To evaluate the treatment results for lower limbs varicose veins using
Endovenous Laser Ablation (EVLA) at King Hussein Medical Center (KHMC).
retrospective review of the records of 87 patients with 116 lower extremities
great saphenous vein (GSV) varicosities treated using EVLA at KHMC /vascular
unit between January 2011 and June 2018 was conducted .Sixty-six patients were
females and 21 were males. The mean age was 40 years. A mean follow up period
of one year included clinical assessment and duplex scan denoting success rate,
efficacy, complications and safety of the procedure.
complete occlusion of the GSV was reported in 107 cases (92.2%) whereas partial
occlusion appeared in 6 legs (5.2%) and 3 showed vein recanalization during follow
up period. Those were further effectively managed using Ultrasound Guided
Sclerotherapy (UGS).No surgical intervention was necessary in any of the limbs.
None of the patients developed significant complications .Eight patients had
mild to moderate post operative pain that was treated with oral analgesics.
Fifteen patients complained of GSV tract induration. All procedures were
performed as day case and patients were mobilized and discharged on same day of
Conclusion: EVLA for treatment of lower
limb GSV appears to be safe and effective technique. It is minimally invasive
with low complications and high success rate.
laser ablation, sclerotherapy , Great saphenous vein
Lower limbs varicose veins represent one of
the common vascular presentations in adult population, affecting 15 % of men
and 25 % of women (1,2).
of the sapheno-femoral junction (SFJ) and reflux of the great saphenous vein
contribute to the majority of lower
extremities varicosities(1-4). For decades, surgical SFJ ligation
and GSV stripping constituted the traditional standard management (1,
2,3,5,6).EVLA is increasingly used during the last few years as a
minimally invasive method to manage leg varicosities efficiently and safely(5-8).
In this article, we report our experience in treating lower limb GSV varicose
veins using EVLA technique.
A retrospective review of the records of 87
patients with 116 lower limbs varicose veins who underwent treatment for their
GSV using EVLA at KHMC /Vascular Unit between January 2011 and June 2018 was
conducted. Sixty six patients were females (76%) and 21 were males (24%).Their
mean age was 40 years (18- 72).All patients were evaluated in the vascular
surgery clinic where history was taken and physical examination was performed.
At the vascular unit laboratory, patients were re-examined with duplex
ultrasound B mode imaging combined with color and pulsed Doppler using 5- 10
MHz linear array introducer. All legs were duplex scanned to document: deep
veins patency, the competence of the superficial veins including reflux
assessment with the patient in the erect position, vein length and diameter.
who had undergone previous sapheno-femoral ligation were included in the study
(15 patients).Those suffering from deep vein thrombosis (DVT) or incompetence,
peripheral arterial disease with impalpable pulses and patients with poor
general conditions were excluded.
comprehensive evaluation, patients who met the inclusion criteria were offered
EVLA as an alternative to surgical management and a written informed consent
ENDOVENOUS LASER ABLATION TECHNIQUE
patients’ EVLA procedures were performed as day cases in the vascular unit
theatres. Fifty two patients preferred spinal anesthesia, including all
patients with bilateral lower limb procedures. Under ultrasound guidance
(PHILIPS HD 11 XE ultrasound machine), GSV was conducted and 6F sheath was
introduced into the vein at an appropriate point near the knee level .Site was
chosen beforehand by duplex ultrasound where the length, diameter and
tortuousity of the vein were noted.
laser fiber (Ceralas E 1470, Biolitec /Germany) is introduced and located 1.5 –
2.0 cm distal to the sapheno femoral junction.
anesthetic solution (500 ml of normal saline 0.9%, 20 ml of lidocaine 2.0% and
10 ml sodium bicarbonate 8.4 %) was infiltrated in the perivenous space of the
whole length of the GSV to be treated.
tip position was rechecked again using longitudinal and transverse ultrasound
views .Laser ablation was commenced and gradually laser was pulled back. Laser
system used a wave length of 1470 nm for all patients with mean energy of 65
Joules/cm (60 -80 J/cm).
