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BOX15.1 INDICATIONS FOR LASER THERAPY
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TREATMENT OF LEGVEINS
BOX15.2 FUNDAMENTAL PROPERTIES
OF A LASER FOR LEGVEINS
•
Refractory noncannulable vessels
•
Telangiectatic matting
•
Angiogenic ushing
•
Scleroresistance
•
Needle-phobic patients
•
Vessels smaller than the diameter of a 30-gauge needle are
present
A physician employing laser therapy should routinely
consider the utility of laser and intense pulsed light (IPL)
technologies versus that of sclerotherapy for the treatment
7
of lower extremity vessels.
e fundamental requirements
for a laser or IPL source in the treatment of leg veins are
delineated in Box15.2.
Laser technology and its role in leg vein reduction is
rooted in the molecule hemoglobin and its absorption
spectrum, which has broad peaks at 410, 540, and 577nm
and smaller peaks at 920 and 940nm. e spectra of oxyhemoglobin and deoxyhemoglobin di er, with bluer
veins responding to wavelengths targeting the deoxyspectrum and red varicosities responding more e ectively to
wavelengths targeting the oxyhemoglobin spectrum (see
Figure 15.1). Generally speaking, any vessel that is less
than 3mm in diameter may be treated by laser and IPL
technologies. However, sclerotherapy is a more e cient
modality for eradicating cannulable vessels, and when
small, di cult-to-cannulate vessels are present microsclerotherapy may be implemented. Microsclerotherapy, however,
is plagued by a number of adverse sequelae, increased incidence of bruising and pigment dyschromia, puncture marks
•
Must have a wavelength proportionately better absorbed by
hemoglobin than the surrounding tissue.
•
Penetration should reach the full depth of the target vessel.
•
Su cient energy must be delivered to damage the vessel
without damaging the overlyingskin.
•
Energy must be delivered over an exposure time long
enough to slowly coagulate the vessel without damaging
surrounding tissue.
from needle use, microulcerations, and inconsistent results
(see Table15.3). Given the adverse aesthetic outcomes of
such procedures, the use of lasers has gained momentum in
the management of cosmeticveins.
1000000
100000
HbO
Hb
2
800 1000
10000
1000
Molar Extinction Coecient (cm-1lM)
100
200 400 600
Figure15.1 Absorption spectrum of hemoglobin/deoxyhemoglobin.
Wavelength (nm)
Table15.1 COMPARISON OF THE 1064NM ND:YAG,
810NM DIODE, AND 755NM ALEXANDRITE LASERS
FOR LEG VEINS 0.33MM IN DIAMETER
LASER PATIENTS ACHIEVING 75% CLEARANCE
1064 nm Nd:YAG
810 nm diode
755 nm Alexandrite
Table15.2 VESSEL THERMAL RELAXATIONTIME
VEIN DIAMETER TIME SECONDS
0.1
0.2
0.4
0.8
1.0
Table15.3 MICROTELANGIECTASIA <0.5MM:
COMPARISON OF MICROSCLEROTHERAPY AND
LASER TECHNOLOGY
MICROSCLEROTHERAPY LASER
AT 3 M ON TH S
88%
29
33
0.010
0.080
0.16
0.6
8.0
128 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Number of
treatments
Bruising – +
Discomfort – +
Clinical e ciency – +
Purpura – +
Pigmentation – –
Ulceration – +
Cost + –
Patient satisfaction – +
Physician skill – –
– –
Table15.4 OPTIMAL LASER PARAMETERS FOR THE
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TREATMENT OF LEGVEINS
Wavelength
Pulse Duration
Fluence
Spot Size
Adapted from Sadick N.Adual wavelength approach for laser/intense pulsed
light source treatment of lower extremity veins, J Am Acad Dermatol . 2002.
46 :66–72.
530–1064nm
2–100 ms
30–150 J/cm
1.5–10mm
2
Lasers and intense pulse light (IPL) have not become
replacements for sclerotherapy, primarily because hydrostatic pressure considerations are not addressed by light
endothelial interactions. It is also more di cult to have suf cient penetration of photons safely through the thick epidermal dermal wall surrounding the lower extremity vessels
when utilizing noninvasive treatment modalities like laser
technology; direct injection into the target chromophore is
intuitively more e cient. Furthermore, an altered pattern of
cytokine release may be observed when using laser technolog y, resulting in injury to the vessel that may lead to increased
incidence of postin ammatory hyperpigmentation.
Wavelength, pulse duration, and spot size are the parameters that are most in uential during the treatment and management of individual vessels (see Table15.4). e larger
vessels tend to respond to longer wavelengths or the ratio
of vessel to epidermal heating increases the probability of
8
achieving complete vessel coagulation.
Shorter wavelengths,
in contrast, partially coagulate the vessel, ultimately increasing the incidence of treatment failures and subsequent epi-
9
dermal damage including hyperpigmentation.
