Overview of Varicose Vein Treatment: Endovenous Laser Therapy
Varicose veins are veins just beneath the skin that get large and noticeable when you stand up. They’re often a symptom of a more serious condition called chronic venous disease. This condition can show up in multiple ways, including as rashes or eczema, dark skin, tiny blood vessels visible on the skin, inflammation of the veins, certain skin conditions, and even ulceration. Factors that increase your risk include getting older, having a family history of the disease, being overweight, and having been pregnant before. Certain factors like gender, smoking, history of lower leg injury, and jobs that make you stand for a long time haven’t been proven to raise your risk consistently, but more research needs to be done. Symptoms of chronic venous disease include feelings of heaviness in the legs, swelling of the feet, and pain that can lower your quality of life.
The cause of venous disease isn’t well-understood, but inflammation seems to play a big part. A dysfunctional blood flow mechanism, like high blood pressure, can trigger a cascade of events that cause blood to pool in the lower legs. The high pressure in the veins is detected by cells lining the blood vessels, which release certain growth factors that trigger the cells to multiply. This, along with increased attraction of white blood cells, disrupts the balance of collagen, a protein needed for strong, flexible veins. Over time, this results in varicose veins that lose their ability to handle high-pressure blood flow. The disease can progress to cause changes in the skin and formation of ulcers. What seems to start the process is a condition called valvular reflux, which disrupts collagen and changes the structure of the venous wall.
Chronic venous disease is classified by a CEAP system based on clinical manifestations, causes, anatomy and pathological changes:
* C0: No visible or noticeable signs of the disease
* C1: Small dilated blood vessels or net-like veins visible on the skin
* C2: Varicose veins
* C2r: Returning varicose veins
* C3: Presence of swelling
* C4: Changes in the skin and tissue below the skin
* C4a: Dark skin or eczema
* C4b: Lipodermatosclerosis or atrophie blanche
* C4c: Corona phlebectatica
* C5: Healed ulcers
* C6: Active ulcers
* C6r: Returning active venous ulcer
The cause could be congenital, primary, secondary or unknown. Based on which vein is affected and where its located, it could be superficial, perforator, deep, or unknown. The cause could be due to backward flow of blood, blockage, both, or neither.
Treatment can range from mild measures like wearing compression stockings, to more aggressive treatments like vein stripping. This piece will focus on endovenous laser ablation, a treatment that uses heat to damage the vein wall and make it collapse. Here, a device called a LASER (light amplification by stimulated emission of radiation) is used. It throws out focused light energy. A fiber optic laser is put inside the vein, it throws out light through a small prism that is spread in all directions and heats up the tissue around it. The heat causes damage to collagen, leading to fibrosis and collapse of the vessel. Tumescent anesthesia, which reduces the amount of blood in the veins and provides a barrier between laser and the tissue around, is given before the procedure. This procedure can be done outside a hospital, without needing anesthesia that puts you to sleep. The advantages of this are quick recovery with ability to get back to work on average in 1 day and 96.7% of vein collapse maintained at 3 and 5 years after the procedure.
Anatomy and Physiology of Varicose Vein Treatment: Endovenous Laser Therapy
When we talk about the veins in your legs, there are a few that are often discussed or looked at more closely:
* The Greater Saphenous Vein (GSV), which is the largest vein in your leg.
* The Small Saphenous Vein (SSV), which is a smaller vein found in your leg.
* The Saphenofemoral Junction (SFJ), which is the point where the saphenous vein joins with the femoral vein in your groin.
* The Inferior Epigastric Vein (IEV), which is found in the lower part of your abdomen.
Why do People Need Varicose Vein Treatment: Endovenous Laser Therapy
If you have problems with the veins in your legs, your doctor will likely suggest an ultrasound test. This test uses sound waves to create an image that helps the doctor see how your blood flows, and examine the structure of your veins.
