LASER ENDO-VEINEUX

Vasa. 1998 Feb;27(1):43-5Arteriovenous fistula after endoscopic dissection of the perforant vein of thelower leg with the neodymium:YAG laser in chronic venous stasis syndromeFolsch C, Rauber K, Langer C

The endoscopic dissection of the perforating veins has been invented by Hauer inthe last decade. He introduced the videoendoscopy to this surgical procedure.The avoidance of operative access through areas of trophic changes is verybeneficial for reducing postoperative complications. Although postoperativethermic lesion have been reported on. Following an endoscopic laser coagulationof a Cockett perforating vein an arterio-venous fistula between the posteriortibial artery and vein developed by the mechanism mentioned. Persisting pain andthe persistence of the ulcer led to several diagnostic measures includingphlebography, digital subtraction angiography and CT-scan. After the fistula hadbeen closed successfully by percutaneous embolization with four platin wires theulcer disappeared.

Dermatol Surg 2001 Feb;27(2):117-22 Endovenous laser: a new minimally invasive method of treatment for varicoseveins--preliminary observations using an 810 nm diode laser.Navarro L, Min RJ, Bone C.

BACKGROUND: Long-term success in the treatment of truncal and significant branchleg varicosities, when the saphenofemoral junction (SFJ) and the greatersaphenous vein (GSV) are involved, depends on the elimination of the highestpoint of reflux and the incompetent venous segment, and is best achieved bysurgical ligation and stripping. Minimally invasive alternatives in thetreatment of varicose veins with SFJ and GSV incompetence have been tried overthe years to increase patient comfort, reduce cost and risk, and allowimplementation by a wide variety of practitioners resulting in varying degreesof success depending on the fulfillment of the above two premises and theeffectiveness of the method used. OBJECTIVE: To demonstrate a novel way to uselaser energy through an endoluminal laser fiber for the minimally invasivetreatment of truncal varicosities that eliminates the highest point of refluxand the incompetent segment. METHODS: Patients were treated with 810 nm diodelaser energy administered endovenously through a bare-tipped laser fiber(400-750 microm). Vein access for endoluminal placement of the fiber through acatheter was achieved by means of percutaneous or stab wound incision underultrasound guidance and local anesthesia. Exact placement of the fiber wasdetermined by direct observation of the aiming beam through the skin and byultrasound confirmation. RESULTS: Preliminary short-term postprocedure results(up to 1 year, 2 months after treatment) in the endovenous laser treatment of 40greater saphenous veins in 33 patients indicate a 100% rate of closure with nosignificant complications. In addition, a 2-year experience of 80 cases ofisolated branch varicosities (Giacomini, anterolateral branch, etc.) also showsa 100% rate of closure. CONCLUSION: Early results of our endoluminal lasermethodology indicate a very effective and safe way to eliminate SFJ incompetenceand close the GSV. With proper patient selection, the ease of methodology andthe reduced risk and cost associated with endovenous laser treatment may make ita successful minimally invasive alternative for a wide group of patients thatpreviously would have required ligation and stripping.

14 Th World Congress of International Union of Phlebology, Rome 9-14 Sept 2001, Abstract P 9Endovenous laser: light at the end of the tunnel ?R. Min

The newest minimally invasive technique for treatment of varicose veins is endovenous laser. Endovenous laser treatment (EVLTTm) allows delivery of laser energy directly into the blood vessel lumen in order to produce vein wall damage with subsequent fibrosis. Results of the first 100 GSVs treated by the above investigator with an 810 nm wavelength diode laser (Diomed, Inc., Andover, MA) are summarized in Table 1. Other than self-limiting ecchymoses and mild discomfort along the treated GSV, there have been no minor or major complications. The early results from more than 400 GSVS treated worldwide with EVLT have been impressive with very effective occlusion of incompetent GSV segments. We eagerly await longer-term follow-up results from patients already treated with EVLT and additional evaluation of this promising new technique, which may offer a good alternative to ligation and stripping for those patients wishing to avoid surgery.

Table 1. Post-Post-EVLTTM FolIow-U of GSVsFollow-U Ratio (%) Closed % Area Reduction

1 month 100/100 (100%) 41 %3 months 72/72 (100%) 76 %6 months 54/55 (98%) 90¨%9 months, 40/41 (98%) >95 %12 months 25/27 (93%) >95 %* Evaluated with Duplex Ultrasound

Phlébologie 2001,54(3) : 293-300L’énergie laser intraveineuse dans le traitement des troncs veineux variqueux : rapport sur 97 casNavarro L, Boné C

Objectif: Éradiquer les varices des troncs et le reflux de la grande veine saphène (GVS) en obstruant la GVS de l'aine au genou par l'énergie laser délivrée par voie intraveineuse au moyen d'une fibre laser à embout nu.Méthodes : Après un test diagnostique approfondi utilisant l'ultrasonographie couleur, un cathéter est placé dans la GVS sous la jonction saphéno-fémorale. L'introduction du cathéter dans la veine est effectuée sous anesthésie locale et guidée par ultrasonographie soit par une ponction sous-cutanée, soit par l'approche « stab wound -Muller Hook ». Une fibre laser à embout nu est introduite dans le cathéter et placée à 1-2 cm sous la jonction saphéno-fémorale. La position exacte de la fibre est appréciée par ultrasonographie et par observation directe de la lumière trans-cutanée. Une anesthésie locale péri-veineuse est réalisée sur toute la longueur de la GVS et l'énergie de la diode laser est appliquée par pulsions d'une seconde toute (s) la (les) 1-3 mm depuis la jonction saphéno-fémorale jusqu'au point d'introduction de la sonde.Résultats : Les résultats des 97 grandes veines saphènes traitées chez 79 patients indiquent une absence de reflux et l'oblitération de la GVS dans chaque cas, avec un suivi moyen de 7,0 mois. Le taux de recanalisation a été de 0 % et aucune complication grave n'a été observée.Conclusion : Les résultats à court terme de cette méthode démontrent qu'il s'agit d'un procédé sûr et efficace pour oblitérer la GVS et pour éliminer les reflux des jonctions saphéno-fémorales et d'une alternative au traitement chirurgical habituel de patients présentant des varices des troncs.

Phlébologie 2001, 54(4) : 367-370Petit fait clinique, grand retentissement potentiel : l’arrivée du laser endoveineuxGorny P, Chahine D, Tran-Duy S

Nous rapportons ici la première expérience en France de traitement de la maladie variqueuse avec le laser endoveineux (LE). Le LE est une nouvelle méthode d'occlusion de la grande veine saphène à l'étage crural. Elle recourt à la chaleur dégagée par une source laser diode 810 nm. La procédure est simple, sûre, bien tolérée, rapide (30 mn) et réalisable en cabinet médical. Elle est menée sous anesthésie locale. Les résultats à court terme (1 à 9mois) sont excellents (99 à 100 % d'occlusion). Les résultats à long terme restent inconnus. Ceux fournis par les diverses techniques d'occlusion ayant précédé celle-là ne soutiennent pas la comparaison, en

termes de qualité et de taux de récidives, avec les résultats de la chirurgie d'exérèse bien exécutée. Par suite, opposer le LE directement à la chirurgie semble pour l'instant prématuré. Néanmoins cette technique mini-invasive apparaît comme une option thérapeutique intéressante, qui permettrait de retarder le recours à une chirurgie d'optique plus radicale. A cet égard le LE pourrait concerner un grand nombre de patients et se révéler une bonne indication chez ceux désireux d'éviter la chirurgie d'exérèse en première approche ou chez ceux désireux de choisir une solution thérapeutique offrant un rapport confort/ bénéfice élevé.

J Vasc Interv Radiol 2001 Oct;12(10):1167-71 Endovenous laser treatment of the incompetent greater saphenous vein.Min RJ, Zimmet SE, Isaacs MN, Forrestal MD.

PURPOSE: To assess the safety and preliminary efficacy of endovenous lasertreatment (EVLT), a novel percutaneous technique for occlusion of theincompetent greater saphenous vein (GSV). MATERIALS AND METHODS: Ninety GSVs in 84 patients with reflux at the saphenofemoral junction (SFJ) into the GSV weretreated endovenously with pulses of laser energy and evaluated in a prospective,nonrandomized, consecutive enrollment multicenter study. Patients were evaluatedat 1 week and at 1, 3, 6, and 9 months to determine efficacy and complications.RESULTS: Eighty-seven of 90 GSVs (97%) were closed 1 week after initialtreatment with endovenous laser. The remaining three GSVs were closed afterrepeat treatment. Eighty-nine of 90 GSVs (99%) remained closed for as long as 9months according to serial duplex ultrasonography. Sonographic evaluationdemonstrated 73% reduction in GSV diameter at 6 months (61 patients) and 81%reduction in GSV diameter at 9 months (26 patients) after EVLT. One patientdeveloped a transient localized skin paresthesia. There have been no other minoror major complications. CONCLUSIONS: EVLT of the incompetent GSV appears to bean extremely safe technique that yields impressive short-term results. Long-termfollow-up is awaited.

Dermatol Surg 2002 Jan;28(1):56-61 Comparison of endovenous radiofrequency versus 810 nm diode laser occlusion oflarge veins in an animal modelWeiss RA

BACKGROUND: Endovenous occlusion using radiofrequency (RF) energy has been shownto be effective for the elimination of sapheno-femoral reflux and subsequentelimination of varicose veins. Recently, endovenous laser occlusion has beenintroduced with initial clinical reports indicating effective treatment forvaricose veins. However, in our practice we note increased peri-operativehematoma and tenderness with the laser. Little is known regarding the mechanismof action of this new laser vein therapy. OBJECTIVE: To better understand themechanism of action of endovenous laser vs. the endovenous RF procedure in thejugular vein of the goat model. METHODS: A bilateral comparison was performedusing 810 nm diode laser transmitted by a bare-tipped optical fiber vs. the RFdelivery by engineered electrodes with a temperature feedback loop using athermocouple (Closure procedure) in three goat jugular veins. Immediate andone-week results were studied radiographically and histologically. Temperaturemeasurements during laser treatment were performed by using an array of up tofive thermocouples, spaced 2 mm apart, placed adjacent to a laser fiber tipduring goat jugular vein treatment. RESULTS: Immediate findings showed that 100%of the laser-treated veins showed perforations by histologic examination andimmediate contrast fluoroscopy. The RF-treated side showed immediateconstriction with maintenance of contrast material within the vein lumen and noperforations. The difference in acute vein shrinkage was also dramatic as lasertreatments resulted in vein shrinkage of 26%, while RF-treated veins showed a77% acute reduction in diameter. At one week, extravasated blood that leakedinto the surrounding tissue of laser treated veins acutely, continued to occupyspace and impinge on surrounding structures including nerves. For the laser

treatment, the highest average temperature was 729 degrees C (peak temperature1334 degrees C) observed flush with the laser fiber tip, while the temperaturefeedback mechanism of the RF method maintains temperatures at the electrodes of85 degrees C. CONCLUSION: Vein perforations, extremely high intravasculartemperatures, failure to cause significant collagen shrinkage, and intactendothelium in an animal model justify a closer look at the human clinicalapplication of the 810 nm endovenous laser technique. Extravasated bloodimpinging on adjacent structures may theoretically lead to increasedperi-operative hematoma and tenderness. Further study and clinical investigationis warranted.

Journal des maladies vasculaires Mars 2002 (27); Suppl 1 : IS 18Laser endo-veineux: résultatsAnastasie B

De mai à décembre 2001 63 patients ont étés traités; 43 femmes et 20 hommes de 24 à 89 ans. 82 axes veineux ont subi le traitement, soit 71 en territoire des grandes saphènes dont 4 récidives récurrentes et 11 petites saphènes. 58 ont eu un abord par ponction percutanée à la malléole ou à la jarretière, 11 ont nécessité une crossectomie saphène interne, ce qui a permis un cathétérisme rétrograde ; 13 autres ont eu un mini abord chirurgical par crochet de phlébectomie. Cette technique a été adaptée à partir de celle du Dr RJ Min en utilisant un laser 810 Diomed (12-14 W, 1 s) et 980 nm Biolitec (8 –12 W, 1,5 – 2,5 s). Les tirs laser sont effectués tous les 3 mm. La reprise d’une activité complète était obtenue en 6 jours en moyenne. Deux patients (2,4 %) au début de la phase d’apprentissage ont eu une endo-sclérose incomplète au hunter, sclérosée ensuite sous échographie. Il est à noter que les territoires occlus sont restés stables chez ces deux patients. Un abcès du scarpa fut à déplorer, 2 patients présentèrent un érythème douloureux et inflammatoire résolutif en 15 jours avec un traitement AINS local et général. Nous n’avons pas noté d’hématomes, ni d’infection cellulitique, thrombose ou embolie pulmonaire, perforation vasculaire. 97,6 % sont occlus jusqu’à 6 mois de suivi. La réduction de diamètre vasculaire mesurée échographiquement était de 40 % à J8 et 60 % à J90 en moyenne. Del giglio (980 nm) obtient, après avoir traité des branches puis des grandes et petites saphènes, 94 % d’occlusion à 24 mois sur 34 membres inférieurs. Boné (810 et 940 nm Dornier) sur 97 grandes saphènes aboutit à 100 % d’occlusion à 7 mois de suivi moyen. Min (810 nm) publie ses résultats sur 90 grandes saphènes ; 99 % des vaisseaux sont occlus sur un suivi moyen de 9 mois. A 24 mois, 97 % des saphènes traitées restent occluses. Aucun effet indésirable important (hématome, infection, thrombose, embolie pulmonaire, perforations) n’était noté dans ces travaux.

J Vasc Surg 2002 Apr;35(4):729-36 Endovenous treatment of the greater saphenous vein with a 940-nm diode laser:thrombotic occlusion after endoluminal thermal damage by laser-generated steambubblesProebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge S, Knop J

PURPOSE: Despite a rapid spread of the technique, very little is known about thelaser-tissue interaction in endovenous laser treatment (EVLT). We evaluated EVLTof the incompetent greater saphenous vein (GSV) for efficacy, treatment-relatedadverse effects, and putative mechanisms of action. METHODS: Twenty-six patientswith 31 limbs of clinical stages C(2-6), E(P), A(S,P), P(R) with incompetent GSVproven by means of duplex scanning were selected for EVLT in an outpatientsetting. A 600-microm fiber was entered into the GSV via an 18-gauge needlebelow the knee and proceeded to the saphenofemoral junction (SFJ). Afterinfiltration of tumescent local anesthesia, multiple laser pulses of 15 J energyand a wavelength of 940 nm were administered along the vein in a standardizedfashion. D-dimers were determined in peripheral blood samples 30 minutes aftercompletion of EVLT in 16 patients and on postoperative day 1 in 20 patients. OneGSV that was surgically removed after EVLT was examined by means ofhistopathology. Additionally, an experimental in vitro set-up was constructed asa means of investigating the mechanism of laser action within a blood-filledtube. RESULTS: A median of 80 laser pulses (range, 22-116 laser pulses) wereapplied along the treated veins. On days 1, 7, and 28, all limbs except one

(97%) showed a thrombotically occluded GSV. In one patient, the vessel showedincomplete occlusion. The distance of the proximal end of the thrombus to theSFJ was a median 1.1 cm (range, 0.2-5.9 cm) in the remaining patients. Adverseeffects in all 26 patients were ecchymoses and palpable induration along thethrombotically occluded GSV that lasted for 2 to 3 weeks. In two limbs (6%),thrombophlebitis of a varicose tributary required oral treatment withdiclofenac. D-dimers in peripheral blood were tested with normal results in 14of 16 patients 30 minutes after completion of the procedure and elevated resultsin 7 of 20 patients at day 1 after EVLT. However, an increase of D-dimers fromday 0 to day 1 was observed in 15 of the 16 patients undergoing tests 30 minutesafter EVLT and on day 1. The 940-nm laser was demonstrated by means of in vitroexperiments and the histopathological examination of one explanted GSV to act bymeans of indirect heat damage of the inner vein wall. CONCLUSION: EVLT of theGSV with a 940-nm diode laser is effective in inducing thrombotic vesselocclusion and is associated with only minor adverse effects. Laser-inducedindirect local heat injury of the inner vein wall by steam bubbles originatingfrom boiling blood is proposed as the pathophysiological mechanism of action ofEVLT.

Phlébologie 2002 ; 55 (3) : 239-43Traitement de l’insuffisance veineuse de la grande saphène par photocoagulation laser endoveineuse : technique et indicationsGuex JJ ; Min RJ ; Pittaluga P

Les procédures de traitement endovasculaires sont devenues extrêmement communes en pathologie vasculaire, le mouvement s'étend également au traitement de certaines varices. Les méthodes endovasculaires déjà connues sont : la sclérothérapie échoguidée, avec ou sans cathéter (et son dernier avatar la mousse), le clip endoveineux (V Clip°) et la radiofréquence (VNUS").

La méthode la plus récente (EVLT Diomed°) emploie un générateur Laser Diode de 15 W et d'une longueur d'onde de 810 nm dont l'énergie est délivrée in situ par une fibre optique de 600 µm.La procédure est strictement ambulatoire, sous anesthésie locale semi-tumescente, et sous contrôle échographique. Il n'y a ni hospitalisation ni arrêt de travail.La fibre optique est montée dans la grande veine saphène à travers un cathéter introduit au genou selon la méthode de Seldinger, puis positionnée grâce à l'échographie. La photocoagulation de la veine variqueuse est obtenue en retirant progressivement la fibre optique, sous compression manuelle, en appliquant des impulsions laser d'une puissance de 12 W et d'une durée de 1 sec suivies d'une pause de 1 sec. Les soins postopératoires se limitent au port d'une compression pendant une semaine.La technique est simple, rapide et efficace.

Dermatol Surg 2002 Jul;28(7):596-600 Thermal damage of the inner vein wall during endovenous laser treatment: keyrole of energy absorption by intravascular bloodProebstle TM, Sandhofer M, Kargl A, Gul D, Rother W, Knop J, Lehr HA

BACKGROUND: Despite the clinical efficacy of endovenous laser treatment (EVLT),its mode of action is incompletely understood. OBJECTIVE: To evaluate the roleof intravascular blood for the effective transfer of thermal damage to the veinwall through absorption of laser energy. METHODS: Laser energy (15 J/pulse, 940nm) was endovenously administered to explanted greater saphenous vein (GSV)segments filled with blood (n = 5) or normal saline (n = 5) in addition to GSVsunder in vivo conditions immediately prior to stripping. Histopathology wasperformed on serial sections to examine specific patterns of damage.Furthermore, in vitro generation of steam bubbles by different diode lasers(810, 940, and 980 nm) was examined in saline, plasma, and hemolytic blood.RESULTS: In saline-filled veins, EVLT-induced vessel wall injury was confined tothe site of direct laser impact. In contrast, blood-filled veins exhibitedthermal damage in more remote areas including the vein wall opposite to thelaser impact. Steam bubbles were generated in hemolytic blood by all three

lasers, while no bubbles could be produced in normal saline or plasma.CONCLUSION: Intravascular blood plays a key role for homogeneously distributedthermal damage of the inner vein wall during EVLT.

Lasers Surg Med 2002;31(4):257-62 Endovenous laser photocoagulation (EVLP) for varicose veinsChang CJ, Chua JJ

BACKGROUND AND OBJECTIVES: Untreated varicose veins have significant morbidityand potential mortality. Treatment aims to relieve symptoms, improve appearance,and to prevent deterioration. Current therapeutic options include graduatedcompression stockings, sclerotherapy, ambulatory phlebectomy, surgical ligation,and stripping. Results of laser photocoagulation of vascular anomalies have beenencouraging. Applying these concepts of laser-tissue interactions, we developeda new method of treatment for varicose veins of the lower extremities. STUDY DESIGN/MATERIALS AND METHODS: One hundred and forty-nine patients with 252 varicose greater saphenous veins underwent endovenous laser photocoagulation(EVLP) from January 1996 to January 2000. Subject's age ranged between 23 years9 months and 80 years 7 months with a mean age of 50 years 8 months. There were122 females and 27 males. Only patients with primary varicose veins andsaphenofemoral reflux documented by Duplex ultrasound were treated. All patientsreceived surgical ligation of the saphenofemoral junction (SFJ). EVLP wasperformed using the neodymium:yttrium-aluminium-garnet (Nd:YAG) (1,064 nm)laser, delivered with a 600 microm optical fiber. Laser power was set at 10 or15 W, delivered with a pulse duration of 10 seconds. The outcome was comparedbefore and after EVLP, based on the score of severity of the varicose veins byHach's classification. RESULTS: The range of total delivered energy is from9,200 to 20,100 J. The entire procedure was completed in 95-175 minutes (mean122.33 minutes) for bilateral procedures, and 65-100 minutes (mean 81.07minutes) for unilateral procedures. The follow-up period ranged from 12 to 28months with a mean of 19 months. One hundred and forty-one patients with 244legs involved (96.8%) demonstrated remarkable improvement (P < 0.05). Commonearly complications of EVLP are: local paraesthesia of the treated area in 92legs (36.5%), ecchymosis and dyschromia in 58 legs (23.0%), superficial burninjury in 12 legs (4.8%), superficial phlebitis in four legs (1.6%), andlocalized hematoma in two legs (0.8%) at 3 weeks post-operatively. The finaloutcome showed no significant morbidity or mortality. All patients recoveredcompletely. CONCLUSIONS: EVLP is a simple effective treatment modality forvaricose veins. This less invasive method can minimize the complications ofconventional surgery.

J Vasc Interv Radiol 2002 Jun;13(6):563-8 Surgical and endovascular treatment of lower extremity venous insufficiency.Bergan JJ, Kumins NH, Owens EL, Sparks SR

Lower extremity venous insufficiency is a highly prevalent condition. Now it isunderstood that telangiectasias, reticular varicosities, and true varicose veinsare physiologically similar and etiologically identical. The four maininfluences causing these abnormalities are heredity, female sex, gravitationalhydrostatic forces, and hemodynamic muscular compartment pressure. There areclear indications and goals for intervention. A cornerstone in the treatment ofvenous insufficiency is elimination of sources of venous hypertension. One ofthese is the refluxing greater saphenous vein. Minimally invasive saphenousablation can be achieved by radiofrequency energy and laser light energy. Thesenew techniques eliminate the psychologic barrier to treatment caused by the term"stripping" and allow the objectives of surgery to be achieved with minimalinvasion and quick recovery. Endovenous techniques show great promise. Theyprovide minimal invasion, often under local anesthesia and intravenous sedation,

thereby eliminating the need for general anesthesia. Objectives of venousinsufficiency have been established and the endoluminal minimally invasivetechniques developed in recent years appear to accomplish their goals.

J Mal Vasc 2002 Oct;27(4):222-5 Feasibility of ambulatory endovenous laser for the treatment of greatersaphenous varicose veins: one-month outcome in a series of 20 outpatientsGerard JL, Desgranges P, Becquemin JP, Desse H, Melliere D

The purpose of this feasibility study was to demonstrate that endovenous lasercan be a useful alternative to conventional surgery for ambulatory treatment ofadvanced varicose veins. We assessed an open, non-randomized series of patientstreated in one center by the same operator. The study protocol was approved bythe local ethics committee. Twenty patients with stage II or III varicose veinsin the Porter classification gave their informed consent to participate in thestudy. The patients were treated with endovenous laser by the first author inthe outpatient clinic of the Henri Mondor University Hospital vascular surgerydepartment. All procedures were conducted under local anesthesia. A 980 nm laserdiode optic fiber was introduced into the vein percutaneously. Laser beams werefired from the sapheno-femoral junction to just under the genu, withdrawing thefiber 3 mm every 1.5 sec. Clinical evaluation with a quality-of-lifequestionnaire and duplex-scan was performed at days 3, 8 and 30 post-op.Complete occlusion and retraction of the treated vein was observed at day 3 and30, from the point of introduction to the sapheno-femoral junction in 18 of the20 patients. The branches of the greater saphenous vein remained patent withphysiological flow in the stump which remained patent 1 to 2 cm upstream fromthe sapheno-femoral junction. The length of the patent stump dependend on thelevel of the anterior or posterior branch. There were no adverse effects relatedto the local anesthesia. Pain was low to mild during treatment and the daysfollowing the procedure, requiring 8 tablets of acetominophen at most. Hematomaswere minimal and had completely resolved by the end of the first month. No workstoppage was required for the 14 patients with occupational activities. Therewere no cases of deep or superficial vein thrombosis. Complete occlusion andretraction of the varicose vein at one month suggests this treatment has along-lasting effect. Long-term evaluation is required. Treatment of advancedvaricose veins with endovenous laser can be an alternative to surgical treatmentproviding the advantage of outpatient ambulatory treatment.

J Vasc Surg. 2002 Apr;35(4):729-36Comment in: J Vasc Surg. 2003 Jan;37(1):242; author reply 242.Endovenous treatment of the greater saphenous vein with a 940-nm diode laser:thrombotic occlusion after endoluminal thermal damage by laser-generated steambubblesProebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge S, Knop J

PURPOSE: Despite a rapid spread of the technique, very little is known about thelaser-tissue interaction in endovenous laser treatment (EVLT). We evaluated EVLTof the incompetent greater saphenous vein (GSV) for efficacy, treatment-relatedadverse effects, and putative mechanisms of action. METHODS: Twenty-six patientswith 31 limbs of clinical stages C(2-6), E(P), A(S,P), P(R) with incompetent GSVproven by means of duplex scanning were selected for EVLT in an outpatientsetting. A 600-microm fiber was entered into the GSV via an 18-gauge needlebelow the knee and proceeded to the saphenofemoral junction (SFJ). Afterinfiltration of tumescent local anesthesia, multiple laser pulses of 15 J energyand a wavelength of 940 nm were administered along the vein in a standardizedfashion. D-dimers were determined in peripheral blood samples 30 minutes aftercompletion of EVLT in 16 patients and on postoperative day 1 in 20 patients. OneGSV that was surgically removed after EVLT was examined by means of

histopathology. Additionally, an experimental in vitro set-up was constructed asa means of investigating the mechanism of laser action within a blood-filledtube. RESULTS: A median of 80 laser pulses (range, 22-116 laser pulses) wereapplied along the treated veins. On days 1, 7, and 28, all limbs except one(97%) showed a thrombotically occluded GSV. In one patient, the vessel showedincomplete occlusion. The distance of the proximal end of the thrombus to theSFJ was a median 1.1 cm (range, 0.2-5.9 cm) in the remaining patients. Adverseeffects in all 26 patients were ecchymoses and palpable induration along thethrombotically occluded GSV that lasted for 2 to 3 weeks. In two limbs (6%),thrombophlebitis of a varicose tributary required oral treatment withdiclofenac. D-dimers in peripheral blood were tested with normal results in 14of 16 patients 30 minutes after completion of the procedure and elevated resultsin 7 of 20 patients at day 1 after EVLT. However, an increase of D-dimers fromday 0 to day 1 was observed in 15 of the 16 patients undergoing tests 30 minutesafter EVLT and on day 1. The 940-nm laser was demonstrated by means of in vitroexperiments and the histopathological examination of one explanted GSV to act bymeans of indirect heat damage of the inner vein wall. CONCLUSION: EVLT of theGSV with a 940-nm diode laser is effective in inducing thrombotic vesselocclusion and is associated with only minor adverse effects. Laser-inducedindirect local heat injury of the inner vein wall by steam bubbles originatingfrom boiling blood is proposed as the pathophysiological mechanism of action ofEVLT.

MMW Fortschr Med. 2002 Dec 5;144(49):47-50Crossectomy--exhairesis--stripping--laser therapy. How even refractory varicoseveins respond to treatmentWelter HF, Mosa T, Kettmann R

Chronic venous insufficiency affects more than 50% of the German population.Major factors involved in its development are age, family disposition, femalesex and an occupation involving much standing. Together with the clinicalpresentation, Doppler and duplex ultrasonography in particular enable a reliablepre-operative diagnosis, and deep venous thrombosis can also be definitivelyexcluded. Indications for surgical treatment are in particular varicosis of thegreater and lesser saphenous vein and perforating vein insufficiency. Commonlyused procedures are crossectomy, restrictive stripping of pathological veinsegments, resection of varicose side branches, and the endoscopic discission ofperforating veins. Recent developments are deep-freezing and extraction of thevein and endovenous laser treatment (EVLT), requiring only tiny incisions. Inmost cases, these interventions can be performed on an outpatient basis.

Dermatol Surg 2003 Apr;29(4):357-61 Endovenous Laser Treatment of the Lesser Saphenous Vein With a 940-nm DiodeLaser: Early ResultsProebstle TM, Gul D, Kargl A, Knop J

BACKGROUND. : Until now, endovenous laser treatment (ELT) of the lessersaphenous vein (LSV) has not been reported. OBJECTIVE. : To evaluate efficacyand side effects for ELT of the LSV. METHODS. : Otherwise unselected patientswith an incompetent LSV were included. After perivenous infiltration oftumescent local anesthesia, laser energy (940 nm) was administered endovenously,either in a pulsed fashion or continuously during constant backpull of the laserfiber. Patients were scheduled for duplex follow-up at Day 1 and also at 1, 3, 6and 12 months, postoperatively. RESULTS. : Forty-one LSVs were targeted in 33patients with a median age of 66 years (range, 35 to 93). Seventy-three percentof patients had skin changes (C4). Thirty-six percent had an open or healedvenous ulcer (C5,6) and 15% a postthrombotic syndrome (ES AS,D PR). Thirty-nineLSVs (95%) completed ELT successfully. During a median follow-up interval of 6

months (range, 3 to 12 months), no recanalization event could be observed. Apartfrom one thrombosis of the popliteal vein in a patient with polycythemia vera,only minor side effects, particularly no permanent paresthesia, could beobserved. CONCLUSION. : ELT of the LSV under tumescent local anesthesia isfeasible and effective. Caution is warranted with ELT of thrombophilic patients.

Lasers Surg Med. 2003;33(2):115-8 Endovenous laser treatment to promote venous occlusionParente EJ, Rosenblatt M

BACKGROUND AND OBJECTIVES: Current treatment methods of superficial venousinsufficiency (SVI) can be painful or result in incomplete occlusion. Theobjective of this study was to evaluate a technique for laser endovenousablation with a newly developed diffuser fiber. STUDY DESIGN/MATERIALS ANDMETHODS: Six lateral saphenous veins in three goats were used. A specificallydesigned diffuser laser fiber tip was employed in all trials to deliver awavelength of 1,064 nm. Each segment was treated with a different energy fluenceby changing the power setting of the laser or the withdrawal rate of the fiber.Energy fluence was calculated by dividing the Joules employed for each segmentover the internal surface area of the vessel. Segments were evaluated withultrasound and histologically. RESULTS: Seventy-five percent of the segmentswere occluded when an energy fluence of greater than 85 J/cm(2) was employed. Noperforations were observed, but perivascular changes were more common at higherenergy fluence. CONCLUSIONS: Endovenous laser occlusion of veins with minimalperivascular effects can be achieved with laser wavelengths of 1,064 nm if anenergy fluence of 84.9-224 J/cm(2) is employed and circumferential effect isachieved. Lasers Surg. Med. 33:115-118, 2003. Copyright 2003 Wiley-Liss, Inc.

J Vasc Interv Radiol. 2003 Jul;14(7):911-5Temperature changes in perivenous tissue during endovenous laser treatment in aswine modelZimmet SE, Min RJ

PURPOSE: To conduct a pilot study to measure temperature at the outer vein wallduring endovenous laser treatment (EVLT). METHOD: Temperature at the outer veinwall was monitored during EVLT in a live pig ear vein (8 W: 1.0 and 2.0 secondspulse duration; 10 W: 1.0 and 1.5 second pulse duration; 12 W: 0.5, 1.0 and 1.5second pulse duration) and exposed hind limb vein (8 W: 0.5, 1.0, 1.5 secondpulse duration; 12 W: 0.5,1.0, 1.5 second pulse duration with perivenoustumescent fluid (TF); and 15 W: 0.5 second pulse duration without and with TF,1.0 second pulse duration with TF). RESULTS: Peak temperatures, near the outervein wall in an ear vein of a live pig, with laser fluence at 8 W were 40.8degrees C and 48.9 degrees C (pulse durations of 1.0 and 2.0 seconds,respectively). At 10 W, peak temperature was 47.1 degrees C and 49.1 degrees C(pulse durations of 1.0 and 1.5 seconds, respectively). At 12 W, peaktemperature ranged from 37.9 degrees C (0.5 second pulse duration) to 49.1degrees C (1.5 second pulse durations). In an exposed hind limb vessel, at 8 W,peak temperature ranged between 34.6 degrees C to 38.5 degrees C (0.5, 1.0 and1.5 second pulse durations). At 12 W and 0.5 to 1.5 second pulse durations, withTF, peak temperature ranged from 35.6 degrees C to 39.4 degrees C. At 15 W and0.5 second pulse duration, peak temperature was 44.0 degrees C without TF and34.5 degrees C with TF. At 15 W and 1.0 second pulse duration, with TF, pulseduration peak temperature was 37.0 degrees C. CONCLUSIONS: In the model studied,peak temperatures of perivenous tissues generated during endovenous laser seemunlikely to cause permanent damage to these perivenous tissues. The peaktemperature generated is reduced with the use of perivenous tumescent fluid.

J Vasc Interv Radiol. 2003 Aug;14(8):991-6

Endovenous laser treatment of saphenous vein reflux: long-term resultsMin RJ, Khilnani N, Zimmet SE

PURPOSE: To report long-term follow-up results of endovenous laser treatment forgreat saphenous vein (GSV) reflux caused by saphenofemoral junction (SFJ)incompetence. MATERIALS AND METHODS: Four hundred ninety-nine GSVs in 423subjects with varicose veins were treated over a 3-year period with 810-nm diodelaser energy delivered percutaneously into the GSV via a 600- micro m fiber.Tumescent anesthesia (100-200 mL of 0.2% lidocaine) was delivered perivenouslyunder ultrasound (US) guidance. Patients were evaluated clinically and withduplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and yearly thereafterto assess treatment efficacy and adverse reactions. Compression sclerotherapywas performed in nearly all patients at follow-up for treatment of associatedtributary varicose veins and secondary telangiectasia. RESULTS: Successfulocclusion of the GSV, defined as absence of flow on color Doppler imaging, wasnoted in 490 of 499 GSVs (98.2%) after initial treatment. One hundred thirteenof 121 limbs (93.4%) followed for 2 years have remained closed, with the treatedportions of the GSVs not visible on duplex imaging. Of note, all recurrenceshave occurred before 9 months, with the majority noted before 3 months. Bruisingwas noted in 24% of patients and tightness along the course of the treated veinwas present in 90% of limbs. There have been no skin burns, paresthesias, orcases of deep vein thrombosis. CONCLUSIONS: Long-term results available in 499limbs treated with endovenous laser demonstrate a recurrence rate of less than7% at 2-year follow-up. These results are comparable or superior to thosereported for the other options available for treatment of GSV reflux, includingsurgery, US-guided sclerotherapy, and radiofrequency ablation. Endovenous laserappears to offer these benefits with lower rates of complication and avoidanceof general anesthesia.

J Vasc Surg. 2003 Sep;38(3):511-6Infrequent early recanalization of greater saphenous vein after endovenous lasertreatmentProebstle TM, Gul D, Lehr HA, Kargl A, Knop J

OBJECTIVE: The frequency of recanalization of the greater saphenous vein (GSV)after endovenous laser treatment (ELT) is unclear. This study was undertaken toestablish the incidence of early recanalization after ELT and to study thehistopathologic features of reperfused and excised GSV. METHODS: One hundrednine GSV in 85 consecutive patients with clinical stage C(2-6) E(P,S) A(S,P,D)P(R) disease were treated with ELT. Twelve months of follow-up with duplexscanning at regular intervals was possible in 104 treated veins (95.4%) in 82patients (96.5%). Recanalized vessels were removed surgically and examined athistopathology. RESULTS: ELT-induced occlusion proved permanent at duplexscanning over 12 months of follow-up in 94 of 104 GSV (90.4%) in 73 patients. In4 patients, 5 GSV (4.8%) were recanalized completely after 1 week, after 3months (n = 3), or after 12 months. Another 5 GSV (4.8%) in 5 patients exhibitedincomplete proximal recanalization over the 12 months of follow-up. Finally, 9recanalized vessels (8.6%) required further treatment with high ligation andstripping. Histopathologic analysis of recanalized GSV revealed a multiluminalpattern, as commonly noted in reperfusion after spontaneous thrombopleboticocclusion of the GSV. During follow-up, secondary incompetency of untreatedlateral accessory saphenous veins was observed in two legs (1.9%). CONCLUSION:Early recanalization requiring retreatment is observed in less than 10% of GSVafter ELT. The histopathologic pattern mimics recanalization afterthrombophlebotic occlusion.

