Endovenous Laser Care & Treatment of Varicose Veins Patient Advice in Essex, UK

Vascualr surgeon for varicose veins, renal and general surgical conditions and procedures

Patient Advice and Information

Endovenous Laser Care & Treatment of Varicose Veins
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

Endovenous laser ablation of varicose veins is a new minimally invasive method for treating varicose veins. It is approved by the National Institute for Excellence [NICE] and most private Health Insurers. EVLC is performed at Hospitals authorised for laser usage and the operator is fully qualified in using Ultrasound and lasers for varicose veins with credentials and certificates in workshops and courses.

1. What are varicose veins?

Varicose veins are abnormally tortuous [dilated, swollen] veins which are visible just below the skin surface, especially on the erect position. Smaller veins in the skin itself are sometimes called “thread veins” or “spider veins” or “teleangiectasias”. These are more common in women and although they may be unsightly, they are not the same as varicose veins and treatment options for these are different.

Varicose veins:

· Insufficiency of a proximal faulty valve

· Dilatation of all tributaries

· Prominent bulging veins especially when standing

· Often bilateral development

· Familial predisposition in most cases

· On the picture they are marked just before surgery

· Intradermal veins

· Thread veins

· Teleangiectasias

Are not varicose veins

2. How do normal veins function?

Veins are the blood vessels that carry blood back to the heart [venous return]. In humans fluids flow according to a gradient of height, like a mountain stream, downwards, or according to a pressure gradient, as in water supply system, from points of higher pressure to points of lower pressure. This principle applies to the whole circulatory system. The calf muscles also help by acting as a pump to propel the blood upwards.

In the leg there are two systems of veins, the deep veins which run between the muscles, have a high pressure and convey 9/10^ths of the blood and the superficial veins, which represent an alternative route with low pressure, conveying only 1/10^th of the blood. The superficial veins start from the ankle and join the deep system at two sites, in the groin [long saphenous vein] and behind the knee [short saphenous vein].

Furthermore, the deep and superficial systems are interconnected through small veins, like the steps of a ladder, called “perforators”. All the leg veins have one way valves which allow blood to flow only from the surface inward and only towards the centre. The presence of valves and the action of the calf muscles [squeeze the veins] overcome gravity and facilitate flow towards the heart.

3. What causes varicose veins?

They are always due to a fault in the one way valves inside the veins. If the valve leaks, then blood will flow backwards [reflux, reverse flow] towards the area with low pressure, assisted by gravity on standing. This reverse flow increases pressure in the superficial veins, which, as blood stagnates, become swollen and varicose. In such a case, venous hypertension ensues, and the pressure does not fall during elevation or walking, as the muscle calf pump is not efficient.

Calf Muscle Pump

However, as valve incompetence [leakage] is always there, it may be caused by a variety of reasons:

a. Weak vein structure. These varicose veins often run in the family and as you get older they are more likely to occur.

b. Valve leakage at the junction between deep and superficial veins This is the commonest cause of varicosities [primary varicose veins, 90%].

Perforator incompetence

When the most proximal valve is not able to close, blood flows like a waterfall from the deep vein that has a far higher pressure into the superficial vein. As a result of this increased refluxing blood volume the main trunk dilates and its small branches become initially varicose, followed by the main trunk. In the lower leg the perforators are overloaded by the retrograde flow and are themselves secondarily dilated, resulting in a blow out. Blood now circulates to and fro and the pumping action of the muscles is lost as well.

c. The same mechanism may cause varicosities during pregnancy or weight gain that increases the pressure in the deep veins, resulting in proximal valve incompetence.

d. Faulty valves in the perforators. Blood then flows from the deep veins [with high pressure] to the small superficial veins in the calf causing them to swell. The extent of these varicosities may not be as much as those caused by proximal valve incompetence but the symptoms are more severe and more evident during exercise.

e. Post-thrombotic varices. In this condition, after thrombosis of the deep veins and destruction of their valves, the pressure increases dramatically, the perforators blow out and blood is forced back into the superficial vein network. The patient has usually suffered a previous episode of deep vein thrombosis [although deep valve destruction may occur spontaneously] with a painful, red, swollen leg. The resulting post thrombotic syndrome gradually causes leg oedema, pigmentation around the ankle and secondary varicosities. The risk of ulceration is significant and without appropriate compression therapy the complications become more evident and the symptoms more prominent.