Maximum
e ciency of vessel clearance is achieved when the penetration depth of the beam equals the vessel diameter. e spot
size should be as large as possible, at least on the order of
four times the optical penetration depth. An adequate spot
size minimizes scattering losses in addition to maximizing
beam penetration, which increases the probability that panendothelial destruction will be achieved. e disadvantage
to this, however, is that the use of larger spot sizes increases
the pain and discomfort subjectively reported by the patient.
ese parameters have in uenced and spurred the
development of a bimodal, dual wavelength approach for
Table15.5 MONOMODAL APPROACH TO THE
TREATMENT OF LEG VEINS USING THE 1064NM
ND:YAGLASER
VESSEL SIZE SPOT SIZE FLUENCE PULSE DURATION
<1mm red
1–3mm (blue)
Adapted from Sadick N.Laser treatment with a 1064nm laser for lower
extremity classI–III veins employing variable spots and pulse width parameters,
Dermatol Surg. 2003. 29 :916–919.
Small
Large
High
Moderate
Short
Long
the treatment of both red and blue lower extremity veins
(see Figure15.2). For the treatment of small, reddish telangiectasias with a high degree of oxyhemoglobin, short
wavelengths (500–600nm) were found to be most e ective; longer wavelengths (800–1100nm) were found to be
most e ective for the treatment of deeper, blue telangiectasias and reticularveins.
With continuing advances, laser technology can now
address both variations in vessel size and depth with a single
long wavelength 1064-nm Nd:YAG laser utilizing a varied
pulse width as the monomodal approach (see Table15.5).
Delicate, red vessels less than 1mm in diameter are super cial, having high oxyhemoglobin saturation. Consequently,
they can be treated e ectively with small spot sizes (<2mm),
2
higher uences (350–600 J/cm
), and short pulse durations
(15–30 ms). Larger blue vessels, in contrast, are typically
1–4mm in diameter, deeper, and possess a lower oxygenated hemoglobin component. As a result, these veins are
e ectively treated with larger spot sizes (2–8 mm), mod-
2
erate uences (100–350 J/cm
), and long pulse durations
(30–50 ms). With the use of the Nd:YAG rapidly gaining
momentum, the transition from a bimodal wavelength
technique to a monomodal approach has evolved.
TREATMENT APPROACH
CANDIDATES FOR LASER THERAPY
Laser therapy may be considered appropriate in patients who
are needle-phobic, cannot tolerate sclerotherapy, are plagued
Figure15.2 Pre- and postclinical pictures of lower extremity veins using biomodal technique.
LASER TREATMENT OF TELANGIECTASIAS AND RETICULARVEINS • 129
by legs veins that are scleroresistant, and/or are susceptible
g
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to telangiectatic matting (see Box 15.1). Ideal candidates for
laser treatment of leg veins previously have undergone appropriate surgery or sclerotherapy for the treatment of varicosities, incompetent perforators, and reticular veins, as well as
sclerotherapy to clear the majority of super cial vessels.
P A T I E N T I N T E R V I E W S
Diagnosis of spider or varicose veins begins with a thorough
medical history detailing potential risk factors or etiologies
for vascular pathology such as hormones, prolonged standing associated with occupation, obesity, pregnancy, heredity, oraging.
treated rst in an e ort to avoid the unsuccessful treatment
of smaller telangiectasias and complications such as dyspigmentation and telangiectatic matting.
In keeping with the treatment algorithm in Figure15.3,
initial treatment should include surgical removal, stripping,
or ambulatory phlebectomy of varicosities and large feeder
vessels. Sclerotherapy should then follow proceeding from
large to small vessels. Adhering to this treatment strategy
will obliterate, on average, 80 to 90% of vessels in a single
session. Laser and light therapy should be utilized in the
treatment of any residual vessels including those that are too
small in diameter to undergo sclerotherapy with a 30- to
32-gauge needle.
LASER TREATMENT SYSTEMS
PHYSICAL EXAMINATION
All potential candidates for laser treatment of leg veins
should undergo a thorough physical examination. During
the exam, the physician should evaluate the type and size of
the leg veins, and the presence/absence of re ux or incompetent valves. e treatment algorithm (see Figure15.3)
suggests that larger varicose veins with re ux should be
Physical Examination
Varicose Veins
Non-invasiveTesting
Doppler/Duplex/Plethysmography
Reux
Incompetent Perforators
or
Saphenofemoral Junction
No Reux
A compilation of laser and intense pulsed light sources
utilized in the setting of laser treatment of legs veins are
presented herein and summarized in Table15.6. e wavelengths of light range from 515nm to 1064nm, depending
on the treatment system employed. As mentioned earlier in
the chapter, the longer the wavelength, the greater the depth
of penetration, as illustrated in Figure15.4.
Spider Telangiectasia
Treat Varicosities and Reticular Veins with Compression
Sclerotherapy or Ambulatory Phlebectomy
Figure15.3 Systematic approach to the treatment of legveins.
Surgical Ligation
or Compression Sclerotherapy
Supercial Sclerotherapy or
Laser or Light erapy of
Supercial Telangiectasia,
Residual Vessels and of Sclerotherapy Induced Mattin
130 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Table15.6 LASERS AND LIGHT SOURCES FOR THE
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TREATMENT OF LEGVEINS
LASER WAVELENGTH
Pulsed Dye
KTP
Alexandrite
Diode
Nd:YAG
Intense Pulsed Light
578 NM COPPER BROMIDECUBR
585–605nm
532 nm
755 nm
810 nm
1064 nm
515–1200nm
its absorption of green light. is increased absorption
is more likely to increase the risk of epidermal damage.