Tech Vasc Interv Radiol. 2003 Sep;6(3):125-31

Endovenous laser treatment of saphenous vein refluxMin RJ, Khilnani NM

Readily available noninvasive diagnostic tests now allow physicians toaccurately map out abnormal venous pathways and identify sources of reflux. Inrecent years, minimally invasive alternatives to surgical treatment of saphenousvein reflux, the main contributor to most cases of symptomatic varicose veins,have been developed with promising results.(1-8) The latest percutaneoustechnique developed to treat incompetent saphenous veins is endovenous laser,which allows delivery of laser energy directly into the vein lumen to causecollagen contraction and denudation of endothelium. This stimulates vein-wallthickening with eventual fibrosis of the vein. These modern percutaneoustechniques now provide patients with alternatives to ligation and stripping fortreatment of significant sources of venous reflux without many of the potentialcomplications associated with surgery.

Phlébologie 2003, 56 (3): 233-239Traitement laser endoveineux des axes saphéniens en ambulatoire. Définition des critères cliniques de destruction per-opératoire (CDD). Etude sur 80 cas.Out patient endovenous laser treatment of saphenous axes. Definition of peroperative clinical criteria of destruction (CDD) in 80 patientsAnido R

Etude du résultat chez 80 patients à un an de la très récente technique endovasculaire permettant la destruction des troncs saphène jusqu’à la jonction saphéno-fémorale ou poplitée.Technique innovante, efficace tant sur le plan fonctionnel qu’esthétique, confortable, strictement ambulatoire, elle est réalisée par l’introduction d’une fibre optique de 600 µm d’un laser diode par voie endoveineuse sous contrôle échographique et de la transillumination jusqu’à la jonction.L’ intervention est faite sous anesthésie locale tumescente et neuroleptanalgésie.Les résultats du traitement par endolaser veineux sont éloquents : ils montrent 98% d’excellents résultats stables à 1 an. Ils reposent sur un apprentissage rigoureux de la méthode appuyé par un écho marquage spécifique au traitement laser, et la perception des critères cliniques de destruction (CCD) per opératoire obtenue par un bon paramétrage des constantes (durée et puissance).

Study of the results in 80 patients with follow up of one year following endovascular destruction of the saphenous trunk up to the saphenofemoral or saphenopopliteal junctions. This new technique which is functionnaly and esthetically effective and strictly ambulatory is realised by the introduction of a laser fiber (diode laser) of 600 µm endovenously up to the junction under echographic and transillumation control under local tumescent anesthesia and neuroleptanalgesia.The results of endolaser treatment are excellent with 98% of success at follow up of one year.The technique requires methodical training centred on specific echo-doppler evaluation, and the preoperative appreciation of the clinical criteria of destruction obtained with the correct parameters (pulse duration and power).

Phlébologie 2003, 56 (4) : 369-382Laser endo-veineux (LEV)Anastasie B, Celerier A, Cohen-solal G, Anido R, Bone C, Mordon S, Vuong P

Le laser endoveineux (LEV), technique récente, a été développé en premier par l’équipe du Dr Carlos Boné en 1997. Il permet de scléroser un vaisseau par une méthode de photocoagulation, en utilisant un laser de longueur spécifique ayant pour cible soit l’oxyhémoglobine seule (810 nm) soit l’oxyhémoglobine et l’eau (940 et 980 nm). La lumière est véhiculée par une fibre optique introduite par un cathéter de guidage. Les résultats montrent sur les études publiées un taux moyen d’occlusion de 97 % à 24 mois.Ce traitement prometteur nécessite pour son utilisation une formation spécifique, sans laquelle des échecs peuvent survenir et par conséquent jeter un discrédit sur la méthode. Les reperméations éventuelles peuvent être reprises par la même méthode, complétée par la sclérose conventionnelle et l’échosclérose. Les excellents taux d’occlusion à deux ans, le fait que l’on puisse traiter au moins jusqu’à 28 mm de calibre saphène, la spécificité vasculaire de l’effet thermique laissent présager sa supériorité aux autres techniques endovasculaires.

Le LEV doit être curatif et non simplement palliatif, les crossectomies et les phlébectomies resteront toujours nécessaires en sachant que nous les pratiquons de moins en moins car en cas de nécessité, un traitement en deux temps peut aussi être proposé. En effet, la suppression du reflux sous-jacent peut aboutir à une inversion circulatoire de la crosse, en quelques mois, qui redevient fonctionnelle en assumant le retour veineux collatéral. La crossectomie sera peut-être remplacée par l’endosclérose de la crosse écho-guidée en cas de crosse incontinente sécurisée par des fibres à diffusion latérale ou à grande ouverture numérique.Les patients réfutés jusque-là et ceux refusant la chirurgie peuvent constituer une indication et subir au moins un LEV du tronc saphène malgré l’indication de la crossectomie, permettant ainsi de supprimer l’essentiel du reflux. Ce traitement concerne aussi bien le chirurgien vasculaire que l’angiologue interventionnel. Le LEV permet d’optimiser la coopération angio-chirurgicale, de traiter uniquement les segments veineux qui sont pathologiques en minimisant, voire en supprimant le traumatisme chirurgical, limitant ainsi l’angiogénèse ultérieure. L’introduction de longueurs d’onde absorbées à la fois par l’eau et l’hémoglobine (980 nm – Double pulse) potentialise le résultat.

The endovenous laser (EVL), a recent technique, was first developed in 1997 by Dr Carlos Boné and his team. EVL permits a vessel sclerosis with photocoagulation using defined wavelength laser targeting oxyhæmoglobin alone (810 nm) or oxyhæmoglobin and water (940 and 980 nm). Light is transported by an optic fiber introduced by a guiding catheter. The results in published studies show an average occlusion rate of 97% after 24 months.This attractive treatment requires special training on the part of the practitioner in order to prevent failure of the proceedings and thus discredit the method. Possible repermeations can be treated with the same process completed by conventional or echo-guided sclerotherapy. Excellent results after 24 months, the possibility of treating up to 28 mm of saphena diameter, and the vascular specificity of thermal effect presage its superiority compared to other endovascular techniques.The EVL must be curative and not simply palliative, crossectomy and phlebectomy will always be necessary, even though they will be used less and less. If necessary the treatment can be proposed in two steps. The suppression of underlying reflux promotes circulatory inversion of the saphenal cross in a few months allowing functional flow taking over collateral branchs. Crossectomy could be replaced by echo-guided cross endosclerosis in case of cross reflux, secured by lateral diffusion fiber or wide aperture angle..Unaccepted patients and those refusing surgery can initially benefit EVL of saphenal trunk to relieve the major part of reflux in spite of the indication of coupled crossectomyThis treatment concerns vascular surgeons as well as interventional angiologists. EVL allows us to optimize co-operation between the angiologist and the vascular surgeon, treating only pathological venous segments, minimizing surgical traumatism and therefore limiting later angiogenesis. Introduction of wavelengths absorbed by both water and hæmoglobin (980 nm - Double pulse) potentializes results.

Dermatol Surg. 2003 Nov; 29(11): 1135-40Endovenous laser surgery of the incompetent greater saphenous vein with a 980-nmdiode laserOh CK, Jung DS, Jang HS, Kwon KS

BACKGROUND: In recent years, the minimal endoluminal invasive alternativesagainst surgical ligation and stripping for the treatment of incompetent greatersaphenous vein (GSV) have been explored. Endovenous laser surgery is one ofthese endoluminal alternatives, and its clinical results are being reported atup to 3 years. OBJECTIVE: To evaluate the safety and efficacy of a 980-nm diodelaser for the elimination of the incompetent GSV. METHOD: Fifteen limbs in 12patients with incompetent GSV were treated via an endovenous route with a 980-nmlaser under local anesthesia in an outpatient setting. The effects wereevaluated clinically along with duplex ultrasound at 1, 4, and 12 weeks afterthe treatment to determine efficacy and possible complications. RESULTS:Complete occlusion and retraction of treated GSV in all patients were observedduring the 12 weeks of the postoperative period. There have been no significantcomplications to be concerned. CONCLUSION: The endovenous 980-nm diode lasersurgery is a relatively simple, safe, office-based procedure that is expected topromise favorable results while a long-term follow-up is awaited.

Angiol Sosud Khir. 2004;10(1):93-100Endovasal laser obliteration of the greater saphenous vein in patients with

varicosisBogachev VIu, Kirienko AI, Zolotukhin IA, Briushkov AIu, Zhuravleva OV

S. I. Spasokukotsky Faculty of Surgery with a Course of Cardiovascular Surgeryand Surgical Phlebology, Faculty for Advanced Medical Training, Russian StateMedical University, Moscow, Russia. phlebo-union@mtu-net.ru

This paper describes the first results of endovasal laser obliteration of thegreater sephenous vein in two patient groups (n=40) math varicosis. In 15 cases(control group), laser obliteration was employed during routine operation as analternative to phlebectomy according to Babcock following crossectomy. In 25patients (the main group), operation was performed without ligation of thesaphenofemoral anastomosis. After puncture and catheterization according toSeldinger the greater saphenous vein was exposed to thermal action over thelength from the osteal valve to the upper third of the leg. The follow up of thepatients amounted to 12 months. The results obtained in the main patient groupseem most interesting. Stable elimination of truncal varicosis could be attainedin more than 90% of cases, which was associated with quick medicosocialrehabilitation, the minimal number of complications and an excellent cosmeticeffect.

Rozhl Chir. 2004 Feb;83(2):96-101Endovascular therapy of truncal varicose veins of the lower extremities with adiode laserKaspar S, Havlicek K

The authors present their experiences with new miniinvasive treatment ofvaricose veins--endovenous diode laser system. The results of 60 procedurestreating truncal varices are reported with special concern to percutaneousaccess technique under ultrasound guidance. This new concept based onhaemodynamic ultrasound findings is compared to the traditional surgicaltechnique of cross-sectomy and stripping.

Dermatol Surg. 2004 Feb; 30(2 Pt 1): 174-8Nonocclusion and early reopening of the great saphenous vein after endovenouslaser treatment is fluence dependentProebstle TM, Krummenauer F, Gul D, Knop J

BACKGROUND: Parameters influencing failure and recanalization rates ofendovenous laser treatment (ELT) of the great saphenous vein (GSV) are still tobe determined. OBJECTIVE: To evaluate treatment-related parameters of ELT withrespect to early failure of occlusion or recanalization of GSVs. METHODS: Aseries of 77 consecutive patients received ELT of 106 GSVs with continuouspullback of the laser fiber. Duplex examination was performed at 1 day, 4 weeks,and 3 months after the procedure. Clinical patient and vessel characteristics aswell as technical parameters of the ELT procedure were evaluated via multiplelogistic regression analysis. RESULTS: A median vein length of 60 cm (range of18 to 90) was treated with a median pullback velocity of 0.6 cm/sec (range of0.4 to 1.3), resulting in a median energy delivery of 23.4 J/cm (range of 11.8to 35.5) and a median laser fluence of 11.8 J/cm2 (range of 2.8 to 37.3). At day1 after ELT, 6 GSVs (6%) were not occluded. At 1 and 3 months after ELT, 9 GSVs(9%) and 11 GSVs (10%), respectively, were found open by color duplexexamination. Risk factors for nonocclusion 3 months after ELT, by univariateanalysis, were laser fluence, laser energy per centimeter of vein length,diameter of the vein before treatment, and distance of the thrombus to thesapheno-femoral junction at day 1 after treatment. Finally, multiple regressionanalysis selected laser fluence (p=0.004, odds ratio=0.40 J/cm2) as the relevantrisk factor for ELT failure or recanalization. CONCLUSION: ELT failure seems to

be related to the administration of low laser fluences

J Endovasc Ther. 2004 Apr; 11(2): 132-8Endovenous laser ablation of the saphenous vein for treatment of venousinsufficiency and varicose veins: early results from a large single-centerexperiencePerkowski P, Ravi R, Gowda RC, Olsen D, Ramaiah V, Rodriguez-Lopez JA, DiethrichEB

PURPOSE: To report early results of a single-center experience with endovenouslaser ablation of the saphenous vein (ELAS). METHODS: From February 2002 toJanuary 2003, 165 eligible patients (116 women; mean age 59.1 years, range27-90) were treated with ELAS for venous insufficiency in 203 lower limbs. Allpatients were symptomatic, and the majority (62%) had class 4 or higher clinicaldisease (CEAP classification). Eighteen (8.9%) patients had ulcers. A 940-nmdiode laser was used in an office setting under local tumescent anesthesia todeliver 100 to 140 laser applications along the course of the vein. Two weeks ofcompression bandages and a 1-week course of ibuprofen were prescribedpostoperatively. All patients underwent a duplex scan of the target vein at 2weeks. RESULTS: The great (154, 76%), short 37 (18%), and accessory 12 (6%)saphenous veins were ablated, achieving a 97% clinical success rate.Postoperative complications were few (mild induration and ecchymosis) and welltolerated (no DVT or nerve injury). Of the 6 (3.0%) recanalized target veins, 4were only partially open and successfully treated with sclerosis. Of the 18patients with active ulceration, 15 (83%) demonstrated healing after ELAS. In asatisfaction survey of patients more than 1 year after ELAS treatment, 84% ofthe 31 responders claimed their symptoms had diminished to none or minimal; 97%were mostly or very satisfied with their treatment results. CONCLUSIONS: ELASfor symptomatic saphenous vein incompetence and varicose veins has excellentshort-term subjective and objective outcomes. This technique appears to be verysuccessful in reducing symptoms, resolving varicose veins, and healing ulcers.

Ann Chir. 2004 May;129(4):248-57 Endovenous therapy for varicose veins of the lower extremitiesPerrin M

Endovenous treatment for varicose veins of the lower extremities is an oldtechnique. New technologies such as radiofrequency and laser have revived itsindications. Thermal energy which is delivered to the vein wall results in afibrous retraction and eventually complete obstruction of the vessel.

J Cosmet Laser Ther. 2004 May;6(1):44-9Combined endovascular laser with ambulatory phlebectomy for the treatment ofsuperficial venous incompetence: a 2-year perspectiveSadick NS, Wasser S

OBJECTIVE: Non-invasive radiofrequency and endovascular technologies arebecoming increasingly popular in the treatment of superficial venousincompetence. In conjunction with stab avulsion of truncal varicosities, thesetechnologies have been able to address functional as well as cosmeticsuperficial venous incompetence in a non-invasive fashion. The present studypresents a 2-year follow-up of 30 patients with combined axial incompetence ofthe greater saphenous vein (GSV) in conjunction with truncal varicositiestreated with combination diode laser technology and ambulatory phlebectomy.METHODS: Thirty patients (mean age 49 years) with Sapheno-Femoral Junctionreflux associated with GSV incompetence (mean 9.2 x 8.5 mm) and enlarged branchvaricosities, as documented by Duplex ultrasound, were enrolled. Patients were

treated with an endovascular diode laser (810 nm, 14 W, continuous mode),followed by ambulatory phlebectomy of residual truncal varicosities. Patientswere examined 3, 6, 12 and 24 months following this procedure to determine thelong-term efficacy of this procedure. RESULTS: A 2-year closure rate of 96.8%was documented by Duplex evaluation. All 273 ambulatory phlebectomy veinsegments were eradicated. Two cases of transient hyperpigmentation and one caseof telangiectatic matting were documented. CONCLUSION: The combination ofendovascular laser and ambulatory phlebectomy appear to be an effective and safetreatment approach for the management of combined saphenous and truncal varicosevein incompetence.

J Vasc Interv Radiol. 2004 Jun;15(6):625-7Arteriovenous fistula after endovenous laser treatment of the short saphenousveinTimperman PE

Reports of major complications from endovenous laser treatment of saphenousveins with use of perivenous tumescent anesthesia are very rare. The authorreports a major complication of endovenous laser treatment, the creation of anarteriovenous (AV) fistula. The fistula was created between the short saphenousvein (SSV) and the superficial sural artery in the popliteal fossa duringendovenous laser treatment of the SSV. The proximity of the superficial suralartery and the SSV in the popliteal fossa increases the risk of fistulaformation. Color-flow Doppler ultrasonography can demonstrate potentiallydangerous anatomic relationships between the vein segment intended for treatmentand adjacent arteries. Recognition of these relationships should increase theoperator's ability to minimize the risk of AV fistula formation.

J Cosmet Dermatol. 2004 Jul;3(3):162-6Intravascular lasers in the treatment of varicose veinsGoldman MP

Historically, surgical treatments, such as high ligation or complete removal ofan incompetent greater saphenous vein, were used to treat varicose veinsresulting from saphenofemoral junction reflux. The relative lack of efficacy ofthese invasive methods, along with potential morbidity and significant patientdowntime, has inspired the search for other treatments. Endovenousradiofrequency closure of the greater saphenous vein is effective and safe butits high cost, in terms of non-reusable catheters, and its slow withdrawal rateimpair its practicality. A new technique for endovenous occlusion usingendoluminal laser technology offers a less invasive alternative to ligation andstripping as well as a faster and less expensive method to treat varicosesaphenous trunks and junctions. Initial clinical experience in several hundredpatients shows a high degree of success with minimal side effects, most of whichcan be prevented or minimized by minor modifications of the technique. Thispaper reviews the use of an intravascular laser to destroy varicose veins.Various wavelengths including 810, 940, 980, 1064 and 1320 nm have been used toproduce intravascular destruction of varicose veins. The 1320-nm intravascularlaser with a motorized pull-back system appears to be the most efficient andreproducible system to effectively close and/or destroy an incompetent greatersaphenous vein.

J Vasc Interv Radiol. 2004 Aug;15(8):865-7Cutaneous thermal injury after endovenous laser ablation of the great saphenousvein

Sichlau MJ, Ryu RK

Herein a case of cutaneous thermal injury in the leg of a patient who underwentendovenous laser (EVL) ablation of an incompetent great saphenous vein (GSV) isreported. Follow-up ultrasonography (US) of the site of skin burn showed thatthe burn was directly over thrombosed superficial tributaries originating fromthe GSV, but medial to the treated GSV. At the level of skin burn, thethrombosed GSV was 22 mm deep, but the tributaries were 1 mm deep. In addition,US showed echogenic fat surrounding and conforming to the superficial thrombosedtributaries. Based on the clinical scenario and follow-up US findings, it wasconcluded that the cutaneous thermal injury resulted from heated blood travelingfrom the 22-mm-deep GSV to the superficial tributaries directly beneath the siteof skin burn.

Zhonghua Wai Ke Za Zhi. 2004 Sep 22;42(18):1125-7Endovenous laser treatment of 62 patients with primary varicose veins of lowerextremitiesCheng YK, Zhu SQ, Luo WJ, Shen QM, Sun JM

OBJECTIVE: To retrospectively analyze the experiences and results of thetreatment on 62 patients with primary varicose of lower extremities withendovenous laser. METHODS: All patients were treated with endovenous laser. Thelaser treatment could begin when the fiber withdraw with 1 cm/2 s. The laserpower was 10 - 12 w with the laser pulse duration and the interval 1 secondrespectively. RESULTS: The duration of follow-up varied from 2 months to 8months. After endovenous treatment, the varicose veins and edema disappeared inall cases. The itching and uncomfortable feeling was dissipated. Nomorphine-like analgesic has been used and no serious complications occurred.CONCLUSION: Endovenous laser treatment of primary varicose of lower extremitiesis a safe and effective technique.

J Vasc Interv Radiol. 2004 Oct;15(10):1061-3Greater energy delivery improves treatment success of endovenous laser treatmentof incompetent saphenous veinsTimperman PE, Sichlau M, Ryu RK

PURPOSE: Early and midterm results of endovenous laser treatment (EVLT) of thesaphenous veins for the treatment of symptomatic insufficiency are promising.However, technical factors contributing to success or failure of saphenous veinEVLT have not been fully investigated. This study was performed to test thehypothesis that treatment success is related to achieving a critical thresholdof energy delivery relative to the length of vein treated.MATERIALS AND METHODS:Data regarding length of treated vein and total energy delivered were collectedfrom prospectively acquired databases at two institutions. Ultrasound (US)examinations were obtained for all treated veins. Successful EVLT was defined asUS-documented absence of flow in the treated vein. EVLT failure was defined byUS evidence of flow at any point in the treated vein segment at any time morethan 1 week after the treatment date. A two-tailed Student t test was performedfor statistical analysis and the null hypothesis was rejected at a P value lessthan .05. RESULTS: One hundred eleven treated veins were followed up with USover 3-78 weeks (mean, 29.5 weeks). During this time, 85 treated veins (77.5%)remained closed. In this group of successfully treated veins, average energydelivered was 63.4 J/cm (range, 20.5-137.8 J/cm). The average energy deliveredto the 26 veins (22.5%) in the failure group was 46.6 J/cm (range, 25.7-78J/cm). This difference in delivered energy was statistically significant (P <.0001). No treatment failures were identified in patients who received doses of80 J/cm or more. CONCLUSION: EVLT is an effective method of incompetentsaphenous vein treatment. Greater doses of energy delivered are associated withsuccessful EVLT, particularly when doses of more than 80 J/cm are delivered.

Zhonghua Wai Ke Za Zhi. 2004 Oct 22;42(20):1244-6Endovenous holmium laser treatment for varicose veinsZhang Q, Huang SM, Meng LY, Wang XD, Ding JQ

OBJECTIVE: To discuss the technical pionts, advantages, follow-up results andmechanism of endovenous holmium laser treatment for varicose veins. METHODS:Endovenous holmium laser procedures were performed for 96 patients (99 legs)with primary varicosity of lower extremities. Perioperative Duplex was used forpreoperative diagnosis, intraoperative guide and postoperative follow-up. Thetime of procedure and clinical results were observed. The mean follow-up timewas 7 months. RESULTS: Sixty-seven in 99 legs with saphenous vein occludedimmediately during operation. All saphenous veins were confirmed to be occluded7 days after the procedure. There was no recanalization with Duplex findingduring the follow-up period. No wound complications. Two cases were with minorskin burn. One case was with saphenous nerve injury. Three cases were with thighecchymosis. CONCLUSION: Preliminary results show endovenous holmium lasertreatment for varicose veins is safe and effective in treating varicose veinswith cosmetic appearance and quicker recovery.

Lasers Surg Med. 2004;34(5):446-5060-minute application of S-Caine Peel prior to 1,064 nm long-pulsed Nd:YAG lasertreatment of leg veinsJih MH, Friedman PM, Sadick N, Marquez DK, Kimyai-Asadi A, Goldberg LH

BACKGROUND AND OBJECTIVES: Advancements in laser treatment of leg veinsnecessitate concurrent investigations in topical anesthesia to minimizetreatment-related pain. To evaluate the efficacy of the S-Caine Peel forproviding topical anesthesia after a 60-minute application. STUDYDESIGN/PATIENTS AND METHODS: A randomized, double-blinded, placebo-controlledtrial was performed in two centers. Sixty patients received S-Caine Peel andplacebo vehicle on different treatment sites for 60 minutes prior to lasertreatment of leg veins using a 1,064 nm long-pulsed Nd:YAG laser. Patients ratedtheir level of pain using a visual analog scale. Adequacy of anesthesia andexpressed pain at each site were rated by the investigator. RESULTS: The meanvisual analog scale (VAS) was 27 mm for active sites compared to 43 mm forplacebo (P < 0.001). Improved pain relief was noted for 67% of active versus 30%of placebo sites (P < 0.001). Anesthesia was judged adequate by the investigatorfor 55% of active compared with 12% of placebo sites (P < 0.001). CONCLUSIONS:The S-Caine Peel is safe and effective when applied for 60 minutes prior tolaser therapy of leg veins.

Dermatol Surg. 2004 Nov;30(11):1380-5Intravascular 1320-nm laser closure of the great saphenous vein: a 6- to12-month follow-up studyGoldman MP, Mauricio M, Rao J

OBJECTIVE: The objective was to determine the safety and efficacy of anintravascular laser with a novel wavelength to close the great saphenous vein.METHODS: Twenty-four cases of an incompetent great saphenous vein (0.5-1.2 cm indiameter) associated with distal varicose veins were treated with a 1320-nmintravascular laser at 5 W with an automatic pullback mechanism at 1 mm/s.Patients were evaluated with duplex ultrasound to determine efficacy oftreatment at various time periods to at least 6 months after the procedure.RESULTS: All patients demonstrated complete closure of the incompetent greatsaphenous vein. In most cases, the treated great saphenous vein was notidentifiable 6 months postoperatively. There was no recurrence of any varicose

veins. All preoperative symptoms resolved after treatment, and no complicationswere noted. All patients were very pleased with the outcome of the procedure.CONCLUSIONS: At 6 months or greater follow-up, a 5-W, 1320-nm intravascularlaser with 1 mm/s automatic pullback, delivered through a diffusion-tip fiber,is safe and effective in treating an incompetent great saphenous vein up to 1.2cm in diameter.

Rofo. 2005 Feb;177(2):179-87Endovenous treatment of primary varicose veins: an effective and safetherapeutic alternative to stripping ?Kluner C, Fischer T, Filimonow S, Hamm B, Kroncke T

Endovenous laser therapy (EVLT) is a new, minimally invasive therapeutic optionfor treating primary varicose veins and provides an effective and safealternative to conventional surgical management (stripping). Short-term andintermediate-term outcome is comparable to surgical stripping in terms ofelimination of venous reflux (90 % - 98 %), resolution of visible varices (85%), and improvement of subjective complaints such as sensations of heaviness andtension (96 %). Complications occur in 1 % - 3 % of cases, which is markedlybelow the rate of conventional surgical management (up to 30 %). Theintermediate-term incidence of recurrent varicosis in a vein treated by EVLTdepends on the laser fluence applied and is reported to range from 7 % - 9 %compared to 10 % - 20 % after surgical intervention. Based on a review of thecurrent literature and our own experience, this survey article presents anoverview of the indications and contraindications, the technique andpathophysiology of laser-induced venous occlusion, and the results and possiblecomplications of EVLT.

J Vasc Surg. 2005 Jan;41(1):130-5Comment in: J Vasc Surg. 2005 Jul;42(1):182; author reply 182-3.Extension of saphenous thrombus into the femoral vein: a potential complicationof new endovenous ablation techniquesMozes G, Kalra M, Carmo M, Swenson L, Gloviczki P

Endovenous techniques such as radiofrequency ablation (RFA) and endovenous lasertherapy (ELT) have emerged as percutaneous minimally invasive procedures forablation of incompetent great saphenous veins in patients with varicosity andvenous insufficiency. Early reports showed safety and efficacy of bothtechniques, with excellent technical success rates and few major complications,such as deep vein thrombosis or pulmonary embolism. During our initialexperience with ELT in 56 limbs of 41 patients, 39 underwent postoperativeduplex scanning. We encountered three cases (7.7%) with thrombus extension intothe common femoral vein. All three patients were anticoagulated, and a temporaryinferior vena cava filter was placed in one. All remained asymptomatic. Thethrombus resolved by 1 month in all three patients. Review of the literaturerevealed that the incidence of thrombus extension into the common femoral veinor deep vein thrombosis in published clinical series is 0.3% after ELT and 2.1%after RFA. This possibility warrants routine postoperative duplex scanning, morealertness during these procedures, and patient education on this possiblecomplication.

Khirurgiia (Mosk). 2005;(1):9-12Laser obliteration in the treatment of varicose disease of the lower limbsShevchenko IuL, Liadov KV, Stoiko IuM, Sokolov AL, Barannik MI, Belianina EO,

Lavrenko SV

Experience of endovenous laser coagulation in the treatment of the varicosedisease of the lower extremities is presented. This method was used in 107patients. Surgical technique of isolated endovenous laser coagulation andcombined phlebectomy was described in detail. Morphologic data on laser injuryof a venous wall are presented. Short- and long-term results were evaluated withclinical and ultrasonic methods. It is demonstrated that endovenous lasercoagulation may be regarded as alternative to traditional saphenectomy. Thismethod decreases surgical trauma, number of complications and hospital stay.

Semin Vasc Surg. 2005 Mar;18(1):15-8Saphenous ablation: what are the choices, laser or RF energyMorrison N

Endovenous ablation has been reported to be safe and effective in eliminatingthe proximal portion of the great saphenous vein from the venous circulation,with faster recovery and better cosmetic results than surgical stripping.However, the definition of a successful outcome in the literature has not beenuniform. As in a successful stripping procedure, complete elimination of atleast the proximal portion of the great saphenous vein should also be thestandard for these endovenous ablation procedures. Our experience with over1,400 endovenous ablation procedures, of which 1,150 were radiofrequency andover 250 were laser procedures, has allowed evaluation and comparison of thesetwo techniques. And while we have not seen as high success rates as in publishedreports (especially with laser ablation), we have still concluded that bothradiofrequency and laser techniques to destroy the saphenous vein are safe andeffective. Patient acceptance is overwhelmingly better than stripping.Physicians performing these techniques should embrace a commitment to addressingall sites of venous insufficiency in a patient, not just the proximal greatsaphenous vein. Without this level of commitment, one will be left with poorresults and a dissatisfied patient.

J Vasc Surg. 2005 Jun;41(6):1018-24; discussion 1025The immediate effects of endovenous diode 808-nm laser in the greater saphenousvein: morphologic study and clinical implicationsCorcos L, Dini S, De Anna D, Marangoni O, Ferlaino E, Procacci T, Spina T, Dini M

BACKGROUND: We conducted this study to evaluate the immediate venous morphologicalterations produced in the great saphenous veins by the endovenous diode 808-nmlaser used for the treatment of superficial venous insufficiency and varicoseveins of the lower limbs and to clarify the clinical implications of thehistologic findings. METHODS: Chosen for the study were 24 limbs of 16 patientswith CEAP classification 3 to 6, ultrasound-documented greater saphenousinsufficiency, and venous diameters between 3.9 mm and 17 mm (mean, 8.04 mm)without phlebitis, saphenous aneurysms, congenital malformations, or deep venousinsufficiency. All limbs underwent surgical saphenofemoral disconnection, andthe greater saphenous vein was treated with an endovenous diode 808-nm laser bycontinuous emission at 8 to 12 W and variable retraction speed (</>1 mm/s).Spinal or local, but not tumescent, anesthesia was used. Twenty-nine specimens(3 to 5 cm long) of 24 proximal greater saphenous and five anterior accessorysaphenous veins were excised and studied by light microscopy for diameter andthickness of the venous wall, extent of injury into the intima, media, andadventitia, as well as penetration of thermal damage. RESULTS: The histologicevaluation showed thermal injury to the intima in all specimens andfull-thickness intimal injury in 22 specimens (75%); the average penetration ofthermal injury in 29 specimens was 194.40 microm (range, 10 to 900 microm;14.61% of the mean wall thickness); complete intimal circumference injury

occurred in 8 specimen veins <10 mm in diameter (27.5%), full thickness damagein 6 (20.7%), and perforation in 2 (6.9%). CONCLUSIONS: Saphenous ablation using808-nm laser by variable retraction speed, combined with saphenofemoralinterruption, leads to sufficient vein wall injury to assure venous occlusion.Full thickness thermal injury or perforation is infrequent. Optimal results canbe obtained in veins <10 mm in diameter.

J Vasc Interv Radiol. 2005 Jun;16(6):791-4Prospective evaluation of higher energy great saphenous vein endovenous lasertreatmentTimperman PE

PURPOSE: In this study, the hypothesis that higher energy dose improvesprocedural success without increasing complications was prospectively evaluatedby performing endovenous laser therapy (ELT) at energies greater than 80 J/cm.MATERIALS AND METHODS: One hundred consecutive great saphenous (GSV), anterioraccessory great saphenous (AAGSV), or posterior accessory great saphenous(PAGSV) veins were treated with the intent to deliver an energy dose of greaterthan 80 J/cm. Eighty-one patients (64 women, 17 men) were treated. Mean age was49 years (range, 25-77 years; SD, 12 years). Ultrasound (US) and clinicalfollow-up was performed at 1 week, 3, 6, 9, and 12 months until all veins had atleast 3 months of follow-up. Success was defined as absence of reflux throughoutthe entire treated segment on follow-up US and clinical resolution of symptoms.Incomplete vein ablation was defined as US evidence of flow in a segment of atreated vein at any point during the follow-up period. RESULTS: One hundredveins were treated with an average energy of 95 J/cm (range, 57-145 J/cm; SD, 16J/cm). Follow-up and success at 1 week was 100%. Four veins could not befollowed up beyond 1 week. Of the 96 remaining veins all had 3 months follow-upwith an average follow-up of 9 months (range, 3-13 months; SD, 4 months). Therewere five failures and 91 successes for a success rate of 95%. Four of thetreatment successes demonstrated segmental patency but no reflux on US for acomplete vein ablation rate of 91%. No major complications occurred. Thetreatment failures occurred at an average energy dose of 98 J/cm. Two of thethree failures were AAGSVs, one was a GSV ipsilateral to one of the failedAAGSVs, and two were bilateral GSVs treated during the same procedure. Averagebody mass index (BMI) was 30 for the successes and 46 for the failures. Thisdifference was statistically significant (P = .0009). The mean length of thefailed treatments from the saphenofemoral junction to their termination into avaricose tributary was 10.9 (range, 8-15 cm; SD, 3.7 cm). This was significantlyless than the length of the successful treatments (P = .000003). CONCLUSION:Higher energy GSV ELT is safe and highly successful.

J Vasc Interv Radiol. 2005 Jun;16(6):879-84Ultrasound-guided endovenous diode laser in the treatment of congenital venousmalformations: preliminary experienceSidhu MK, Perkins JA, Shaw DW, Bittles MA, Andrews RT

Department of Radiology, Children's Hospital and Regional Medical Center, 4800Sand Point Way NE, R5438-1, Seattle, WA 98105, USA.

The authors present their experience in treating congenital venous malformationswith ultrasound (US)-guided endovenous diode laser. Six patients underwenttreatment of eight venous malformations for complaints including pain, activitylimitation, or cosmetic defect. At a mean follow-up interval of 14.5 months, allhad either resolution of (five patients) or marked decrease in (one patient)pain, allowing them to resume previously limited activities. There were noinstances of nerve damage or skin necrosis. One patient had a self-limitedmucosal tongue base ulcer. In this small series of patients, endovenous lasertreatment of venous malformations was effective during short-term follow-up.

Di Yi Jun Yi Da Xue Xue Bao. 2005 Jul;25(7):889-91.Comparison of immediate therapeutic effects of endovenous laser treatment andconventional therapy for lower extremity varicose veinsWu LP, Huang ZH, Wang J, Zhou HF, Zhang YX

OBJECTIVE: To compare the immediate therapeutic effects of endovenous lasertreatment (ELT) and conventional surgery for lower extremity varicosity (LEV).METHODS: Twenty-two limbs of 20 patients with ELT and 36 limbs of 30 patientswith traditional surgery were analyzed in terms of operation time, number of theincision, postoperative pain, complications, postoperative hospital stay andone-year recurrence rate. RESULTS: ELT group had shorter operation time, fewerincisions, less postoperative pain and shorter hospital stay than conventionalsurgery group, but the two groups showed no significant difference incomplications and one-year recurrence rate. CONCLUSIONS: As a safe and effectivenew treatment of LEV with minimal invasiveness and leaving no scars ELT has thepotential to replace conventional surgery and extends the surgical indicationsfor LEV treatment.

J Cardiovasc Surg (Torino). 2005 Aug;46(4):395-405Endovenous laser ablation of varicose veinsMin RJ, Khilnani NM

Readily available non-invasive diagnostic tests now allow physicians toaccurately map out abnormal venous pathways and identify all sources of reflux.Minimally invasive alternatives to surgical removal of incompetent truncal veinshave been developed with impressive RESULTS: Endovenous laser treatment can beperformed in the office under local anesthesia and is associated with virtuallyno recovery period. Better understanding of the primary mechanism of energytransfer by direct contact between the laser fiber tip and vein wall hasunderscored the importance of vein emptying. Improved utilization of tumescentanesthesia has helped facilitate circumferential laser fiber to vein wallcontact and virtually eliminated the incidence of heat-related complications.Further refinements in the technique and optimization of laser energy parametershave improved success rates of vein closure from 90% to nearly 100%. Compared tosurgery, endovenous laser has also demonstrated lower rates of recurrencelargely due to the absence of neovascularity. This review of endovenous lasertreatment should validate this exciting technique as a scientifically acceptableoption for eliminating truncal vein reflux. If measured by patient acceptanceand satisfaction, endovenous laser and other minimally invasive methods havealready supplanted traditional surgery as the treatment of choice forsuperficial venous insufficiency.