4. What trouble do varicose veins cause?

Varicose veins are very common [10-15% of the population are affected] and usually give no symptoms, although they may look unsightly. However, aching in the leg is common, especially after a day of standing, and ankle swelling may occur. Often as well they may cause heaviness in the leg, jumpiness, fatigue and night cramps which are a manifestation of venous hypotonia.

Occasionally, severe varicose veins, usually associated with deep vein disease, can damage the skin of the leg above the ankle causing itchiness, pigmentation and discoloration [eczema]. Without treatment an ulcer may eventually occur. Here it should be reiterated that not every leg ulcer is venous.

Sometimes, one of the varicose veins may become red, hard and tender. This inflammation is called thrombophlebitis and usually settles within a week with conservative management.

Rarely, one of the varicose veins may burst and bleed profusely.

However, the risk of all these serious complications [skin changes/ulcer, thrombophlebitis, bleeding] is only 2-5% in a lifetime.

5. What treatment is available?

a. Conservative.

b. Sclerotherapy [injections]

c. Classical surgery

Foam [Varicofoam] sclerotherapy with ultrasound guidance.
EVL ablation [Endoveous laser treatment]
VENUS closure [Radiofrequency endovenous heating]

6. How does EVL work?

The principle behind EVL [ELVes, EVLT] is the usage laser heat [passing the laser instrument into the vein] to obliterate the main trunk of the incompetent vein that supplies the troublesome varicose veins in the leg [especially the LSV from the groin] by getting into it rather than taking it away.

This stops the faulty valve at the reflux point [communication with the deep veins assessed by ultrasound], achieving the same effect as conventional surgery, but without an incision at the groin and without stripping the vein.

The laser fibre is positioned at the correct point using ultrasound guidance and locked in place, to achieve vein obliteration by laser heat as the laser fibre is gradually removed.

7. Which types of varicose veins are suitable for EVL?

Of most primary varicose veins, EVL is feasible in about 50%. The main factor is the need for a long and straight part of major trunk, so the wire and the laser fibre can be introduced and positioned near the proximal faulty valve. Regarding recurrent varicose veins, EVL is feasible in about 20%, especially when the main trunk was not stripped.

The tiny veins, called “flare”, “spider”, “thread”, “broken” veins, are not treated by EVL. However, another form of laser treatment [with smaller fibres and smaller frequencies] can be used. Sclerotherapy is another option for these small veins.

EVL does not also treat the smaller varicosities of the leg, which lie near the skin. In about 50-70% of cases further avulsions [surgical removal under 1mm incisions] will have to follow to achieve a better cosmetic result. Sclerotherapy is also another option for these residual lumpy veins.

8. How can we tell if your veins are suitable for EVL?

You will be asked to complete a brief questionnaire about any symptoms or skin changes plus any other medical or health problems you may have.

The form can be posted to you or even downloaded here via this website:

EVL_Form.doc

We will examine your legs clinically and we will perform an ultrasound scan to identify the faulty valves [points of reflux] and the presence of a suitable straight length of the major vein trunk to be cannulated for the insertion of the laser fibre.

As it was previously stated, about 50% of primary and 20% of recurrent varicose veins are suitable for endovenous laser ablation.

The form you signed and the drawings will be kept as notes for all the further decisions made, interventions performed and the records will be digitalised with photographs before and after the procedures.