Treatment failure, consequently, is higher in this subset of
patients because the lower uences are not very e ective in
coagulating the target vessel. Patient acceptance of this laser
treatment system is high with minimal treatment discomfort of the longer penetrating wavelengths and a relatively
11
uncomplicated postoperative course.
Other technologies
including the Aura (Laserscope, San Jose, California) have
produced comparable results.
Yellow LightLaser
A new yellow light laser employing a copper bromide
medium has demonstrated e cacy in the treatment of red
lower extremity telangiectasias that are less than 2mm in
size. An average of 1.7 patient sessions produced signi cant
clearing of 75 to 100% in 71.8% of patients. e positive
results have been con ned to the treatment of red vessels
(1mm).
For small telangiectatic leg veins in fair-skinned patients,
the pulsed potassium-titanyl-phosphate (KTP) laser has
become the treatment of choice. e Versapulse KTP
laser (Lumenis, Santa Clara, California) uses the following parameters:a spot size of 3–5mm, pulse duration of
10–15ms, and uences of 14–20 J/cm
to be e ective. A4ºC chilled tip provides epidermal protection. Side e ects include transient erythema crusting super cially, and purpura. When administering the pulsed KTP
laser, lower uences must be employed in the darker skinned
or tanned patient because of their increased melanin and
Figure15.4 Relationship between wavelength and depth of penetration.
10
P U L S E D L A S E R S A N D L I G H T
SOURCES
POTASSIUMTITANYLPHOSPHATE
LASER
2
, which have proven
FLASHLAMPPUMPED PULSED DYELASER
e pump pulsed dye laser was the rst laser to achieve
notable results in the treatment of leg veins in the 1980s.
is treatment system utilizes short wavelength technology, at a wavelength of 577nm. is has become acceptable
for treatment of leg vessels <1.0mm, but cannot be recommended for treatment of blue vessels or red vessels >1.0mm
given its short wavelength, relatively short pulse duration,
12
and moderate energy uence.
is system, in contrast to
long wavelength technologies, is less e ective and is associated with a number of side e ects including bruising and
posttherapy hyperpigmentation.
LONGER WAVELENGTH PULSEDLASERS
With the advent of longer wavelength technologies, including the long-pulsed alexandrite laser, 1064nm Nd:YAG,
and longer pulse duration lasers and light sources, there has
been a great improvement in treatment outcomes. Presently,
there are several long-pulse dye lasers available with variable
pulse durations capable of deeper penetration into the skin
and treatment of larger caliber spider and feeding reticular
veins of the lower extremity.
LONGPULSED ALEXANDRITELASERS
is system recently has been applied to the treatment of leg
telangiectasias and reticular veins, less than 3mm in diameter,
with good results. e longer wavelength (755nm) provides
deeper tissue penetration and an ability to treat larger diameter and more deeply situated vessels. Although hemoglobin
absorption of this wavelength is lower than that of 532 and
595nm wavelengths, it is su cient to achieve photocoagulation of a wide range of vessel sizes with the use of higher
uences. Optimal treatment parameters for the long-pulsed
2
alexandrite laser include 20 J/cm
, double pulsed at a repetition of 1 Hz. To penetrate tissue more deeply and to allow
greater thermal di usion time to treat larger vessels, the alexandrite laser has been modi ed to provide pulse duration
of up to 20 ms. Side e ects include purpura, matting, and
long-term pigmentary alterations due to melanin absorption.
In a recent study, the alexandrite laser system evoked
a signi cant in ammatory response with concomitant
LASER TREATMENT OF TELANGIECTASIAS AND RETICULARVEINS • 131
purpura and matting when used at a uence of 60–70 J/cm 2
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and a wavelength of 755nm, in comparison with other available laser treatment systems. Astudy conducted by Eremia
etal. concluded that the 755-nm wavelength utilized by the
alexandrite system is limited to use in nontanned patients
13
with I–III skin types.
D I O D E L A S E R S
e diode lasers utilize a wavelength of 800nm at 5- to
250-ms duration, and have been indicated in the treatment
of super cial leg telangiectasis and reticular veins. is technology system with near infrared wavelengths allows deeper
tissue penetration with decreased absorption of melanin.
e e caciousness of the diode was demonstrated in a study
conducted by Garden etal. e patients, having a vessel size
between 0.2 to 0.5mm, were treated with an 810-nm quasicontinuous diode laser 20-ms pulse duration. e results of
the study showed a 60% mean vessel clearance a er a mean
14
of 2.2 treatment sessions.
With the recent introduction of
higher uence capability, the diode laser’s e cacy continues
4,15
to increase.