In many cases, if you have a type of leg vein disease called varicose veins, and if the condition isn’t too severe, the usual first step for treatment is to use compression stockings for three to six months. Compression stockings apply gentle pressure to your legs to help move blood up your legs. This can reduce pain and swelling. However, it’s important to note that more research is needed to conclusively show how effective this method is.
If the compression stockings don’t help, your doctor may recommend other treatments. These could include techniques like using radio waves or lasers to harmlessly destroy the varicose veins (ablation), injecting a frothy solution into the veins to close them up (foam sclerotherapy), or surgically taking out the veins (venous stripping). These treatments are particularly effective if the problematic veins are the larger ones in your leg, known as the GSV or SSV.
When a Person Should Avoid Varicose Vein Treatment: Endovenous Laser Therapy
Some health conditions can make it unsafe for a person to have certain medical procedures. These conditions include:
* A recent clot in a deep vein, known as acute deep vein thrombosis.
* Not enough blood getting to an artery, known as arterial insufficiency.
* A new skin infection at the procedure site.
* A blocked deep vein that needs to help blood flow round the blockage, also known as collateral.
* Pregnancy.
In individuals who have a certain vein condition post-thrombotic syndrome (a long-term problem from a blood clot in the veins) or a condition called venous reflux along with an abnormal connection between an artery and a vein (arterial-venous fistula), extra precaution will be needed. To ensure safe treatment, it is crucial that doctors use imaging tests, like an ultrasound, to check the deep veins. These tests will be done to make sure there’s good blood flow – this is what the term ‘patency of the deep veins’ means.
Equipment used for Varicose Vein Treatment: Endovenous Laser Therapy
An ultrasound machine with a protective cover for the probe is needed. This machine uses sound waves to create internal images that help doctors see what they’re doing.
A percutaneous venous access kit is also important. This involves lidocaine for numbing, a needle with a syringe for drawing or injecting fluids, a guidewire to guide the placement of devices in the body, a scalpel for making cuts, a dilator to widen openings, and sutures for stitches.
A fiber-optic laser is needed, and it comes with safety glasses to protect your eyes and a catheter sheath. This high-intensity light source helps the doctor see what they’re doing and can also be used for treatment.
Lastly, a special numbing solution called tumescent anesthetic is used along with an injector pump. This solution contains lidocaine, a medication that numbs the skin and the area around it. However, the amount used should not exceed 15 milligrams per kilogram of body weight.
Who is needed to perform Varicose Vein Treatment: Endovenous Laser Therapy?
A variety of medical professionals can carry out this process. These can include vascular surgeons, pain management specialists, interventional radiologists, and interventional cardiologists. These are all types of doctors who have specialized training in their areas. A vascular surgeon, for example, treats blood vessel diseases. An interventional radiologist uses imaging techniques like X-rays to guide procedures, and an interventional cardiologist specializes in treatments that involve entering the body with small tubes or wires. Sometimes, additional helpers may step in to assist with using ultrasound imaging, a tool that creates pictures of the body’s interior, and positioning your body in the correct way for the process.
Preparing for Varicose Vein Treatment: Endovenous Laser Therapy
Before undergoing surgery, every patient should have a specific type of ultrasound performed on their leg veins. This procedure, called a pre-operative duplex ultrasound, helps doctors understand various details about the veins such as where the blood is moving the wrong way (reflux), the size or thickness of the veins (vein diameter), the speed of the reflux, and whether the veins are open or blocked (patency).
An abnormal reflux time is typically more than 500 milliseconds. The ultrasound can help highlight unusual vein structures, the start point of abnormally enlarged, twisted veins (venous varicosity), veins that connect the surface veins to the deeper veins (perforating veins) as well as help assess the deeper vein system. This information acts as a guide for the doctors while planning and performing the surgery.
How is Varicose Vein Treatment: Endovenous Laser Therapy performed
The patient is first positioned face-down, with their body slightly inclined and their leg being monitored through EKG and pulse oximetry, which are methods to check the heart’s electrical activity and oxygen levels in the blood. The area of the leg below the knee is then cleaned and prepared for the procedure.