J Vasc Surg. 2005 Sep;42(3):488-93Endovenous laser therapy and radiofrequency ablation of the great saphenousvein: analysis of early efficacy and complicationsPuggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P

BACKGROUND: Endovenous laser therapy (EVLT) and radiofrequency ablation (RFA)are new, minimally invasive percutaneous endovenous techniques for ablation ofthe incompetent great saphenous vein (GSV). We have performed both procedures atthe Mayo Clinic during two different consecutive periods. At the time of thisreport, no single-institution report has compared RFA with EVLT in themanagement of saphenous reflux. To evaluate early results, we reviewed saphenousclosure rates and complications of both procedures. METHODS: Between June 1,2001, and June 25, 2004, endovenous GSV ablation was performed on 130 limbs in92 patients. RFA was the procedure of choice in 53 limbs over the first 24-month

period of the study. This technique was subsequently replaced by EVLT, which wasperformed on the successive 77 limbs. The institutional review board approvedthe retrospective chart review of patients who underwent saphenous ablation.According to the CEAP classification, 124 limbs were C2-C4, and six were C5-C6.Concomitant procedures included avulsion phlebectomy in 126 limbs, subfascialendoscopic perforator surgery in 10, and small saphenous vein ablation in 4(EVLT in 1, ligation in 1, stripping in 2). Routine postoperative duplexscanning was initiated at our institution only after recent publicationsreported thrombotic complications following RFA. This was obtained in 65 limbs(50%) (54/77 [70%] of the EVLT group and 11/53 [20.8%] of the RFA group) between1 and 23 days (median, 7 days). RESULTS: Occlusion of the GSV was confirmed in93.9% of limbs studied (94.4% in the EVLT [51/54] and 90.9% in the RFA group[10/11]). The distance between the GSV thrombus and the common femoral vein(CFV) ranged from -20 mm (protrusion in the CFV) to +50 mm (median, 9.5 mm) andwas similar between the two groups (median, 9.5 mm vs 10 mm). Thrombus protrudedinto the lumen of the CFV in three limbs (2.3%) after EVLT. All three patientswere treated with anticoagulation. One received a temporary inferior vena cavafilter because of a floating thrombus in the CFV. Duplex follow-up scans ofthese three patients performed at 12, 14, and 95 days, respectively, showed thatthe thrombus previously identified at duplex scan was no longer protruding intothe CFV. No cases of pulmonary embolism occurred. The distance between GSVthrombus and the saphenofemoral junction after EVLT was shorter in olderpatients (P = .006, r(2) = 0.13). The overall complication rate was 15.4% (20.8%in the EVLT and 7.6% in the RFA group, P =.049) and included superficialthrombophlebitis in 4, excessive pain in 6 (3 in the RFA group), hematoma in 1,edema in 3 (1 in the RFA group), and cellulitis in 2. Except for two of thethree patients with thrombus extension into the CFV, none of these adverseeffects required hospitalization. CONCLUSION: GSV occlusion was achieved in >90%of cases after both EVLT and RFA at 1 month. We observed three cases of thrombusprotrusion into the CFV after EVLT and recommend early duplex scanning in allpatients after endovenous saphenous ablations. DVT prophylaxis may be consideredin patients >50 years old. Long-term follow-up and comparison with standard GSVstripping are required to confirm the durability of these endovenous procedures.

J Vasc Surg. 2005 Sep;42(3):494-501; discussion 501Endovenous laser treatment combined with a surgical strategy for treatment ofvenous insufficiency in lower extremity: a report of 208 casesHuang Y, Jiang M, Li W, Lu X, Huang X, Lu M

BACKGROUND: We assessed the safety and efficacy of endovenous laser treatment(EVLT) of the saphenous vein combined with a surgical strategy for treatment ofdeep venous insufficiency in the lower extremity. METHODS: Two hundred thirtyvenous insufficiencies of the lower limbs in 208 consecutive patients (93 menand 115 women; mean age, 54.15 years) were treated with EVLT combined withsurgical strategies. All patients were symptomatic. There were 84 limbs (36.5%)in C(2), 25 (10.9%) in C(3), 109 (47.7%) in C(4), 1 (0.4%) in C(5), and 9 (3.9%)in C(6) (CEAP), and Klippel-Trenaunay syndrome was present in 2 limbs. A totalof 119 (51.7%) had perforator vein incompetence. Four therapeutic methods wereincluded in this series according to symptoms, CEAP classification, and venousreflux. Simple EVLT was performed for 15 patients with only great saphenous vein(GSV) incompetence or Klippel-Trenaunay syndrome in 19 lower limbs. EVLTcombined with high ligation of the GSV and open ligation of perforators wasperformed for 5 patients with GSV and perforator incompetence in 5 lower limbs.EVLT was combined with high ligation of the GSV for 76 patients with GSVincompetence in 94 lower limbs. EVLT was combined with external banding of thefirst femoral venous valve and high ligation of the GSV for 112 patients withprimary deep venous insufficiency in 112 lower limbs. All patients were followedup on an outpatient basis for physical examinations and postoperativecomplaints, and duplex ultrasonography was performed 2 weeks, 6 months, and 1

year after operation. RESULTS: All patients tolerated the procedure well andreturned to normal daily activities immediately, achieving a 100% immediateclinical success rate. Spot skin burn injuries occurred in 2 patients (1.0%).Paresthesia in the gaiter area was noted in 15 patients (7.2%). Nopostprocedural symptomatic deep venous thrombosis or pulmonary embolismoccurred. Three patients had local recurrent varicose veins in the calf (1.4%)during a 2- to 27-month follow-up (mean, 6.12 months). Postoperative clinicalclasses were significantly improved between 2 weeks and 24 months (P = .0001 at2 weeks and 3 to 18 months; P = .0055 at 24 months compared with beforeoperation), especially in preoperative C(2) to C(3) stage patients, who achievedcomplete amelioration. CONCLUSIONS: EVLT is a novel minimally invasive treatmentwith advantages of safety, effectiveness, and simplicity, and it leaves noscars. Its indications can be expanded by combining EVLT with surgicalstrategies.

Br J Surg. 2005 Oct;92(10):1189-94Systematic review of endovenous laser treatment for varicose veinsMundy L, Merlin TL, Fitridge RA, Hiller JE

BACKGROUND: The safety and effectiveness of endovenous laser treatment (EVLT)for varicose veins are not yet fully evaluated. METHODS: Medical bibliographicdatabases, the internet and reference lists were searched from January 1966 toSeptember 2004. Only case series were available for inclusion in the review.RESULTS:: Thirteen studies met the inclusion criteria. Self-limiting features,such as pain, ecchymosis, induration and phlebitis, were commonly encounteredafter treatment. Deep vein thrombosis and incorrect placement of the laser invessels were uncommon adverse events. No study has yet assessed theeffectiveness of laser therapy in comparison to saphenofemoral junction ligationwith saphenous vein stripping. Occlusion of the saphenous vein and abolition ofvenous reflux occurred in 87.9-100 per cent of limbs, with low rates ofre-treatment and recanalization. CONCLUSION: From the low-level evidenceavailable it seems that EVLT benefits most patients in the short term, but ratesof recanalization, re-treatment, occlusion and reflux may alter with longerfollow-up. The lack of such data, in addition to the small numbers of patientsin the available studies, demonstrates the need for a randomized clinical trialof EVLT versus conventional surgery.

Di Yi Jun Yi Da Xue Xue Bao. 2005 Oct;25(10):1334-5 Minimally invasive surgical treatment for venous leg ulcerWu LP, Huang ZH, Wang J, Zhang YX, Xie ZY

OBJECTIVE: To evaluate therapeutic effects of endovenous laser treatment (ELT)and subfascial endoscopic perforator surgery (SEPS) in the treatment of venousleg ulcer (VLU). METHODS: ELT and SEPS were performed in 10 patients with VLU(involving 10 legs). Among them, external valvuloplasty was performed in 4 legswith deep venous valve insufficiency. RESULTS: Ulcer of the 10 legs healedwithin 10-60 days after the operation, and follow-up study ranging from 2 to 8months with the average of 6 months revealed no recurrences. CONCLUSION: ELTcombined with SEPS provides an effective approach for VLU treatment with minimalinvasion, and when combined with external valvuloplasty, this approach mayeffectively reduce ulcer recurrence.

J Endovasc Ther. 2005 Dec;12(6):731-8Is there recanalization of the great saphenous vein 2 years after endovenouslaser treatment ?Disselhoff BC, der Kinderen DJ, Moll FL

PURPOSE: To report the 2-year single-center results of endovenous laser

treatment (EVLT) for reflux in the great saphenous vein (GSV). METHODS: FromJanuary 2002 to January 2003, 85 symptomatic patients (56 women; mean age 49years, range 27-80) underwent EVLT in 100 limbs. All patients were symptomatic,and the majority (67, 79%) had CEAP clinical class C2 venous disease. Aftertreatment, they were monitored by clinical evaluation and duplex imaging.RESULTS: The initial treatment was completed in 93 limbs. Complicationsconsisted of bruising (31%), tightness (17%), pain (14%), induration (2%), andsuperficial thrombophlebitis (2%). No severe complications were observed. Over amean follow-up of 29 months (range 24-37), 3 patients died and 14 were lost tofollow-up, leaving 88 (95%) and 76 (82%) limbs available for imagingsurveillance at 1 and 2 years, respectively. At 3 months, treatment wasanatomically successful in 84% of cases (78 complete occlusion, 7 partialocclusion, and 8 nonocclusion) and functionally successful in 89% (83 no reflux,10 reflux). All technical failures and 73% (n=11) of the treatment failuresoccurred in the first half of the studied population, indicating a learningcurve effect (p=0.015). Mean energy delivered per unit length was 39+/-8 J/cm(range 25-65) for successful treatment (n=78) and 30+/-10 J/cm (range 21-50) forfailed treatment (n=15). No recanalization or recurrent GSV reflux afteranatomically and functionally successful treatment was observed in 73 and 61limbs at 1 and 2-year follow-up, respectively. CONCLUSIONS: EVLT is a feasible,safe, and fast procedure for eliminating GSV reflux and has excellent cosmeticresults. Despite the learning curve, we believe that the treatment results arepromising. When successful treatment is achieved by EVLT, a prospectivefollow-up of 2 years demonstrates durable results.

Dermatol Surg. 2005 Dec;31(12):1685-94; discussion 1694Comparison of endovenous treatment with an 810 nm laser versus conventionalstripping of the great saphenous vein in patients with primary varicose veinsde Medeiros CA, Luccas GC

BACKGROUND: Patients with varicose veins seek medical assistance for manyreasons, including esthetic ones. The development of suitable and more flexibleinstruments, along with less invasive techniques, enables the establishment ofnew therapeutic procedures. OBJECTIVE: To compare endovenous great saphenousvein photocoagulation with an 810 nm diode laser and the conventional strippingoperation in the same patient. METHODS: Twenty patients selected for operativetreatment of primary great saphenous vein insufficiency on duplex scanning wereassigned to a bilateral random comparison. In all cases, both techniques wereperformed, one on each lower limb. Clinically, evaluation was assessed on theseventh, thirtieth, and sixtieth postoperative days. Patients underwentexamination with duplex ultrasonography and air plethysmography during thefollow-up. RESULTS: Patients who received endovenous photocoagulation presentedwith the same pain but fewer swellings and less bruising than the strippingside. Most patients indicated that the limb operated on by laser received morebenefits than the other. There was only one recanalization and no adverseeffects. The venous filling time showed better hemodynamics in both techniques.CONCLUSION: The endovenous great saphenous vein photocoagulation is safe andwell tolerated and presents results comparable to those of conventionalstripping.

Dermatol Surg. 2005 Dec;31(12):1678-83; discussion 1683-4Endovenous treatment of the great saphenous vein using a 1,320 nm Nd:YAG lasercauses fewer side effects than using a 940 nm diode laserProebstle TM, Moehler T, Gul D, Herdemann S

BACKGROUND: Limited data are available about treatment-related side effects with

respect to laser wavelength in endovenous laser treatment (ELT) of the greatsaphenous vein (GSV). OBJECTIVE: To compare the results and side effects of a940 nm diode and a 1,320 nm neodymium:yttium-aluminum-garnet (Nd:YAG) laser.METHODS: Three patient cohorts (A, B, and C) received ELT of the GSV using a 940nm diode laser at 15 W (group A) or 30 W (group B) or using a 1,320 nm laser at8 W (group C). In all cases, energy was administered continuously with constantpullback of the laser fiber under perivenous tumescent local anesthesia.RESULTS: The GSVs of group A (n = 113), group B (n = 136), and group C (n = 33)received ELT. An average linear endovenous energy density of 24, 63, and 62 J/cmand an average endovenous fluence equivalent of 12, 30, and 33 J/cm2 wereadministered to the vein. Occlusion rates were 95% (group A), 100% (group B),and 100% (group C) at day 1 after ELT and 90.3% (group A), 100% (group B), and97% (group C) at 3 months after ELT. With the 1,320 nm laser ELT (group C),treatment-related pain (50%) and the need for analgesics (36%) weresignificantly reduced (p < .005) in comparison with treatment-related pain (81%)and the need for analgesics (67%) after the 30 W 940 nm laser ELT (group B).Ecchymosis was also significantly reduced (p < .05) in group C (1,320 nm)compared with group B (30 W, 940 nm). CONCLUSION: ELT of the GSV using a 1,320nm Nd:YAG laser causes fewer side effects compared with 940 nm diode laser ELT.

Cardiovasc Intervent Radiol. 2006 Jan-Feb;29(1):64-9Lower energy endovenous laser ablation of the great saphenous vein with 980 nmdiode laser in continuous modeKim HS, Nwankwo IJ, Hong K, McElgunn PS

PURPOSE: To assess clinical outcomes, complication rates, and unit energyapplied using 980 nm diode endovenous laser treatment at 11 watts forsymptomatic great saphenous vein (GSV) incompetence and reflux disease. METHODS:Thirty-four consecutive ablation therapies with a 980 nm diode endovenous laserat 11 watts were studied. The diagnosis of GSV incompetence with reflux was madeby clinical evaluation and duplex Doppler examinations. The treated GSVs had amean diameter of 1.19 cm (range 0.5-2.2 cm). The patients were followed withclinical evaluation and color flow duplex studies up to 18.5 months (mean 12.19months +/- 4.18). RESULTS: Using 980 nm diode endovenous laser ablation incontinuous mode, 100% technical success was noted. The mean length of GSVstreated was 33.82 cm (range 15-45 cm). The mean energy applied during thetreatment was 1,155.81 joules (J) +/- 239.50 (range 545.40-1620 J) for a meantreatment duration of 90.77 sec +/- 21.77. The average laser fiber withdrawalspeed was 0.35 cm/sec +/- 0.054. The mean energy applied per length of GSV was35.16 J/cm +/- 8.43. Energy fluence, calculated separately for each patient,averaged 9.82 J/cm(2) +/- 4.97. At up to 18.5 months follow-up (mean 12.19months), 0% recanalization was noted; 92% clinical improvement was achieved.There was no major complication. Minor complications included 1 patient withhematoma at the percutaneous venotomy site, 1 patient with thrombophlebitis onsuperficial tributary varices of the treated GSV, 24% ecchymoses, and 32%self-limiting hypersensitivity/tenderness/"pulling" sensation along thetreatment area. One patient developed temporary paresthesia. Four endovenouslaser ablation treatments (12%) were followed by adjunctive sclerotherapies forimproved cosmetic results. CONCLUSION: Endovenous laser ablation treatment ofGSV using a 980 nm diode laser at 11 watts in continuous mode appears safe andeffective. Mean energy applied per treated GSV length of 35.16 J/cm or meanlaser fluence of 9.82 J/cm(2) appears adequate, resulting in 0% recanalizationand low minor complication rates.

J Vasc Surg. 2006 Jan;43(1):88-93Outcome of different endovenous laser wavelengths for great saphenous veinablationKabnick LS

OBJECTIVE: The objective of this randomized, prospective, blinded study was todetermine the relative effects of two laser wavelengths in the treatment ofgreat saphenous vein (GSV) insufficiency. METHODS: Fifty-one male and femalepatients scheduled for routine laser treatment of GSV insufficiency providedsigned informed consent for the procedure. Patients were randomized to receiveendovenous laser treatment with a wavelength of 810 or 980 nm. The same surgeon,blinded to the wavelength, performed all procedures. Nonoperating study staff,blinded to the laser wavelengths, evaluated patients before and after theprocedure regarding physical signs and symptoms. Patients were monitored within72 hours after the procedure (via duplex ultrasonography), at 1 week (byprocedural site photos scored for bruising, as well as a pain score), at 3weeks, and at 4 months for bruising, physical and emotional effects of theprocedure (scored by patients on a five-point visual analogue scale), andsymptoms (scored by the physician), along with adverse events. Patients werefollowed up for a year to determine the long-term efficacy of the procedure.RESULTS: The 51 patients (38 women and 13 men; mean age, 52.4 +/- 11.7 years)completed treatment and follow-up examination (30 legs for each wavelength). At72 hours after the procedure, no significant differences were noted betweenpatient outcomes, physical conditions, and symptoms and or possible adverseevents. At 1 week after the procedure, bruising scores were significantlydifferent (P < .005): patients in the 980-nm group showed less bruising of theprocedure site than the patients in the 810-nm group. Only three physical orsymptom parameters presented with significant differences (P < .05) overtime-less itching was noted by 810 nm-treated patients at 3 weeks after theprocedure, lower levels of pain intensity were seen in the 980 nm-treatedpatients at the 4-month follow-up visit, and lower varicose vein ratings wereseen for the 980 nm-treated patients at the 4-month follow-up visit. Thirteenlegs were phlebitic at 7 days after the procedure (10 in the 810-nm group and 3in the 980-nm group). Two treatment failures occurred (one patient in eachtreatment group); both patients exhibited flow in the treated venous segment atthe 4-month follow-up visit. Two other patients (one in each group) hadtreatment failure at the 1-year follow-up, demonstrating venous insufficiency inthe treated segment. CONCLUSIONS: Both laser wavelengths were effective intreating GSV insufficiency, with no major complications and a paucity of adverseoutcomes.

Eur J Vasc Endovasc Surg. 2006 Feb;31(2):219-22. Epub 2005 Aug 15Neovascularization after great saphenous vein ablationLabropoulos N, Bhatti A, Leon L, Borge M, Rodriguez H, Kalman P

OBJECTIVE: To determine the prevalence, distribution, and flow characteristicsof intraluminal neovascularization in patients undergoing great saphenous vein(GSV) endovenous laser (EVLT) or radiofrequency ablation (RFA). METHODS: Duplexultrasound (DU) was performed in patients undergoing EVLT or RFA before, during,and after their procedures. Follow-up included assessment for deep venousthrombosis and obliteration. When new vessels were identified, the source,extent, direction, and location of flow were noted. Flow channel diameters weremeasured and the resistivity index (RI) was used to characterize the flowpatterns. RESULTS: A total of 102 venous ablations were performed of which 46were RFA, and 56 EVLT. Arterio-venous fistulae (AVF) were found in five patientsthat were not identified by DU prior to intervention. Involved segments hadvariable length and multiple channels (mean diameter 2.2mm). No patient hadlocal or systemic symptoms related to the AVF. The mean RI was 0.42, consistentwith an AVF. The perivenous arteries feeding the AVF had enhanced flow but asignificantly higher RI (0.63, p<0.001). CONCLUSION: Multiple small vessels werefound directly adjacent to the involved vein segments forming small AVF withinthe obliterated vein. The prevalence of AVF in the ablated GSV was 5%. Thisprocess may be responsible for recanalization or recurrence after endovenous

ablation procedures.

J Cardiovasc Surg (Torino). 2006 Feb;47(1):3-8Endovenous laser therapy and radiofrequency ablation of saphenous varicoseveinsPannier F, Rabe E

Radiofrequency ablation (RFA) and endovenous laser treatment (EVLT) are minimalinvasive methods to treat saphenous varicose veins. The short- and mid-termresults are excellent with an occlusion rate for RFA of almost 90% after 5 yearsand about 95% for EVLT after 2 years. Severe side effects are rare in bothcases. Prospective randomised comparative studies are available for RFA andsurgery showing comparable short-term results and superiority of RFA concerningshort-term quality of life outcome. For laser treatment no prospectiverandomised comparative studies are available. Endovenous treatment is only apart of the complex treatment concept of varicose veins. Insufficienttributaries have to be treated in addition. The fact that the insufficientsaphenous vein is treated without high ligation seems not to influence theshort-term and mid-term recurrence rates. More prospective randomisedcomparative studies comparing endovenous treatment and surgery or foamsclerotherapy are necessary to decide which method is the best for whichpatient.

Radiol Med (Torino). 2006 Feb;111(1):85-92Endovenous laser therapy of the incompetent great saphenous veinPetronelli S, Prudenzano R, Mariano L, Violante F

PURPOSE: The aim of this study was the development of a new, even less invasivetechnique, for the treatment of varicose veins of the lower limbs thantraditional surgery (ligation with stripping of the saphenous vein). MATERIALSAND METHODS: The new interventional radiological procedure uses the 810- to980-nm endovascular laser fibre proposed by Min et al. Our technique involvesthe superselective catheterisation of the great saphenous vein under fluoroscopywith contralateral venous access achieved by performing iliac crossover.Retrograde and anterograde phlebographies are performed with a needle cannulapositioned in the dorsum of the foot. This enables accurate venous mappingduring the procedure of laser photothermolysis. We treated 52 patients betweenJune 2003 and June 2004, with a percentage of recanalisation of 7.5% at 1 year.RESULTS AND CONCLUSIONS: The contralateral approach allows greater control overthe entire procedure, with a reduction in potential risks in relation to thesaphenofemoral junction given that, unlike in the technique proposed by Min etal. the tip of the laser is directed at all times towards the saphenous vein andnever towards the femoral vein. This more radical procedure offers a significantreduction in the possibility of relapse of varicose disease of thesaphenofemoral junction.

Zentralbl Chir. 2006 Feb;131(1):45-50The endovenous laser therapy of varicose veins--substantial innovation orexpensive playing?Lahl W, Hofmann B, Jelonek M, Nagel T

INTRODUCTION: The aim of the study was to evaluate the efficiency of the

endovenous use of laser for treatment of varicose veins. In particular theinfluence of laser energy on the perivenous temperature, the postoperativeclinical and duplex ultrasound course was taken into account. METHOD: Thepatients were divided into two groups. In 33 cases the laser therapy was usedwithout perivenous liquid protection. In 30 cases a 0.9 % NaCl solution has beeninjected around the vein. The laser used was a 980 nm diode laser (Ceralas D980, Biolitec AG, Bonn). The pulse-mode procedure has been applied fortriggering the laser impulse (1.5 s pulse length, 1.5 s pause with a 3 mmwithdrawal of the laser fibre. The laser energy was 15 watt. 20 cm distal to thesaphenofemoral or saphenopopliteal junction a thermo unit measured continuouslythe perivenous temperature. Clinical and duplex ultrasound checks were carriedout before and on the day of the operation. Further checks followed on the firstand tenth day after the operation and 8 weeks and 6 months afterwards. RESULTS:The perivenous temperature prior to ELT was 31.3 degrees C, then dropping afterthe injection of the NaCl solution by 3.4 degrees C. During the ELT thetemperature rose by 10.0 degrees C without and by 5.5 degrees C withinfiltration. The rise in temperature happened only 3 cm before the tip of thelaser fibre arrived at the thermo unit and fell quite rapidly. 98 % of the veinsshowed within the time period of 2 to 14 months an effective occlusioncontrolled by duplex ultrasound without refluxing segments. All operations wereout-patient treatments. The patients were able to take up work after 1 to 7days. CONCLUSION: The endovenous laser treatment is an innovative method for thetreatment of varicose veins. Considering the mid-term subjective and objectiveoutcomes this method can not only compete with the conventional surgery but hasproved to be superior as regards the recurrence rate and patient's comfort. Thestudy presented here, did not find a risk of damage to surrounding non-targettissue.

Vasc Endovascular Surg. 2006 Mar-Apr;40(2):125-30Endovenous saphenous ablation corrects the hemodynamic abnormality in patientswith CEAP clinical class 3-6 CVI due to superficial refluxMarston WA, Owens LV, Davies S, Mendes RR, Farber MA, Keagy BA

This investigation was designed to determine whether minimally invasiveradiofrequency or laser ablation of the saphenous vein corrects the hemodynamicimpact and clinical symptoms of chronic venous insufficiency (CVI) in CEAPclinical class 3-6 patients with superficial venous reflux. Patients with CEAPclinical class 3-6 CVI were evaluated with duplex ultrasound and airplethysmography (APG) to determine anatomic and hemodynamic venousabnormalities. Patients with an abnormal (>2 mL/second) venous filling index(VFI) and superficial venous reflux were included in this study. Saphenousablation was performed utilizing radiofrequency (RF) or endovenous lasertreatment (EVLT). Patients were reexamined within 3 months of ablation withduplex to determine anatomic success of the procedure, and with repeat APG todetermine the degree of hemodynamic improvement. Venous clinical severity scores(VCSS) were determined before and after saphenous ablation. Eighty-nine limbs in80 patients were treated with radiofrequency ablation (RFA) (n = 58), or EVLT (n= 31). The average age of patients was 55 years and 66% were women. There wereno significant differences in preoperative characteristics between the groupstreated with RFA or EVLT. Postoperatively, 86% of limbs demonstrated near totalclosure of the saphenous vein to within 5 cm of the saphenofemoral junction.Eight percent remained open for 5-10 cm from the junction, and 6% demonstratedminimal or no saphenous ablation. The VFI improved significantly after ablationin both the RF and EVLT groups. Postablation, 78% of the 89 limbs were normal,with a VFI <2 mL/second, and 17% were moderately abnormal, between 2 and 4mL/second. VCSS scores (11.5 +/-4.5 preablation) decreased significantly afterablation to 4.4 +/-2.3. Minimally invasive saphenous ablation, using either RFAor EVLT, corrects or significantly improved the hemodynamic abnormality andclinical symptoms associated with superficial venous reflux in more than 90% of

cases. These techniques are useful for treatment of patients with more severeclinical classes of superficial CVI.

Biomed Eng Online. 2006 Apr 25;5:26Mathematical modeling of endovenous laser treatment (ELT)Mordon SR, Wassmer B, Zemmouri J

BACKGROUND AND OBJECTIVES: Endovenous laser treatment (ELT) has been recentlyproposed as an alternative in the treatment of reflux of the Great SaphenousVein (GSV) and Small Saphenous Vein (SSV). Successful ELT depends on theselection of optimal parameters required to achieve an optimal vein damage whileavoiding side effects. Mathematical modeling of ELT could provide a betterunderstanding of the ELT process and could determine the optimal dosage as afunction of vein diameter. STUDY DESIGN/MATERIALS AND METHODS: The model isbased on calculations describing the light distribution using the diffusionapproximation of the transport theory, the temperature rise using the bioheatequation and the laser-induced injury using the Arrhenius damage model. Thegeometry to simulate ELT was based on a 2D model consisting of a cylindricallysymmetric blood vessel including a vessel wall and surrounded by an infinitehomogenous tissue. The mathematical model was implemented using theMacsyma-Pdease2D software (Macsyma Inc., Arlington, MA, USA). Damage to the veinwall for CW and single shot energy was calculated for 3 and 5 mm vein diameters.In pulsed mode, the pullback distance (3, 5 and 7 mm) was considered. For CWmode simulation, the pullback speed (1, 2, 3 mm/s) was the variable. The totaldose was expressed as joules per centimeter in order to perform comparison toresults already reported in clinical studies. RESULTS: In pulsed mode, for a 3mm vein diameter, irrespective of the pullback distance (2, 5 or 7 mm), aminimum fluence of 15 J/cm is required to obtain a permanent damage of theintima. For a 5 mm vein diameter, 50 J/cm (15W-2s) is required. In continuousmode, for a 3 mm and 5 mm vein diameter, respectively 65 J/cm and 100 J/cm arerequired to obtain a permanent damage of the vessel wall. Finally, the use ofdifferent wavelengths (810 nm or 980 nm) played only a minor influence on theseresults. DISCUSSION AND CONCLUSION: The parameters determined by mathematicalmodeling are in agreement with those used in clinical practice. They confirmthat thermal damage of the inner vein wall (tunica intima) is required toachieve the tissue alterations necessary in order to lead the vein to permanentocclusion. However, in order to obtain a high rate of success without adverseevents, the knowledge of the vein diameter after tumescent anesthesia isrecommended in order to use the optimal energy. As clearly demonstrated by ourcalculations, both pulsed and continuous mode operations of the laser can beefficient. An interesting observation in our model is that less amount of energyis required in pulsed mode than in continuous mode. Damaging the veinsequentially along its entire length may lead to permanent occlusion. However,the pulsed mode requires a very precise positioning of the fiber after eachpullback and the duration of the treatment is much longer. For these reasons,continuous irradiation seems to be preferred by most clinicians. This modelshould serve as a useful tool to simulate and better understand the mechanism ofaction of the ELT.

J Endovasc Ther. 2006 Apr;13(2):244-8Endovenous ablation of incompetent saphenous veins: a large single-centerexperienceRavi R, Rodriguez-Lopez JA, Trayler EA, Barrett DA, Ramaiah V, Diethrich EB

PURPOSE: To evaluate the effectiveness of endovenous treatment of symptomatic

varicose veins using the endovenous laser (EVL) or radiofrequency (RF) energyover a >3-year follow-up. METHODS: From February 2002 to August 2005, 981consecutive patients (770 women; mean age 51 years, range 15-90) withsymptomatic varicose veins in 1250 lower limbs underwent endovenous ablation of1149 great saphenous veins (GSV) and 101 small saphenous veins (SSV) undertumescent anesthesia without intravenous sedation or regional anesthesia. Therewere 990 GSV and 101 SSV procedures using EVL; 159 GSVs were treated with RFenergy. An ultrasound evaluation was performed within 2 weeks of the procedureto evaluate occlusion of the vein, wall thickness, and clot extension into thedeep venous system. Follow-up from the first 200 procedures in the seriesincluded clinical evaluation and duplex ultrasound scanning at 6 and 12 monthsand annually thereafter. RESULTS: Of the 1149 GSVs treated, 39 (3.4%)recanalizations were seen in 33 of the EVL and 6 of the RF procedures forinadequate treatment as judged by ultrasound. There were 9 (9.0%) failures amongthe 101 SSVs treated with EVL. Overall, both EVL and RF procedures were welltolerated, with only minor complications. One obese patient with ulcer developedpulmonary embolus on the fourth postoperative day. There were no differencesbetween EVL and RF in efficacy or complications. Follow-up at a mean 3 years(range 30- 42 months) in 143 treated limbs showed no neovascularization in thegroin. CONCLUSION: Outcomes with EVL and RF were good, with low complicationrates that may be related to the use of local tumescent anesthesia withoutintravenous sedation.

J Vasc Surg. 2006 May;43(5):1056-8Diffuse phlegmonous phlebitis after endovenous laser treatment of the greatersaphenous veinDunst KM, Huemer GM, Wayand W, Shamiyeh A

Endovenous laser treatment (EVLT) has become a valuable and safe option in thetreatment of varicose veins. Although long-term results are lacking, mostpatients seem to benefit in the short-term from EVLT. Reported postoperativecomplications are limited, consisting usually of pain, ecchymosis, induration,phlebitis, or spot skin burn injuries. The most feared complication is anextension of the saphenous thrombus into the femoral vein, with possiblepulmonary embolism. Here we report a septic thrombophlebitis after EVLTresulting in a phlegmonous infection of the whole leg that was treated bysurgical drainage. Aggressive local therapy and antibiotic treatment resulted incomplete resolution of symptoms and eventual satisfactory healing.

Semin Vasc Surg. 2006 Jun;19(2):109-15Endovascular treatment of varicose veinsStirling M, Shortell CK

Within the past 5 years, radiofrequency ablation and endovenous laser treatmenthave been introduced as important new endovenous ablative techniques for theminimally invasive treatment of superficial venous reflux and varicose veins.Although sclerotherapy has been a well-established technique for spidertelangectasia, recent reports have documented that administration of aerated orfoamed sclerosants provides an excellent cost-effective option for treatment ofvaricose veins. This report reviews the indications for these minimally invasivetechniques, the technical aspects of these approaches, and describes in detailthe short and long-term success rates. To date, results of minimally invasivetherapies are equivalent to or surpass those of surgical vein stripping, whileoffering dramatically reduced recovery time and complication rates.

Minerva Cardioangiol. 2006 Jun;54(3):369-76Indications and results of endovenous laser tratment (EVLT) for greater

saphenous vein incompetentce. Our experienceSiani A, Flaishman I, Rossi A, Schioppa A, La Vigna R, Zaccaria A

AIM: Endovenous laser treatment (EVLT) seems to be a safe and less invasivemethod for the treatment of the great saphenous vein (GSV) incompetence. The aimof our study was to evaluate the indications and results of EVLT. METHODS:Between January 2003 and October 2004, 77 patients (55 C3 and 22 C4) underwentEVLT. In 23 cases phlebectomy was performed, in 16 patients a subfascialperforator vein ligations occurred. In 62 patients we used a percutaneous accessto the distal GSV, in 15 cases a surgical isolation was performed. In all casesa 600 nm with 1 mm diameter laser was used. RESULTS: Follow-up was performed fora period of 6 months and showed GSV recanalization in 2 cases; 18 patients(23.3%) developed a transient postoperative pain along GSV, in 4 (5.1%) of themthe pain persisted for 3 months. In 6 cases a reversible paresthesia due to alesion of the saphenous nerve were recorded (7.7%) and in 1 case (1.2%) a skinburn occurred. No deep vein thromboses were observed. CONCLUSIONS: EVLT is asafe technique, with low incidence of recanalizations and postoperativecomplications. Our opinion is to extend the indication in selected cases of GSVincompetence.

Int Angiol. 2006 Jun;25(2):209-15The first 1000 cases of Italian Endovenous-laser Working Group (IEWG).Rationale, and long-term outcomes for the 1999-2003 periodAgus GB, Mancini S, Magi G; IEWG

AIM: The innovations for disease management need to be thoroughly evaluated sothat their benefits and potential downsides can be compared with the alreadyexisting approaches. Endovascular laser (EVL) treatment for varicose veinsoffers today several advantages over surgical standard stripping. The ItalianEndovenous-laser Working Group (IEWG) is a homogeneous group of surgeons andphlebologists who have been using EVL since 1999 and has undertaken to examineEVL in a multicenter study starting from a well defined rationale, with thebenefit of a single protocol to use. METHODS: In a cooperative, multicenter,clinical study, 1076 limbs in 1050 patients, mean age of 54.5 years, 241 malesand 809 females affected by chronic venous insufficiency (CVI) were consideredeligible for surgery and stratified by CEAP classification in a four-year period(January 1999 December 2003). Inclusion criteria were insufficiency of the greatand/or small saphenous vein at various levels, beyond those accessory saphenoustrunks with incompetence in the saphenofemoral junction. In all cases truncularreflux apparead up on duplex scan examination, with or without associatedvaricosities. All the patients underwent a surgery on the basis of the clinicalassessment. All the centres involved performed treatment in conformity with theFood and Drug Administration (FDA) validated procedure, using an endo-laservenous system kit with a 810-980 nm diode. Duplex scan was performed in allpatients after 36 months with very few lost to follow-up cases. RESULTS: In theimmediate postoperative period the results have been impressive, with a veryeffective closure of incompetent great saphenous vein and the other treatedvaricose veins (the early occlusion rate has been 99%). Major complications havenot been detected: in particular, no deep venous thrombosis (DVT) evaluatedduplex ultrasound. The patients' acceptability and satisfaction regarding theprocedure, have been measured by means of a questionnaire on the quality oflife, and the result was 96.7%. After 36 months, the total occusion rate ofsaphenous trunks has been 97%. CONCLUSIONS: The first important Italianexperience with EVL based on preoperative, perioperative and postoperativeduplex control and which is also based on the patients' satisfaction atmid/long-term has indicated some advantages over the standard treatment with thestripping method. In terms of reduced postoperative pain, shorter sick leave, afaster resumption of the normal activities, and, in particular, the totalabsence of DVT, we can conclude that EVL is a good solution for all patients

with anatomic and hemodinamic patterns for saphenous vein surgery.