LONGPULSED ND:YAG LASER1064
e treatment of choice for spider and feeding reticular
veins is the long-pulsed Nd:YAG laser (1064). As discussed
earlier in the chapter, spot sizes, energy, and pulse duration
can be adjusted to target both small telangiectasias and
larger reticular veins with a single device. In addition, this
system via its utility of a longer, deeper penetrating wavelength and subsequent epidermal bypass increases the e cacy of this system in treatment of darker skin phenotypes.
is system also addresses issues stemming from the hydrostatic pressure of feeder and reticular veins because veins
up to 3mm can be treated, although the patient’s tolerance
to pain may become an issue as pain increases with treatment of larger vessels. e newer pulsed 1064-nm lasers
have pulsed durations between 1 and 200 ms (Vasculight
Lumenis [Palo Alto, California], Cool touch Vantage
[San Jose, California], Cool Glide Excel [Burlingame,
California], Lyra [Laserscope, San Jose, California], Gemini
[Laserscope, San Jose, California], and Sciton Pro le
[Sciton, Palo Alto, California]). For super cial vessels less
than 1 mm in diameter, the optimal parameters include
small spot sizes of less than 2mm, short pulse durations of
2
15–30 ms, and high uences of 350–600 J/cm
. For reticular veins, 1 to 4mm in diameter, larger spot sizes (2–8mm),
longer pulse durations (30–60 ms), and moderate uences
2
(100–370 J/cm
) should yield successful results. As a result,
the Nd:YAG laser has been embraced by many clinicians
worldwide as the state of the art for laser treatment of lower
extremity vessels.
e Lyra and Gemini systems use contact cooling and
encompass a 1064-nm Nd:YAG technology. Seventy- ve
percent improvement of veins of all colors and sizes has been
reported with this technology. e Sciton Image has been
used predominantly for treatment of the lower extremity
telangiectasias and reticular veins up to 3mm in diameter.
Its high energy uence and large spot size have increased its
e cacy in treating both large-diameter vessels (i.e., reticular
veins) and small capillary mats less than 1mm in diameter.
Astatic cooling device also is employed in this treatment
system. e Vasculight also has been utilized for treatment
of both smaller vessels and larger reticular veins up to 4mm
in diameter. e operator applies a coupling cooling gel
in addition to an internal dynamic cooling device (DCD)
(1–4ºC) and applies the laser tip directly to the treatment
vessel under consideration. Super cial red telangiectasias
less than 1mm in diameter may be treated with the hand
piece coagulated and defocused o the skin and a lower
2
energy uence of 90–100 J/cm
with a pulse duration of 10
to 12 ms delivered as a singlepulse.
Weiss etal. achieved 75% improvement at the 3-month
follow-up of 0.3- to 3.0-mm vessels documented by duplex
closure. Settings in this study including uence of 80 to 120
2
and single-pulse durations of 10 to 30 ms were uti-
J/cm
16
Sadick etal. treated twenty patients with Fitzpatrick
lized.
skin type II to IV with a similar technology. Amean of 2.5
treatments produced 100% clearance in 88% of patients.
Mild purpura was noted in 20% of patients, and postlaser
17
hyperpigmentation was noted in 10% of patients.
I P L
IPL devices have also been indicated in the treatment of leg
veins, albeit with variable results. ese systems have been
shown to have dual success in penetration of both super cial and deep tissues, in addition to absorption by both oxygenated and deoxygenated hemoglobin (Photoderm VL,
Vasculight IPL, Lumenis, Palo Alto CA). e main advantage of IPL technology in the treatment of leg veins has
been the use of large spot sizes, causing minimal purpura.
is technology, in contrast to other treatment modalities,
uses a noncoherent pulsed light source with wavelengths
between 500–1,200nm, emitting a spectrum of light rather
than a single wavelength in single, double, or triple pulses.
e results of this current system are variable. Schroter etal.
reported immediate clearing in 73.6% of patients and clearing in 84.3% of patients a er 4 weeks. With respect to the
immediate response, 82% clearing was seen in the group
with veins up to 0–2mm, 78.9% was seen in the group from
0.2 up to 0.5mm, and 59.7% was seen in the groups from
18
0.5 to 1.0mm.
Other investigators, in contrast, have found lesser success utilizing this technology for management of lower
extremity spider veins. Results from a study done by Green
showed no improvement in 56% of patients, partial clearing in 25% of patients, and no improvement in 56% of
132 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
telangiectasias. It is worth mentioning that this particular
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study was done at the incipient stages of the IPL system’s
19
development.
Associated side e ects include blistering,
crusting, and discoloration, especially in darker skinned
patients. With growing sophistication and use, however,
IPL stands at the forefront of laser vein technology, being
the most e ective for treating telangiectatic matting associated with di use erythema.
COMBINED LASER/
RADIOFREQUENCY
TECHNOLOGIES
e most recent development in laser technology in the
treatment of leg veins is the combination of bipolar radiofrequency and optical energy, using either the diode laser
or an IPL source. e basis of this technology is rooted in
the idea that the two forms of energy act synergistically to
enhance clearance of the target vessel; with utilization of
this system a high energy penetration depth (>2mm) and
2
a high energy density on the treated vein (>100 J/cm
) can
be achieved. e laser component selectively heats the vessel, allowing the preferential absorption of radiofrequency
energy because of the increased temperature and the high
electrical conductivity of blood. Moreover, this system has
demonstrated 80% clearing of vessels less than 3 mm in
diameter a er an average of 2.5 treatment sessions by the
author.