Next, the patient is covered with a protective cloth, and the ultrasound probe used for imaging is protected with a sterile sheath. The patient is then mildly sedated for their comfort.
The doctor then injects a local anesthetic, lidocaine, to numb the part of the leg where the procedure will take place. With the guidance of ultrasound imagery, the doctor will then access the vein using a needle. Once the vein is accessed, the doctor threads a guidewire through the needle and moves it towards the area named the saphenofemoral junction.
The needle is then removed and replaced with a wider tube, called a dilator. The doctor then creates a small cut at the point where the guidewire comes out of the skin to help guide the dilator into the vein. The wider tube, or dilator, is replaced with a catheter (a thin, flexible tube).
The guidewire is then replaced with a laser fiber. Using the ultrasound, the doctor steers the laser tip upwards until it’s about an inch away from the saphenofemoral junction, and makes sure the relevant veins are visible.
With the patient turned supine (lying face upward), the doctor introduces a local anesthetic into the area around the vein, from the access point of the catheter to the saphenofemoral junction. The anesthetic is typically injected at intervals of 1 to 2 inches apart, and its placement can be confirmed by looking at the ultrasound images.
The doctor then turns on the laser and slowly pulls back the laser and the catheter while watching the ultrasound to confirm the vein is being closed by the laser. During this part, it’s essential to avoid applying too much pressure on the area over the catheter.
After the procedure, the doctor closes the small skin cut, returns the bed to a flat position, and looks out for any complications due to the procedure.
Possible Complications of Varicose Vein Treatment: Endovenous Laser Therapy
Thrombosis, a condition where a blood clot (thrombus) forms in a vein, can happen after treating large veins in the leg. The clot may even extend into the large vein in the thigh. There are four types of this, from type 1 where the clot is at the connection of a small and large vein to type 4 where the vein is fully blocked with a clot. It’s pretty rare though, with only 1.4% of cases having this problem. Even less common are deep vein thrombosis (a blood clot in deeper veins) at 0.3% and pulmonary embolus (a blood clot in the lungs) at 0.1%.
After the procedure, some people might experience a hematoma (a collection of blood outside of blood vessels) or ecchymoses (skin discoloration due to bleeding underneath). But, these aren’t always considered complications as they depend on what people were expecting from the procedure. Using certain types of lasers can actually reduce these issues because they’re better absorbed by water and less by blood.
Burns can happen when treating veins close to the skin, but with better anesthetic practice, the likelihood of burns happening reduces significantly. If it does happen, local wound care and keeping an eye out for infection can help.
Nerve damage can also occur. Treating the great saphenous vein in the upper leg could lead to temporary tingling or numbness in the inside of the leg. Similarly, treating the small saphenous vein can cause temporary tingling or numbness in the side of the foot. But don’t worry, most nerve injuries can be avoided with careful placement of the needle under ultrasound guidance and better practice of anesthetic administration.
Lastly, there’s a chance the treated vein might come back, but this happens in about 36.6% of cases within five years. It’s worth noting this is not different from other treatments like radiofrequency ablation (using heat to block the vein) or conventional surgery.
What Else Should I Know About Varicose Vein Treatment: Endovenous Laser Therapy?
Varicose veins are swollen, bulging veins that can often be seen through the skin. They occur when the walls and valves of your veins, which help blood flow back to your heart, weaken, leading to a build-up of blood, hence causing the veins to expand. Almost half of all adults experience this issue. It tends to affect overweight individuals and women who have given birth to multiple children more often.
When varicose veins worsen, they can cause discomfort and affect your overall well-being. A modern procedure called Endovenous Laser Ablation (a type of laser treatment) provides a less invasive solution. This treatment, which is usually well tolerated, helps eliminate varicose veins and improves blood flow in your veins.