EVLA process, intra operative ultrasound scan was performed to confirm the
shrinkage of the vein.
graduated above knee compression stocking therapy class II (20-30 mmHg) was
applied at the end of the procedure and for one week duration.
were discharged and advised to return to their usual activities as soon as possible.
They were called for clinical and ultrasound evaluation at 1 week ,6 months , 1
and 2 years ( mean one year) checking for obliteration , fractional occlusion
or recanalization of the vein.
During the study interval, a total of 116
incompetent GSV in 87 patients were managed by means of EVLA procedure. Twenty
nine patients had bilateral veins involvement .Fifteen patients had previous
unilateral SFJ surgical ligation with residual GSV incompetence. CEAP
classification (clinical, etiologic, anatomic and patho-physiologic) ranged
from (C2-C6, Ep, As,Pr). The median length of veins treated was 35 cm
(22-45cm), since in 90 cases (78%) the treatment was started at below knee
level. The diameter of the treated segment of the GSV varied between 3 – 15 mm
(median 6.4 mm). Table I and II
technical access success was reported in all patients although complexity was
faced in 3 cases. In one patient, the advancement of the introducer sheath was
difficult as the vein was very tortuous and became small in size as it went
into spasm. In the other two patients , cannulation of the vein at below knee
level was hard .The vein was re-punctured and cannulated successfully 10 cm
proximal to the original chosen site ,while an open cut wound was used for the
all patients, intra operative ultrasound scans was performed at the end of the
process as well as one week after and confirmed the obliteration of the handled
mean follow up period of one year ( 6 -24 months) was carried out where
clinical assessment and duplex scan demonstrated successful complete occlusion
in 107 GSV (92.2%), partial vein obliteration in 6 legs ( 5.2%) and three (2.6
%) showed vein recanalization with a large thigh tributary identified .
guided sclerotherapy (UGS) was performed to obliterate the recurrent veins at
different intervals of the follow up resulting in secondary success .No
surgical treatment was necessary in any of the limbs.
of our patients developed significant complications like DVT, pulmonary
embolism (P.E.), bleeding, cellulitis, skin burns, hematomas or nerve injury.
In fifteen patients, the presence of erythematous streaks and induration at the
tract of the treated GSV were noted.Eight patients had mild to moderate post
operative pain that was controlled by oral analgesics.
the procedures were performed on out- patient basis and the patients were
discharged on the same day of the procedure.
I: Demographic data and veins characteristics
of treated legs
( 18-72 years)
treated vein length
(22- 45 cm )
Diameter of treated vein
( 3 – 13 mm )
sizes distribution :
than 10 mm
Table II: CEAP
classification of the treated varicose veins
63 (54.3 %)
37 (32 %)
12 (10.3 %)
3 ( 2.6 %)
1 (0 .86%)
Lower limbs varicose veins are quiet
common problem in the community (1,2,5). The classical treatment is
surgical in the form of SFJ ligation and GSV stripping (2,3,9).Endovenous
delivery of laser energy was first reported by Bone in 1999 (10).Since
then EVLA of the saphenous vein has gained increasing popularity as a minimally
invasive technique for treatment of varicose veins and has been shown by many
authors to be a safe and effective method(11,12) .
successful outcomes of EVLA have been reported by different series to be
considerably high, ranging between 90 – 100 % in obliterating incompetent GSV(2,5,6,12).Our
complete occlusion rate of the vein treated effectively appeared in the same
range (92%), confirming reliability of the technique.
vein occlusion and recanalization ( 5.2 and 2.6 % respectively) were noticed in our study as
well as in other studies (1,5,7).A
large mid thigh perforator reflux was identified in some patients while in
others ,residual GSV communicating with veins draining at the anterior
accessory saphenous branch and short saphenous veins was noticed. Further
management by UGS for the residual varices, partially occluded and recanalized
veins was performed successfully during follow up sessions. No surgical
treatment was required in any of these limbs.
