standardized system for evaluating EVLA outcomes, it is
clearly effective and safe in the treatment of varices (see
Table 30.5). There is no scientifi c evidence demonstrating
superior long-term results using one laser wavelength over
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