Br J Surg. 2006 Jul;93(7):831-5Endovenous laser treatment for long saphenous vein incompetenceSharif MA, Soong CV, Lau LL, Corvan R, Lee B, Hannon RJ

BACKGROUND:: Endovenous laser treatment is a percutaneous technique used for thetreatment of long saphenous vein (LSV) incompetence. This paper presents theresults of an uncontrolled case series undertaken to assess the feasibility,safety and efficacy of this technique. METHODS:: Some 145 incompetent LSVs in136 patients with saphenofemoral reflux were treated with endovenous laser. Thedata were evaluated prospectively. Assessment was carried out at 1 week, 3 and12 months for LSV occlusion and symptomatic relief. RESULTS:: Primary proceduralsuccess was achieved in 124 (85.5 per cent) of 145 LSVs. Reasons for primaryfailure included failed cannulation, failure to pass the guidewire and patientdiscomfort. At 3 months' follow-up, 105 (89.7 per cent) of 117 veins weretotally and nine (7.7 per cent) were partially occluded. At 12 months, 63 (76per cent) of 83 veins were totally and 15 (18 per cent) were partially occluded.At this stage 73 (88 per cent) of 83 patients remained satisfied, but 26 (31 percent) had residual or recurrent varicosities. Of these, only five requiredfurther treatment. Complications included saphenous nerve injury in one patientand superficial skin burns in a second. CONCLUSION: Endovenous laser treatmentfor LSV reflux is safe and can be carried out under local anaesthesia in anoutpatient setting with good patient satisfaction and low complication rates.

Ann Vasc Surg. 2006 Jul;20(4):451-7. Epub 2006 Jun 27A nonrandomised controlled trial of endovenous laser therapy and surgery in thetreatment of varicose veinsMekako AI, Hatfield J, Bryce J, Lee D, McCollum PT, Chetter I

Endovenous laser therapy (EVLT) is a minimally invasive treatment for varicoseveins. This study compares early quality-of-life (QoL) outcomes following EVLTand surgery. Two nonrandomized groups were studied: an EVLT group with 70patients, median age 49 (interquartile range [IQR] 35-58) years, and a surgerygroup with 62 patients, median age 49 (IQR 35-61) years. Patients were assessedprior to and at 1, 6, and 12 weeks following the procedure using the Short Form36 (SF-36), the Aberdeen Varicose Veins Questionnaire (AVVQ), and the VenousClinical Severity Score (VCSS). Follow-up at 1, 6, and 12 weeks was 100%, 77%,and 70% following EVLT and 100%, 85%, and 47% following surgery. SF-36 scoreswere significantly better in the EVLT group at 1 week (Physical Functioning,Role Physical, Bodily Pain, Vitality, and Social Functioning domains) and at 6weeks (Physical Functioning and Role Physical). At 12 weeks, no significantdifferences were evident between the groups. AVVQ scores were significantlybetter in the EVLT group at 6 and 12 weeks. VCSS scores were significantlyimproved in both groups at 12 weeks. EVLT and surgery provide similar QoLimprovements in patients with varicose veins. EVLT, however, removes the QoLlimitations experienced by patients in the early postoperative period.

Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2006 Jun;28(3):457-9Endovenous laser combined with ligation and striping therapy for varicosesaphenousYe W, Liu CW, Guan H, Liu B, Li YJ, Zheng YH, Wang S, Li WJ

OBJECTIVE: To evaluate the curative effect of the combination of endovenous

laser treatment of varicose saphenous vein (ELVS) and classic ligation andstripping treatment. METHODS: We retrospectively analyzed the clinical data of21 patients with varicose saphenous vein (VS) who were treated with ELVS aloneor combined with ligation and stripping in our hospital. RESULTS: All thepatients got good therapy result. The early symptom relief rate was 82.4%, whilethe late symptom relief rate was 100%. No infections, haematoma of wound, andany other major complications were reported. The common complications includedpain induced by remains of the thrombosis phlebitis (n = 2, 11.7%), minor skinburn (n = 1, 5.9%), residue vein varicose (n = 1, 5.9%), numbness of the calf (n= 1, 5.9%), and mild peri-phlebitis (n = 1, 5.9%). All the complications wereresolved after proper management. The 1-year follow-up showed no recurrence.CONCLUSION: The combination of ELVS and classic ligation and stripping is safeand effective in the treatment of varicose saphenous.

Eur J Vasc Endovasc Surg. 2006 Jul 21; (apub ahaed of print)Combined Endovenous Laser Therapy and Ambulatory Phlebectomy: Refinement of aNew TechniqueMekako A, Hatfield J, Bryce J, Heng M, Lee D, McCollum P, Chetter I

OBJECTIVE: Sclerotherapy (IS) or ambulatory phlebectomy (AP) are required assubsequent interventions in majority of cases following endovenous laser therapy(EVLT). We assessed whether AP performed concomitantly with EVLT (EVLTAP), iseffective, acceptable, and reduces subsequent requirement for interventions.METHOD: 67 patients (70 limbs) with great saphenous varicosities underwentEVLTAP. Pain was assessed on days 1, 4 and 7 using a visual analogue scale (VAS)of 0 to 10. Clinical and ultrasound assessments were done at 1, 6 and 12 weeks(no ultrasound at 6 weeks). Residual varicosities underwent further AP or IS.Patients' satisfaction with the cosmetic outcome and overall treatment wasassessed at 12 weeks using a VAS rating. RESULTS: 49 patients (70%) completedfollow-up. Median pain scores were 1.6 (IQR 0.2-4.8), 0.3 (0-1.4) and 0.2(0-1.1) on days 1, 4 and 7 respectively. Ultrasound demonstrated 69 (99%) and 47(96%) occluded long saphenous veins at 1 and 12 weeks respectively. SubsequentIS or AP was performed on 3 (4%) or 1 (1%) limbs respectively. Cosmeticsatisfaction was 9.6 (IQR 8.9-10) and overall satisfaction 9.8 (IQR 9.3-10).CONCLUSION: EVLTAP produces excellent results, is feasible and acceptable, andobviates need for subsequent procedures in the short-term.

Am Surg. 2006 Aug;72(8):672-5; discussion 675-6Endovenous laser ablation of saphenous vein is an effective treatment modalityfor lower extremity varicose veinsKavuturu S, Girishkumar H, Ehrlich F

We present our first experiences with the use of a new minimally invasivetreatment of lower extremity varicose veins. We studied the occlusion rates ofthe great saphenous vein (GSV) with laser ablation, its failure rates, and itscomplications. Sixty-six limbs in 62 consecutive patients were treated andfollowed-up for 1 year. All of the patients had incompetent GSV proven by meansof duplex scanning. The GSV segment from 2 cm distal to the sapheno-femoraljunction to just above the knee was ablated by using laser energy. In addition,all patients had stab avulsions of the varicose veins of the leg with Crochethooks. All patients were followed postoperatively on the 3rd day, 1 month, 3months, and 1 year after surgery. All patients were treated as day-casesurgeries. Among 62 patients studied, 46 patients were women (74%) and 16 weremen (26%). The median age of the patients was 53 years (range 28-69 years).Median operation time was 65 min (range 40-140 min). Successful treatment (totalobliteration of the GSV on duplex) was accomplished in 64 of 66 limbs (97%). Intwo cases, recanalization of the lower one-third of the treated segment of theGSV was noted after 3 months. There were no instances of neuropathy or skin

burn. Endovenous laser ablation of varicose veins is effective in inducingthrombotic vessel occlusion and is associated with only minor adverse effects.The procedure seems to be a promising alternative for surgical stripping of theGSV.

Med J Aust. 2006 Aug 21;185(4):199-202Treatment of varicose veins by endovenous laser therapy: assessment of resultsby ultrasound surveillanceMyers K, Fris R, Jolley D

OBJECTIVE: To assess the efficacy of endovenous laser therapy (EVLT) fortreating varicose veins with saphenous reflux. DESIGN: A trial of treatment,with results assessed by ultrasound surveillance. SETTING: Outpatient clinicswith sonographer and nursing support. MAIN OUTCOME MEASURES: Control of reflux;occlusion or obliteration of the saphenous veins assessed by ultrasound.RESULTS: EVLT was used to treat 404 veins in 308 patients. Univariate life tableanalysis showed primary success in 80% (95% CI, 69%-87%) and secondary successafter further treatment of recurrent saphenous vein reflux by ultrasound-guidedsclerotherapy in 88% (95% CI, 78%-95%) at 3 years. On multivariate Coxregression analysis, none of the covariates studied were associated withultrasound failure. CONCLUSIONS: Early results indicate that EVLT effectivelycontrolled saphenous reflux. Its advantages are that it is performed as anoutpatient procedure under local anaesthesia with immediate mobilisation, causesminimal disruption of activities, and avoids surgical trauma.

J Vasc Surg. 2006 Oct;44(4):834-9. Epub 2006 Aug 30Reduced recanalization rates of the great saphenous vein after endovenous lasertreatment with increased energy dosing: Definition of a threshold for theendovenous fluence equivalentProebstle TM, Moehler T, Herdemann S

BACKGROUND: Recent reports indicated a correlation between the amount of energyreleased during endovenous laser treatment (ELT) of the great saphenous vein(GSV) and the success and durability of the procedure. Our objective was toanalyze the influence of increased energy dosing on immediate occlusion andrecanalization rates after ELT of the GSV. METHODS: GSVs were treated witheither 15 or 30 W of laser power by using a 940-nm diode laser with continuousfiber pullback and tumescent local anesthesia. Patients were followed upprospectively with duplex ultrasonography at day 1 and at 1, 3, 6, and 12months. RESULTS: A total of 114 GSVs were treated with 15 W, and 149 GSVs weretreated with 30 W. The average endovenous fluence equivalents were 12.8 +/- 5.1J/cm(2) and 35.1 +/- 15.6 J/cm(2), respectively. GSV occlusion rates accordingto the method of Kaplan and Meier for the 15- and 30-W groups were 95.6% and100%, respectively, at day 1, 90.4% and 100% at 3 months, and 82.7% and 97.0% at12 months after ELT (log-rank; P = .001). An endovenous fluence equivalentexceeding 20 J/cm(2) was associated with durable GSV occlusion after 12 months'follow-up, thus suggesting a schedule for dosing of laser energy with respect tothe vein diameter. CONCLUSIONS: Higher dosing of laser energy shows a 100%immediate success rate and a significantly reduced recanalization rate during 12months' follow-up.

J Vasc Interv Radiol. 2006 Sep;17(9):1449-55Endovenous Laser Ablation of the Great Saphenous Vein with a 980-nm Diode Laserin Continuous Mode: Early Treatment Failures and Successful Repeat TreatmentsKim HS, Paxton BE

PURPOSE: To investigate the efficacy of lower-energy endovenous laser treatment

for great saphenous vein (GSV) incompetence and treatment parameters associatedwith early treatment failure. MATERIALS AND METHODS: Sixty consecutiveendovenous laser treatments (32 left, 28 right; 57 initial treatments, threerepeat treatments) in 48 patients (13 men, 35 women; mean age, 55.2 +/- 12.9years), with bilateral treatments in nine patients, were studied. Preproceduralclinical signs, etiology, anatomy, and physiologic classifications demonstratedclass 2 limbs in 11.7% of cases, class 3 limbs in 25.0%, class 4 limbs in 48.3%,and class 5 limbs in 15.0%. All initial and repeat treatments were performedwith lower-energy with use of a 980-nm diode endovenous laser at 11 W incontinuous mode. Patients wore class II compression stockings for 2 weeks andwere followed up at 1, 3, and 6 months with clinical and duplex ultrasoundexaminations. Treatment failures were diagnosed at 3 months on the basis of GSVpatency or lack of clinical improvement. Diameter and length of GSV treated,treatment energy parameters, and clinical outcomes were prospectively measuredand compared between successful and failed treatments. RESULTS: The initialtreatment success rate was 94.7% (54 of 57). The mean maximum diameter ofsuccessfully treated GSVs was 1.12 +/- 0.52 cm, and the mean maximum diameter ofGSVs in which treatment failure occurred was 2.05 +/- 0.23 cm (P = .008). Meantotal energy applied for successful treatments was 1,131.3 +/- 248.1 J, and meantotal energy applied for failed treatments was 1,439.6 +/- 425.0 J (P = 0.053).Mean unit energy applied for successful treatments was 32.7 +/- 7.5 J/cm, andthat for failed treatments was 32.8 +/- 4.9 J/cm (P = .986). All patients inwhom treatment failed were successfully treated again with a mean total energyof 1,393.0 +/- 81.0 J and a mean unit energy of 29.4 +/- 4.9 J/cm. There were nosignificant differences in mean total energy or unit energy applied amongsuccessful, failed, and repeat treatments (P > .05). Mean follow-up duration was6.8 months. CONCLUSIONS: Endovenous laser treatment with lower energy appears tobe safe and effective. Larger GSV diameter is associated with early treatmentfailures.

J Vasc Surg. 2006 Oct;44(4):828-33Combined saphenous ablation and iliac stent placement for complex severe chronicvenous diseaseNeglen P, Hollis KC, Raju S

BACKGROUND: Severe chronic venous disease frequently has a complexpathophysiology. This study describes results after combined interventions tocorrect outflow obstruction and superficial reflux, even in the presence of deepvenous reflux. METHODS: Between 1997 and 2005, 99 limbs in 96 patients hadpercutaneous iliofemoral venous stenting combined with great saphenous vein(GSV) stripping (39 limbs), or percutaneous GSV ablation performed byradiofrequency (27 limbs) or laser (33 limbs). Clinical severity score in CEAPwas C4 in 51 limbs, C5 in eight limbs, and C6 in 40 limbs; median age was 56years (range, 27 to 87 years); left-right limb ratio, 2.3:1; female-male ratio,1.8:1; primary-secondary etiology, 58:41. Perioperative investigations includedvisual analogue pain scale (VAS), degree of swelling (grade 0 to 3);quality-of-life questionnaire; venous filling index in milliliters per second(VFI90), venous filling time in seconds (VFT), percentage in ambulatory venouspressure drop (AVP), duplex Doppler scanning, and radiologic studies. RESULTS:Clinical follow-up was performed in 97 (98%) of 99 for up to 5.5 years. Axialdeep reflux was found in 27% (27/99). At least three venous segments wererefluxing in 40% of limbs. Preoperative hemodynamic parameters reflected thepresence of reflux and improved significantly (P < .01) after the procedure(VFI90, 3.8 to 2.3 mL/s; VFT, 11 to 16 seconds; AVP, 55% to 65%). No patientsdied, and the morbidity with endovenous GSV ablation was largely limited toecchymosis and thrombophlebitis in the thigh area. Cumulative primary, assistedprimary, and secondary stent patency rates at 4 years were 83%, 97%, and 97%,respectively. After treatment, limb swelling and pain substantially improved.The rate of limbs with severe pain (>or=5 on VAS) fell from 44% to 3% after

intervention. Gross swelling (grade 3) decreased from 30% to 6% of limbs.Cumulative analysis showed sustained complete relief of pain (VAS = 0) andswelling (grade 0) after 4 years in 73% and 47% of limbs, respectively. Ulcershealed in 26 (68%) of 38 ulcerated limbs. Cumulative ulcer-healing rate was 64%at 48 months. All quality-of-life categories significantly improved aftertreatment. CONCLUSION: The single-stage combination of percutaneous venousstenting and superficial ablation in patients with severe chronic venous diseaseis safe, gives excellent symptom relief and improvement of quality of life, anda well-maintained ulcer-healing rate. It seems logical to initially performmultiple minimally invasive interventions rather than open surgery. Anyassociated deep reflux can initially be ignored pending clinical response to thecombined intervention.

Bratisl Lek Listy. 2006;107(6-7):231-4Laser-tissue interaction in endovenous laser treatmentVeverkova L, Kalac J, Capov I, Wechsler J, Pac L, Svizenska I, Pitr V

The authors present the results of recorded changes in the endothelium inrabbit's veins following photocoagulation by laser diode. This studyconcentrates mainly on the detailed description of individual changes in therabbit's venous system in the area of pelvis following laser therapy. The aim ofour experiments was to reach the obliteration of rabbits' lateral saphenous veinusing 980 nm laser diode with 200 micron fibre. The intensity of discharge was3, 5, 6 and 7 watts. We examined the relationship between changes and the amountof joules that affect the endothelium of the rabbit's veins. The operation wasconducted under general anaesthesia. All animals survived treatment and werereturned to breeders. Within the time span of one, three, six and eight weeksthe laser treated veins were removed. They were fixed in formaldehyde and sentfor microscopic examination. We were interested in how long it will take forfibrous changes to occur in the endothelium of the vein and thus also thesubsequent occlusion of the vein depending on the amount of joules applied perone centimetre of the vein (Tab. 1, Fig. 4, Ref 6).

Dermatol Surg. 2006 Dec;32(12):1453-7Incompetent great saphenous veins treated with endovenous 1,320-nm laser:results for 71 legs and morphologic evolvement studyYang CH, Chou HS, Lo YF

BACKGROUND: Endovenous lasers with various wavelengths have been utilized withgood outcomes in treating leg varicose veins. The natural history and evolutionof treated veins after endovenous procedures, however, have seldom beenaddressed. OBJECTIVE: This study determines the efficacy vein ablation andserial venous morphologic evolution of incompetent great saphenous veins (GSVs)after endovenous 1,320-nm laser treatment. METHODS: Fifty patients withsymptomatic varicose veins secondary to GSV insufficiency treated with 1,320-nmendovenous laser ablation were enrolled. The treated varicose veins in each limbwere mapped and sized before laser treatment. Vein wall diameters were measuredwith duplex ultrasound at follow-up visits. RESULTS: Seventy-one limbs in 50patients were enrolled. During the mean 13.1-month follow-up, closure of GSVswas observed in 94% of limbs (67/71). Vein diameters at 3 cm belowsaphenofemoral junction level were reduced to 81% at 2 days, 75% at 1 month, 48%at 3 months, and 39% at 5 months. Average mean duration for treated GSVs tonarrow as fibrotic cords (internal diameter,<2.5 mm) was 5.8 months. CONCLUSION:The endovenous 1,320-nm laser ablation procedures have excellent efficacy intreating incompetent GSVs. This excellent shrinkage behavior may be the basisfor nice long-term results of patients treated with 1,320-nm Cooltouchendovenous laser.

Eur J Vasc Endovasc Surg. 2007 Jan 13; [Epub ahead of print]Initial Experience in Endovenous Laser Ablation (EVLA) of Varicose Veins Due toSmall Saphenous Vein RefluxTheivacumar NS, Beale RJ, Mavor AI, Gough MJ

OBJECTIVE: Conventional surgery for varicose veins due to small saphenous refluxis associated with high recurrence rates (up to 50%), many resulting frominadequate surgery. This prospective audit examines the safety and efficacy ofEVLA in the treatment of this. METHOD: 65 patients (68 limbs) with varicositiesdue to primary or recurrent sapheno-popliteal junction (SPJ) and small saphenousvein (SSV) reflux underwent out-patient EVLA (810nm diode laser). The SSV wasablated from mid-calf to the SPJ. Symptomatic improvement (Aberdeen VaricoseVein Severity Score [AVVSS]), time to return to normal activity, post-EVLAanalgesic requirements, and complications were recorded. RESULTS: Duplexultrasound follow-up (median 6-months) confirmed abolition of SPJ/SSV reflux inall limbs following a median total laser energy delivery of 1131J (IQR 928-1364)at an energy density of 66.3 Joules/cm (IQR 54.2-71.6). AVVSS improved from 15.4(IQR 11.8-19.7) to 4.6 (IQR 3.2-6.7) at three months (p<0.001). Median analgesiarequirement was 3 days (23% [15/65] patients required none) and the median timeto normal activity was 0 (0-4) days (65% [42/65] returning to normal dailyactivity immediately). There were no instances of skin burns or DVT but 3patients (4.4%) developed transient cutaneous numbness (sural nerve). 98%(64/65) patients would undergo EVLT again. CONCLUSIONS: EVLA abolished SPJ/SSVreflux in all limbs. This is likely to be more effective than conventionalsurgery, although long-term follow up is required. Data from a randomisedcontrol trial would be desirable.

Lasers Surg Med. 2007 Jan 24; [Epub ahead of print]Mathematical modeling of 980-nm and 1320-nm endovenous laser treatmentMordon SR, Wassmer B, Zemmouri J

BACKGROUND AND OBJECTIVES: Endovenous laser treatment (ELT) has been proposed asan alternative in the treatment of reflux of the great saphenous vein (GSV) andsmall saphenous vein (SSV). Numerous studies have since demonstrated that thistechnique is both safe and efficacious. ELT was presented initially using diodelasers of 810 nm, 940 nm, and 980 nm. Recently, a 1,320-nm Nd:YAG laser wasintroduced for ELT. This study aims to provide mathematical modeling of ELT inorder to compare 980 nm and 1,320 nm laser-induced damage of saphenous veins.STUDY DESIGN/MATERIALS AND METHODS: The model is based on calculationsdescribing light distribution using the diffusion approximation of the transporttheory, the temperature rise using the bioheat equation, and the laser-inducedinjury using the Arrhenius damage model. The geometry to simulate ELT was basedon a 2D model consisting of a cylindrically symmetric blood vessel including avessel wall and surrounded by an infinite homogenous tissue. The mathematicalmodel was implemented using the Macsyma-Pdease2D software (Macsyma, Inc.,Arlington, MA). Calculations were performed so as to determine the damageinduced in the intima tunica, the externa tunica and inside the peri-venoustissue for 3 mm and 5 mm vessels (considered after tumescent anesthesia) anddifferent linear endovenous energy densities (LEED) usually reported in theliterature. RESULTS: Calculations were performed for two different veindiameters: 3 mm and 5 mm and with LEED typically reported in the literature. For980 nm, LEED: 50 to 160 J/cm (CW mode, 2 mm/second pullback speed, power: 10 Wto 32 W) and for 1,320 nm, LEED: 50 to 80 J/cm (pulsed mode, pulse duration 1.2milliseconds, peak power: 135 W, repetition rate 30 Hz to 50 Hz). DISCUSSION ANDCONCLUSION: Numerical simulations are in agreement with LEED reported inclinical studies. Mathematical modeling shows clearly that 1,320 nm, with abetter absorption by the vessel wall, requires less energy to achieve walldamage. In the 810-1,320-nm range, blood plays only a minor role. Consequently,

the classification of these lasers into hemoglobin-specific laser wavelengths(810, 940, 980 nm) and water-specific laser wavelengths (1,320 nm) isinappropriate. In terms of closure rate, 980 nm and 1,320 nm can lead to similarresults and, as reported by the literature, to similar side effects. This modelshould serve as a useful tool to simulate and better understand the mechanism ofaction of the ELT.

Eur Radiol. 2007 Feb 8; [Epub ahead of print]Endovascular optical coherence tomography ex vivo: venous wall anatomy andtissue alterations after endovenous therapyMeissner OA, Schmedt CG, Hunger K, Hetterich H, Sroka R, Rieber J, Babaryka G,Steckmeier BM, Reiser M, Siebert U, Mueller-Lisse U

Endovascular optical coherence tomography (OCT) is a new imaging modalityproviding histology-like information of the venous wall. Radiofrequency ablation(RFA) and laser therapy (ELT) are accepted alternatives to surgery. This studyevaluated OCT for qualitative assessment of venous wall anatomy and tissuealterations after RFA and ELT in bovine venous specimens. One hundred andthirty-four venous segments were obtained from ten ex-vivo bovine hind limbs.OCT signal characteristics for different wall layers were assessed in 180/216(83%) quadrants from 54 normal venous cross-sections. Kappa statistics (kappa)were used to calculate intra- and inter-observer agreement. Qualitative changesafter RFA (VNUS-Closure) and ELT (diode laser 980 nm, energy densities 15 Joules(J)/cm, 25 J/cm, 35 J/cm) were described in 80 venous cross-sections. Normalveins were characterized by a three-layered appearance. After RFA, loss ofthree-layered appearance and wall thickening at OCT corresponded with circulardestruction of tissue structures at histology. Wall defects after ELT rangedfrom non-transmural punctiform damage to complete perforation, depending on theenergy density applied. Intra- and inter-observer agreement for reading OCTimages was very high (0.90 and 0.88, respectively). OCT allows for reproducibleevaluation of normal venous wall and alterations after endovenous therapy. OCTcould prove to be valuable for optimizing endovenous therapy in vivo.

Dermatol Surg. 2007 Feb;33(2):162-8Early results and feasibility of incompetent perforator vein ablation byendovenous laser treatmentProebstle TM, Herdemann S

BACKGROUND: Dissection of incompetent perforator veins even when using thesubfascial endoscopic perforator surgery technique is associated with substantialside effects. OBJECTIVE: The objective was to evaluate the feasibility ofendovenous laser ablation of incompetent perforator veins. PATIENTS AND METHODS: A 940-nm diode laser and a Nd:YAG laser with 1,320 nm were used with laser fibersof 600 microm diameter. Perforators were accessed by ultrasound-guided punctureusing 16- and 18-gauge cannulas, respectively. Fiber tips were placed below thefascia with at least 1-cm distance from the deep vein system. Afteradministration of perivascular local anesthesia, laser energy was delivered in a pulsed fashion using laser power in the range between 5 and 30 W. RESULTS: Atotal of 67 perforators were treated. Except one vein, all others were occludedat Day 1 after treatment. With 1,320 nm at 10 W, a median of 250 J (range,103-443 J) was delivered resulting in significantly reduced posttreatmentdiameters to a mean of 69+/-23% (p=.0005). With 940 nm at 30 W, a median of 290 J(range, 90-625 J) was administered, showing no significant posttreatment diameterreduction. Side effects were moderate. CONCLUSION: Ultrasound-guided endovenousablation of incompetent perforators is safe and feasible.

Rozhl Chir. 2007 Feb;86(2):78-84

Endovenous laser photocoagulation of the insufficient saphenous vein inexperimentKaspar S, Cervinková Z

Ustav zdravotnických studií Univerzity Pardubice. kaspar@flebocentrum.cz

AIMS: The endovenous laser treatment of varicose veins has been using for severalyears throughout the world with clinical results comparable to traditionalsurgery. Nevertheless, many controversies still exist in the world literature in terms of parameters of laser generator and procedure itself. The aim of thislaboratory study was the standardisation of the procedure and set-up of theoptimal technical parameters to achieve maximal vein shrinkage as basic marker ofsuccessful long-term result. MATERIAL AND METHODS: The insufficient trunks of thelong saphenous veins which were stripped during the traditional Babcock'sstripping procedure, were irradiated with the laser energy delivered by the diodegenerator emitting 980 nm laser beam in the laboratory settings. In total, 279vein segments were treated. We used the power of 5W, 8W, 10W, 12W and 15W during the maximal time possible to achieve the maximal shrinkage of the saphenous vein with minimal number of perforations. The study cohort consisted of two groups -inthe first group the veins were filled with the blood (n = 139), in the other one the veins were empty (n = 140) to simulate the patient's position on theoperating table. After the procedure, every vein segment was cut longitudinally, unfolded and its inner circumference was measured and compared to innercircumference of untreated part of the same venous segment. RESULTS: Maximalshrinkage and minimal number of perforations were achieved using lower or medium power (8 to 12 W). Circumference of shrunken vein compared to normal venouscircumference (100%) was as follows: 50% (power 5W), 45% (power 8W), 40% (powerO1W), 45% (power 12W) and 58.6% (power 15W). These differences are statistically significant (p < 0.001). When higher power was used (15W), the perforations andcarbonisations were more frequent and total energy was lower but the differencein amount of energy delivered was not significant (p = 0.379). CONCLUSIONS:Shrinkage of the vein depends on laser power. Based on our experiments, werecommend photocoagulation with lower or medium power (8 to 12 W) and slowerpull-back (0.2 to 2 mm/s) to achieve the sufficient energy per centimeter of the vein and the optimal long-term outcome.

Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2007 Feb;29(1):40-3Surgical treatment for varicose veinYe ZD, Liu P, Wang F, Lin F, Cao DS, Yang YG, Wang FL

OBJECTIVE: To explore the techniques and outcomes of the surgical treatment forvaricose vein. METHODS: Totally 2 200 patients with varicose vein receivedsurgical treatment in our hospital from July 2000 to January 2006. The latesttechniques for endovenous occlusion were used for most cases, among which 1 802cases were treated with endovenous laser treatment (EVLT) combined withtransilluminated powered phlebectomy (TIPP), 82 cases with radiofrequencyendovenous occlusion (RFO) combined with TIPP, and 218 cases with limitedinvaginated vein stripping and foam sclerotherapy. The remaining 98 cases weretreated with laser, radiofrequency or ligation for saphenous vein trunk, and withresection, electric coagulation, and transfixation for vein clusters asadditional methods. Perforators were also cutted and ligated as well. RESULTS:Satisfied surgical results were obtained in all cases. The average operative timewas 40 minutes (range 20-78 minutes). CONCLUSIONS: Limited invaginated veinstripping, EVLT, and RFO can be used to treat saphneous vein reflux. Surgicalresection, transfixation, electric coagulation, and sclerotherapy are reasonaloptions for vein cluster or tributaries. Transection and ligation of theperforators are important. TIPP is ideal for the treatment of vein clusters.

Rozhl Chir. 2007 Feb;86(2):78-84

Endovenous laser photocoagulation of the insufficient saphenous vein inexperimentKaspar S, Cervinková Z

AIMS: The endovenous laser treatment of varicose veins has been using for severalyears throughout the world with clinical results comparable to traditionalsurgery. Nevertheless, many controversies still exist in the world literature in terms of parameters of laser generator and procedure itself. The aim of thislaboratory study was the standardisation of the procedure and set-up of theoptimal technical parameters to achieve maximal vein shrinkage as basic marker ofsuccessful long-term result. MATERIAL AND METHODS: The insufficient trunks of thelong saphenous veins which were stripped during the traditional Babcock'sstripping procedure, were irradiated with the laser energy delivered by the diodegenerator emitting 980 nm laser beam in the laboratory settings. In total, 279vein segments were treated. We used the power of 5W, 8W, 10W, 12W and 15W during the maximal time possible to achieve the maximal shrinkage of the saphenous vein with minimal number of perforations. The study cohort consisted of two groups -inthe first group the veins were filled with the blood (n = 139), in the other one the veins were empty (n = 140) to simulate the patient's position on theoperating table. After the procedure, every vein segment was cut longitudinally, unfolded and its inner circumference was measured and compared to innercircumference of untreated part of the same venous segment. RESULTS: Maximalshrinkage and minimal number of perforations were achieved using lower or medium power (8 to 12 W). Circumference of shrunken vein compared to normal venouscircumference (100%) was as follows: 50% (power 5W), 45% (power 8W), 40% (powerO1W), 45% (power 12W) and 58.6% (power 15W). These differences are statistically significant (p < 0.001). When higher power was used (15W), the perforations andcarbonisations were more frequent and total energy was lower but the differencein amount of energy delivered was not significant (p = 0.379). CONCLUSIONS:Shrinkage of the vein depends on laser power. Based on our experiments, werecommend photocoagulation with lower or medium power (8 to 12 W) and slowerpull-back (0.2 to 2 mm/s) to achieve the sufficient energy per centimeter of the vein and the optimal long-term outcome.

Rozhl Chir. 2007 Mar;86(3):144-9Crossectomy doesn't improve outcome of endovenous laser ablation of varicoseveinsKaspar S, Siller J

AIMS: Crossectomy (extended saphenofemoral or saphenopopliteal junction ligation)and stripping of refluxing saphenous trunk represent the basis of the traditionalsurgical therapy of varicose veins. Endovascular techniques of saphenous ablationare the mini-invasive alternatives of the radical surgical treatment. Theobjective of this study is the comparison of the endovenous laser ablation withand without crossectomy through open groin access. MATERIAL AND METHODS:Retroprospective study compares the results of the group of patients treated withsimple endovenous laser ablation (HVL - 329 limbs) and HVL completed withcrossectomy (35 limbs). Both groups were comparable in terms of basic demographicand preoperative clinical data (p > 0.05). In both cohorts, subgroups withidentical laser parameters were selected (p > 0.05). All procedures wereperformed according the same standard protocol, EVL patients received LMWH in thepostoperative period. The results were evaluated by the comparison of CEAPclinical class pre and postoperatively, the percentage of recanalizations andalso using the Kaplan-Meier life-table method. RESULTS: No thrombosis, norpulmonary embolism were diagnosed in the post-operative period. During thefollow-up (98% treated limbs), venous occlusion was observed in 88% of them(91.05 % in the endovenous group and 65.71% in the combined group). Thesedifferences are not statistically significant (p = 0.24). Same results were foundusing the Kaplan-Meier method (p = 0.086). Treatment significantly reduced CEAP

clinical class in both groups but the results are better (C = 0.41 vs. 0.8) inthe endovenous group (p = 0.004). CONCLUSIONS: Endovenous ablation of therefluxing saphenous vein represents good alternative of crossectomy andstripping. Combination of both procedures is not effective and, on the contrary, can cause short and long-term complications.

Perspect Vasc Surg Endovasc Ther. 2007 Mar;19(1):67-70Comment in: Perspect Vasc Surg Endovasc Ther. 2007 Mar;19(1):71-2Reflux testing and imaging for endovenous ablationLabropoulos N, Abai B

Endovenous ablation is a newer therapy for treating superficial veins in patientswith chronic venous disease. The saphenous veins and their accessory veins can betreated. Radiofrequency and laser energy are used to ablate the veins. Accurateultrasound mapping is needed to plan and perform these procedures. The length andthe number of the veins treated are determined. The diameter of the vein, itsdistance from the skin, and segments with tortuosity, thrombosis, and anatomicvariations are documented. During the procedure the access in the vein, and theintroduction of the wire, sheath, catheter, and tumescent anesthesia are doneunder ultrasound guidance. The success of the procedures and the complicationsare monitored. In most studies, the failure rate is 10% or less at 2 years, andthe prevalence of deep vein thrombosis is less than 3%. Currently, endovenousablation has become the method of choice for treating superficial veins and ithas almost replaced the traditional ligation and stripping.

Ann Vasc Surg. 2007 Mar;21(2):155-8Adjunctive proximal vein ligation with endovenous obliteration of great saphenousvein reflux: does it have clinical value?Gradman WS

The risk of clot extension to the deep venous system or pulmonary embolismfollowing endovenous great saphenous vein (GSV) obliteration is possibly related to the size of the proximal GSV. Some practitioners therefore exclude endovenous GSV obliteration for veins greater than an arbitrary size, starting as little as 15 mm. Others provide adjunctive proximal GSV ligation either routinely, or inselected patients with large veins. The clinical value of adjunctive proximal GSVligation is unknown. A survey of either the American Venous Forum or the AmericanCollege of Phlebology, selected for their pedagogic or long-time experience with endovenous GSV obliteration. Respondent characteristics included obliterationtechnique (laser, radiofrequency [RF], or foam sclerotherapy), academic status,surgical training, indication for and frequency of adjunctive proximal GSVligation, and society membership. The incidence of pulmonary embolus (PE) anddeep vein thrombus (DVT) was also tallied. Twenty-one thousand nine hundredsixty-five endovenous GSV obliteration cases were reported, 10,290 with a laser(46.8%), 6,275 (28.6%) with RF, and 5,400 (24.6%) with foam. Only two PEs werereported. Of the 34 patients with DVT, at least 11 had only asymptomaticultrasound evidence of thrombus extension into the femoral vein, and at leastfive had only calf vein thrombosis. Comparing ligators (7) with non-ligators(15), the only characteristic significantly correlating with adjunctive proximal GSV ligation was whether the respondent had complete general or vascular surgicaltraining; non-surgeons never ligated the saphenous vein (p < .001). There was no difference between outcomes of ligators and non-ligators. Endovenous obliterationof the GSV poses little risk of PE or DVT, no matter what size the proximal GSV. Although these adverse events may be reduced with adjunctive proximal GSVligation, the results of this study suggest that adjunctive proximal GSV ligationis superfluous in most patients.

Ann Vasc Surg. 2007 Mar;21(2):245-8Treatment of incompetent vein of Giacomini (thigh extension branch)Bush RG, Hammond K

Most varices secondary to truncal insufficiency arise from the greater saphenous vein (GSV), short saphenous vein (SSV), or accessory saphenous branch. However,an important etiology for varices that arise on the posterior thigh or calf isoften overlooked. The thigh extension (TE) branch, also known as the vein ofGiacomini in many patients, may also contribute to venous pathology. Patientswere assigned to one of three categories depending on the anatomical findings.All patients were treated with a combination of endovenous ablation using a 940nm Skin Pulse S laser and foam sclerotherapy. Eighteen patients were treated and followed for at least 2 years. There were no complications. All patients hadsuccessful ablation of the TE branch with successful obliteration of anyperforators or collateral vessels. Varices secondary to TE branch insufficiencyare common when coexisting SSV insufficiency is present. The incidence increases when both SSV insufficiency and GSV insufficiency exist. This study groups thepattern of TE branch pathology into three anatomical patterns. Combinationtherapy based on the prevalent anatomical group being treated was done. There wassuccessful ablation in all groups with no complications. As experience in venous disease and expertise by the surgeon increases, more examples of this pattern of pathology will become evident.