ADMINISTERING LASER
THERAPY
Most laser therapy patients tolerate treatment without dif culty. If a patient exhibits increasing sensitivity to pain or
if larger telangiectatic or reticular veins are being treated, a
topical anesthetic cream should be applied 1 hour prior to
treatment and covered with a plastic dressing. Once the area
has been numbed adequately, the area should be cleansed
with alcohol. e physician, patient, and any medical
assistants present during treatment should wear protective
eyewear.
When using the 532-nm KTP laser in the treatment of
smaller telangiectasias, a spot size of 3–5 mm, uence of
2
12–20 J/cm
, and a pulse duration of 10–15 ms is recommended. Skin cooling, as discussed earlier in the chapter,
should be used before, during, and a er treatment to prevent thermal damage to surrounding tissues and decrease
patient discomfort. Laser pulses should then be applied
individually, separated by at least 1–2mm. Each laser pulse
should be traced along the length of the vein with no overlap or double pulse. Aminimal amount of pressure with the
application device should be applied to avoid compression
of the selected target vessel. e goal of treatment should be
either vessel spasm with immediate clearance or thrombosis with darkening of the vessel. Typically patients require
two to three treatment sessions with 6- to 12-week nontreatment intervals because of the intense cytokine release
generated by the laser endothelial interaction for maximal
results. However, complete clearance may be achieved following one treatment.
For reticular or telangiectasias greater than1 mm,
long-pulsed Nd:YAG laser is the treatment of choice. e
1064-nm lasers make it possible to vary spot sizes and pulse
width parameters, resulting in a wide treatment range of leg
veins including small telangiectasias. For super cial vessels
less than 1mm in diameter, the optimal parameters include
small spot sizes of less than 2mm, short pulse durations of
2
15–30 ms, and high uences of 350–600 J/cm
. For reticular veins 1 to 4mm in diameter, larger spot sizes (2–8mm),
longer pulse durations (30–60 ms), and moderate uences
2
(100–370 J/cm
) yield successful results. As with other laser
modalities, cooling before, during, and a er the pulse protects the patient’s epidermal layer from damage when using
higher uences, and also increases patient comfort. With
application of this system, it is o en useful to apply mild
pressure with the hand piece when treating reticular veins
to minimize the diameter and the amount of hemoglobin
in the lumen. is allows greater vessel penetration with less
total heat and reduced thermal damage to surrounding skin/
tissue. A er treatment with the Nd:YAG laser, small vessels
experience immediate resolution; larger telangiectasias and
reticular veins experience no visual change during the treatment, but demonstrate improvement and ultimately clearance within weeks to months following treatment.
Complications following treatment with any laser system include swelling, urtication, or erythema around the
treated vessels. e aforementioned side e ects may resolve
quickly with the application of ice packs, or a topical steroid. Application of this treatment may also decrease the
risk of postin ammatory hyperpigmentation. Although
compression stockings are considered unnecessary a er the
treatment of small telangiectasias, they may improve results,
if worn for a week following the treatment of larger telangiectasias and reticular veins, by preventing vessel re lling.
THE BENEFITS OF LASER
THERAPY
With its increasing momentum, laser therapy has become
one of the most e ective treatment options for treating
varicosities of the lower extremity. Generally at the time of
treatment, both the patient and the physician may observe
a disappearance of small telangiectatic vessels giving an
immediate visual record of success of treatment. However,
the larger telangiectasias and the deeper reticular veins typically do not demonstrate resolution at the time of treatment,
o en resolving gradually over the course of several months.
LASER TREATMENT OF TELANGIECTASIAS AND RETICULARVEINS • 133
A recent study using the monomodal approach with
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the 1064-nm Nd:YAG and variable spot sizes and pulse
width parameters to treat spider telangiectasias and reticular veins produced the following results:Twenty percent of
the treated vessels exhibited a 50 to 75% improvement a er
three treatments administered following 1-month intervals. Gradual improvement was observed at the 6-month
follow-up visit, with 80% of the treated vessels exhibiting
75% clearing. Ninety percent of patients were highly satis-
20
ed with the treatment.
Another comparative study examined the e ectiveness
of the 1064-nm Nd:YAG versus the 810nm diode and the
755nm alexandrite lasers in the treatment of 0.3–3 mm
in diameter. e results summarized in Table15.1 demonstrated that the Nd:YAG laser was the most e ective treatment modality at 3-month follow-up. Purpura and matting
were problematic with the alexandrite laser; the results
produced by the long-pulsed diode were unpredictable in
13
the subjects enrolled.
Presently, no long-term controlled
studies have been done regarding the persistence of vessel
clearing a er laser treatment of legveins.
ROLE OF COOLING AND
OTHER ADVANCES IN LASER
TECHNOLOGY
e development of cooling devices (Chess Chamber,
VersaPulse, Chill Tip, IPL Chiller, Zimmer Cooler) provides epidermal bypass, which protects the epidermis from
damage, allowing delivery of higher uences of energy. As
a result, contact or dynamic cooling devices are presently
incorporated into all devices currently manufactured. e
increased utilization of extended pulse durations also allows
delivery of greater amounts of energy in a more gentle fashion, providing more consistent panendothelial destruction,
translating into more consistent results with fewer treatments and lesser side e ects. To date, the pulse duration
most suited for the thermal destruction of leg telangiectasias appears to be 1–50 ms. Other advances including those
made in gentle cavitation, captured pulsing, and the regular
use of large diameter beams have all led to improvements in
21
laser/IPL technology.
for thermocoagulation to occur even when the appropriate
parameters are utilized. In the setting of a clearly resistant
vessel, it is better to work on a distinctly separate treatment
area and return to the resistant vessel in 5to 10 minutes.