authors compared outcomes of endovenous procedures with surgical management(5,7,13,14,15).They
demonstrated results to be at least as
good for EVLT as for surgery including technical success and safety(3,4,5,16,17).There
was some benefit over open surgery in terms of post operative pain , recovery
and time to return to normal activities. Most of our patients were pain-free
post EVLA and they were sent home within few hours after complete recovery from
the anesthesia with recommendations to ambulate .Those with post procedure pain
were advised to use oral analgesics that were prescribed to all patients but to
be used only if circumstances require.
duplex ultrasound to evaluate GSV may be of great help to avoid access failure.
The vein characteristics including: tortousity, diameter, length, existence of
occluded thrombotic segments and presence of large branches can help in
choosing puncture site and avoid difficult cannulation. Some authors described
helpful maneuvers in cases of vein spasm and difficult access which we used in
some of our patients(3,5,6).They described re-puncturing the vein at
a proximal site, applying warm towels and local massaging, rotating the angled
access wire and the use of surgical exploration.
the introduction of laser system, different wavelengths have been used (810,
940, 980, 1470 nm)(3,8,11) . Different studies suggested that higher
wavelength like 1470 nm have a better absorption of laser in water and cause
less pain , bruising and vein wall perforation(11,18,19,20,21,22) .
They recommended the use of 1470nm laser fiber with energy density of 80 J/cm
or less as an advisable option for the management of saphenous vein
incompetency(19-21).All our patients reviewed from the medical
records , received same laser system with fixed wave length of 1470 nm and a
mean energy of 65 J/cm.
EVLA is considered as a minimally invasive procedure ,some complications have
been recorded(1,2,3,6).These included : hematoma formation, DVT ,
P.E. ,nerve damage, skin ulceration and infection .In our review, as well as
other studies ,no major complications occurred apart from induration and
ecchmosis along the managed vein in few patients confirming safety of the procedure(1-3).
our study, as in other publications, the majority of our patients were young
females(1,5,8,9) .This may verify the cosmetic outcome of the EVLA
procedure usually seeked by this age group. Also some of our patients were
above 65 years making EVLA a suitable procedure in elderly patients who might
be at poor risk for surgical intervention.
Minimally invasive techniques such as EVLA
for the GSV incompetence appear to be safe and effective. It is simple to
perform, manage large diameter saphenous vein percutaneously and on outpatient
basis with mild procedure complications.
1.Gulek B, Arslan M, Sozutok S. Results of a long-term performance and follow-up of Endovenous Laser Ablation procedures performed for treating great saphenous vein incompetence. Pak J Med Sci. 2018 Nov-Dec; 34(6):1332-1335.
2.Van den Bremer J, Joosten PP, Hamming JF, Moll FL. Implementation of endovenous laser ablation for varicose veins in a large community hospital: the first 400 procedures. Eur J Vasc Endovasc Surg. 2009 Apr; 37(4):486-91.
3.Rustempasic N, Cvorak A, Agincic A. Outcome of Endovenous Laser Ablation of Varicose Veins. ACTA Inform Med. 2014 Dec 22(6): 329-332
4.Siribumrungwong B, Srikuea k, Orrapin S, Benyakorn T, Rerkasem K, Thakkinstian A. Endovenous ablation and surgery in great saphenous vein reflux: a systematic review and network meta-analysis of randomized controlled trials protocol. BMJ Open 2019; 9:e024813.
5.Myers KA , Jolley D. Outcome of endovenous laser therapy for saphenous reflux and varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg. 2009 Feb; 37(2):239-45.
6.Van den Bos RR , Kockaert MA, Neumann HA, Nijsten T. Technical review of endovenous laser therapy for varicose veins. Eur J Vasc Endovasc Surg. 2008 Jan; 35(1):88-95.
7.Rasmussen LH, Bjoern L, Lawaetz M, Lawaetz B, Blemings A, Eklöf B. Randomised clinical trial comparing endovenous laser ablation with stripping of the great saphenous vein: clinical outcome and recurrence after 2 years. Eur J Vasc Endovasc Surg. 2010 May; 39(5):630-5.