J Cosmet Laser Ther. 2007 Mar;9(1):9-13Combined endovascular laser plus ambulatory phlebectomy for the treatment ofsuperficial venous incompetence: a 4-year perspectiveSadick NS, Wasser S

BACKGROUND: Combination endovascular laser obliteration of the greater saphenous vein in conjunction with ambulatory phlebectomy has become the treatment ofchoice for superficial venous incompetence. OBJECTIVES: The present studyexamines the treatment of saphenofemoral junction (SFJ) incompetence withsimultaneous treatment of associated truncal varicosities by ambulatoryphlebectomy. METHODS: Four-year follow-up data for recurrence rate andcomplication profile was ascertained for 90 patients (mean age 40 years) with SFJreflux associated with greater saphenous vein (GSV) incompetence (4-12 mm; mean7.8 mm) and enlargement of branch varicosities as documented by Duplexultrasound, which were treated with a combined approach of endovascular laserobliteration of the GSV (810 nm, Diomed S30) followed by hook avulsion(ambulatory phlebectomy) of the remaining truncal varicosities. Follow-up byDuplex ultrasound to ensure closure was carried out at week 1 and months 1, 3, 6,12, 24, 36 and 48. RESULTS: A total recurrence rate (r = 94 limbs) of 4.3 wasfound in the patient cohort. All recurrences occurred within 12 months, with the majority documented at month 6. CONCLUSIONS: Combination endovascular lasertreatment (EVLT) with ambulatory phlebectomy is an effective treatment modalityfor superficial venous incompetence in the outpatient ambulatory setting. Lowrecurrence rates are noted with this approach. In the present patient series, allrecurrences were noted within 12 months of the aforementioned procedure. Theseresults are comparable with other endovenous and radiofrequency technologies.

J Vasc Surg. 2007 Apr;45(4):795-801; discussion 801-3. Epub 2007 Feb 15Erratum in: J Vasc Surg. 2007 Jun;45(6):1293Endovenous laser treatment of the small [corrected] saphenous vein: efficacy and complicationsGibson KD, Ferris BL, Polissar N, Neradilek B, Pepper D

OBJECTIVE: The study was conducted to assess the efficacy and rate ofcomplications of endovenous laser treatment (EVLT) of the short saphenous vein(SSV). METHODS: During a 17-month period, 210 (187 patients) with SSVincompetence documented by duplex ultrasound studies were treated with EVLT usinga 980-nm diode laser. Duplex ultrasound examinations were performed on the day ofthe procedure, within the first week, and 2 to 11 months after the procedure(mean follow-up, 4 months). Clinical examinations were performed at 2 weeks and 6weeks. Patients were assessed for deep venous thrombosis (DVT), nerve injury, andresolution of symptoms. RESULTS: All procedures were technically successful, and in the 126 patients (60%) who completed final follow-up scanning, 96% of SSVsremained closed. Three patients (1.6%) had numbness at the lateral malleolus atthe 6-week follow-up. DVT, defined as a tail of thrombus protruding into thepopliteal vein, was not detected in any limbs at the initial duplex study, butwas noted in 12 limbs (5.7%) at the 1-week follow-up examination. Nine patientswere treated with 3 days to 3 months of fractionated heparin and Coumadin(Bristol-Myers Squibb, Princeton, NJ), and there were no DVT extensions orpulmonary emboli. The anatomic configuration of the saphenopopliteal junction wasthe only factor predictive of DVT. CONCLUSIONS: Intermediate-term results of EVLTof the SSV demonstrate that the technique is effective at eliminating SSV reflux and affording symptomatic relief. The incidence of nerve injury is low, but theincidence of DVT is higher than reported for the great saphenous vein. Anatomicfeatures of the SSV may predict patient risk for DVT.

Ned Tijdschr Geneeskd. 2007 Apr 28;151(17):960-5Endovenous laser therapy: a new treatment for varicose veinsVan den Bremer J, Hedeman Joosten PP, Moll FL

Varicose veins are very common. For years the most commonly applied treatment forgreat saphenous vein (GSV) insufficiency was saphenofemoral junction ligationwith saphenous vein stripping. Minimally invasive methods, such as the endovenouslaser therapy, are increasingly used during the last few years. In endovenouslaser therapy, a diode laser fibre is inserted percutaneously into the GSV using ultrasonography to confirm the position. Thermal laser energy is applied to theendothelium ofthe GSV, resulting in local venous occlusion. The procedure hasrapidly become popular with clinicians who treat varicose veins due to itsrelative simplicity and high rate of patient satisfaction. Efficacy outcomes are good with an occlusion rate of up to 100%. Recanalisation is rarely occurringeven after several years. Pain, haematoma and phlebitis are common adverse eventsassociated with endovenous laser therapy but in most cases are self-limiting.Serious adverse events, such as deep vein thrombosis, are uncommon. Theadvantages ofendovenous laser therapy are the lack of surgical wounds, soinfection and scarring are avoided, and that the procedure can be performed in anoutpatient setting using local anaesthesia. Endovenous laser therapy appears tobe a safe and effective treatment option for refluxing varicose veins.

Ann Vasc Surg. 2007 May 11; (Epub ahaed of print)Cutaneous Hyperpigmentation after Endovenous Laser Therapy: A Case Report andLiterature ReviewMekako A, Chetter I

Endovenous laser therapy (EVLT) for the treatment of varicose veins has been

shown to be effective and relatively safe. Reported complications are few andtransient. Whereas it is not uncommon to have cutaneous hyperpigmentationfollowing treatment modalities such as sclerotherapy, only a few reports oftransient hyperpigmentation following EVLT have been mentioned in the literature.We report a case of persistent hyperpigmentation following successful varicosevein treatment by EVLT.

J Vasc Surg. 2007 May;45(5):1047-58. Epub 2007 Mar 28Evaluation of endovenous radiofrequency ablation and laser therapy withendoluminal optical coherence tomography in an ex vivo modelSchmedt CG, Meissner OA, Hunger K, Babaryka G, Ruppert V, Sadeghi-Azandaryani M, Steckmeier BM, Sroka R

BACKGROUND: This study evaluated the ability of endovascular optical coherencetomography (eOCT) to detect qualitative tissue alteration and quantitativechanges of vein wall thickness and vein lumen diameter comparing endovenousradiofrequency ablation (RFA) and endovenous laser therapy (ELT) in anestablished ex vivo model. METHODS: Endoluminal eOCT was performed by means of a new prototype rotating system (System M1, LightLab Imaging Inc, Boston, Mass)with automatic pullback of 1 mm/s. In the course of an eOCT examination of a50-mm vein segment, 264 electronic cross section images with a spatial resolutionof 15 to 20 mum are acquired. The eOCT scans were performed before and aftertreatment of each of 13 treated vein segments and of six control vein segments.Thirteen subcutaneous cow foot veins were reperfused in situ, and the defined50-mm vein segments in the study were treated with RFA (n = 2) and ELT (n = 11). RFA followed the clinical VNUS-Closure protocol (VNUS Medical Technologies, SanJose, Calif) using a 6F 60-mm Closure-Plus catheter. ELT was performed usinglight of lambda = 980 nm with a laser power of 3 (n = 2), 5 (n = 2), and 7 W (n =4) with a paced pullback protocol with laser irradiation for 1.5 seconds every 3 mm, resulting in linear endovenous energy densities (LEED) of 15, 25, and 35J/cm. Using 11 W (n = 3) with a continuous pullback protocol at 3 mm/s resultedin a LEED of 36.5 J/cm. Ten histologic cross sections of each treated and controlvein segment were correlated with the corresponding eOCT cross sections toevaluate qualitative representation of vein wall layers and tissue alterationssuch as ablation and vein wall perforation. In addition, 26 eOCT cross sectionsof every treated vein segment before and after treatment and every control veinsegment were analyzed to calculate quantitative changes in media thickness andvein lumen diameter. RESULTS: In all specimens, qualitative analysis with eOCTdemonstrated a clear match with histologic cross sections. A symmetrical,complete, circular disintegration of intima and media structures, without anytransmural tissue defects, was shown after RFA. Pronounced semicircular tissueablations (3 to 14 per 50 mm) and complete vessel wall perforations (0 to 16 per 50 mm) were detected after ELT. The quantitative analysis demonstrated asignificant (P < .0001) increase in intima-media thickness after RFA (37.8% to66.7%) and ELT (11.1% to 45.7%). A significant (P < .0001) reduction of vessellumen diameter (36.3% to 42.2%) was found after RFA. Owing to the limited number of treated vein segments and inhomogeneous baseline vein lumen diameters, nolinear correlation between laser energy level and effects on tissue such asablation/perforation, media thickening, or vein lumen diameter could beidentified. CONCLUSIONS: In our ex vivo cow foot model, eOCT is able to reproducenormal vein wall structures and endovenous acute thermal alterations, such astissue ablation and vessel wall perforations. Endovenous eOCT images can also be analyzed quantitatively to measure media thickness or vein lumen diameter.Endovascular OCT could become a valuable alternative tool for morphologicinvestigation of tissue alterations after endovenous thermal procedures.

Int Angiol. 2007 Jun;26(2):183-8Endovenous thermal ablation Standardization of laser energy: literature reviewand personal experience

Kontothanassis D, Di Mitri R, Ferrari Ruffino S, Ugliola M, Labropoulos N

Endovenous laser treatment is a new, minimally invasive technique for ablation ofthe incompetent great and small saphenous vein and their tributaries. Althoughthe satisfactory safety/efficacy results of this technique, literature is poorregarding standardization of the energy needed to ablate the incompetent vein in order to have success and durability of the procedure. The aim of this paper is areview of the literature to find out if authors with large experience onendovenous laser treatment achieved a standardization of the delivered energy at the incompetent vein wall and if new concepts proposed by the authors, like cold saline anesthesia, echogenic vein occlusion and regular distribution of laserenergy to the vein wall, can improve the technique in order to have optimumresults.

Br J Surg. 2007 Jun;94(6):722-5Fate and clinical significance of saphenofemoral junction tributaries followingendovenous laser ablation of great saphenous veinTheivacumar NS, Dellagrammaticas D, Beale RJ, Mavor AI, Gough MJ

BACKGROUND: Unlike surgery, endovenous laser ablation (EVLA) abolishes greatsaphenous vein (GSV) reflux but does not specifically interrupt the GSVtributaries at the groin. The fate and clinical significance of these tributarieswere assessed in a prospective study. METHODS: Eight-one legs (70 patients)underwent colour flow duplex ultrasonography 12 months after GSV ablation forprimary varicose veins. Saphenofemoral junction (SFJ) reflux, tributary patency, and recurrent or residual varicosities were recorded, and Aberdeen Varicose Vein Severity Scores (AVVSS) were compared with pretreatment values. RESULTS: The GSV had recanalized without evidence of reflux in two patients. None of the 81 legsshowed SFJ reflux although one or more patent tributaries were visible in 48 (59 per cent); all were competent. In 32 legs (40 per cent) there was flush GSVocclusion with the SFJ and no tributaries were detectable. One leg showedevidence of neovascularization in the groin. AVVSS values were similar in groups with or without visible tributaries, both before and after EVLA: median(interquartile range) 13.9 (7.6-19.2) before EVLA and 2.9 (0.6-4.8) at follow-up in patients with visible tributaries, and 14.9 (9.2-20.2) and 3.1 (0.8-5.1)respectively in those without. Recurrent varicosities were present in one legonly, due to an incompetent mid-thigh perforating vein. CONCLUSION: Persistentnon-refluxing GSV tributaries at the SFJ did not appear to have an adverse impacton clinical outcome 1 year after successful EVLA of the GSV. (c) 2007 BritishJournal of Surgery Society Ltd.

Chirurg. 2007 Jul;78(7):620-629.Primary varicosisNoppeney T, Rewerk S, Winkler M, Nüllen H, Schmedt HC

The classic varicose vein operation still represents the "gold standard" in theoperative therapy of varicose veins. The results of this procedure in view ofperioperative complications are very good, with the incidence of perioperativedeep venous thrombosis varying between 0.05% and 0.1%. Recurrence rates between6% and 60% are published. However, the true recurrence rate is unknown since anexact definition of recurrent varicosis is still lacking. In recurrent varices itis essential to distinguish between disease progression, includingneorevascularisation, and technical errors. Endovascular procedures forelimination of the superficial venous system - radiofrequency obliteration andendovenous laser therapy - meanwhile have established themselves as alternative, minimally invasive procedures. The perioperative complication rate of endovenous procedures is very low and comparable to that of the classic operation. Goodresults, with occlusion rates of the treated vein around 87% to 93% up to 2 years

postoperatively, have been published for both endovenous laser therapy andradiofrequency obliteration. For the latter, 5-year results were published, with occlusion of the treated vein in 87%. Results in the literature forradiofrequency are better documented than for endovenous laser treatment because there are now five prospective randomised trials for the former and mostpublications for endovenous laser treatment are single-center experiences. Theadvantage of endovenous procedures, especially radiofrequency obliteration, over the classic operation is the lower rate of perioperative pain and better quality of life. The spectrum of operative treatment methods of the superficial venoussystem has increased tremendously due to new technical developments. For thesurgeon this implies the necessity of informing patients conscientiously aboutthe pros and cons and available results of each procedure, and carefully weighingwhich methods are at the time best for the patient.

Eur J Vasc Endovasc Surg. 2007 Aug;34(2):224-8. Epub 2007 May 2Standardisation of Parameters during Endovenous Laser Therapy of Truncal VaricoseVeins - Experimental Ex-vivo StudyKaspar S, Siller J, Cervinkova Z, Danek T

BACKGROUND: Vein shrinkage is a surrogate marker for successful laser treatmentof varicose veins. However, many controversies still remain concerning the bestlaser parameters to use. The aim of this study was standardisation ofintraoperative energy dosages and pull-back rates to achieve optimal clinicalresults. DESIGN: Ex-vivo study in surgically removed saphenous trunks. MATERIALAND METHODS: Great saphenous veins were removed by Babcock stripping andirradiated with laser energy delivered by a laser diode emitting at 980nm. Intotal, 279 vein segments (5cm long) were treated using powers from 5-15W. Veinsegments were opened longitudinally and the circumference measured in the treatedand untreated regions to assess thermal shrinkage. RESULTS: The greatestshrinkage and minimum number of perforations was achieved using lower or mediumpower (8 to 12W) with longer exposure to administer laser energy. The medianpercentage vein shrinkage was 50% (power 5W), 45% (8W), 40% (10W), 45% (12W) and 59% (15W). When a higher power was used (15W), the perforations were morefrequent and carbonisation was marked. CONCLUSIONS: Our data suggests thatsimilar efficacy with fewer vein perforations may be obtained with low or medium power settings and increased exposure when undertaking laser obliteration ofsaphenous trunks. This may result in fewer adverse events such as ecchymosisfollowing treatment in patients.

Eur J Vasc Endovasc Surg. 2007 Aug;34(2):229-31. Epub 2007 Feb 27Endovenous Laser Ablation (EVLA) of Great Saphenous Vein to Abolish "Paradoxical Reflux" in the Giacomini Vein: A Short ReportTheivacumar NS, Dellagrammaticas D, Mavor AI, Gough MJ

INTRODUCTION: Reflux in the GSV due to sapheno-popliteal incompetence associated with ascending (paradoxical) reflux in the Giacomini vein is a rare but welldescribed pattern of reflux. Treatment of this type of reflux is controversialand only surgical treatment has been described. REPORT: We describe 2 patients inwhom this type of reflux was successfully abolished following endovenous laserablation (EVLA) of the GSV with the SPJ and Giacomini vein regaining competency. DISCUSSION: Paradoxical reflux in the Giacomini vein and SPJ is secondary to GSV incompetence which exerts a syphon effect. EVLA of the refluxing segment of GSVinterrupts this effect and prevents the paradoxical reflux at the SPJ.

Surg Technol Int. 2007;16:167-74Varicose vein surgery and endovenous laser therapyReijnen MM, Disselhoff BC, Zeebregts CJ

Varicose veins are a widespread problem, and are encountered by various medicalspecialists. Symptoms can appear from mild, such as tiredness of the legs, tosevere chronic ulcers. Varicose veins are generally caused by the reflux of anincompetent saphenofemoral junction and long saphenous vein. In the presence ofreflux, the treatment should be directed at the ablation of the hydrostaticforces of the reflux. Conventional surgical treatment consists of a high ligationof the saphenofemoral junction and stripping of the saphenous vein. In the era ofminimally invasive surgery, various endovenous techniques have been developed,including endovenous laser therapy. This technique is relatively cheap and can beperformed under only local anesthesia. During endovenous laser therapy, energy isdelivered to the vein wall, causing it to shrink and eventually occlude.Currently, the mechanisms of action involved in laser treatment are not fullyunderstood. Clinical studies have shown occlusion rates to be very competitive toconventional high ligation and stripping and superior cosmetics. Complicationsmay include mild to moderate pain, ecchymosis, induration, hematoma, andphlebitis. All of these are generally self-limiting. In the challenge of finding the correct balance between a low incidence of varicose vein recurrence andcomplications and optimal cosmetic results, endovenous laser therapy is apromising modality. However, controlled studies that assess the effectiveness of endovenous laser therapy in comparison to saphenofemoral ligation with saphenous vein stripping are crucial before considering endovenous laser therapy as the newstandard treatment.

J Vasc Surg. 2007 Aug;46(2):308-15. Epub 2007 Jun 27Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: Short-termresultsRasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B

BACKGROUND: Endovenous laser (EVL) ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity and reduce work loss compared withhigh ligation and stripping (HL/S). However, the procedures have not previouslybeen compared in a randomized trial with parallel groups where both treatmentswere performed in tumescent anesthesia on an out-patient basis. METHODS: Patientswith varicose veins due to GSV insufficiency were randomized to either EVL (980nm) or HL/S in tumescent anesthesia. Miniphlebectomies were also performed.Patients were examined preoperatively and at 12 days, and 1, 3, and 6 monthspostoperatively. Sick leave, time to normal physical activity, pain score, use ofanalgesics, Aberdeen score, Medical Outcomes Study Short Form-36 quality-of-life score, Venous Clinical Severity Score (VCSS), and complication rates wereinvestigated. The total cost of the procedures, including lost wages andequipment, was calculated. Cost calculations were based on the standard fee forHL/S with the addition of laser equipment and the standard salary andproductivity level in Denmark. RESULTS: A follow-up of 6 months was achieved in121 patients (137 legs). The groups were well matched for patient and GSVcharacteristics. Two HL/S procedures failed, and three GSVs recanalized in theEVL group. The groups experienced similar improvement in quality-of-life scoresand VCSS score at 3 months. Only one patient in the HL/S group had a majorcomplication, a wound infection that was treated successfully with antibiotics.The HL/S and EVL groups did not differ in mean time to resume normal physicalactivity (7.7 vs 6.9 calendar days) and work (7.6 vs 7.0 calendar days).Postoperative pain and bruising was higher in the HL/S group, but no differencein the use of analgesics was recorded. The total cost of the procedures,including lost wages, was euro3084 ($3948 US) in the HL/S and euro3396 ($4347 US)in the EVL group. CONCLUSIONS: This study suggests that the short-term efficacyand safety of EVL and HL/S are similar. Except for slightly increasedpostoperative pain and bruising in the HL/S group, no differences were found

between the two treatment modalities. The treatments were equally safe andefficient in eliminating GSV reflux, alleviating symptoms and signs of GSVvaricosities, and improving quality of life. Long-term outcomes, particularlywith respect to recurrence rates, shall be investigated in future studies,including the continuation of the present.

Mekako A, Chetter ICutaneous hyperpigmentation after endovenous laser therapy: a case report and literature reviewAnn Vasc Surg. 2007 Sep;21(5):637-9. Epub 2007 May 17

Endovenous laser therapy (EVLT) for the treatment of varicose veins has beenshown to be effective and relatively safe. Reported complications are few andtransient. Whereas it is not uncommon to have cutaneous hyperpigmentationfollowing treatment modalities such as sclerotherapy, only a few reports oftransient hyperpigmentation following EVLT have been mentioned in the literature.We report a case of persistent hyperpigmentation following successful varicosevein treatment by EVLT.

Sharif MA, Lau LL, Lee B, Hannon RJ, Soong CV Role of endovenous laser treatment in the management of chronic venousinsufficiencyAnn Vasc Surg. 2007 Sep;21(5):551-5

Endovenous laser therapy (EVLT) is a recognized option in the treatment ofuncomplicated varicose veins. This uncontrolled case series evaluates itseffectiveness in the management of chronic venous insufficiency. Patients with a history of active or healed ulcers were selected for EVLT. The procedure wascarried out in an outpatient setting over a period of 12 months. Assessment wascarried out for evidence of ulcer healing and recurrence, long saphenous veinocclusion, and patient satisfaction at 3, 12, and 22 months. Results areexpressed as means with range. EVLT was used to treat 23 limbs in 20 patientswith a median age of 59 years (range 32-76) including 12 females and eight males.All patients had evidence of chronic venous insufficiency, graded at C5 orgreater on the CEAP classification (C5 16, C6 7). Patients with long saphenousvein insufficiency were included, whereas those with either deep or combined deepand superficial venous incompetence were excluded. The cumulative 3-, 12-, and22-month healing rates were 87% (20/23), 100% (23/23), and 95% (21/22),respectively. The only patient having a recurrence of ulcers at 22 months'follow-up (CEAP 6) had mid-calf perforator incompetence with recanalized longsaphenous vein. Duplex scan demonstrated long saphenous vein occlusion in 100%(23/23), 96% (22/23), and 91% (20/22) at 3, 12, and 22 months, respectively. Inall, 84% (16/19) of patients were satisfied with the results of treatment withoutany major procedure-related complication. These results demonstrate that EVLT,carried out in an outpatient setting, is effective in the treatment andprevention of chronic venous ulcers, with good patient satisfaction and no major complication.

Constantea N, Crişan S, Donca V, Buzdugan E, Pop T, Chirilă D, Capâlneanu C,Jianu F, Dudric VEndovenous laser treatment (EVLT) for treatment of great saphenous veininsufficiency Rev Med Chir Soc Med Nat Iasi. 2007 Jul-Sep;111(3):664-8

OBJECTIVE: To assess the efficacy and rate of complications of endovenous lasertreatment (EVLT) of the great saphenous vein (GSV) insufficiency. METHOD: Betweenaugust 2002 and june 2007, 341 of the lower limbs of 322 patients were treatedwith EVLT using a 980-nm diode laser. Duplex ultrasound and clinical examinationswere performed on the day of the procedure, the next day, and 6 to 12 monthsafter the procedure. RESULTS: All procedures were technically successful, and at the 3 months follow-up the Doppler ultrasound indicated the complete obstruction in all cases. 67 of the 70 lower limbs presented a complete obstruction at the 2 year follow-up. Only in two cases (2.85%) the GSV recanalization was observedafter 6 months. As side effects reversible paresthesia, transient postoperativepain and ecchymosis were observed. CONCLUSION: EVLT is a safe technique, with lowincidence of recanalization and postoperative complications.

Yilmaz S, Ceken K, Alparslan A, Sindel T, Lüleci EEndovenous laser ablation for saphenous vein insufficiency: immediate andshort-term results of our first 60 proceduresDiagn Interv Radiol. 2007 Sep;13(3):156-63

PURPOSE: To present the immediate and short-term results of our first 60endovenous laser (EVL) ablation procedures. MATERIALS AND METHODS: Between July2005 and December 2006, 60 EVL ablations were performed in 36 symptomaticpatients (26 females, 10 males; mean age +/- SD, 46 +/- 14 years). Theincompetent veins included the great saphenous vein (GSV) (n = 52), smallsaphenous vein (n = 6), and major branches of the GSV (n = 2). In all casesincompetent veins were punctured under ultrasound (US) guidance and the laserfiber was placed into these veins through a vascular sheath or with the help of acatheter. After tumescent anesthesia was administered, the veins were ablatedwith laser by delivering 50-100 joules/cm energy to the vein wall. Following EVL ablations, 29 patients also underwent foam sclerotherapy to treat the remainingvaricosities. After the EVL ablation +/- sclerotherapy, patients were followed-up with Doppler US at 1 week, and then 3, 6, and 12 months post procedure.RESULTS: In all patients EVL ablation was technically successful. Complicationswere minor and included transient visual disturbance due to foam sclerotherapy (n= 1), bruising/ ecchymoses (n = 24), postoperative pain (n = 16), and superficialthrombophlebitis (n = 6). All patients returned to normal activity within 2 days.During the 7 +/- 5 months (mean +/- SD) of follow-up, recurrent reflux was seenin only one patient, in both GSVs, which was successfully treated with foamsclerotherapy. CONCLUSION: EVL ablation is a safe and effective method for themanagement of saphenous vein insufficiency.

Viarengo LM, Potério-Filho J, Potério GM, Menezes FH, Meirelles GVEndovenous laser treatment for varicose veins in patients with active ulcers:measurement of intravenous and perivenous temperatures during the procedureDermatol Surg. 2007 Oct;33(10):1234-42; discussion 1241-2

BACKGROUND: Conventional saphenous vein stripping is difficult to be indicatedfor the treatment of varicose veins in patients classified as CEAP C4, C5, or C6.OBJECTIVE: This study was developed to evaluate treatment results for varicoseveins with active ulcers using endovenous laser (EVL), compared to a groupundergoing clinical treatment, during 1 year. PATIENTS AND METHOD: Fifty-twopatients presenting with varicose veins with active ulcers for more than 1 yearwere divided for treatment into two randomized groups: Group 1, clinicaltreatment, composed of 25 subjects, was submitted to elastic or inelasticcompression therapy; Group 2, EVL treatment, composed of 27 subjects, wassubmitted to great and or small saphenous vein ablation with a 980-nm diode EVL, plus the clinical treatment. Intravenous and perivenous temperatures weremeasured continuously during the EVL treatment. All patients were followed for 12months and studied with ultrasound at the beginning and end of the study. The

ulcers' areas were evaluated initially and at every 3 months. RESULTS: In 12months, 81.5% of the wounds in patients in Group 2 and only 24% in patients inGroup 1 had healed. Ulcer recurrence rate was 44.4% in Group 1. The mean woundarea in Group 1 decreased from 17.48 to 12.76 cm(2) at the end of the year. InGroup 2, the wound area decreased from 22.26 to 2.7 cm(2) (p=.0037). Meanintravenous and perivenous temperatures of 79.3 and 43.0 degrees C were recorded.CONCLUSION: The treatment for varicose veins with EVL is safe in patients withactive ulcers. Wounds healed faster than in patients undergoing clinicaltreatment alone during a 1-year period. There was no ulcer recurrence in patientstreated with EVL.

Park SW, Yun IJ, Hwang JJ, Lee SA, Kim JS, Chang SH, Chee HK, Hong SJEndovenous laser ablation of varicose veins after direct percutaneous puncture:early resultsDermatol Surg. 2007 Oct;33(10):1243-9

BACKGROUND: Although endovenous laser ablation has been demonstrated toeffectively occlude incompetent saphenous veins, it does not treat branchvaricosities directly. OBJECTIVE: The objective was to evaluate the technicalfeasibility and early results of the direct ablation of branch varicosities usinga 980-nm diode laser. MATERIALS AND METHODS: From July to August 2005, 17patients (21 limbs; male:female ratio, 7:10; mean age, 50.1 years; range, 24-62years) with varicose veins were enrolled in this study. Endovenous laser ablationwas performed in incompetent saphenous veins. Thereafter, branch varicositieswere percutaneously punctured and a direct laser ablation was performed using a400-microm laser fiber. Patients were evaluated at 1 week and at 1-, 3-, and6-month intervals. RESULTS: Technical success in branch varicosities was achievedin 11 of 15 limbs (71.4%). Continued closure of treated saphenous veins wasevident in 11 of 11 limbs (100%) at 1-month follow-up. Successful ablation invaricose tributaries was seen in 6 of 11 limbs (54.5%) at 1-month follow-up andablation failed in 5 limbs. One of the 11 limbs (9%) had a skin burn thatrequired treatment. CONCLUSION: Despite partly successful occlusion, we suggestthat direct laser ablation cannot replace classic methods of treating branchvaricosities, because of its high failure rate and the risk of skin burns.

Longhini A, Borelli P, Franzini M, Kazemian AR, Munarini G, Marcolli GCombination of endovenous laser treatment and a surgical approach for venousdiseaseChir Ital. 2007 Jul-Aug;59(4):475-9

The aim of our study was to report our experience with endovenous laser treatment(EVLT), initiated with an exclusively US-guided approach, but then combined with a surgical approach. Over the period from September 2003 to December 2005 in the Sondrio Hospital General Surgery Unit 61 patients were submitted to EVLT. In the first 13 cases the procedure was performed under ultrasonographic guidance,whereas later we opted for a combined technique in which the use of the laser waspreceded by high ligation of the saphenous vein ("crossectomy") together withcomplete sectioning of the venous collaterals (48 cases). We observed nocomplications related to the saphenous vein ligation, whilst EVLT proved safe andeasy to perform. Considering successful EVLT as ultrasonographically documentedabsence of flow in the saphenous vein, a statistically significant difference (p < 0.01) was found between the patients treated using the combined strategy(absence of flow in 92.0% of cases) and those treated with EVLT alone (absence offlow in 54.6% of cases). If EVLT is combined with high ligation of the saphenous vein, it is easier to obtain complete sclerosis of the saphenous trunk, avoiding possible recurrences, amongst other things thanks to the ligation of all thecollateral veins that flow into the cross. Moreover, particular selection ofpatients to be submitted to EVLT proves less necessary, thus substantially

increasing the indications for the procedure.

Timperman PEEndovenous laser treatment of incompetent below-knee great saphenous veinsJ Vasc Interv Radiol. 2007 Dec;18(12):1495-9

Purpose To test the hypotheses that below-knee great saphenous vein (GSV) reflux after successful ablation of the incompetent above-knee GSV is a cause ofincomplete clinical success and that endovenous laser treatment (ELT) of theincompetent below-knee GSV can safely eliminate persistent symptoms. Materialsand Methods The author evaluated 576 consecutive ELT procedures of the GSV. FiftyELT procedures in incompetent calf GSVs were included in this study. Patientswith reflux of the entire GSV were selected. All patients underwent clinical and ultrasonographic (US) follow-up. Results In 16 of the 50 procedures, ELT wasperformed in the GSV both above and below the knee in separate sessions. In 34procedures, ELT of the GSV above and below the knee was performed at the samesession. An 810-nm laser was used at 14 W. The mean energy was 82 j/cm (range,56.4-114 j/cm; standard deviation [SD], 14 j/cm). The mean follow-up was 11months (range, 0-28 months; SD, 7 months). Four paresthesias occurred. Medialankle pain resolved in all patients, and swelling resolved in all but six limbs. No recanalization occurred. Conclusions Patients with incompetence of the entire GSV treated with only ELT of the above-knee GSV experienced incomplete relief of medial ankle pain and swelling; however, symptomatic relief is obtained safelyand effectively with additional ELT of the below-knee GSV.

Shamma AR, Guy RJLaser ablation of unwanted hand veinsPlast Reconstr Surg. 2007 Dec;120(7):2017-24

BACKGROUND: Many patients express dissatisfaction with prominent and bulging handveins. Abolishing these veins with sclerotherapy requires higher concentrationsof sclerosing agents than are used for leg veins and often results in a tender,phlebitic cord. Phlebectomy is another treatment option. Endovenous occlusion andshrinkage techniques have been used successfully to treat varicose veins of thelower extremities. The authors demonstrate a new and unique endovenous lasertechnique to abolish unwanted hand veins. METHODS: Fifty-four hands (28 patients)with prominent hand veins were treated using a 600-microm laser fiber. TheDornier MedTech 940-nm diode laser system was used. The laser fiber wasintroduced through a 4-French sheath, which tracked as a coaxial system over an0.018-inch guidewire. Initial entry into the treated vein was accomplished with a20-gauge angiocatheter percutaneously. On average, four veins were treated ineach hand. Tumescent anesthesia was infiltrated around the laser fiber/sheathunit before activating the laser, and all procedures were performed in an office setting. A compressive dressing was used postoperatively. RESULTS: All but one ofthe unwanted hand veins were cannulated successfully. The uncannulated vein wastreated with sclerotherapy and eventually required phlebectomy. Hand swellingoccurred in all treated hands and lasted 2 weeks or less. There was one skin burnof approximately 3 mm at a laser exit site. All 28 patients were satisfied withtheir results during follow-up, which ranged from 2 weeks to 31 months.CONCLUSIONS: This is the first report of endovenous treatment of unwanted handveins. Laser ablation of unwanted hand veins can be performed in an officesetting. These cosmetically conscious patients were satisfied with their results.

Desmyttère J, Grard C, Wassmer B, Mordon SEndovenous 980-nm laser treatment of saphenous veins in a series of 500 patientsJ Vasc Surg. 2007 Dec;46(6):1242-7

BACKGROUND: In recent years, endovenous laser treatment (ELT) has been proposedto treat incompetent great saphenous veins (GSV). This study reports thelong-term outcome of ELT in a series of 500 patients. METHODS: Incompetent GSVsegments in 500 patients (436 women, 64 men) with a mean age of 52.6 years(range, 19 to 83 years) were treated with intraluminal ELT using a 980-nm diodelaser (Pharaon, Osyris, France). The GSV diameter was measured by Duplexexamination in an upright position in different GSV segments (1.5 cm below thesaphenofemoral junction, crural segment, condylar segment, and sural segment).These measurements were used to determine the optimal linear endovenous energydensity (LEED) for each segment. During treatment, patients were maintained inthe Trendelenburg position. Patients were evaluated clinically and by duplexscanning at 1 and 8 days, 1 and 6 months, and at 1, 2, 3, and 4 years to assesstreatment efficacy and adverse reactions. RESULTS: A total of 511 GSVs weretreated. The mean diameter was 7.5 mm (range, 2.4 to 15.0). The LEED was tuned asa function of the initial GSV diameter measured in the orthostatic position, from50 J/cm (3 mm) up to 120 J/cm (15 mm). At the 1-week follow-up, 9.3% of thepatients reported moderate pain. In the immediate postoperative period, theclosure rate was 98.0% and remained constant during the 4-year follow-up to reach97.1%. After 1 year, a complete disappearance of the GSV or minimal residualfibrous cord was noted. Major complications have not been detected; inparticular, no deep venous thrombosis. Ecchymoses were seen in 60%, transitoryparesthesia was observed in 7%. There was no dyschromia, superficial burns,thrombophlebitis, or palpable indurations. Complementary phlebectomy was done in 98% of patients. Failures occurred only in large veins (saphenofemoral junctiondiameter >1.1 cm or for GSV truncular diameter >0.8 cm) CONCLUSION: ELT of theincompetent GSV with a 980-nm diode laser appears to be an extremely safetechnique, particularly when the energy applied is calculated as a function ofthe GSV diameter. It is associated with only minor effects. Currently, ELT hasbecome the method of choice for treating superficial veins and has almostreplaced the treatment of traditional ligation and stripping.

Yin HH, Ye CS, Lin Y, Li XX, Wang SMClinical effects of endovenous laser therapy plus transilluminated poweredphlebectomy in treatment of primary varicose veinsZhonghua Yi Xue Za Zhi. 2007 Oct 30;87(40):2849-51

OBJECTIVE: To evaluate the clinical and cosmetic effects of endovenous lasertherapy (EVLT) plus transilluminated powered phlebectomy (TIPP) in the treatment of primary varicose veins. METHODS: The clinical effects of EVLT plus TIPP intreatment of 82 patients of primary varicose vein with 105 extremities wereevaluated. The procedure-related parameters, clinical outcomes, and complicationswere recorded. The venous function was assessed by venous photoelectricplethysmography (VPPG). Aberdeen Varicose Veins Questionnaire (AVVQ) and VenousClinical Severity Score (VCSS) surveys were used to appraise the quality of life and symptomatic alleviation. RESULTS: The successful rates of EVLT and TIPP was98.1% (103/105) and 100% (105/105) respectively. The average operating time was53.8 min (35 approximately 108 min). The average number of wounds was 4.4 (3approximately 7). The postoperative hospitalization time was 4.8 d (2approximately 6 d). The follow-up rates 3, 6, and 12 months after operation were 100%, 93.9%, and 35.4% respectively. Obvious symptom alleviation or entiredisappearance was noticed in all the limbs 3 months after operation. Thehemodynamic parameters, such as venous filling index (VFI), ejection fraction(EF), and residual volume fraction (RVF) were significantly ameliorated 1 monthafter the operation compared with those measured preoperatively (all P < 0.01).No further improvements were noticed from then on (P > 0.05). Disease specificquality of life was greatly improved after operation (P = 0.000). 91.5% of thepatients were satisfied with the postoperative appearance of the involved limbs. CONCLUSION: EVLT plus TIPP is an efficacious minimally invasive strategy for the treatment of primary varicose veins, resulting in approving cosmetic effect as

well.