It is also important to use the lowest possible uence that
will e ectively treat a selected vessel to minimize complications. As a rule a rule of thumb, the physician should
always start at the lowest uence and incrementally increase
to higher energy levels as needed depending on the vessel
response. Blanching of the skin is a physical manifestation of
excessive thermal injury and should be avoided at all costs.
Furthermore, the physician should take note of the lateral
spread of the thermal energy into surrounding areas, particularly with the longer wavelength 1064-nm laser. Nontreated
vessels connected to or adjacent to the desired treatment
pulse area may receive enough thermal damage to unintentionally coagulate. All pulses, consequently, ideally should be
separated by 1–2mm. Because of high cytokine, treatment
sessions should be spaced at least 6 to 8 weeks apart in order
to reduce the risk of postin ammatory hyperpigmentation.
SIDE EFFECTS, COMPLICATIONS, AND
ALTERNATIVE APPROACHES
Complications of the laser therapy of leg veins include
epidermal damage, thrombosis, hyperpigmentation, matting, and incomplete clearance (see Table15.4). During the
actual procedure patients typically complain of discomfort,
but rarely do they feel uncomfortable postoperatively. For
those patients who develop telangiectatic matting or incomplete vessel clearance, retreatment should be o ered with
either laser or microsclerotherapy as deemed appropriate.
Localized areas of thrombosis may resolve independently
from treatment or easily can be expressed with an 18-gauge
needle. Postprocedure hyperpigmentation is usually transient and has become less of an issue with the advent of the
longer wavelength technologies and improvement of epidermal cooling devices. Moreover, wound care should follow any procedure that results in epidermal damage, thereby
decreasing the incidence of scarring.
THE FUTURE OF LASER
THERAPY
ADDRESSING THE COMMON
PITFALLS IN LASER THERAPY
e laser treatment of leg veins is not free of common pitfalls
(see Table15.3). Retreatment or double pulsing of the target
vessels vessel should be avoided to prevent excessive thermal
damage that potentially can result in scarring and ulceration.
e physician or the medical personnel administering the
treatment should be aware that change of the target vessel
may take up to several minutes given the time that it takes
e laser treatment of leg veins continues to gain momentum with advances in laser, pulsed light, and combined
radiofrequency/IPL technologies. Other advances include
enhancement of longer wavelength treatment systems,
improved cooling technologies, varied spot size, pulse
durations, and uence-related monomodal approaches
and combined lasers/radiofrequency systems. e continued development of laser technologies not only enhances
the phlebologist’s armamentarium in the treatment and
management of telangiectasias and reticular veins, but also
134 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
provides the patient with an array of safe, noninvasive treat-
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ment options with minimal side e ects or complications.
R E F E R E N C E S
1 . K a u va r A . e role of lasers in the treatment of leg veins , Sem Surg
Cutan Med . 2000 . 19 : 245–252 .
2. Lupton J , Alster T , Romero P . Clinical comparison of sclerotherapy
versus long-pulsed Nd:YAG laser treatment for lower extremity telangiectasias , Dermatol Surg . 2002 . 28 : 694–697 .
3. Fournier N , Brisot P , Murdon S . Treatment of leg telangiectasias
with a 532nm KTP laser in multipulse model , Dermatol Surg . 2002 .
28 : 564–571 .
4. Passeron T , Ollivier V, Duteil L , et al. e new 940 nanometer
diode laser:An e ective treatment for leg venulectasia , J Am Acad
Dermatol . 2003 . 48 : 768–774 .
5. Sonden A , Svensson B , Roman N , Ostmark H , Bismar B . Laser
induced shock wave endothelial cell injury , Lasers Surg Med . 2002 .
6 : 364–375 .
6. Dover J , Sadick N , Goldman M . e role of lasers and light sources
in the treatment of leg veins, Dermatol Surg. 1999 . 25 : 328–336 .
7. Sadick N . Updated approaches to the management of cosmetic leg
veins , Phlebol . 2003 . 18 : 53–54 .
8. Goldman M . Treatment of leg veins with lasers and intense pulse
light , Dermatol Clin . 2001 . 19 : 467–473 .
9. Sadick N . A dual wavelength approach for laser/intense pulsed light
source treatment of lower extremity veins , J Am Acad Dermatol .
2002 . 46 : 66–72 .
10. Sadick N , Weiss R . e utilization of a new yellow light laser
(578nm) for the treatment of ClassIred telangiectasia of the lower
extremities , Dermatol Surg . 2002 . 28 : 21–25 .
11. Adrian R . Treatment of leg telangiectasias using a long-pulse
frequency-doubled neodymium: YAG laser at 532nm , Dermatol
Surg . 1998 . 24 : 19–23 .
