Endovenous Laser Therapy for Lower Limb Varicose

Veins: intermediate outcomes of 800 limbs

..Khalid AL-Ghamdi,Khalid AL-Ghamdi, MD MD Vascular Fellow , King Saud University Vascular Fellow , King Saud University

King Khalid University Hospital King Khalid University Hospital . Riyadh,

Saudi Arabia

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Therapeutic Options for truncal varicose veinsTherapeutic Options for truncal varicose veins

Open procedures:Open procedures:• High ligation :High ligation : Barrier techniques.Barrier techniques.

• Stripping :Stripping : Invagination.

Cryostripping.

Electrical stripping.

Endoscopic stripping.

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Therapeutic Options for truncal varicose veinsTherapeutic Options for truncal varicose veins

Endovenous procedures:Endovenous procedures:• Endothermal obliteration:Endothermal obliteration: - - Radiofrequency ablation (RFA)Radiofrequency ablation (RFA) VNUS Closure plus & fast. Celon RFITT - Laser Therapy (ELT) 810 – 1470 nm Bare fiber Cylindrical diffuser Radial fiber

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Therapeutic Options for truncal varicose veinsTherapeutic Options for truncal varicose veins

Endovenous procedures:Endovenous procedures:

Chemical obliteration:Chemical obliteration:

• Ultra-sound Guided Foam Sclerotherapy.Ultra-sound Guided Foam Sclerotherapy.

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

First Publication of Endovenous LaserFirst Publication of Endovenous Laser

Endovenous Laser : Endovenous Laser : a new minimally invasive method of a new minimally invasive method of

treatment for varicose veins – preliminary observation using treatment for varicose veins – preliminary observation using an 810 nm diode laser.an 810 nm diode laser.

Navarro L et al Dermato Surg 2001:27(2):117-22. Vein treatment Center & Beth Israel Medical Center.NY,USA.

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Interventions for varicose veinsInterventions for varicose veins

Millennium Research Group – Market Growth in Varicose Veins Procedures (USA)Millennium Research Group – Market Growth in Varicose Veins Procedures (USA)

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

How EVLT WorkHow EVLT Work

VEIN WALL

CATHETER

FIBER

BLOOD

LASER BEAM

HEATING

HEATING

HEATING

INTERACTION GEOMETRYINTERACTION GEOMETRY irreversible localizedirreversible localized venous tissue damagevenous tissue damage

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Tissue AblationTissue Ablation

• 10 C – 45 C: Conformation change of proteins

• 50 C: Reduction of enzyme activity

• 60 C: Denaturation

• 100 C: Water vaporizes

• Thermal damage

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Endolaser Endolaser

Available Wave Lengths:Available Wave Lengths:• 810 nm - Dropped.810 nm - Dropped.• 940 nm.940 nm.• 980 nm.980 nm.• New 1320.New 1320.• New 1470 - The best so far.New 1470 - The best so far.

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

EndolaserEndolaser

Advantages:Advantages:

• Efficient : more than 95%.Efficient : more than 95%.• Adapt energy according size of the vein.Adapt energy according size of the vein.• Adapt energy according depth of the vein.Adapt energy according depth of the vein.• Less painful & less ecchymosis with 1470nm.Less painful & less ecchymosis with 1470nm.

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ObjectivesObjectives

Early & IntermediateEarly & Intermediate

Outcomes of EVLT in patients with varicose veins.

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

MethodsMethods

Study DesignStudy DesignProspective Non – Randomized Clinical TrialProspective Non – Randomized Clinical Trial

Setting Setting Vascular Surgery Division - KKUHVascular Surgery Division - KKUH

PeriodPeriodMarch 1,2006 – february 28, 2013March 1,2006 – february 28, 2013

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

MethodsMethods

Inclusion CriteriaInclusion CriteriaPatients with incompetent GSV & SSVPatients with incompetent GSV & SSV

InterventionInterventionEVLT using 980-nm and 1470-nm laser EVLT using 980-nm and 1470-nm laser

tumescent local anaestheticstumescent local anaesthetics

Follow - upFollow - upVenous Duplex at 1week and 6months Venous Duplex at 1week and 6months

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ResultsResults DemographicsDemographics::

Patients 625

Limbs 867

Mean Age 35

Female 72%

CEAP 85% C2

General Anesthesia was used in 0.6%

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ResultsResults

Intervention : Intervention :

• Average voltage used 14.6W ( range 10 to 15W).Average voltage used 14.6W ( range 10 to 15W).

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ResultsResults

Concomitant avulsion phlebectomyConcomitant avulsion phlebectomy

75.1% of limbs75.1% of limbs

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ResultsResults

Complications:Complications:

• Significant bruising - 19%.Significant bruising - 19%.• Superficial thrombophlebitis – 0.5%.Superficial thrombophlebitis – 0.5%.• NoNo edema, excessive pain, haematoma or cellulitis. edema, excessive pain, haematoma or cellulitis.• Thrombus protruding into the lumen of common femoral Thrombus protruding into the lumen of common femoral

vein was seen in 11 limbs (1.3%)vein was seen in 11 limbs (1.3%) Disappeared after 3 months.Disappeared after 3 months.

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ResultsResults

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ResultsResultsPreoperativePreoperative PreoperativePreoperative 2 days PO2 days PO 2 weeks PO2 weeks PO

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

• Currently 8282 articles have been published on RF obliteration and EVLT for treating varicose veins - English (68) - French (14)• 19 ------------ compared RF versus EVLT but no RCT.• 7 ------------ compared RF versus HL + Stripping +/Stab Avulsion

including 4 RCT• 1 ------------ compared RF, EVL, L+stripping

Discussion

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Between Jan 1994 – Feb 200792% in the last 5 years 72 study arms, 81% prospective 7 RCTs 12320 limbs

2804 (23%) stripped 2126 (17%) UGFS4876 (40%) EVLA2514 (20%) RFA

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Meta-analysisMeta-analysis

Meta-analysis

Anatomical Success

Rate

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

Early technical success EVLT-Duplex findings<6months.Early technical success EVLT-Duplex findings<6months.

KKUH 2013KKUH 2013 867867 98.3%98.3% Occlusion at 6 Occlusion at 6 monthsmonths

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ConclusionConclusionEVLT treatment is coming closer to the goal of

standardizing an effective method standardizing an effective method

for the treatment of varicose veins

Further controlled studies are required to compare optimized EVLT treatment protocols

with not only other endothermal modes of treatment but also with conventional open surgery

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

ConclusionConclusion

• Early and intermediate results of EVLT are excellent.Early and intermediate results of EVLT are excellent.

• Greater doses of energy delivered are associated with Greater doses of energy delivered are associated with better results.better results.

• Long term follow - up is required to confirm the Long term follow - up is required to confirm the durability of EVLT.durability of EVLT.

Endovenous Laser Therapy for Lower Limb Varicose Veins.Endovenous Laser Therapy for Lower Limb Varicose Veins.

King Khalid University Hospital King Khalid University Hospital