Christenson JTThe impact of the creation of a venous surgical centre within the department ofcardiovascular surgery at a university hospitalPhlebology. 2007;22(2):70-4

BACKGROUND: The establishment of specialty vein clinics has proven beneficial in terms of expansion of clinical volume. Depending on the local situation, thecreation of a venous surgical centre may, in addition, result in bettercollaboration between various specialties, enable active participation in thedevelopment and evaluation of new treatment modalities, offer bettertraining/education and provide venues for more complex treatment modalities such as reconstructive surgery of the deep venous system. OBJECTIVES: The aim of this study was to analyse the impact of the creation of a venous surgical centre underthe auspices of a department of cardiovascular surgery at a university hospital. METHODS: A venous surgical centre was established on 1 October 2003, under thedirection of one senior surgeon. The impact on clinical activity was measured in terms of patient volume, percentage distribution between venous and arterialsurgery and surgical procedures performed, complications following venous surgeryas well as evaluation of patient and referring physician satisfaction. Data, fromthe department's databank, on all patients evaluated and surgically treated forvenous and arterial problems from 1 January 2000 to 30 June 2006 were analysed.Number of outpatient clinic visits and operations (patients and surgicalprocedures) were calculated. RESULTS: The establishment of the venous surgicalcentre, without additional funding, led to a significant increase in clinicalvolume. There was a 433% increase in vein surgical procedures and a 774% increasein outpatient clinic visits (comparing 2002 with 2004). Endovenous lasertreatment of varicose veins and reconstructive surgery for the deep venous systemwas started, and a program for training surgeons was established. Complicationrate following varicose vein surgery decreased from 5.8% to 1.2% (hematomas andgroin infection). Patient and referring physician satisfaction was documented in 2004 and 2006 using questionnaires. CONCLUSIONS: The establishment of an academicvenous surgical centre has proven useful in increasing clinical activity in termsof patient volume, providing more efficient and better continuity of care,ensuring less complications following varicose vein surgery, allowing theintroduction of new treatment modalities, and resulting in overwhelming patientand treating physician satisfaction.

Uchino IJEndovenous laser closure of the perforating vein of the legPhlebology. 2007;22(2):80-2

BACKGROUND: Endovenous procedures have been proven effective in treating axialvein reflux. This report describes a new application, namely endovenous lasertherapy of the incompetent perforating vein of the leg. OBJECTIVE: To explore an alternative option for treatment of incompetent perforating vein of the leg.METHODS & MATERIALS: An 80-year-old male underwent ultrasound-guidedsclerotherapy of the neovascularization vessels at the groin and the refluxingvein of the left thigh. Endovenous laser therapy of the incompetent perforatingvein was then performed to treat a persisting incompetency of the posteriortibial perforating vein (Cockett's perforating vein). RESULTS: Follow-up duplexscan showed that not only was the tributary vein (run-off vein) thrombosed, butthe perforating vein itself was thrombosed with an intact posterior tibial veinat one-week, three-week, and 12-week follow-up examinations. The onlycomplication was a slight erythematous change of the overlying skin, whichsubsided spontaneously. CONCLUSIONS: There are many options in the treatment ofincompetent perforating vein of the leg. An endovenous procedure should be

considered as one of the options, especially where tissue around the incompetent perforating vein of the leg is compromised.

Gloviczki P, Driscoll DJKlippel-Trenaunay syndrome: current managementPhlebology. 2007;22(6):291-8

Klippel-Trenaunay syndrome (KTS) is a rare, sporadic, complex malformationcharacterized by the clinical triad of (1) capillary malformations (port winestain); (2) soft tissue and bone hypertrophy or, occasionally, hypotrophy ofusually one lower limb; and (3) atypical, mostly lateral varicosity. KTS is amixed vascular malformation, with predominant capillary, venous and lymphaticcomponents, without significant arteriovenous shunting. Management is largelyconservative and the extent of diagnostic evaluation is determined by the plannedtreatment. Compression is the hallmark of conservative management; laser can beused to treat port wine stains. Imaging before vascular interventions mustconfirm venous anatomy and deep venous drainage. Techniques for ablation ofsuperficial veins and malformations are individualized and may includesclerotherapy with alcohol or foam, endovenous thermal ablation or, as used most frequently in our practice, surgical stripping and phlebectomy. Intraoperativeuse of tourniquet will decrease bleeding, selective use of an inferior vena cava filter will prevent pulmonary embolism. A multidisciplinary approach tomanagement of KTS is warranted.

Lin Y, Ye CS, Huang XL, Ye JL, Yin HH, Wang SM A random, comparative study on endovenous laser therapy and saphenous veinsstripping for the treatment of great saphenous vein incompetenceZhonghua Yi Xue Za Zhi. 2007 Nov 20;87(43):3043-6

OBJECTIVE: To evaluate the therapeutic effects of endovenous laser therapy (EVLT)and saphenous veins stripping in the treatment of great saphenous veinincompetence. METHODS: Eighty cases (80 limbs) with great incompetent saphenousvein were randomly divided into 2 equal groups: EVLT group and stripping group.The patients in the EVLT group underwent EVLT and those in the stripping groupunderwent upper ligation and stripping of great saphenous vein. The duration ofoperation, blood losing, complications, pain grade, and hospitalization time werecompared. All cases were followed up for 6 months and 12 months using Dopplersonography and air Plethysmography. RESULTS: The blood losing (P < 0.01),hospitalization time (P < 0.05) and pain grade (P < 0.05) in the EVLT group were all significantly less than those in the stripping group, while the operationduration and complication were not significantly different between the two groups(P > 0.05). All patients in both groups got improvements of venous volume (P <0.05), Venous Filling Index (P < 0.01), and residual Venous Fraction (P < 0.01), yet there were no statistical differences between the two groups (P > 0.05).CONCLUSION: Endovenous laser therapy is a safe, effective, minimal invasiveprocedure for the patients with great saphenous vein incompetence. Its short-timeefficiency is similar to that of the traditional upper ligation and laceration ofgreater saphenous vein.

Van den Bos RR, Kockaert MA, Neumann HA, Nijsten TTechnical review of endovenous laser therapy for varicose veinsEur J Vasc Endovasc Surg. 2008 Jan;35(1):88-95. Epub 2007 Oct 24

BACKGROUND: In the last decade, several new treatments of truncal varicose veins have been introduced. Of these new therapies, endovenous laser therapy (EVLT) is

one of the most widely accepted and used treatment options for incompetentgreater and lesser saphenous veins. OBJECTIVE: The objective of this report is toinform clinicians about the EVLT procedure and to review its efficacy and safety in treatment of truncal varicose veins. Also, we discuss some of the underlyingtheoretical principles and laser parameters that affect EVLT. METHODS: We carriedout a literature review of EVLT;s efficacy and safety. We included reports thatincluded 100 or more limbs with a follow-up of at least 3 months. The principals and procedure of EVLT are described. Of the laser parameters, mode ofadministration, wavelength, fluence, wattage and pullback speed are discussed.CONCLUSION: EVLT appears to be a very effective and safe option in the treatment of varicose veins but large randomized comparative studies are needed.

Theivacumar NS, Dellagrammaticas D, Beale RJ, Mavor AI, Gough MJFactors influencing the effectiveness of endovenous laser ablation (EVLA) in the treatment of great saphenous vein refluxEur J Vasc Endovasc Surg. 2008 Jan;35(1):119-23. Epub 2007 Nov 1

OBJECTIVE: Endovenous laser ablation (EVLA) is an alternative to surgery fortreating sapheno-femoral and great saphenous vein (GSV) reflux. This studyassesses factors that might influence its effectiveness. DESIGN: Prospective,observational study. METHOD: EVLA was used to treat the great saphenous vein in644 limbs as part of the management of varicose veins. Body mass index (BMI),maximum GSV diameter, length of vein treated, total laser energy (TLE) and energydensity (ED: Joules/cm) delivered were recorded prospectively. Data from limbswith ultrasound confirmed GSV occlusion at 3-months were compared with thosewhere the GSV was partially occluded or patent. Complications were recordedprospectively. RESULTS: GSV occlusion was achieved in 599/644 (93%) limbs (group A). In 45 limbs (group B) the vein was partially occluded (n=19) or patent(n=26). Neither BMI [group A: 25.2 (23.0-28.5); group B: 25.1 (24.3-26.2)], norGSV diameter [A: 7.2mm (5.6-9.2); B: 6.9 mm (5.5-7.7)] influenced success. TLEand ED were greater p<0.01) in group A (median [inter-quartile range]: 1877J(997-2350), 48 (37-59)J/cm) compared to group B (1191J (1032-1406), 37(30-46)J/cm). Although TLE reflects the greater length of GSV ablated in Group A (33 cm v 29 cm, p=0.06) this does not influence ED. GSV occlusion always occurredwhen ED>/=60 J/cm with no increase in complications. CONCLUSIONS: ED (J/cm) oflaser delivery is the main determinant of successful GSV ablation following EVLA.

Janne d'Othée B, Faintuch S, Schirmang T, Lang EVEndovenous laser ablation of the saphenous veins: bilateral versus unilateralsingle-session proceduresJ Vasc Interv Radiol. 2008 Feb;19(2 Pt 1):211-5

PURPOSE: To assess the feasibility of bilateral endovenous laser ablation (EVLA) of saphenous veins in a single session with use of diluted lidocaine fortumescent anesthesia. MATERIALS AND METHODS: Among 122 consecutive EVLAprocedures (112 patients; mean age, 49 years; 75% women) over a 12-month period, there were 75 unilateral procedures (n = 67) and 47 bilateral interventions (n = 45). Tumescent anesthesia consisted of lidocaine diluted to 0.10% for unilateral procedures versus 0.05% for bilateral cases (lidocaine dose <4.5 mg/kg bodyweight). Procedural data, immediate success rates on an intent-to-treat basis,and outcomes at 3-6-month follow-up were compared between groups withnonparametric tests. RESULTS: Bilateral procedures could be performedsuccessfully with low lidocaine dilutions with a similar success rate (96%) asunilateral procedures (100%). No significant variation in systolic and diastolic blood pressure and heart rate was observed between bilateral and unilateralgroups. No patient experienced signs of lidocaine toxicity. After adjusting forlength of vein treated, there were no significant differences in the totallidocaine dose used, tumescent anesthesia volume, or procedure duration.

CONCLUSIONS: Bilateral saphenous vein ablation in a single session appears safeand effective when tumescent anesthesia is given with very dilute lidocaine(0.05%). This approach may help meet patients' requests for simultaneousbilateral treatment and reduce duration of postprocedural discomfort.

Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AI, Gough MJRandomized clinical trial comparing endovenous laser ablation with surgery forthe treatment of primary great saphenous varicose veinsBr J Surg. 2008 Mar;95(3):294-301

BACKGROUND: Endovenous laser ablation (EVLA) is a minimally invasive techniquefor treating varicose veins due to truncal vein incompetence. This randomizedtrial compared EVLA with conventional surgery in patients with primarysaphenofemoral and great saphenous vein (GSV) reflux. METHODS: Consecutiveconsenting patients with symptomatic varicose veins were randomized to EVLA 1(stepwise laser withdrawal), EVLA 2 (continuous laser withdrawal) or surgery(saphenofemoral ligation, GSV stripping, multiple phlebectomies). Principaloutcome measures were abolition of GSV reflux and improvement in AberdeenVaricose Vein Symptom Score (AVVSS) 3 months after treatment. RESULTS: GSV refluxwas abolished in 41 of 42 legs treated with EVLA 1, 26 of 29 following EVLA 2 and28 of 32 after surgery (P = 0.227). The median (interquartile range, i.q.r.)AVVSS improvement was similar: 9.38 (4.54-14.93) with EVLA 1, 10.26 (5.03-15.03) after EVLA 2 and 8.36 (4.54-13.21) following surgery (P = 0.694). Return tonormal activity (median (i.q.r.) 2 (0-7) versus 7 (2-26) days; P = 0.001) andwork (4 (2-7) versus 17 (7.25-33.25) days; P = 0.005) was quicker after EVLA byeither method. CONCLUSION: Abolition of reflux and improvement indisease-specific quality of life was comparable following both EVLA and surgery. The earlier return to normal activity following EVLA may confer importantsocioeconomic advantages.

Park SJ, Yim SB, Cha DW, Kim SC, Lee SHEndovenous laser treatment of the small saphenous vein with a 980-nm diode laser:early resultsDermatol Surg. 2008 Apr;34(4):517-24; discussion 524. Epub 2008 Jan 31

BACKGROUND: Whereas numerous studies have been conducted regarding the outcome ofthe treatment of the great saphenous vein, few studies have been conducted on thesmall saphenous vein (SSV), especially concerning endovenous laser treatment.OBJECTIVE: The objective was to evaluate the safety and efficacy of the 980-nmdiode laser for the treatment of SSV reflux caused by saphenopopliteal junction(SPJ) incompetence. MATERIALS AND METHODS: From October 2003 to April 2006, 390SSVs in 344 subjects with varicose veins were treated with 980-nm diode laserenergy delivered percutaneously into the SSV. Tumescent anesthesia (70-220 mL of 0.1% lidocaine) was delivered perivenously under ultrasound (US) guidance. Thepatients were evaluated clinically and with duplex US at 1 week, 1 month, 3months, 6 months, 1 year, and thereafter to assess the efficacy of the treatment and the adverse reactions of the patients to it. RESULTS: Successful occlusion ofthe SSV, defined as the absence of flow on color Doppler imaging, was noted in389 of the 390 SSVs (99.7%) after the initial treatment. The remaining 1 SSV was closed after the repeat treatment. Of 108 SSVs, 102 (94.4%) remained closedthroughout the 12th-month follow-up. Bruising and tightness along the course ofthe treated vein was present in almost all the patients, but these disappeared in1 to 2 weeks. Seven patients (2%) noted localized skin paresthesia, but therewere no major complications like skin burns and deep vein thrombosis. CONCLUSION:Taking into account the high failure rates of incompetent SSV surgery and theanatomic complexity of SPJ, the endovenous 980-nm diode laser surgery is a safeand effective, cosmetically preferential procedure while a long-term follow-up isbeing awaited.

Vuylsteke M, Liekens K, Moons P, Mordon S Endovenous laser treatment of saphenous vein reflux: how much energy do we needto prevent recanalizations ?Vasc Endovascular Surg. 2008 Apr-May;42(2):141-9. Epub 2008 Jan 31

The aim of this study was to report the results of high-energy endovenous lasertreatment to measure the relationship between the fluence and the outcome interms of recanalization. In 97 patients, 129 great saphenous veins were treatedwith endovenous laser treatment, using a 980-nm diode laser. Follow-up visitswere done at 3 days, 1 month, and 6 months. The best results were noted 1 monthpostoperative, but at 6 months, control late recanalizations occurred decreasing occlusion rate to 90.6%. Patients were divided into 2 groups according to theoutcome (occlusion or recanalization) at 6 months, and statistical analysis was done. The authors found 52 J/cm(2) mean fluence in the occlusion group and 43.7J/cm(2) in the nonocclusion group. This was a statistical significant difference (P < .01). The occlusion rate on long term is fluence dependent. Butrecanalizations might occur even in these higher fluence treatment groups. Afluence of 52 J/cm(2) is advised.

Kalteis M, Berger I, Messie-Werndl S, Pistrich R, Schimetta W, Pölz W, Hieller FHigh ligation combined with stripping and endovenous laser ablation of the great saphenous vein: early results of a randomized controlled study1J Vasc Surg. 2008 Apr;47(4):822-9; discussion 829. Epub 2008 Mar 4

OBJECTIVE: This study compared postoperative patient comfort and the surgicaloutcome of endovenous laser ablation (EVLA) or stripping of the great saphenousvein, both performed in conjunction with high ligation. METHODS: The studyrandomized 100 patients with primary trunk varicosities of the great saphenousvein (CEAP clinical class II to IV) to EVLA or stripping. The success of surgery was followed-up by duplex ultrasound imaging at 1, 4, and 16 weeks. Primary endpoints were the size of the hematoma 1 week after the operation and thepreoperative disease-specific Chronic Venous Insufficiency Questionnaire (CIVIQ) quality of life score compared with 4 weeks postoperatively. Secondary end pointswere postoperative symptoms (pain, use of analgesics, paresthesia at the ankle,residual hematoma), complications, time taken to resume work, the patient'ssatisfaction with the cosmetic outcome, and the CIVIQ quality of life score at 16weeks. RESULTS: The groups were well matched at baseline. In all, 95 patientscould be followed up in accordance with the protocol. The treatment wassuccessful in all patients. Endovenous laser ablation was associated with anocclusion rate of 100%. Hematomas were significantly smaller after EVLA (median[quartiles]) at 125 (55-180) cm(2) vs stripping 200 (123-269) cm(2) (P = .001).No difference was registered between groups for the CIVIQ quality of life score, with EVLA at -1.25 (-7.5-11.25) vs stripping at 4.38 (-5.94-14.38; P = .34).Several postoperative symptoms favored EVLA, but the only significant differenceswere seen in the minor side effects of surgery at 1 and 4 weeks and discomfortdue to paresthesia at the ankle in the first postoperative week. EVLA wasassociated with a longer period of time until return to work (median [quartiles])of 20 (14-25.5) days vs 14 (12.8-25) days (P = .054). CONCLUSION: Endovenouslaser ablation combined with high ligation is safe and effective. Postoperativehematomas are significantly smaller than those after stripping. Short-termquality of life is at least as good as that after stripping. The long-termresults warrant further investigation.

Disselhoff BC, der Kinderen DJ, Moll FL Is there a risk for lymphatic complications after endovenous laser treatmentversus cryostripping of the great saphenous vein? A prospective study

Phlebology. 2008;23(1):10-4

OBJECTIVE: To investigate whether lymphatic complications occur after endovenous laser treatment (EVLT) versus cryostripping. METHODS: A prospective analysis ofpatients who underwent lymphoscintigraphy before and six months after treatmentof primary varicose veins. RESULTS: Of 120 patients randomized in a clinicaltrial comparing EVLT and cryostripping, 33 agreed to participate in this study.Six months after treatment, none of the 17 patients treated with EVLT and one(6.3%) of the 16 patients treated with cryostripping had clinical grade 1lymphoedema, with marked disruption of the lymphatics around the knee. Thispatient also showed an abnormal uptake of radioactive tracer at the groin, 120min after injection. CONCLUSION: This study demonstrated that no lymphaticcomplications occurred six months after EVLT, whereas one lymphatic complication occurred after cryostripping, however not in the groin but at the knee.

Elmore FA, Lackey DEffectiveness of endovenous laser treatment in eliminating superficial venousrefluxPhlebology. 2008;23(1):21-31Comment in: Phlebology. 2008;23(2):99

OBJECTIVE: To describe a protocol for endovenous laser treatment that is highlyeffective, has no significant complications, and is well accepted by patients.This is the first published report that designates complete absence of thetreated vein as the definition of a successful endovenous laser treatment.METHODS: A retrospective review of 516 endovenous laser treatments performed by asingle physician in private medical practice over a 69-month period. Follow-upranged from 3 to 65 months. All treatments were performed utilizing 810nm laserenergy (Diomed, Inc.). Periodic duplex ultrasound examinations were performeduntil the treated vein was absent. Surveys were done to assess post treatmentpain and to evaluate the effect of treatment on quality of life. RESULTS: Thedescribed protocol for endovenous laser treatment has successfully eliminated98.1% of 516 treated veins with a single laser treatment. Additionally, in thelast 386 treated veins when increased energy levels were utilized, the successrate was 99.7%. There were no significant complications. Patient satisfactionwith the procedure is extremely high. CONCLUSIONS: Endovenous laser treatment is a highly effective procedure for eliminating superficial venous reflux invaricose veins selected for treatment when sufficient 810 nm (Diomed, Inc.) laserenergy is utilized.

Janne D'Othée B, Ghiorse DNon-infected, non-haematic fluid collections after endovenous laser ablation ofthe saphenous veins: a noteworthy complicationPhlebology. 2008;23(1):47-9

OBJECTIVES: To describe an uncommon complication after endovenous laser ablation (EVLA) of the saphenous veins and its percutaneous management. METHODS:Symptomatic greater saphenous vein reflux was successfully treated by EVLA using standard technique. Local pain, redness and swelling around the priorpercutaneous access site were investigated at the clinical and duplexultrasonographic follow-up visit one week later. RESULTS: Duplex ultrasonography demonstrated a subcutaneous fluid collection with surrounding hyperechogenicity. Needle aspiration of the collection under real-time ultrasound guidance allowedcomplete evacuation of the clear yellowish fluid. Immediate symptom relief wasobserved. Direct examination and anaerobic and aerobic culture of the fluid were negative. No further complication was observed during the following 11 months of

follow-up. CONCLUSIONS: Seroma after EVLA is a rare but possible complication,while haematomas and infections seem much scarcer. Diagnosis is easily made byduplex ultrasonography. Treatment by fine needle aspiration can successfullyrelieve symptoms without delayed recurrence.

Durai R, Srodon PD, Kyriakides C Endovenous laser ablation for superficial venous insufficiency Int J Clin Pract. 2008 Apr 12. [Epub ahead of print]

Background: Endovenous laser ablation (EVLA) is a new minimally invasivealternative to conventional surgery for superficial venous insufficiency andvaricose veins, where laser energy is used to ablate the incompetent veins.Discussion: Endovenous laser ablation avoids the need for surgical incisions, andthe complications of surgical exploration of the groin or popliteal fossa, andstripping. The procedure is commonly performed under local anaesthesia, withimmediate mobilisation and rapid return to normal activity. Severe varicosity of tributaries may require adjunctive procedures such as microphlebectomy orsclerotherapy. Conclusion: Early outcomes and cosmesis are superior, andlong-term data is accumulating that recurrence of EVLA rates may be lower.

Yildirim E, Saba T, Ozulku M, Harman A, Aytekin C, Boyvat FTreatment of an Unusual Complication of Endovenous Laser Therapy: Multiple Small Arteriovenous Fistulas Causing Complete RecanalizationCardiovasc Intervent Radiol. 2008 May 28. [Epub ahead of print]

A 67-year-old woman was admitted to our institution with pain, night cramping,and visible varicose veins on her left leg. Doppler ultrasonography revealedcontinuous reflux in the great saphenous vein when the patient did the Valsalvamaneuver. Endovenous laser therapy was applied to the great saphenous vein.Doppler ultrasonography 7 days later showed recanalization of, and arterializedflow in, the great saphenous vein. There also were small arterial vessels adjunctto the recanalized side. A left femoral angiography via a right femoral approach showed multiple small arteriovenous fistulas between superficial femoral arterymuscle branches and the great saphenous vein. A second endovenous laser treatmentwas done at 80 J/cm, but the recanalization persisted. We offered to treat thisendovascularly, but the patient preferred a surgical option. To the best of ourknowledge, this is the first report of the demonstration of such a complicationwith endovenous laser therapy.

Theivacumar NS, Dellagrammaticas D, Mavor AI, Gough MJEndovenous laser ablation: does standard above-knee great saphenous vein ablationprovide optimum results in patients with both above- and below-knee reflux? Arandomized controlled trialJ Vasc Surg. 2008 Jul;48(1):173-8. Epub 2008 Apr 28

BACKGROUND: Following above-knee (AK) great saphenous vein (GSV) endovenous laserablation (EVLA) 40% to 50% patients have residual varicosities. This randomizedcontrolled trial (RCT) assesses whether more extensive GSV ablation enhancestheir resolution and influences symptom improvement. METHOD: Sixty-eight limbs(65 patients) with varicosities and above and below-knee GSV reflux wererandomized to Group A: AK-EVLA (n = 23); Group B: EVLA mid-calf to groin (n =23); and Group C: AK-EVLA, concomitant below-knee GSV foam sclerotherapy (n =22). Primary outcomes were residual varicosities requiring sclerotherapy (6weeks), improvement in Aberdeen varicose vein severity scores (AVVSS, 12 weeks), patient satisfaction, and complication rates. RESULTS: EVLA ablated the treatedGSV in all limbs. Sclerotherapy requirements were Group A: 14/23 (61%); Group B: 4/23 (17%); and Group C: 8/22 (36%); chi2 = 9.3 (2 df) P = .01 with P(A-B) =

0.006; P(B-C) = 0.19; P(A-C) = 0.14. AVVSS scores improved in all groups asfollows: A: 14.8 (9.3-22.6) to 6.4 (3.2-9.1), (P < .001); B: 15.8 (10.2-24.5) to 2.5 (1.1-3.7), (P < .001); and C: 15.1 (9.0-23.1) to 4.1 (2.3-6.8), (P < .001)and P(A-B) = 0.011, P(A -C) = 0.042. Patient satisfaction was highest in Group B.BK-EVLA was not associated with saphenous nerve injury. CONCLUSIONS: ExtendedEVLA is safe, increases spontaneous resolution of varicosities, and has a greaterimpact on symptom reduction. Similar benefits occurred after concomitant BK-GSVfoam sclerotherapy.

Disselhoff BC, Rem AI, Verdaasdonk RM, Kinderen DJ, Moll FLEndovenous laser ablation: an experimental study on the mechanism of actionPhlebology. 2008;23(2):69-76

OBJECTIVES: The aim of this experimental study was to investigate the mechanismof action of endovenous laser ablation (EVLA) using an 810-nm diode laser.METHODS: We compared intermittent and continuous delivery of laser energy andstudied the absorption of laser light by blood, intravascular temperatures in ex vivo human vein segments using an intravascular thermography catheter and heatdissipation in a model tissue using the Schlieren technique. RESULTS: Laser lightis absorbed by blood and converted to heat leading to coagulation, vaporizationand carbonization, and forming an isolating layer at the fibre tip. Laser energy is then absorbed into the isolating layer forming black patches that burned onthe laser fibre. Intravascular temperature increased rapidly above carbonization temperatures (300 degrees C) after the fibre tip reached the thermocouple, stayedat this temperature for a few seconds and decreased gradually to around 30degrees C, 10 s after the fibre tip passed the thermocouple. Schlieren techniquesrevealed that heat spread from the laser was locally distributed and closelyaround the laser fibre tip while heat dissipation is minimal and comparable forboth exposures. Compared with intermittent exposure, continuous exposure results in more carbonization, higher mean maximum intravascular temperature (128 +/- 7vs. 75 +/- 4 degrees C), and long-lasting temperature of 100 degrees C (1.2 +/-0.4 vs. 0.1 +/- 0.1 s). CONCLUSION: In this experimental study, application ofendovenous laser shows to be dominated by carbonization at the fibre tip.Although intraluminal laser-induced heat was heterogeneously distributed, withlaser tip temperatures up to 1200 degrees C, heat dissipation was minimal.Continuous exposure of laser light appears to be better suited in EVLA thanintermittent.

Nwaejike N, Srodon PD, Kyriakides CEndovenous Laser Ablation for Short Saphenous Vein IncompetenceAnn Vasc Surg. 2008 Jul 9. [Epub ahead of print]

Conventional surgery for short saphenous vein (SSV) incompetence has a highincidence of recurrence and is associated with neurovascular injury. The aim ofthis study was to evaluate the safety and efficacy of endovenous laser ablation(EVLA) as an alternative to open surgery for SSV incompetence. Data wereprospectively collected for all patients undergoing EVLA for SSV disease in ourunit, including clinical outcomes and postoperative duplex. There were 368 EVLAprocedures performed from April 2004 through December 2007, of which 66 (18%)were for SSV incompetence. Six (9%) SSV procedures were for recurrent diseaseafter conventional surgery. Forty (61%) procedures were performed under localanesthesia, including four patients who underwent bilateral procedures at thesame session. There were no intraoperative complications, and there was noevidence of neurovascular injury. During a median follow-up of 14 months(interquartile range 6-24) there was no clinical or duplex evidence of recurrenceand no recanalization of the SSV. Our early results suggest that EVLA is a safealternative to conventional surgery for the treatment of SSV incompetence inpatients with C2-C4 disease. Bilateral procedures have been performed under local

anesthesia.

Gonzalez-Zeh R, Armisen R, Barahona SEndovenous laser and echo-guided foam ablation in great saphenous vein reflux:one year follow up resultsJ Vasc Surg. 2008 Jul 17. [Epub ahead of print]

BACKGROUND: Great saphenous vein (GSV) reflux is the most frequent form of venousinsufficiency in symptomatic patients and is commonly responsible for varicoseveins of the lower extremity. This non-randomized prospective controlled studywas designed to test the hypothesis that 1) endovenous laser treatment is moreeffective than foam sclerotherapy in the closure of the refluxing GSV (asmeasured by degree of great saphenous vein reflux and venous clinical severityscore changes) and 2) to record the associated complications of echo-guidedendovenous chemical ablation with foam and endovenous laser therapy for thetreatment of great saphenous vein reflux and to further identify risk factorsassociated with treatment failure. METHODS: Between January 1, 2006 and June 25, 2006, patients seeking treatment of varicose veins at a private practice ofvascular medicine were assessed for the study. Inclusion criteria were: 1)presence of great saphenous vein reflux and 2) C2-6, Epr, A s, according to theCEAP classification. The selected patients consented into the study and wereallowed to choose between foam (53 patients) or laser (45 patients) treatment.Duplex examinations were performed prior to treatment and at seven and 14 days,four weeks, six months, and one year after treatment. Venous clinical severityscore was assessed pre-treatment and at one year post-procedure. RESULTS: Thecohorts showed no statistically significant differences in age, sex, clinical andanatomical presentation, great saphenous vein diameter, and venous clinicalseverity score before the treatments. After one year follow up, occlusion of the great saphenous vein was confirmed in 93.4% (42/45) of limbs studied in the lasergroup and 77.4% (41/53) of limbs in the foam group (P < .0465). Venous clinicalseverity score significantly improved in both groups (P < .0001). Procedureassociated pain was higher in the laser group (P < .0082). Induration, phlebitis,and ecchymosis were the most common complications. Logistical regression andsubgroups analysis shown that a larger great saphenous vein diameter measuredbefore treatment was associated with treatment failure in the foam (odds ratio1.68, 95% CI 1.24-2.27, P < .0008) and in the laser group (odds ratio 1.91, 95%CI 1.02-3.59, P < .0428). A 90% treatment success is predicted for veins <6.5 mm in the foam group versus veins <12 mm in the laser group. CONCLUSIONS: Overall,endovenous laser ablation achieved higher occlusion rates than echo-guidedchemical ablation with foam after one year follow-up. Matching the patient to thetechnique based on great saphenous vein diameter measured before treatment mayassist in boosting the treatment success rate to >90%. A larger patient cohortfollowed and compared over a longer period of time would be required to confirmthese findings.

Hayes CA, Kingsley JR, Hamby KR, Carlow JThe effect of endovenous laser ablation on restless legs syndromePhlebology. 2008;23(3):112-7

OBJECTIVES: Venous disease was proposed as a cause of restless legs syndrome(RLS) by Dr Karl A Ekbom in 1944, but has since remained largely unexplored. Thisstudy examines the effect of endovenous laser ablation (ELA) in patients withconcurrent RLS and duplex-proven superficial venous insufficiency (SVI). METHODS:Thirty-five patients with moderate to very severe RLS (as defined by the 2003National Institute of Health (NIH) RLS criteria) and duplex-proven SVI completed an international RLS rating scale questionnaire (IRLS) and underwent standardduplex examination to objectively measure the baseline severity of theirconditions. They were separated into non-operative and operative cohorts. The

operative cohort underwent ELA of refluxing superficial axial veins using theCoolTouch CTEV 1320 nm laser and ultrasound-guided sclerotherapy of theassociated varicose veins with foamed sodium tetradecyl sulphate (STS). Allpatients then completed a follow-up IRLS questionnaire. Baseline and follow-upIRLS scores were compared. RESULTS: Operative correction of the SVI decreased themean IRLS score by 21.4 points from 26.9 to 5.5, corresponding to an average of80% improvement in symptoms. A total of 89% of patients enjoyed a decrease intheir score of > or =15 points. Fifty-three percent of patients had a follow-upscore of < or =5, indicating their symptoms had been largely alleviated and 31%had a follow-up score of zero, indicating a complete relief of RLS symptoms.CONCLUSIONS: ELA of refluxing axial veins with the CTEV 1320 nm laser and foamed STS sclerotherapy of associated varicosities alleviates RLS symptoms in patients with SVI and moderate to very severe RLS. RECOMMENDATIONS: SVI should beruled-out in all patients with RLS before initiation or continuation of drugtherapy.

Theivacumar NS, Dellagrammaticas D, Darwood RJ, Mavor AI, Gough MJ Fate of the great saphenous vein following endovenous laser ablation: doesre-canalisation mean recurrence?Eur J Vasc Endovasc Surg. 2008 Aug;36(2):211-5. Epub 2008 May 13

OBJECTIVE: To assess changes in great saphenous vein (GSV) diameter and thesignificance of re-canalisation following endovenous laser ablation (EVLA).DESIGN: Prospective cohort study. METHODS: Two groups were studied. Group A: 73consecutive patients (84 GSVs) underwent EVLA followed by duplex ultrasound at 6,12 and 52 weeks. Vein diameter and patency were recorded. Group B: From aprospectively maintained database 27 patients with a GSV that was found to haverecanalised 6-12 weeks post-EVLA were identified and rescanned at 52 weeks. Pre- and post-treatment Aberdeen varicose vein severity scores (AVVSS) were measured. RESULTS: Group A: 81/84 (96%) GSVs were ablated and 3/84 (4%) had re-canalised(flash reflux <1s). GSV diameter diminished with time: pre-EVLA: mean diameter7.7 S.D .2.0mm; 6 weeks: 5.1 S.D. 1.3mm; 12 weeks: 3.2 S.D. 1.2; 52 weeks: 85%non-visible (p<0.001). Group B: 3/27 (11%) with reflux >1s underwent repeat EVLA.16/27 (59%) remained competent at 52 weeks and 8/27 (30%) showed trickle reflux. Vein diameter decreased in both subgroups (mean diameter 7.3 S.D. 2.5mm to 3.1S.D. 0.8mm (p=0.006) and 7.2 S.D. 2.3mm to 3.0 S.D. 0.7mm (p=0.009) respectively)as did the AVVSS (p<0.001). CONCLUSIONS: Successful EVLA causes GSV shrinkagewith transition from a non-compressible "thrombosed" vein to a non-visible veinby 1 year. A re-canalised GSV usually remains small with no/minimal reflux andpersisting clinical benefit.

Marston WA, Brabham VW, Mendes R, Berndt D, Weiner M, Keagy BThe importance of deep venous reflux velocity as a determinant of outcome inpatients with combined superficial and deep venous reflux treated with endovenoussaphenous ablationJ Vasc Surg. 2008 Aug;48(2):400-5; discussion 405-6

INTRODUCTION: Twenty to thirty percent of patients with symptomatic chronicvenous insufficiency (CVI) are found to have combined superficial and deep venousreflux on duplex testing. It is currently unclear whether endovenous ablation(EVA) of the saphenous vein will result in correction of CVI without addressingthe deep venous reflux. In this study, we examined deep venous reflux velocities to determine whether these would predict outcome after endovenous ablation.METHODS: Patients with symptomatic CVI and both saphenous and deep venous reflux were identified using duplex ultrasonography. Reflux times and maximal refluxvelocity (MRV) in each examined vein segment were determined. In each limb, thevenous filling index (VFI) and the venous clinical severity score (VCSS) wereobtained both before and after laser ablation of the great and/or small saphenous

veins. Preoperative venous reflux velocities were correlated with improvement in VFI and VCSS after ablation. RESULTS: 75 limbs with both deep and superficialvenous reflux were identified. Seventy-five percent of limbs were CEAP clinicalclass 3 or 4 and the other 25% were class 5 or 6. Forty limbs demonstrated deepvenous reflux in the femoral and/or popliteal vein. After EVA, significantimprovements in VFI and VCSS were seen, but this depended on MRV in the deepvein. When MRV in the popliteal or femoral vein was <10 cm/sec, limbs hadsignificantly better outcomes than limbs with MRV >10 cm/sec as measured by both VFI (P = .01) and VCSS (P = .03). In 35 limbs, deep venous reflux was identified only in the CFV. In this group, the average pre-procedure VFI (6.54 +/- 3.9cc/sec) decreased significantly to 2.2 +/- 1.9 cc/sec (P < .001) and the VCSSimproved markedly from 7.0 +/- 2.8 to 1.3 +/- 1.4 (P < .001). CONCLUSIONS: EVA ofthe saphenous veins can be performed in patients with concomitant deep venousinsufficiency with hemodynamic and clinical improvement in most cases. Patientswith popliteal or femoral reflux velocities lower than 10 cm/sec usuallyexperience marked improvement in both the VFI and the VCSS. Patients with femoralor popliteal reflux velocities greater than 10 cm/sec have a high incidence ofpersistent symptoms after EVA.