12. Goldman M , Fitzpatrick R . Pulsed dye laser treatment of leg telangiectasia:With and without simultaneous sclerotherapy , J Dermatol
Surg . 1990 . 16 : 338–344 .
13. Eremias L , Umars H . A side by side comparative study of
1064nmNd:YAG, 310nm diode and 755nm alexandrite lasers
for treatment of 0.3–3.0 mm leg veins , Dermatol Surg . 2002 .
28 : 224–230 .
14. Garden J , Bakus A , Miller I . Diode laser treatment of leg veins, Lasers
Surg Med. 1998 . 10 ( Suppl ): 38 .
15. Kaudewitz P , Klorekorn W , Rother W . Treatment of leg vein telangiectasias:1-year result with a new 940nm diode laser, Dermatol .
2002 .
16. Weiss R , Dover J . Laser surgery of leg veins , Dermatol Clin . 2002 .
17. Sadick N . Long-term results with a multiple synchronized pulse
18. Schroeter C , Wilder D , Reineke T , et al. Clinical signi cance of
19. Green D . Photothermal removal of telangiectases of the lower
20. Sadick N . Laser treatment with a 1064nm laser for lower extremity
21. Sadick N , Weiss R , Goldman M . Advances in laser surgery for leg
28 : 1031–1034 .
20 : 19–36 .
1064nm Nd:YAG laser for the treatment of leg venulectasias and
reticular veins , Dermatol Surg . 2001 . 27 : 365–369 .
an intense, pulsed light source on leg telangiectasias of up to 1mm
diameter , Eur J Dermatol . 1997 . 7 : 38–42 .
extremities with the Photoderm VL , J Am Acad Dermatol . 1998 .
38 : 61–68 .
classI–III veins employing variable spots and pulse width parameters , Dermatol Surg . 2003 . 29 : 916–919 .
veins: Bimodal wavelength approach to lower extremity vessels,
new cooling techniques, and longer pulse durations , Dermatol Surg .
2002 . 28 : 16–20 .
LASER TREATMENT OF TELANGIECTASIAS AND RETICULARVEINS • 135
16.
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OVERVIEW
TREATMENT OF VENOUS INSUFFICIENCY
J o h n J . B e r g a n
he term “venous insu ciency” implies that normal
functioning is deranged. Terms used to describe
T
lend confusion to the general topic. Some of these terms,
such as “telangiectasias,” “thread veins,” and “spider veins,”
are descriptive but imply di erent conditions. And it is in
the chronic disorders, dominated by venous re ux through
failed check valves causing hyperpigmentation, ulceration,
and corona phlebectatica, where disorientation reigns.
Some order can come from subscribing to a unifying
theory of primary venous insu ciency and to a common
theory of e ects of an in ammatory cascade to clarify both
situations.
e manifestations of simple primary venous insu ciency
appear to be di erent from one another. However, reticular
varicosities, telangiectasias, and major varicose veins are all
elongated, dilated, and tortuous. Investigations into valve
damage and venous wall abnormalities eventually may lead
to an understanding of the problem, and therefore, a solution by surgery or pharmacotherapy.
degrees of thinning of the varicose venous wall. ese areas
of thinning coincide with areas of varicose dilation and
replacement of smooth muscle by collagen, which is also a
characteristic of varicose veins.
been to assume that both the venous valve and the venous
wall are a ected by the elements that cause varicose veins.
We and others have observed that in limbs with varicose
veins, an absence of the subterminal valve at the saphenofemoral junction is common.
ting, and atrophy of saphenous venous valves have been seen
both by angioscopy
specimens.
the various manifestations of venous insu ciency
P R I M A R Y V E N O U S
INSUFFICIENCY
1–4
Scanning electron microscopy has shown varying
5,6
Our approach to this has
7
Further, perforation, split-
8,9
10
and by direct examination of surgical
Supporting the theory of weakness of the venous wall
leading to valvular insu ciency is the observation that there
is an increase in the vein wall space between the valve leaf-
10
is is the rst and most commonly observed abnor-
lets.
mality associated with valve re ux.
our investigations have led us to explore the possible role of
leukocyte in ltration of venous valves and the venous wall
as part of the cause of varicose veins. In our investigations of
surgical specimens, leukocytes in great number have been
observed in the venous valves and wall, and monoclonal
antibody staining has revealed their precise identi cation
as monocytes.
patients with venous insu ciency.
Removal of the great saphenous vein (GSV) from the circulation is one of two essential steps in treating lower limb varicose veins. Incompetent valves along the GSV allow blood
to re ux down the vein and into its tributaries, transmitting
high pressure into smaller tributaries, which become varicose as a result. Much emphasis has been placed on the correct technique of high saphenofemoral ligation, in which
meticulous attention is paid to identifying, ligating, and
dividing all the tributaries of the GSV as they join the vein
in the groin. It has always been a matter of surgical dogma
that overlooking any of these allows continued re ux into
the residual tributary and subsequent development of recurrent varicoseveins.