8.Goode SD , Chowdhury A, Crockett M, Beech A, Simpson R, Richards T, Braithwaite BD. Laser and radiofrequency ablation study (LARA study): a randomised study comparing radiofrequency ablation and endovenous laser ablation (810 nm). Eur J Vasc Endovasc Surg. 2010 Aug; 40(2):246-53.
9.Theivacumar NS , Gough MJ. Endovenous laser ablation (EVLA) to treat recurrent varicose veins. Eur J Vasc Endovasc Surg. 2011 May; 41(5):691-6.
10.Bone C. Tratamiento endoluminal de las varices con laser de diodo: studio preliminary. Rev patol Vasc 1999; 5: 35-46.
11.Malskat W S J , Poluektova A A, van der Geld C W M, Neumann H A M , Weiss R A, Bruijninckx C M A, et al. Endovenous laser ablation (EVLA): a review of mechanisms, modeling outcomes, and issues for debate. Lasers Med Sci (2014) 29: 393–403.
12.Van den Bremer J , Hedeman Joosten PP, Moll FL. Endovenous laser therapy: a new treatment for varicose veins. Ned Tijdschr Geneeskd. 2007 Apr 28; 151(17):960-5.
13.Siribumrungwong B , Noorit P , Wilasrusmee C . Attia J, Thakkinstian A.A systematic review and meta-analysis of randomised controlled trials comparing endovenous ablation and surgical intervention in patients with varicose vein. Eur J Vasc Endovasc Surg 2012; 44:214–23.
14.Disselhoff BC , der Kinderen DJ , Kelder JC, Moll FL .Five-year results of a randomised clinical trial of endovenous laser ablation of the great saphenous vein with and without ligation of the saphenofemoral junction. Eur J Vasc Endovasc Surg 2011; 41:685–90.
15.Theivacumar NS , Darwood R , Gough MJ .Neovascularisation and recurrence 2 years after varicose vein treatment for sapheno-femoral and great saphenous vein reflux: a comparison of surgery and endovenous laser ablation. Eur J Vasc Endovasc Surg 2009; 38:203–7.
16.Rasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B. Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results. J Vasc Surg 2007; 46:308-15.
17.De Medeiros CAF. Comparison of endovenous laser therapy vs. conventional stripping of the great saphenous vein: midterm results. J Vasc Bras 2006; 5:277-87
18.Disselhoff BC , der Kinderen DJ, Kelder JC, Moll FL. Randomized clinical trial comparing endovenous laser ablation of the great Saphenous vein with and without ligation of the saphenofemoral junction:2-year results.Eur J Vasc Endovasc Surg. 2008 Dec; 36(6):713-8.
19.Doganci S, Demirkilic U. Comparison of 980 nm Laser and Bare-tip Fiber with 1470 nm Laser and Radial Fibre in the Treatment of Great Saphenous Vein Varicosities: A Prospective Randomised Clinical Trial. Eur J Vasc Endovasc Surg. 2010; 40(2): 254-259
20.Almeida J, Mackay E, Javier J, Mauriello J, Raines J. Saphenous laser ablation at 1470 nm targets the vein wall, not blood. Vasc Endovascular Surg. 2009; 43 (5): 467-472
21.Park JA, Park SW, Chang IS, Hwang JJ, Lee SA, Kim JS, et al. The 1470-nm Bare-Fiber Diode Laser Ablation of the Great Saphenous Vein and Small Saphenous Vein at 1-Year Follow-up Using 8-12 W and a Mean Linear Endovenous Energy Density of 72 J/cm. J Vasc Interv Radiol. 2014 Nov; 25(11):1795-800.
22.Johnson CM, McLafferty RB. Endovenous laser ablation of varicose veins: review of current technologies and clinical outcome. Vascular .2007 Set- Oct; 15(5):250-4.