9. What does laser treatment involve?

The procedure begins with an ultrasound scan to identify the reflux and also mark the course of the vein to be treated on your leg.
An injection of local anaesthetic is given to freeze the skin over the vein, so a small 2mm incision can be made to insert a needle and a sheath into the vein to be treated. With ultrasound guidance the vein is cannulated and a flexible wire is passed up into the vein. You will not feel this. The position of the laser fibre is checked with US.
Once the laser fibre is in place, some more local anaesthetic is injected around the vein to minimise any discomfort and compress the vein around the laser fibre. You may feel some pressure but no pain.
When everything is in place and all the precautions [like laser Spectacles, signs, etc] looked after, the laser is fired. It works by closing the vein from the inside, as it is gradually pulled out [4-6 pulses per second].
Lasers are powerful sources of energy and you and the staff will wear protective glasses whilst the laser is used.
When the vein is sealed up, the laser is removed and small steri-strips are applied to the entry point. A bandage is applied on the leg which should be kept for 3-7 days, followed by a class 2 stocking.
After the laser treatment, you will be asked to walk around for 15min, have a drink and after half an hour you will be able to go home. You should not drive and, if travelling by car for more than 1 hour, sit on the rear with your leg on the seat. You should stop hourly and walk for 5 minutes.
Normal activity, including work, can be resumed as you feel like it [usually 2 days], although we would recommend avoidance of contact sports, gym and swimming for 2 weeks.
Pain killers may be used for the first 2-3 days, as you may have some tightness or discomfort over the treated vein. Diclophenak [Voltarol] or paracetamol [Panadol] may be used. However, more than 90% of the cases do not require any pain killers.
When the bandage is removed, you may have some minor bruising over the treated veins, or some hardness under the skin. This will always settle in some weeks.
We will arrange to see you in about 6 weeks from the procedure. By then, most of your varicose veins may have shrunk and many may have disappeared. If some remain, these may have to be treated by injection or avulsions through small incisions.

10. Are there any complications from laser treatment?

Complications following endovenous laser ablation of varicose veins are uncommon.

Failure to obliterate the vein occurs in about 3-5%. If that is the case and you still need to have treatment, then the options are either to try the laser again or perform classical surgery.
Excessive bruising or tenderness may occur in about 5% of patients.
About 1% of patients may experience some numbness in the lower leg, but this is almost always temporary.
The risk of deep venous thrombosis is remote, especially if you resume your normal activities early and follow the instructions.

11. What are the advantages of EVL compared to surgery?

It is performed under local anaesthesia
The procedure can normally be performed on an outpatient basis, taking about 45-60min.
You should be able to resume your normal activities straight away and return to work the following day.
Avoids the groin incision from conventional surgery and the complications that open surgery may have [although they are rare]
There is very little discomfort or pain after the procedure.
It gives a far better cosmetic result in properly selected cases.
There is minimal bruising and discomfort in the thigh, as the vein is not stripped away.
It can be used under general anaesthesia in cases of multiple varicose veins that should be removed by avulsions at the same time, especillay in legs with massive varices.
If the veins recur [20%] there is still a clean area which can be easily approached by open surgery

12. Are there any disadvantages of EVL?

EVL is a new minimally invasive treatment and certainly has some limitations. However, the disadvantages may be treated at a second stage.

It is not feasible to 30-50% of cases and it cannot treat all cases of venous reflux, compared to surgery.
It may not achieve an excellent cosmetic result in patients with multiple clusters of varicose veins as it cannot treat them all at the same stage. 50-70% may need further future intervention in form of either avulsions or sclerotherapy.
Sclerotherapy has a 5% chance of skin staining.

Heating can cause damage of the nerves that follow the main vein trunk and this is the reason why it is not always suitable for short saphenous surgery, as the sural nerve lies in close proximity to the venous trunk. However, numbness appears in less than 1% of legs treated endovenously
It does not disconnect all the tributaries from the main vein at the groin, the presence of which is the commonest form of recurrence of the varicosities.
It cannot be used in most cases with recurrent varicose veins.

13. What are the results of EVL?

We still do not know if EVL is or will be better, as good or worse than an operation in the long-run. However, the immediate results, seem to be equal or better than surgery, with a better cosmetic result in most cases. The mechanism of success for each procedure lies on proper patient selection. During the past 10 years we understood far more regarding veins than our predecessors knew. The use of ultrasound is essential and extremely useful. We believe that in selected cohorts of patients, EVL is the treatment of choice. At the worst, some veins may have to be treated after 6 weeks or some may later come back [recur]. If this happens, surgery can also be performed on a clean and not operated area, making thus the procedure far easier and with a significantly less risk.

The taking of regular exercise, modification of your life style, the wear of light support stockings and the avoidance of risk factors and becoming overweight will all help prevent you being troubled by varicose veins in the future.

Return to top of page.

Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.

This page was last updated on 01/10/2006