A number of studies have con rmed that patients in
whom the GSV is stripped tend to have fewer recurrences
than those undergoing simple high ligation of the saphenofemoral junction (SFJ). Sarin etal. studied eighty-nine
limbs in sixty-nine patients with GSV incompetence.
were randomized to SFJ ligation with or without stripping,
and evaluated by photoplethysmography (PPG), duplex
scanning, clinical examination, and patient satisfaction. e
10
Similar ndings are present in the skin of
S U R G I C A L T R E A T M E N T
11
Realizing these facts,
12
13
Legs
136
follow-up period was 18months. Signi cant di erences in
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favor of the stripped group were found in all four parameters at nal evaluation.
A similar study of seventy-eight patients (110 limbs)
was reported by Dwerryhouse etal. in 1999, with a longer
14
follow-up period of 5years.
is demonstrated a signi cantly lower reoperation rate among patients undergoing
GSV stripping (6%), as opposed to 20% in those undergoing high SFJ ligationalone.
Duplex scanning showed a much lower incidence of
residual re ux in the remaining GSV when the proximal
vein had been stripped to the knee than when it had not.
However, the patient satisfaction rate was not signi cantly
di erent between the two groups. Ninety percent of the
stripped groups were satis ed as opposed to 87% in the
nonstripped group (p=ns).
A further study from Jones etal. came to similar con-
15
clusions.
One hundred patients (133 limbs) were randomized as before. A er 2years, 43% of those who had not had
GSV stripping demonstrated recurrent varicose veins as
opposed to 25% who had. ere was a statistically signi cant di erence.
NEOVASCULARIZATION
Of great importance was the fact that duplex scanning
showed that neovascularization in the groin was the most
common cause of varicose recurrence. It was o en seen in
the ligation group that re ux through the neovascularization
entered the residual saphenous vein and perpetuated the old
varices while new ones developed. e authors concluded
that by stripping the GSV, one was removing the runo into
which the new vessels could drain. Again, however, the satisfaction was broadly similar between the two groups:91%
in the stripped group and 87% in the unstripped.
All these authors concluded that stripping the long
GSV gave better long-term results than simple high saphenous ligation. is appears to be true in terms of objective
assessment of recurrence rates and in objective measurement of postoperative venous function but is not generally
re ected in patient satisfaction rates, which tend to be similar whichever procedure is performed. is led Woodyer
and Dormandy to reach a contrary conclusion—that stripping the GSV was a procedure based on surgical dogma, and
one that did not confer subjective bene t to the patients so
16
treated.
is leads one to conclude that a better method of
evaluation of treatment results should be developed.
recovery and better cosmetic results than stripping.
17,18
e
two currently available methods used to achieve ablation of
the GSV are the Closure procedure using a radiofrequency
(RF) catheter and generator (VNUS Medical Technologies,
Sunnyvale, California), and the endovenous laser ablation
(EVLT) procedure using a laser ber and generator (various
manufacturers). Both systems use electromagnetic energy
to destroy the GSV insitu.
One of the di culties in evaluating reports of successful
ablation of the GSV lies in the de nition of success. Some,
especially in the RF ablation reports, de ne success as “no
re ux in any segment longer than 5cm.” Some laser reports
refer to success as “stable occlusion” or “reduction in re ux,”
and Min has applied the much clearer standard of success as
17
“no ow by color ow Doppler.”
ose who report results
have not used the life table method, which takes into consideration dropouts and early and midterm failures. us
the reported favorable 4- and 5-year rates of elimination of
re ux may be exaggerated.
e major di culty with de ning success as reduction
or absence of re ux is that attempts to establish whether
re ux is present in a portion of a previously closed GSV may
be inaccurate. Also, most recurrent patency is seen in the
proximal portion of the treated GSV. erefore, distal compression of the closed portion of the GSV to identify re ux
in a proximal segment is futile. Likewise, using the Valsalva
maneuver is unreliable and lacks reproducibility. Finally,
the importance of distinguishing a partially patent channel
with ow, from one with re ux, is academic, since the valves
are just as thoroughly destroyed as the rest of the vein wall.
19
Initially, reports of successful ablation of the GSV using
either RF or laser energy without ligation or stripping were
treated with great skepticism. However, the absence of neovascularization is striking, and many skeptics have begun
to believe that former emphasis on a clean groin dissection
may have been in error. Although it is still early, acceptance
of endovenous techniques is increasing. Patient acceptance
of these minimally invasive procedures is overwhelmingly
better than with stripping.
Choosing which procedure to adopt, according to
19
Morrison,
is in uenced by a variety of factors including
reported results (and especially reporting methods); economic factors such as equipment and disposables costs,
reimbursement, and procedure time; availability of and
experience with ultrasound equipment and trained personnel; individual support by industry before, during, and a er
acquisition of the generator; and the practitioner’s own
level of expertise and comfort with ultrasound-guided tech-
19
niques and minimally invasive surgery.
NONSURGICAL TREATMENT
In recent years, endovenous ablation has been found to
be safe and e ective in eliminating the proximal portion
of the GSV from the venous circulation, with even faster
CHEMICAL VENOUS CLOSURE
Some phlebologists have advocated liquid sclerotherapy of
the saphenous vein, but the results of such treatment have
OVERVIEW:TREATMENT OF VENOUS INSUFFICIENCY • 137
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