Pleister I, Evans J, Vaccaro PS, Satiani BNatural history of the great saphenous vein stump following endovenous lasertherapyVasc Endovascular Surg. 2008 Aug-Sep;42(4):348-51. Epub 2008 May 16

BACKGROUND: Little is known about the ideal residual length of the greatsaphenous vein (GSV) stump and its potential role in complications such as acute deep venous thrombosis (DVT) and recanalization. This study was designed to learnabout the natural history of the residual GSV stump length following endovenouslaser treatment. METHODS: Prospective data were collected from 50 limbs of 50patients over an 11-month period. Clinical assessment and duplex ultrasound were performed preoperatively, at 24 hours and at 3 months after the procedure.RESULTS: The residual GSV stump decreased in length from a mean of 15 mm at 24hours to 13 mm at 3 months after the procedure. None of the patients developedacute DVT or proximal recanalization when the laser tip was positioned 28 mmdistal to the saphenofemoral junction. CONCLUSION: Endovenous laser therapy ofthe GSV for symptomatic reflux is safe and effective. The residual GSV stumpdecreased in length over a 3-month period.

Kim HK, Kim HJ, Shim JH, Baek MJ, Sohn YS, Choi YHEndovenous Lasering Versus Ambulatory Phlebectomy of Varicose Tributaries inConjunction with Endovenous Laser Treatment of the Great or Small Saphenous VeinAnn Vasc Surg. 2008 Aug 4. [Epub ahead of print]

Endovenous laser treatment (EVLT) is a widely used minimally invasive alternativeto stripping of varicose veins involving the great and small saphenous veins. We expanded the applications to tributary varicosities and compared EVLT alone with combined EVLT and ambulatory phlebectomy. The study included 132 patients (76males, 56 females) who were treated with EVLT and ambulatory phlebectomy. Inaddition, 133 patients (67 males, 66 females) were treated only with EVLT.Perforating vein reflux was identified in 65 patients in the combination group(49.2%) and in 121 patients (91.0%) in the EVLT only group (p= 0.000).Postoperative complications and reoperation rates were compared between the twogroups and the risk factors for reoperation analyzed. Ecchymosis (about 85%) and pain (>20%) were the major postoperative complications for both groups. Therewere no significant differences in the complications noted between thecombination and EVLT only groups. During the follow-up period (25.6+/-12.8months, range 15.5-37.3, in combination group; 11.8+/-8.2 months, range 1.3-18.5,in EVLT only group), residual tributary varicosities were noted in 12 patients

(9.1%) in the combination group and in 11 (8.3%) in the EVLT only group (p=0.813). For patients who had reflux in the perforating veins, the reoperationrate was significantly higher compared to the patients without reflux in theperforating veins in each group (p= 0.015 in combination group, p= 0.006 in EVLT only group). The presence of perforating reflux was a significant risk factor(odds ratio=3.938, 95% confidence interval 1.05-14.78, p= 0.042). EVLT as thesole therapy for the management of combined saphenous and tributary varicoseveins was found to be safe and effective. However, longer follow-up is needed forconfirmation of these findings.

Fernández CF, Roizental M, Carvallo JCombined endovenous laser therapy and microphlebectomy in the treatment ofvaricose veins: Efficacy and complications of a large single-center experience J Vasc Surg. 2008 Aug 7. [Epub ahead of print]

OBJECTIVE: This study evaluated the safety and clinical and anatomiceffectiveness of endovenous laser therapy (EVLT) and microphlebectomy in thetreatment of varicose veins secondary to saphenous reflux. METHODS: From January 1, 2005, to December 31, 2007, 1985 EVLT procedures were performed in 1559eligible patients (1263 women) with a mean age of 52.8 years (range, 18-89years). A 810-nm diode laser and microphlebectomy were used. All sites ofsuperficial axial reflux above and below the knee were ablated. Symptoms ofvenous insufficiency were present in 97%, and 102 patients (6.54%) had an openulcer when they underwent operation. Patients had clinical follow-up visits,including duplex ultrasound examination, at 1 week, 1 month, 3 months, and yearlyand were assessed for deep venous thrombosis (DVT), recanalization of the ablatedvein, nerve injury, ulcer healing, and resolution of symptoms. RESULTS: A totalof 1652 great saphenous veins (83.22%), 285 small saphenous veins (14.36%), 40anterolateral tributaries (2.02%), and 8 posteromedial tributaries (0.40%) wereablated. An average of 19 phlebectomies were performed per case treated (range,1-58). The primary ablation rate at 15 and 30 months was 91.26% and 78.25% byKaplan-Meier analysis. Recanalization occurred in 35 veins (1.76%); in thisgroup, 15 (42.9%) exhibited symptoms of venous insufficiency and weresuccessfully closed with a second EVLT. Body mass index >30 kg/m(2) and a veindiameter >/=8.5 mm were the only factors predictive of recanalization.Postoperatively, the 102 ulcers showed healing at a mean of 5.2 weeks (range,2-10 weeks), and only three reopened (2.94%). No major complications occurred.Two DVT (0.13%) occurred, but no pulmonary emboli or skin burns. Local transient paresthesia at the ankle and midcalf level occurred in 38 patients (2.43%).CONCLUSIONS: EVLT of all sites of superficial axial reflux above and below theknee and microphlebectomy demonstrated that the combined approach is safe andeffective at eliminating reflux, affording symptomatic relief, and healingulcers. It offers the additional advantage of resolving varicose veins and itscause in just one visit, leading to immediate better cosmetic results.

Van den Bos R, Arends L, Kockaert M, Neumann M, Nijsten TEndovenous therapies of lower extremity varicosities are at least as effective assurgical stripping or foam sclerotherapy: Meta-analysis and meta-regression ofcase series and randomized clinical trialsJ Vasc Surg. 2008 Aug 8. [Epub ahead of print]

BACKGROUND: Minimally invasive techniques such as endovenous laser therapy,radiofrequency ablation, and ultrasound-guided foam sclerotherapy are widely usedin the treatment of lower extremity varicosities. These therapies have not yetbeen compared with surgical ligation and stripping in large randomized clinicaltrials. METHODS: A systematic review of Medline, Cochrane Library, and Cinahl wasperformed to identify studies on the effectiveness of the four therapies up toFebruary 2007. All clinical studies (open, noncomparative, and randomizedclinical trials) that used ultrasound examination as an outcome measure wereincluded. Because observational and randomized clinical trial data were included,both the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) andQuality Of Reporting Of Meta-analyses (QUORUM) guidelines were consulted. Arandom effects meta-analysis was performed, and subgroup analysis andmeta-regression were done to explore sources of between-study variation. RESULTS:Of the 119 retrieved studies, 64 (53.8%) were eligible and assessed 12,320 limbs.Average follow-up was 32.2 months. After 3 years, the estimated pooled successrates (with 95% confidence intervals [CI]) for stripping, foam sclerotherapy,radiofrequency ablation, and laser therapy were about 78% (70%-84%), 77%(69%-84%), 84% (75%-90%), and 94% (87%-98%), respectively. After adjusting forfollow-up, foam therapy and radiofrequency ablation were as effective as surgicalstripping (adjusted odds ratio [AOR], 0.12 [95% CI, -0.61 to 0.85] and 0.43 [95% CI, -0.19 to 1.04], respectively). Endovenous laser therapy was significantlymore effective compared with stripping (AOR, 1.13; 95% CI, 0.40-1.87), foamtherapy (AOR, 1.02; 95% CI, 0.28-1.75), and radiofrequency ablation (AOR, 0.71;95% CI, 0.15-1.27). CONCLUSION: In the absence of large, comparative randomizedclinical trials, the minimally invasive techniques appear to be at least aseffective as surgery in the treatment of lower extremity varicose veins.

Lu X, Ye K, Li W, Lu M, Huang X, Jiang MEndovenous ablation with laser for great saphenous vein insufficiency andtributary varices: a retrospective evaluation J Vasc Surg. 2008 Sep;48(3):675-9. Epub 2008 Jun 30

BACKGROUND: Endovenous laser ablation (EVLA) is a minimally invasive techniquefor treating great saphenous vein (GSV) reflux for several years. We report ourexperience with EVLA and evaluate its effectiveness. METHODS: A consecutiveseries of patients (639 women [60%] and 421 men [40%], age 23 to 79 years) weretreated by EVLA for GSV reflux and tributary varices at our institution. Aquestionnaire was used to assess preoperative and postoperative symptoms. Theprimary outcomes for assessing safety were mortality and morbidity, includinglaser-related adverse events, postoperative infection, thrombotic events, etc.Effectiveness was assessed by the obliteration of the vein, disappearance ofvaricosities, and so on. RESULTS: All patients tolerated the procedure well,recovered uneventfully, and returned to daily activities and work 3 days and 10to 14 days, respectively, after the operation. Treatment with EVLA plus ligation of the GSV resulted in occlusion in all cases at 2 weeks follow-up and in 1169 of1186 (99%) at 6-month follow-up; the rate of retreatment was low (36/1186).Complications were minor and improved quickly. CONCLUSIONS: EVLA can reduce andrelieve symptoms associated with varicose veins and achieve cosmetic goals. Vein emptying before exposure to laser energy and compression treatment afterwards mayimprove results.

Jung IM, Min SI, Heo SC, Ahn YJ, Hwang KT, Chung JKCombined endovenous laser treatment and ambulatory phlebectomy for the treatment of saphenous vein incompetencePhlebology. 2008;23(4):172-7

OBJECTIVES: The aim of this retrospective study is to assess the safety and

effectiveness of endovenous laser treatment (EVLT) combined with ambulatoryphlebectomy (AP) as a single procedure for treating saphenous vein incompetence. METHODS: The study enrolled 148 patients with saphenofemoral or saphenopopliteal junction reflux associated with saphenous vein incompetence and enlarged branchveins. Patients were treated with EVLT (135 great saphenous veins, 41 smallsaphenous veins) concomitantly with AP as a single procedure. All patients werefollowed up by clinical assessment and duplex ultrasound at one week and 12 weeksafter the procedure. RESULTS: No postprocedural deep vein thrombosis andpulmonary embolism occurred. Saphenous vein recanalization rate at three monthswas 5.7%. Residual varicosities were found in 11.4% of the patients at threemonths after procedure, but only 2.3% of those required subsequent interventions.CONCLUSION: Combined EVLT and AP could be a safe and effective treatment modalityfor the saphenous vein incompetence.

Kambal AA, De'ath HD, Albon H, Watson A, Shandall A, Greenstein DEndovenous laser ablation for persistent and recurrent venous ulcers aftervaricose vein surgeryPhlebology. 2008;23(4):193-5

A 75-year-old woman presented with painful recurrent venous ulcers (VU)continuously for the past 33 months on a background of frequent intermittentproblems for the last 16 years. She had previously been treated with varicosevein surgery and trials of compression bandaging. Subsequently, she underwentendovenous laser ablation (EVLA) targeting the distal incompetent remnant of her great and small saphenous veins. This resulted in complete healing of her ulcers within four weeks. The dramatic response demonstrated in this case suggests that EVLA may represent an effective intervention in the management of postsurgeryrefractory VU.

Fan CM, Rox-Anderson REndovenous laser ablation: mechanism of actionPhlebology. 2008;23(5):206-13

OBJECTIVES: The objective of this study is to review the basics of laser andestablished tissue response patterns to thermal injury, with specific referenceto endovenous laser ablation (EVLA). This study also reviews the current theoriesand supporting aspects for the mechanism of action of EVLA in the treatment ofsuperficial venous reflux. METHODS: The method involves the review of publishedliterature and original investigation of histological effects of 810 nm and 980nm wavelength EVLA on explanted blood-filled bovine saphenous vein in an in vitrosystem. RESULTS: The existing histological reports confirm that EVLA produces atransmural vein wall injury, typically associated with perforations andcarbonization. The pattern of injury is eccentrically distributed, with maximuminjury occurring along the path of laser contact. Intravenous temperaturemonitoring studies during EVLA have confirmed that the peak temperatures at thefibre tip exceed 1000 degrees C, and continuous temperatures of at least 300degrees C are maintained in the firing zone for the majority of the procedure.Steam production during EVLA, which occurs early in the photothermolytic process when temperatures reach 100 degrees C, accounts for only 2% of applied energydose, and is therefore unlikely to be the primary mechanism of action of thermal injury during the procedure. CONCLUSION: EVLA causes permanent vein closurethrough a high-temperature photothermolytic process at the point of contactbetween the vein and the laser.

Hogue RS, Schul MW, Dando CF, Erdman BEThe effect of nitroglycerin ointment on great saphenous vein targeted venousaccess site diameter with endovenous laser treatment

Phlebology. 2008;23(5):222-6

OBJECTIVES: To assess the effect of topically applied nitroglycerin (NTG)ointment (2%) on preoperative targeted venous access site great saphenous vein(GSV) diameter in patients undergoing endovenous laser treatment (ELT). METHODS: In this double-blinded randomized study design, 75 patients received either (A)treadmill ambulation only, (B) topically applied NTG ointment only, or (C)topically applied NTG ointment + treadmill ambulation. Targeted venous accessvein diameters were measured before therapeutic intervention and then repeatedafter approximately 30 min following pretreatment intervention. Presence ofvenospasm and the number of ultrasound-guided venous access attempts during each ELT procedure were assessed during the study. RESULTS: The mean pretreatment veindiameter was 2.6 mm (range 0.9-4.9 mm). The post-treatment percentage change invein diameter for group A (treadmill ambulation only) was +2.7% (P = 0.403),whereas group B (NTG only) and group C (NTG + treadmill ambulation) demonstrated significant venodilatation of +69.0% (P < 0.0001) and +51.7% (P < 0.0001),respectively. Statistical analysis of variances and multivariate linearregression model revealed topically applied NTG ointment and 'C' classificationof clinical, aetiological, anatomical and pathological elements (CEAP) were each significant predictors for venodilatation percentage change (P < 0.001 and =0.028, respectively). CONCLUSION: Pretreatment with topically applied NTGointment (2%) produced a statistically significant, as well as subjectiveclinically significant venodilatation change in the targeted venous access sitediameter of patients undergoing ELT of the GSV in this study.

Knipp BS, Blackburn SA, Bloom JR, Fellows E, Laforge W, Pfeifer JR, Williams DM, Wakefield TW; Michigan Venous Study GroupEndovenous laser ablation: Venous outcomes and thrombotic complications areindependent of the presence of deep venous insufficiencyJ Vasc Surg. 2008 Sep 30. [Epub ahead of print]

OBJECTIVE: We hypothesize that endovenous laser ablation (EVA) therapy is equallysuccessful in improving venous insufficiency symptoms in patients with or withoutdeep venous insufficiency (DVI). METHODS: From January 2005 through August 2007, EVA of the great saphenous vein (GSV) was attempted in 364 patients (460 limbs)with symptomatic GSV reflux. The GSV was successfully cannulated and obliterated in all but 17 limbs. EVA was performed alone in 308 limbs (69.5%) and withphlebectomy or perforator ligation (EVAP) in 135 limbs (30.5%). Venous clinicalseverity scores (VCSS) were recorded preoperatively and at 30, 90, 180, and 360days postoperatively. Patients were classified as those with or without DVI basedon duplex imaging valve closure times at the common femoral vein (CFV) andpopliteal vein (PV). In a subset of 181 patients undergoing EVA therapy in theoperating room, perioperative thrombosis prophylaxis was administered based on a risk-stratification protocol. Patients were assessed with direct end points(VCSS) and indirect end points (vein occlusion rates). RESULTS: Successfulperformance of EVA led to complete saphenous vein ablation in 99.8% at 1 monthand 95.9% at 1 year. Median VCSS preoperatively was 6 (interquartile range, 5-8),generally decreasing over all time points to 4 (interquartile range, 2-5) beyond 360 days (P < .001). Male gender was independently associated with greaterimprovement in scores with time (P = .019). Changes in VCSS and duration ofvessel occlusion were equivalent regardless of DVI for both isolated EVA andEVAP. For EVAP, the true deep venous thrombosis (DVT) rate was 2.2%, whereas for isolated EVA, the rate was 0% (P = .028); the rate of saphenofemoral thrombusextension was 5.9% for EVAP vs 7.8% for isolated EVA (P = .554). The use ofrisk-adjusted heparin prophylaxis in patients undergoing EVAP did not have asignificant effect on thrombotic complications. There were no differences in trueDVT, thrombus extension, or superficial thrombophlebitis between patients with orwithout DVI. Performance of concomitant phlebectomy, DVI, gender, and age had no effect on the duration of vessel occlusion. CONCLUSION: EVA produces successful

ablation and is associated with sustained improvement in VCSS. These outcomes areindependent of the presence of DVI. Finally, the use of a risk-adjustedthrombosis prevention protocol had no effect on the rate of superficial thrombus extension from EVA or EVAP in patients undergoing general anesthesia.

Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FLRandomized Clinical Trial Comparing Endovenous Laser Ablation of the GreatSaphenous Vein with and without Ligation of the Sapheno-femoral Junction: 2-year ResultsEur J Vasc Endovasc Surg. 2008 Oct 9. [Epub ahead of print]

OBJECTIVE: To evaluate whether ligation of the sapheno-femoral junction (SFJ)improves the 2-year results of endovenous laser ablation (EVA). METHODS:Forty-three symptomatic patients with bilateral varicose veins were studied inwhich one limb was randomly assigned to receive EVA without SFJ ligation, and theother limb received EVA with SFJ ligation. Recurrence of varicose veins andabolition of great saphenous vein (GSV) reflux on duplex ultrasound imaging, and venous clinical severity score (VCSS) were investigated at 6, 12, and 24 monthsafter treatment. RESULTS: Two-year life table analysis showed freedom from groin varicose vein recurrence in 83% of 43 limbs (95% CI; 67-95%) in the EVA withoutligation group and in 87% of 43 limbs (95%; CI 73-97) of limbs in the EVA withligation group (P=0.47). Thirty-eight (88%) treated GSV segments were ablatedcompletely in the EVA without ligation group and 42 (98%) in the EVA withligation group (N.S.). Groin recurrence was due to an incompetent SFJ/GSV (9%)and to incompetent tributaries (7%) in the EVA without ligation group and due to neovascularisation (12%) in the EVA with ligation group. The VCSS improvedsignificantly and was comparable in both groups. CONCLUSION: The addition of SFJ ligation to EVA makes no difference to the short-term outcome of varicose veinstreatment. Establishing whether SFJ ligation results in a poorer long-termoutcome because of neovascularisation needs to be studied in larger populationswith longer follow-up.

Holdstock JM, Marsh P, Whiteley MS, Price BAIt is possible to cause damage to a laser fibre during delivery of tumescentanaesthesia for endovenous laser ablation (EVLA)Eur J Vasc Endovasc Surg. 2008 Oct;36(4):473-6

AIMS: To establish a possible mechanism of damage to a laser fibre significantenough to cause a retained segment within a patient. METHODS: A 21 G needle wasused to pierce a VARILASE 810 nm Laser Fibre inserted within a 4F sheath. A tiny pin source of light from the aiming beam emerged from the needle hole in thesheath. Using laser protection protocol, the generator was fired for one minuteat 14 Watts (W) continuous wave. The sheath and fibre were then examined. In acontrol experiment, we were unable manually to break a fibre where the coatinghad been damaged prior to the laser being fired. RESULTS: The aiming beam wasnoted to be concentrated at the side of the catheter at the point of needledamage rather than at the fibre tip. When the fibre was removed from the sheaththe distal length, from the point of damage to the tip, was retained within thesheath. Longer firing with the sheath surrounded by a wet towel or a pork loinresulted in complete severance of the sheath and fibre. CONCLUSION: There are no firm manufacturer's guidelines on whether Tumescent Anaesthesia should bedelivered before or after the laser fibre has been inserted into the patient.Some units performing EVLA prefer to do this with the laser fibre in situ as itis easier to image on ultrasound than the sheath alone. The results of thisin-vitro experiment would suggest it is possible to cause sufficient needledamage to fracture a laser fibre when fired. In the interests of safety we would recommend administration of tumescent anaesthesia should always be carried outbefore introduction of the laser fibre.

Prince EA, Ahn SH, Dubel GJ, Soares GMAn investigation of the relationship between energy density and endovenous laser ablation success: does energy density matter?J Vasc Interv Radiol. 2008 Oct;19(10):1449-53. Epub 2008 Aug 29

PURPOSE: To assess the relationship between energy density and the success ofendovenous laser ablation (EVLA) treatment. MATERIALS AND METHODS: A total of 586EVLAs were performed in a period of 35 months. Retrospective chart review wasperformed, and data collected included the patients' age, sex, and history ofvenous stripping procedures, as well as the name, laterality, and length of thetreated vein segment(s) and the total energy delivered. Energy density wascalculated by dividing total energy delivered (in J) by the length of vein (incm). Energy density selection was based on the treating interventionalist'spreference. Ablated segments were grouped into those treated with less than 60J/cm, 60-80 J/cm, 81-100 J/cm, and more than 100 J/cm. Failure of EVLA wasdefined by recanalization of any portion of the treated vein during follow-up as assessed by duplex Doppler ultrasound examination. Failure rates were comparedwith the chi(2) test and Wilcoxon rank-sum test. RESULTS: A total of 471 segmentswere included in the analysis with an average follow-up period of 5 months(range, 0.2-28.7 months). Overall, 11 failures were encountered, including fourin the group treated with less than 60 J/cm (n = 109; 4%), two in the 60-80-J/cm group (n = 77; 3%), four in the 81-100-J/cm group (n = 169; 3%), and one in thegroup treated with more than 100 J/cm (n = 116; 1%). There was no statisticallysignificant difference in failure rates among energy density ranges. CONCLUSION: EVLA has a low failure rate that is not affected by energy density.

Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FLRandomized clinical trial comparing endovenous laser with cryostripping for greatsaphenous varicose veinsBr J Surg. 2008 Oct;95(10):1232-8

BACKGROUND: The aim of this randomized single-centre trial was to compare the2-year results of endovenous laser ablation (EVLA) and cryostripping for varicoseveins. METHODS: A total of 120 patients with uncomplicated great saphenousvaricose veins were randomized equally to one of the two treatments. Principaloutcomes measures were: freedom from recurrent varicose veins on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen VaricoseVein Severity Score (AVVSS) 6, 12 and 24 months after treatment. RESULTS:Life-table analysis showed overall freedom from recurrent incompetence at 2 yearsin 77 (95 per cent confidence interval (c.i.) 72 to 78) per cent of patientsafter EVLA and in 66 (95 per cent c.i. 60 to 67) per cent after cryostripping (P = 0.253). VCSS and AVVSS values improved significantly after treatment, but thedifferences between the treatments were not significant. EVLA providedsignificantly more favourable results than cryostripping with respect to durationof operation, postprocedural pain, induration and resumption of normal activity. CONCLUSION: EVLA and cryostripping were similarly effective in patients withvaricose veins, but patients favoured EVLA because of less pain and postoperativemorbidity, and quicker return to normal activity.

Park SW, Hwang JJ, Yun IJ, Lee SA, Kim JS, Chang SH, Chee HK, Hong SJ, Cha IH,Kim HCEndovenous Laser Ablation of the Incompetent Small Saphenous Vein with a 980-nmDiode Laser: Our Experience with 3Years Follow-upEur J Vasc Endovasc Surg. 2008 Oct 11. [Epub ahead of print]

PURPOSE: To demonstrate the long-term treatment outcomes of endovenous laser

ablation (EVA) of incompetent small saphenous veins (SSV) with a 980-nm diodelaser. MATERIALS AND METHODS: Eighty-four patients (96 limbs), with varicoseveins and reflux in the SSV on duplex ultrasound examination, were treated with a980-nm diode laser under ultrasound- or fluoroscopy-guidance. Patients wereevaluated at 1week and 1, 3, 6months, 1year and yearly thereafter. RESULTS: Inthe 96 limbs, the technical success rate was 100%. The SSV remained closed in 89 of 93 limbs (96%) after 1month, all of 82 limbs after 6months, 77 limbs after1year, 71 limbs after 2years and 55 limbs after 3years. In four limbs whererecanalisation was observed, repeat EVA was done resulting in successfulobliteration of the SSV. No major complication occurred however bruising (27%),tightness or pain (13%) and paraesthesia (4.2%) were observed. CONCLUSION:Endovenous laser ablation with a 980-nm laser wavelength is an easy and safeprocedure in incompetent SSVs. After successful treatment, there is a very lowrate of recanalisation of the SSV, which suggests that the procedure will providelasting results.

Vaz C, Matos A, Oliveira J, Nogueira C, Almeida R, Mendonça MIatrogenic Arteriovenous Fistula Following Endovenous Laser Therapy of the Short Saphenous VeinAnn Vasc Surg. 2008 Oct 28. [Epub ahead of print]

Short saphenous vein incompetence is present in up to 20% of patients withvaricose veins. Studies looking at the success and complication rates associated with endovenous laser ablation of the short saphenous vein included only a small number of patients. The authors report the case of a 51-year-old woman presentingwith a painful right leg edema. She had a history of previous endovenous laserablation of the right and left great saphenous veins and right short saphenousvein. Duplex scan was performed and showed an arteriovenous fistula betweenbranches of the popliteal artery and vein. Surgical ligation of the fistula wasperformed. At 8-month follow-up, the patient remains asymptomatic.

Eidson JL 3rd, Shepherd LG, Bush RLAneurysmal dilatation of the great saphenous vein stump after endovenous laserablation.J Vasc Surg. 2008 Oct;48(4):1037-9

Endoluminal ablation either by laser or radiofrequency energy of the greatsaphenous vein has become the standard therapy for varicose veins caused by greatsaphenous vein insufficiency. The rapid recovery time and low complicationprofile are both reasons practitioners and patients choose this treatmentmodality. Complications are rare and are usually minor. This report presents apatient who presented with aneurysmal dilatation of the saphenous vein remnant,with evidence of an arteriovenous fistula, 15 months after endovenous lasertherapy. The abnormality was surgically resected and the fistula successfullyligated. This may be the first report of the formation and treatment of a venous aneurysm with arteriovenous fistula involving the great saphenous vein stumpafter endovenous laser therapy.

Myers KA, Jolley DOutcome of endovenous laser therapy for saphenous reflux and varicose veins:medium-term results assessed by ultrasound surveillanceEur J Vasc Endovasc Surg. 2009 Feb;37(2):239-45. Epub 2008 Nov 6

OBJECTIVE: To assess the efficacy of endovenous laser therapy (EVLT) for treatingsaphenous reflux associated with varicose veins. DESIGN: Out-patient treatment by

EVLT with an 810nm laser wavelength with results assessed by ultrasoundsurveillance. PATIENTS: 361 patients who received EVLT for 509 incompetentsaphenous veins over a five-year period. METHODS: EVLT was used for proximalsaphenous veins and ultrasound-guided sclerotherapy (UGS) for distal saphenousveins and tributaries. Control of reflux and occlusion or obliteration of thesaphenous veins was assessed by serial ultrasound studies. UnivariateKaplan-Meier life table analysis showed cumulative primary and secondary success rates, and multivariate Cox regression analysis assessed covariates that could beassociated with increased risk of ultrasound failure. RESULTS: Life tableanalysis showed primary success at four years in 76% (95% CI 56-87%) andsecondary success at four years after further treatment of recurrence by UGS in97% (95% CI 93-99%). Cox regression analysis showed a non-significant trendtowards worse primary success in male patients and worse results for olderpatients and limbs with clinical CEAP categories C4-6. Cox regression showedsignificantly worse secondary success for limbs with clinical CEAP C4-6.CONCLUSIONS: EVLT effectively controls saphenous reflux particularly withultrasound surveillance to detect early recurrence that can be treated by UGS.Modifications in technique may be required to improve the late primary successrate.

Bush RG, Shamma HN, Hammond KHistological changes occurring after endoluminal ablation with two diode lasers(940 and 1319 nm) from acute changes to 4 monthsLasers Surg Med. 2008 Dec;40(10):676-9

BACKGROUND: Endovenous laser ablation of the saphenous vein was studied from ahistologic analysis to establish changes that occur from time of injury to 4months when the vein is difficult to visualize by ultrasound. METHODS:Twenty-four patients were examined after treatment with either a 1319 nm diodelaser (Sciton, Palo Alto, CA) or a 940 nm diode (Dornier, Kennasaw, GA) 12patients were randomly assigned to the 940 nm group and 12 patients to the 1319nm group. Histologic evaluations were only done once per patient. All patientshad symptomatic saphenous insufficiency with varicosities. All were in CEAP class3 or 4. Sections of treated veins were submitted for evaluation after stainingwith hematoxylin-eosin. The evaluations were done acutely, at 1 and 4 months.Ultrasound findings were also evaluated and compared at the same intervals.RESULTS: Acutely, all examined veins revealed loss of intima. In the 1319 nmgroup numerous vacuoles were present in the subintimal layer. On gross exam at 1 month, both groups showed vein wall thickening, intraluminal thrombus andinflammatory changes. Histologic evaluation showed thrombus was present with manyfibroblasts and inflammatory cells. At 4 months, collagen was the predominanthistologic finding. However, the changes were less in regards to the injuryresponse with the 1,319 nm group as manifested by less collagen deposition at 4months. CONCLUSION: This study demonstrates the cellular sequence that occursafter endovenous ablation. Fibroblast infiltration is a result of the injuryresponse which leads to negative modeling of the thrombus and eventual collagendeposition. Replacement of the thrombus with collagen is necessary for eventuallong-term success.

Pannier F, Rabe EMid-term results following endovenous laser ablation (EVLA) of saphenous veinswith a 980 nm diode laserInt Angiol. 2008 Dec;27(6):475-81

AIM: To assess the mid-term results after endovenous laser ablation (EVLA) ofsaphenous veins by a standardized duplex and clinical protocol. METHODS: A

non-randomized prospective trial was performed. We included a total of 67unselected legs of 65 patients with incompetent great or small saphenous veins(GSV and SSV), confirmed by duplex ultrasound. EVLA was carried out with a 980 nmdiode laser in pulsed mode and using tumescent local anaesthesia. All patientswere given heparin prophylaxis and compression therapy. Patients underwentstandard clinical and duplex follow-up examinations with an average of 2.2 years (0.5-3.5 years) after EVLA. RESULTS: Reflux was eliminated in 59 (88.1%) of the67 treated veins after 2.2 (SD 0.9) years with an average energy density of 48J/cm vein (19.8-96.1, SD 13.2). 11.9% of the cases demonstrated antegrade flowwithout reflux. In 8 of 67 treated legs (11.9%) reflux >0.5 s was still present. In these patients the initial vein diameter was significantly (P=0.01) higherthan in the successfully treated limbs. Without reflux, the majority of treatedveins, 41 of 59 (69.5%), were no longer detectable by ultrasound. In all groupswith still visible veins, there was a diameter reduction of about 50%. Clinicalclassification (CEAP) and pitting edema similarly improved in all groups, andpatient satisfaction was very high across the board. Recurrent varicose veinswere significantly more frequent in the reflux group. Severe complications suchas deep vein thrombosis or pulmonary embolism did not occur in any of the 67treated cases. CONCLUSIONS: EVLA of the GSV and SSV is a minimally invasive, safeand efficient treatment option with a high mid-term success rate. Not onlystandardized duplex, but also clinical criteria should be used in assessing the results.

Zafarghandi MR, Akhlaghpour S, Mohammadi H, Abbasi Endovenous Laser Ablation (EVLA) in Patients With Varicose Great Saphenous Vein(GSV) and Incompetent Saphenofemoral Junction (SFJ): An Ambulatory Single Center ExperienceA Vasc Endovascular Surg. 2008 Dec 16. [Epub ahead of print]

Objectives: To evaluate treatment results for varicose great saphenous vein (GSV)using endovenous laser ablation (EVLA) in an ambulatory single center.Materialand methods: We prospectively studied 77 limbs with varicose GSV in 74 patientswho were treated using 980-nm EVL with a 600-microm laser fiber and the powersettings of 10-25 Watts. The patients were followed using color Dopplerultrasound.Results: Continued closure of treated GSV was found in 98.3% of thelegs evaluated at 3-week follow-up (n = 60). At 3- and 6-month intervals, 94.1%and 97% successful occlusion was achieved, respectively. The main complicationsof the procedure included prolonged leg pain (2 cases), hyperestheasia (one case)and lidocaine sensitivity (one case).Conclusion: EVLA treatment of the GSV is asafe and highly effective method accompanied with few complications in midtermfollow-up. It is feasible in ambulatory settings and the patients return to theirdaily activities early after intervention.

Disselhoff BC, Buskens E, Kelder JC, der Kinderen DJ, Moll FLRandomised Comparison of Costs and Cost-Effectiveness of Cryostripping andEndovenous Laser Ablation for Varicose Veins: 2-Year ResultsEur J Vasc Endovasc Surg. 2008 Dec 24. [Epub ahead of print]

BACKGROUND: Although endovenous laser ablation for varicose veins is replacingsurgical stripping, proper economic evaluation with adequate follow-up in arandomised clinical trial is important for considered policy decisions regarding the implementation of new techniques. METHODS: Data from a randomised controlled trial comparing cryostripping and endovenous laser ablation in 120 patients were combined to study Short Form (SF) 6D outcome, costs and cost-effectiveness 2years after treatment. Incremental cost per quality-adjusted life year (QALY)gained 2 years after treatment was calculated using different strategies, anduncertainty was assessed with bootstrapping. RESULTS: Over the total studyperiod, mean SF-6D scores improved slightly from 0.78 at baseline to 0.80 at 2years for patients who underwent cryostripping and from 0.77 to 0.79 for patients

who underwent endovenous laser. QALY (SF-6D) was 1.59 in patients who underwentcryostripping and 1.60 in patients who underwent endovenous laser 2 years aftertreatment. The costs of cryostripping and endovenous laser per patient wereeuro2651 and euro2783, respectively. Bootstrapping indicated that cryostrippingwas associated with an incremental cost-effectiveness ratio of euro32 per QALYgained. With regard to different strategies, outpatient cryostripping was lesscostly and more effective 2 years after treatment. CONCLUSION: In this study, in terms of costs per QALY gained, outpatient cryostripping appeared to be thedominant strategy, but endovenous laser yielded comparable outcomes for arelatively little additional cost.

Hoggan BL, Cameron AL, Maddern GJ Systematic Review of Endovenous Laser Therapy Versus Surgery for the Treatment ofSaphenous Varicose VeinsAnn Vasc Surg. 2009 Jan 5. [Epub ahead of print]

This systematic review compares the safety and efficacy of endovenous lasertherapy (ELT) and surgery involving saphenous ligation and stripping astreatments for varicose veins. Systematic searches of medical bibliographicdatabases, the Internet and lists of references were conducted in August 2007 andApril 2008 to identify relevant primary studies. Inclusion of papers was resolvedthrough application of a predetermined protocol. Information on the safety andeffectiveness of ELT and surgery was analyzed. Fifty-nine studies were included, with seven studies directly comparing ELT with surgery. Serious adverse eventsafter ELT or surgery were rare. While occurrence rates of some minor adverseevents appeared higher after ELT in collated data, comparative studies commonlyfavored ELT over surgery. Few differences were apparent between treatments withrespect to clinical effectiveness outcomes, although long-term follow-up waslacking. Nonclinical effectiveness outcomes generally favored ELT over surgery inthe first 2 months after treatment. ELT appears to be at least as safe assurgery. While ELT offers short-term benefits and appears to be as clinicallyeffective as surgery up to 12 months after treatment, clinical trials with aminimum of 3 years of follow-up are required to establish the enduringeffectiveness of ELT.

Theivacumar NS, Darwood RJ, Dellegrammaticas D, Mavor AI, Gough MJ The clinical significance of below-knee great saphenous vein reflux followingendovenous laser ablation of above-knee great saphenous vein Phlebology. 2009;24(1):17-20

AIMS: The standard technique for endovenous laser ablation (EVLA) for varicoseveins due to great saphenous vein (GSV) reflux involves obliteration of theabove-knee (AK) GSV. This study assesses the significance of persistentbelow-knee (BK) GSV reflux following such therapy. METHODS: Sixty-nine limbs (64 patients) with varicosities and GSV reflux underwent AK-EVLA. Post treatment, GSVreflux (ultrasound: six, 12 weeks) and Aberdeen varicose vein severity scores(AVVSS, 12 weeks) were assessed, and residual varicosities treated with foamsclerotherapy (six weeks). RESULTS: The untreated BK-GSV remained patent in alllimbs. Ultrasound showed normal antegrade flow in 34/69 (49%, Group A), flashreflux <1 s in 7/69 (10%, Group B) and >1 s reflux in 28/69 (41%, Group C).Although AVVSS improved in all groups (P < 0.001): A: 14.6 (8.4-19.3) versus 2.8 (0.5-4.4), B: 13.9 (7.5-20.1) versus 3.7 (2.1-6.8), C: 15.1 (8.9-22.5) versus 8.1(5.3-12.6) the improvement was less in Group C (P < 0.001 versus A and B) and wasassociated with a greater requirement (A: 4/34 [12%]; B: 1/7 [14%]; C: 25/28[89%]) for sclerotherapy (persisting varicosities) (P < 0.001). CONCLUSION:Although AK-GSV EVLA improves symptoms regardless of persisting BK reflux, thelatter appears responsible for residual symptoms and a greater need forsclerotherapy for residual varicosities.

Pannier F, Rabe E, Maurins UFirst results with a new 1470-nm diode laser for endovenous ablation ofincompetent saphenous veinsPhlebology. 2009 Feb;24(1):26-30

INTRODUCTION: Most of the published EVLA data concern 810, 940, 980 nm diodelasers and 1064 or 1320 nm Nd:Yag laser systems. Major side effects arepostoperative pain and bruising. The aim of this study was to show the outcomeone year after EVLA of incompetent saphenous veins with a 1470 nm Diode laser(Ceralas E, biolitec). Patients and method Between December 2006 and February2007, 134 saphenous veins (108 GSV, 26 SSV) in 117 legs of 100 consecutivepatients where treated by EVLA for GSV and SSV incompetence. All patients wereexamined clinically and with duplex by an experienced phlebologist prior tointervention, and at the follow-up visits for complications, occlusion, flow and reflux in the treated vein segment. The clinical evaluation included clinicalCEAP and the presence of recurrent varicose veins. Patient satisfaction wasassessed by a 0 to 4 scale. RESULTS: After a mean follow-up period of 184 days(SD 27) 127 treated veins (102 GSV, 25 SSV) of 111 limbs in 94 patients and after329 days (SD 14) 105 treated veins (94 GSV, 21 SSV) of 105 limbs in 83 patientswere reinvestigated. Six patients were lost to follow up after six months and an additional 11 patients after one year. Up to one year follow-up all treated veinsremained occluded. At six months, one new insufficient anterior accessorysaphenous vein (AASV) and after 12 months, three new insufficient AASV occurred. After one year 45 patients were very satisfied with the method, 34 weresatisfied, three were fairly and one was not satisfied. The mean of all answerswas 0.5 (SD 0.5). In three cases phlebitic reactions after 10 days, but no severecomplications such as deep vein thrombosis occured. After six months in 9.5% ofthe legs paresthesia was present in the treated area which reduced to 7.6% after one year. Intake of painkillers was mean 6.7 tablets (SD 3.5). When we comparedGSV legs treated with LEED below or above 100 J/cm, the paresthesia rate wassignificantly lower in the first group with 2.3% compared to 15.5 % in the higherLEED group. The differences for number of days with analgesic intake and for the paraesthetic area were significant. Discussion In this prospective follow-upstudy with 100 consecutive patients and 134 treated saphenous veins a highocclusion rate of 100% could be demonstrated one year after treatment. However,with LEED > 100 J/cm in this study, the incidence of paresthesia rosesignificantly. Therefore it seems adequate to stay below 100 J/cm in the futureas the occlusion rate was the same below and above 100 J/cm. CONCLUSION: EVLA of GSV and SSV with a 1470 nm diode laser is a minimally invasive, safe andefficient therapy option with a high success rate.

Maurins U, Rabe E, Pannier F Does laser power influence the results of endovenous laser ablation (EVLA) ofincompetent saphenous veins with the 1 470-nm diode laser? A prospectiverandomized study comparing 15 and 25 WInt Angiol. 2009 Feb;28(1):32-7

AIM: Major side effects after endovenous laser ablation (EVLA) are pain andbruising. The aim of this study was to compare outcome and side effects afterEVLA of incompetent great saphenous veins (GSV) with a 1 470 nm diode laser(Ceralas E, biolitec) using a power of 15 or 25 W. METHODS: Between 28 November2007 and 15 January 2008, 40 consecutive patients (40 legs) with an incompetentGSV were treated by EVLA. The patients were randomized in two groups. In Group A (20 patients) was used a 15-W-power laser and in Group B (20 patients) a25-W-power laser was used. All patients were re-examined after 1, 10 and 30 days clinically and by Duplex for complications and occlusion in the treated veinsegment in a standardized way. RESULTS: There was no significant difference

concerning gender, age, C of CEAP, body mass index or diameter of the treatedvein. In Group A a mean of 465 mL tumescence fluid (TF) was used and in Group BTF was of 433 mL. In Group A the mean linear endovenous energy density (LEED) was109.7 J/cm and in Group B 132.6 J/cm. The subgroup Bsub included 16 patients ofGroup B with a comparable mean LEED of 115.8 J/cm. In all groups occlusion of thetreated veins was achieved for all patients. The diameter of the GSV reduced at 3cm below the sapheno-femoral junction from 1.1 to 0.6 cm, 1.0 to 0.6 cm and 0.9to 0.6 cm respectively in the three groups. The modified CEAP clinical scoreimproved significantly in all groups. In Group A patients have been administered analgesic tablets for a shorter period. There was also a trend to lesspostinterventional pain and analgesic use in Group A, but it was not significant.Ecchymosis was rare in both groups (8 in Group A, 7 in Group B). CONCLUSIONS: In this prospective randomized comparative study the power of the laser did notinfluence the occlusion rate when a high LEED with comparable values was used. Inboth groups pain and ecchymoses were less frequent in this study with a 1 470 nm diode laser than reported in studies with 810-980 nm systems. A lower power levelsignificantly reduced use of analgesic tablets.

Ho P, Poon JT, Cho SY, Cheung G, Tam YF, Yuen WK, Cheng SW Day surgery varicose vein treatment using endovenous laser Hong Kong Med J. 2009 Feb;15(1):39-43

OBJECTIVE. To examine the safety and efficacy of endovenous laser obliteration totreat varicose vein in a day surgery setting, using sedation and localanaesthesia. DESIGN. Prospective study. SETTING. Day surgery centre in a regionalhospital in Hong Kong. PATIENTS. A total of 24 patients with duplex-confirmedlong saphenous vein insufficiency underwent endovenous laser (940 nm) varicosevein treatment from July to November 2007 in a single day surgery centre.Adjuvant phlebectomy and injection sclerotherapy were performed in the samesession if indicated. All patients had postprocedural venous duplex scan andclinic assessment on day 7 and day 10 respectively. MAIN OUTCOME MEASURES.Procedure success rate, unplanned hospital admissions and re-admissions, majorcomplications, and long saphenous vein obliteration rate. RESULTS. A total of 31 limbs of the 24 patients were treated with endovenous laser varicose veintreatment under local anaesthesia and sedation. The procedural success rate was100%. All but two patients were admitted on the day of treatment and none werere-admitted. The patients' mean visual analogue pain score for the wholeprocedure was 2.3 (standard deviation, 1.5; range, 0-5). Post-procedural duplexscans showed 100% thrombosis of the treated long saphenous veins with no deepvein thrombosis. There were no skin burns or instances of thrombophlebitis.Induration of the treated long saphenous vein was relatively common (54%). Themajority of the patients (54%) experienced mild discomfort in the earlypostoperative period. CONCLUSION. Endovenous laser varicose vein treatmentperformed under local anaesthesia and sedation in a day surgery setting is safe, and yields satisfactory clinical and duplex outcomes.

Theivacumar NS, Darwood RJ, Gough MJEndovenous Laser Ablation (EVLA) of the Anterior Accessory Great Saphenous Vein(AAGSV): Abolition of Sapheno-Femoral Reflux with Preservation of the GreatSaphenous VeinEur J Vasc Endovasc Surg. 2009 Feb 6. [Epub ahead of print]

AIM: During surgery for sapheno-femoral junction (SFJ) and anterior accessory

great saphenous vein (AAGSV) reflux, many surgeons also strip the great saphenousvein (GSV). This study assesses the short-term efficacy (abolition of reflux onDuplex ultrasound) of endovenous laser ablation (EVLA) of the AAGSV withpreservation of a competent GSV in the treatment of varicose veins occurring due to isolated AAGSV incompetence. METHOD: Thirty-three patients (21 women and 12men) undergoing AAGSV EVLA alone (group A) and 33 age/sex-matched controlsundergoing GSV EVLA (Group B) were studied. Comparisons included ultrasoundassessment of SFJ competence, successful axial vein ablation, Aberdeen VaricoseVein Symptom Severity Scores (AVVSS) and a visual analogue patient-satisfactionscale. RESULTS: At the 1-year follow-up, EVLA had successfully abolished thetarget vein reflux (AAGSV: median length 19cm (inter-quartile range, IQR:14-24cm) vs. GSV: 32cm (IQR 24-42cm)) and had restored SFJ competence in allpatients. Twenty of the 33 patients (61%) in group A and 14 of the 33 (42%) ingroup B (p=0.218) required post-ablation sclerotherapy at 6 weeks post-procedure for residual varicosities. The AVVSS at 12 months follow-up had improved from thepre-treatment scores in both the groups (group A: median score 4.1 (IQR 2.1-5.2) vs. 11.6 (IQR: 6.9-15.1) p<0.001; group B: median score 3.3 (IQR 1.1-4.5) vs.14.5 (IQR 7.6-20.2), p<0.001), with no significant difference between the groups.Patient-satisfaction scores were similar (group A: 84% and group B: 90%).Previous intervention in group A included GSV EVLA (n=3) or stripping (n=9).Thus, the GSV was preserved in 21 patients. The AVVSS also improved in thissubgroup (4.4 (2.0-5.4) vs. 11.4 (6.0-14.1), p<0.001) and SFJ/GSV competence was found to be restored at the 1-year follow-up. CONCLUSIONS: AAGSV EVLA abolishesSFJ reflux, improves symptom scores and is, therefore, suitable for treatingvaricose veins associated with AAGSV reflux.

Van den Bos RR, Kockaert MA, Martino Neumann HA, Bremmer RH, Nijsten T, vanGemert MJ.Heat conduction from the exceedingly hot fiber tip contributes to the endovenous laser ablation of varicose veins.Lasers Med Sci. 2009 Feb 14. [Epub ahead of print]

Lower-extremity venous insufficiency is a common condition, associated withconsiderable health care costs. Endovenous laser ablation is increasingly used astherapy, but its mechanism of action is insufficiently understood. Here, directabsorption of the laser light, collapsing steam bubbles and direct fiber-wallcontact have all been mentioned as contributing mechanisms. Because fiber tipshave reported temperatures of 800-1,300 degrees C during endovenous laserablation, we sought to assess whether heat conduction from the hot tip couldcause irreversible thermal injury to the venous wall. We approximated the hotfiber tip as a sphere with diameter equal to the fiber diameter, having a steady state temperature of 800 degrees C or 1,000 degrees C. We computed venous walltemperatures due to heat conduction from this hot sphere, varying the pullbackvelocity of the fiber and the diameter of the vein. Venous wall temperaturescorresponding to irreversible injury resulted for a 3 mm diameter vein andpullback velocities <3 mm/s but not for 5 mm and >/=1 mm/s. The highest walltemperature corresponded to the position on the wall closest to the fiber tip,hence it moves longitudinally in parallel with the moving fiber tip. We concludedthat heat conduction from the hot fiber tip is a contributing mechanism inendovenous laser ablation.

Br J Surg. 2009 Apr;96(4):369-75.Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins.Carradice D, Mekako AI, Hatfield J, Chetter IC.

BACKGROUND: The management of residual varicosities following endovenous laser therapy (EVLT) for varicose veins is contentious. Ambulatory phlebectomy may be performed concomitantly with the initial EVLT,

or sequentially as a secondary procedure. This randomized trial compared these two approaches. METHODS: Fifty patients with great saphenous varicose veins were randomized to EVLT alone or EVLT with concomitant ambulatory phlebectomies (EVLTAP). Principal outcomes were procedure duration, pain scores, requirement for secondary procedures and quality of life after 3 months. RESULTS: EVLTAP took longer, but significantly decreased the requirement for subsequent interventions. There was no impairment in immediate postprocedural pain, Short Form 36 or EuroQol 5D scores with EVLTAP. Median (i.q.r.) Venous Clinical Severity Score (VCSS) at 3 months was lower for EVLTAP than for EVLT alone (0 (0-1) versus 2 (0-2); P < 0.001), with lower Aberdeen Varicose Vein Questionnaire (AVVQ) scores at 6 weeks (7.9 (4.1-10.7) versus 13.5 (10.9-18.1); P < 0.001) and 3 months (2.0 (0.4-7.7) versus 9.6 (2.2-13.8); P = 0.015). At 1 year, there were no differences in VCSS or AVVQ scores. CONCLUSION: Concomitant phlebectomy with EVLT prolonged the procedure, but reduced the need for secondary procedures and significantly improved quality of life and the severity of venous disease.

J Vasc Surg. 2009 Apr;49(4):973-979.e1.Endovenous laser treatment of the small saphenous vein.Kontothanassis D, Di Mitri R, Ferrari Ruffino S, Zambrini E, Camporese G, Gerard JL, Labropoulos N.

PURPOSE: Endovenous laser treatment is a minimally invasive technique for ablation of the incompetent great (GSV) and small saphenous vein (SSV). Compared with the GSV, fewer data are available on SSV laser ablation and are not validated. This multicenter prospective study evaluated the feasibility, safety, and efficacy of endovenous laser ablation to treat SSVs. METHODS: Between January 2003 and January 2007, 204 patients (229 limbs) with CVD and incompetent SSVs (evaluated by the CEAP classification) who were eligible for surgery underwent consecutive laser ablation procedures. Many required additional treatment for varicose tributaries and perforator veins with phlebectomy and foam sclerotherapy, Energy was delivered to the vein wall by a 600-microm optical fiber using 810-nm or 980-nm diode laser. Ablations were performed with duplex ultrasound (DU) guidance and tumescent anesthesia. Follow-up was with clinical examination and DU imaging. RESULTS: DU imaging showed immediate occlusion of the SSV with no thrombosis in the proximal veins. No complications occurred intraoperatively. All patients had postoperative ecchymosis, but it was minimal. Three patients had distal thrombotic complications. Superficial phlebitis after complementary surgery occurred in three cases. Complete occlusion with absence of flow </=2 months of follow-up was detected in 226 SSV (98.7%). It occurred 22 in patients with large SSV diameter. Recanalization was found in one patient at 12 months and in two patients at 24 months. Seven limbs had reflux in previously treated areas, treated segments, and segments in continuity with them. Three underwent an intervention to correct symptomatic reflux. The other four had no symptoms. After 1 year, eight limbs developed reflux in new locations and four underwent treatment. Symptoms resolved in most patients soon after the operation. The mean follow-up was 16 months (range, 2-39 months). After 8 to 12 months postprocedurally, the laser-treated veins were fibrotic and almost indistinguishable on DU imaging from the surrounding tissues. In five patients (2.25%) postoperative paresthesia occurred >2 to 3 days postoperatively and persisted in the follow-up. No paresthesia occurred in our last series whenever a larger amount of tumescent cold saline was infused around the vein. CONCLUSION: Endovenous laser ablation of the SSV has excellent early and midterm results. The prevalence of thrombosis and paresthesia is very low. Symptom relief is very good.

Dermatol Surg. 2009 May;35(5):804-12. Epub 2009 Mar 30.Fluoroscopy-guided endovenous foam sclerotherapy using a microcatheter in varicose tributaries followed by endovenous laser treatment of incompetent saphenous veins: technical feasibility and early results.Park SW, Yun IJ, Hwang JJ, Lee SA, Kim JS, Chang SH, Chee HK, Kim HC, Sun K, Park SJ.

OBJECTIVES: To evaluate the technical feasibility and preliminary results of endovenous foam sclerotherapy using a microcatheter in varicose tributaries followed by endovenous laser treatment (EVLT) of incompetent saphenous veins. MATERIALS AND METHODS: From July 2005 to August 2006, 312 patients (M:F=139:173, mean age 45.8) who presented with varicose veins with reflux in the saphenofemoral, saphenopopliteal junction or tributaries were enrolled. Under ultrasound or fluoroscopy guidance, selective microcatheterization and endovenous foam slcerotherapy were first performed in varicose tributaries, followed by EVLT (980 nm) of incompetent saphenous veins. Follow-up at 1-week and 1-, 3-, and 6-month intervals was done. RESULTS: Technical success was seen in 410 of 411 limbs (99%). Continued closure of the saphenous veins and the complete sclerosis of varicose tributaries were noted in 332 of 373 limbs (89%) at the 1-month follow-up, all 307 limbs (100%) at the 3-month follow-up, and all 274 limbs (100%) at the 6-month follow-up. No serious

complication was noted. CONCLUSION: Endovenous foam sclerotherapy using a microcatheter in varicose tributaries followed by EVLT in incompetent saphenous veins is a safe, effective, and technically feasible treatment for varicose veins. It not only reduces additional sclerotherapy and technical failure, but also makes multiple therapeutic sessions unnecessary.

J Vasc Interv Radiol. 2009 Jun;20(6):752-9. Epub 2009 Apr 22.Radiofrequency endovenous ClosureFAST versus laser ablation for the treatment of great saphenous reflux: a multicenter, single-blinded, randomized study (RECOVERY study).Almeida JI, Kaufman J, Göckeritz O, Chopra P, Evans MT, Hoheim DF, Makhoul RG, Richards T, Wenzel C, Raines JK.

PURPOSE: The present study was designed to address the hypothesis that radiofrequency (RF) thermal ablation, as represented by the ClosureFAST system, is associated with improved recovery and quality-of-life (QOL) parameters compared with 980-nm endovenous laser (EVL) thermal ablation of the great saphenous vein (GSV). MATERIALS AND METHODS: Eighty-seven veins in 69 patients were randomized to ClosureFAST or 980-nm EVL treatment of the GSV. The study was prospective, randomized, single-blinded, and carried out at five American sites and one European site. Primary endpoints (postoperative pain, ecchymosis, tenderness, and adverse procedural sequelae) and secondary endpoints (venous clinical severity scores and QOL issues) were measured at 48 hours, 1 week, 2 weeks, and 1 month after treatment. RESULTS: All scores referable to pain, ecchymosis, and tenderness were statistically lower in the ClosureFAST group at 48 hours, 1 week, and 2 weeks. Minor complications were more prevalent in the EVL group (P = .0210); there were no major complications. Venous clinical severity scores and QOL measures were statistically lower in the ClosureFAST group at 48 hours, 1 week, and 2 weeks. CONCLUSIONS: RF thermal ablation was significantly superior to EVL as measured by a comprehensive array of postprocedural recovery and QOL parameters in a randomized prospective comparison between these two thermal ablation modalities for closure of the GSV.

Phlebology. 2009;24 Suppl 1:50-61.Endovenous laser treatment for uncomplicated varicose veins.Darwood RJ, Gough MJ.

OBJECTIVE: Endovenous laser ablation (EVLA) of incompetent truncal veins has been proposed as a minimally invasive alternative to conventional surgery for varicose veins. Various strategies have been proposed for successful treatment and this study reviews the evidence for these. METHOD: A Medline and 'controlled trials online database' search was performed to identify original articles and randomized controlled trials (RCTs) reporting outcomes for EVLA. Information on patient selection, equipment, technique and outcomes were recorded. RESULTS: Ninety-eight original studies, including five RCTs, were identified. RCT data indicate short-term outcomes (abolition of reflux, improvement in quality of life [QOL], patient satisfaction) were equivalent to those for surgery. Long-term follow-up is not available. A further RCT showed superior outcomes for ablation commencing at the lowest point of superficial venous reflux rather than at an arbitrary point (fewer residual varicosities, greater improvement in QOL). Non-randomized series suggest that laser energy of >60 J/cm results in reliable truncal vein occlusion and that longer wavelength lasers may be associated with less post-treatment discomfort. CONCLUSION: In the short-term EVLA is a safe and effective treatment for patients with varicose veins. Long-term follow-up is still required.

Int J Surg. 2009 Aug;7(4):347-9. Epub 2009 May 14.5-years of endovenous laser ablation (EVLA) for the treatment of varicose veins--a prospective study.Nwaejike N, Srodon PD, Kyriakides C.

PURPOSE: This prospective study evaluates the results of Endovenous laser ablation (EVLA) for the treatment of varicose veins. METHODS: Data were prospectively collected for all patients undergoing EVLA for varicose veins in our unit including clinical outcomes (CEAP classification) and post-operative duplex. RESULTS: 624 EVLA procedures were performed from April 2004 to February 2009. There were 527 LSV EVLA cases, 449 of which were for the above-knee segment only. There were 94 SSV EVLA cases and 3 patients needed LSV EVLA on the same leg at the same time. 84% were done under general anesthetic including 126 patients who underwent bilateral procedures at the same session. There were no intra-operative complications, and a 1% incidence of thrombophlebitis, and <1% incidence of neuropraxia. During a median follow-up of 20 months

(Range 2-51) there was no clinical or duplex evidence of recurrence and no recannalisation of the treated vein. CONCLUSIONS: Our 5-year experience suggests that EVLA is a safe and effective alternative to conventional surgery for the treatment of varicose veins. Bilateral procedures were well tolerated by patients even under local anaesthesia.

Eur J Vasc Endovasc Surg. 2009 Aug;38(2):208-12. Epub 2009 May 22.Introducing endovenous laser therapy ablation to a national health service vascular surgical unit - the Aberdeen experience.Mackenzie RK, Cassar K, Brittenden J, Bachoo P.

OBJECTIVES: To report early clinical outcomes and learning experience following the introduction of endovenous laser ablation (EVLA) to an NHS vascular unit. DESIGN: Prospective observational study. RESULTS: Between February 2006 and January 2008, 631 consecutive patients underwent EVLA to 704 refluxing truncal veins - 579 GSV, 119 SSV and 6 straight segments of anterior accessory GSV. 275/631 (44%) patients had local anaesthesia (LA) plus sedation, 237 (38%) had LA only and 119 (18%) had general anaesthesia. All were treated using the 810 nm diode laser. Adjuvant procedures on-table included foam sclerotherapy 129/704 (18%), multiple stab avulsions 53/704 (8%) and 3 limbs had both. Three-month follow-up with duplex examination is complete in 635/704 limbs (90%). Complete occlusion was noted in 610 veins (96%), 14 (2.2%) were partially occluded and 11 (1.7%) showed no occlusion. 193 (30%) of the 635 limbs seen at follow-up required further treatment for residual varicosities using foam sclerotherapy. There has been one non-fatal pulmonary embolus associated with EVLA and no other complications. CONCLUSIONS: EVLA is safe and technically effective. It has a defined learning curve requiring new operator skills which can be readily acquired.

Dermatol Surg. 2009 Aug;35(8):1206-14. Epub 2009 May 15.Endovenous laser ablation-induced complications: review of the literature and new cases.Van Den Bos RR, Neumann M, De Roos KP, Nijsten T.

BACKGROUND: In the last decade, minimally invasive techniques have been introduced in the treatment of lower extremity varicosities. Of these therapies, endovenous laser ablation is the most widely accepted and used treatment option for insufficient great and short saphenous veins. OBJECTIVE: To present a review of reported common and rare and minor and major complications associated with endovenous laser ablation. METHODS: A systematic review of studies and case reports on endovenous laser ablation-induced complications. The complications were classified as minor or major according to the Society of Interventional Radiology Standards of Practice Committee guidelines on reporting complications. A case-series of complications after endovenous laser ablation is presented. RESULTS: Ecchymoses and pain are frequently reported side effects of endovenous laser ablation. Nerve injury, skin burns, deep vein thrombosis and pulmonary embolism seldom occur. An exceptional complication is a material or device that by accident remains inside the body after the procedure. Ecchymosis, pain, induration, skin burns, dysesthesia, superficial thrombophlebitis, and hematoma were classified as minor complications. Deep vein thrombosis and nerve injury were classified as major complications. CONCLUSION: Endovenous laser ablation may be considered a safe treatment of lower extremity varicosities. The incidence of common side effects may decrease with better laser parameters.

Phlebology. 2009 Jun;24(3):125-30.Endovenous laser procedure in a clinic room: feasibility and side effects study of 1,700 cases.Hamel-Desnos C, Gérard JL, Desnos P.. OBJECTIVES: To assess the feasibility of saphenous veins ablation by laser in a clinic room. To study immediate and short term (1 to 6 months) complications and to pinpoint those that could be directly linked to this environment. Efficacy of the technique should also be documented. METHODS: Retrospective study (22 centres) carried out in France and Switzerland. Patients with insufficiency of great saphenous vein (GSV) or small saphenous vein (SSV). Clinical stages of clinical, [corrected] aetiological, anatomical and pathophysiological classification (CEAP) C2 to C6. Endovenous laser procedures were performed outside an operating theatre, under local anaesthesia and without high ligation. Efficacy criteria: occlusion of the vein and disappearance of the pathological reflux (duplex scan assessment). The side effects and complications were studied. RESULTS: A total of 1703 procedures (1422 patients) were performed; 74% of the patients were women. [corrected] The mean age of the patients was 57. A total of 1394 GSV and 309 SSV were treated (mean

diameters 7.2 mm and 6.4 mm, respectively). Overall success level was 97% and mean length of veins treated was 40 cm for GSV and 21 cm for SSV. Energy applied in joules per centimeter was homogenous (mean and median 64 for GSV and 65 for SSV). Complications were rare and 'simple' apart from one pulmonary embolism which occurred 10 days after a GSV procedure, although no deep vein thrombus was found. A total of two infections were observed: one was an infection localized at the site of access and the other was erysipelas. [corrected] CONCLUSION: Except 2 limited infections (0.1%), this large retrospective study of laser procedures performed outside the operating theatre did not reveal any significant specific complications as regards the environment required. The efficacy results were equivalent to those found in the literature. Regarding cost and constraints induced by operating theatre environment, the clinic room should be able to offer an easier and economic alternative option for saphenous veins ablation with laser .

Eur J Vasc Endovasc Surg. 2009 Aug;38(2):203-7. Epub 2009 Jun 12.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.Theivacumar NS, Darwood R, Gough MJ.

OBJECTIVE: Neovascularisation is a major cause of recurrent varicosities following surgery. This prospective cohort study compares recurrence rates and the occurrence of neovascularisation following surgery or endovenous laser ablation (EVLA) for great saphenous vein reflux. METHOD: 118 consecutive patients (72 female, 46 male, median age 48 [range 32-68 years]), 129 limbs were reviewed at a median of 24 months (range 18-30) after surgery (n=60 limbs) or EVLA (n=69 limbs) for primary sapheno-femoral and GSV reflux. Varicose vein recurrence, ultrasound detected groin neovascularisation and patient satisfaction (visual analogue scale) were recorded. RESULTS: Recurrence rates at 2 years were: surgery group 4/60 (6.6%; mid-thigh perforator n=2, residual GSV with neovascularisation n=2), EVLA group 5/69 (7%; GSV recanalisation n=3 (all received <50 J/cm laser energy), mid-thigh perforator n=1, new anterior saphenous vein reflux n=1) p=0.631. Neovascularisation was detected in 11/60 (18%) of the surgery group and 1/69 (1%) of the EVLA group, p=0.001. Patient satisfaction rates were 90% and 88% respectively (p=0.37). CONCLUSIONS: Although the frequency of recurrent varicosities 2 years after surgery and EVLA was similar, neovascularisation, a predictor of future recurrence, was less common following EVLA. Further, current recommendations on delivering > or =70 J/cm laser energy should reduce recanalisation rates and recurrence after EVLA.

Eur J Vasc Endovasc Surg. 2009 Aug;38(2):234-6. Epub 2009 Jun 12.Arterio-venous fistula following endovenous laser ablation for varicose veins.Theivacumar NS, Gough MJ.

Endovenous laser ablation (EVLA) obliterates incompetent truncal veins as an alternative to varicose veins surgery. We describe 3 patients who developed an arterio-venous fistula (AVF) following great (GSV: 1) or small (SSV: 2) saphenous vein EVLA. Two fistulae closed spontaneously with conservative management. Concomitant venous and arterial wall thermal injury or needle trauma during administration of tumescent anaesthesia may cause this rare complication. Haemodynamic effects appear minimal and spontaneous closure is likely, supporting a non-interventional policy.

Rozhl Chir. 2009 Mar;88(3):106-14.[A six-year experience with endovenous laser in the treatment of lower extremity varices][Article in Czech]Kaspar S, Pirkl M, Príborská J, Kaspar D.

AIMS: Endovascular techniques of saphenous ablation are the miniinvasive alternatives of the radical surgical treatment. This study summarizes our own clinical experience with endovenous laser. MATERIAL AND METHODS: During 6 year period we performed in total 723 endovenous laser procedures of trunk varicose veins of lower extremities in 630 patients. Every patient was preoperatively examined clinically and with color duplex machine. Primary varicose veins were operated on in 664 cases, in 59 cases the procedure was performed in recurrent varicose veins with reflux in the residual saphenous trunk. Post-operative follow-up (clinical and duplex ultrasound) was performed after 5 days and 1 month, 6 months and yearly thereafter. The results were evaluated by comparison of CEAP clinical class and quality of life (QoL) pre- and post-operatively, by the percentage of recanalizations and also using Kaplan-Meier life-table method. RESULTS: No thrombosis, nor pulmonary embolism were diagnosed in the post-operative period; from the whole cohort of 723 laser

procedures, the postoperative data were available during different time periods in 718 cases (99.3%). Saphenous occlusion was verified in 97.3% after 1 month, non-occlusion or early reopening was seen in 2.7%. In total, 44 non-occluded trunk veins were found during the whole follow-up period (1-72 months, mean 15 months) which represents the final occlusion result of 93.9%. With stronger Kaplan-Meier analysis, we reached 88.9% occlusion rate during the follow-up period of 6 years. Cox regression analysis of factors influencing non-occlusion and early or late recanalisation of saphenous vein found 2 factors with statistical importance: energy per centimeter of vein length (p = 0.04) and laser power (p = 0.04). Cumulative rate of occlusions in 72 months horizon is significantly higher (94%) in patients treated with more than 50 J/cm compared to less than 50 J/cm (87%), log-rank test 0.039. When comparing the influence of laser power on the quality of saphenous occlusion, the treshold of 13W was set arbitrary based on median values in occluded and non-occluded cohorts and using the Kaplan-Meier survival method, the results of the treatment with power less than 13W and more than 13W were analysed. Using the power values less than 13W, the results were significantly better (p = 0.031) compared to power values of 13 W or more. Mean clinical CEAP classification improved from 2.22 (before operation) to 0.24 (1 month after) and 0.48 (last visit) and also QoL was significantly better in laser group compared to traditional surgery group (p < 0.001). The sick leave was also significantly shorter in the laser group ( median 0 days) compared to traditional group (median 40 days), p < 0.01. CONCLUSIONS: The results of endovenous laser ablation of varicose veins depend mainly on meticulous pre-operative ultrasound examination and sufficient technical parameters of the therapy. The present study supports the concept of "slow heating" during the endovenous laser treatment of varicose veins to achieve sufficient energy per centimetre of the vein and the optimal clinical outcome.

Cardiovasc Intervent Radiol. 2009 Sep;32(5):988-91. Epub 2009 Jun 18.Suitability of varicose veins for endovenous treatments.Goode SD, Kuhan G, Altaf N, Simpson R, Beech A, Richards T, MacSweeney ST, Braithwaite BD.

The aim of the study was to assess the suitability of radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and foam sclerotherapy (FS) for patients with symptomatic varicose veins (VVs). The study comprised 403 consecutive patients with symptomatic VVs. Data on 577 legs from 403 consecutive patients with symptomatic VVs were collected for the year 2006. Median patient age was 55 years (interquartile range 45-66), and 62% patients were women. A set of criteria based on duplex ultrasonography was used to select patients for each procedure. Great saphenous vein (GSV) reflux was present in 77% (446 of 577) of legs. Overall, 328 (73%) of the legs were suitable for at least one of the endovenous options. Of the 114 legs with recurrent GSV reflux disease, 83 (73%) were suitable to receive endovenous therapy. Patients with increasing age were less likely to be suitable for endovenous therapy (P = 0.03). Seventy-three percent of patients with VVs caused by GSV incompetence are suitable for endovenous therapy.

Singapore Med J. 2009 Jun;50(6):591-4.Endovenous laser treatment for varicose veins in Singapore: a single centre experience of 169 patients over two years.Tan KK, Nalachandran S, Chia KH.

INTRODUCTION: Endovenous laser therapy (EVLT) is one of the many minimally-invasive procedures that have been developed in recent years for the treatment of varicose veins. We present our single centre experience of 169 patients who underwent EVLT. METHODS: All patients who underwent EVLT since its introduction in our institution were included in our series. RESULTS: A total of 270 incompetent long saphenous veins in 169 patients were ablated by EVLT from February 2006 to January 2008. Bilateral EVLT was performed in 101 (59.8 percent) patients, with the remaining 68 (40.2 percent) undergoing unilateral EVLT. The mean age of the patients was 54 (range 19-78) years and there were 112 (66.3 percent) women. The majority of our patients (63.3 percent) had symptoms for more than five years. The symptoms included lower limb cramps and aches (47.9 percent) as well as lower limb swelling (16.6 percent). The median follow-up was six months. Complications from our series included numbness over the affected lower limbs (10.7 percent) and skin pigmentation (4.1 percent). Only 2.4 percent of patients had recurrence after one year. CONCLUSION: Early results with EVLT have been impressive, and this study has reaffirmed the safety and effectiveness of EVLT in the treatment of varicose veins.

ANZ J Surg. 2009 May;79(5):352-7.

980-nm laser therapy versus varicose vein surgery in racially diverse Penang, Malaysia.Lakhwani MN, Dadlani NI, Wong YC.

BACKGROUND: Chronic venous disorders are conditions of increasing prevalence in the developing world, and venous ulceration is the terminal sequel. Currently there are only limited data on all aspects of this from Southeast Asia. The aim of the present study was to assess differences in the demography and outcome between varicose vein surgery (VVS) and the relatively new endovenous laser therapy (EVT) in patients from Penang, Malaysia. METHODS: A retrospective study was performed. Patients who presented to the outpatient clinic of the surgical department with saphenofemoral junction and/or saphenopopliteal junction incompetence associated with reflux of the great saphenous vein or small saphenous vein, respectively, underwent either surgery (1999-2004) or laser therapy (2004-2006). A single surgeon at a single institution performed all procedures. RESULTS: A total of 350 limbs were treated from 292 patients. Demographics, symptoms, outcomes and complications that arose in both groups were compared. There were significant improvements in pains, swelling, cramps and heaviness postoperatively (P < 0.001) in both groups. Deep venous thrombosis was present as a complication in the VVS group at 3.0%, but was absent altogether in the EVT group. CONCLUSIONS: Although both are highly effective procedures, laser therapy has become popular as an elective procedure with its minimally invasive nature, cosmesis, rapid recovery and other advantages. Surgery remains an important and very cost-effective procedure, especially in a developing society such as Penang.

Eur J Vasc Endovasc Surg. 2009 Oct;38(4):506-10. Epub 2009 Jul 4.Influence of warfarin on the success of endovenous laser ablation (EVLA) of the great saphenous vein (GSV).Theivacumar NS, Gough MJ.

BACKGROUND: Although warfarin is routinely stopped prior to varicose vein surgery the absence of incisions may make this unnecessary prior to EVLA. Nevertheless continuing therapy may compromise ablation rates resulting in treatment failure. Since EVLA is particularly suitable for older patients with co-morbidities this study investigates whether warfarin influences outcome. METHOD: A prospective observational cohort study was designed to assess ablation rates (1 year, duplex ultrasound), Aberdeen varicose vein symptom severity scores (AVVSS) and patient satisfaction following GSV EVLA in 22 patients ("warfarin group": 12 female, 10 male; 24 limbs) taking warfarin and 24 age/sex and disease-severity matched controls who were not taking anticoagulants ("no-warfarin group"). RESULTS: Complete ablation of the treated-length of GSV was achieved in 20/24 (83%) limbs in the "warfarin group" versus 23/24 (96%) in the "no-warfarin" group (p=0.347, chi squared). Suboptimal energy densities were delivered to 3/4 failures in the "warfarin group". A similar, significant (p<0.001, Wilcoxon) improvement in AVVSS occurred in both groups [warfarin: median 14.6 (inter-quartile range 8.9-19.1) to 3.8 (1.9-6.2), no-warfarin: median 13.9 (IQR 7.6-20.1) to 3.5 (2.2-6.4)]. Patients were equally satisfied with outcomes (warfarin=92%, no-warfarin=90%; p=0.391, Mann-Whitney). No major complications occurred. CONCLUSIONS: EVLA in patients taking warfarin is safe and effective. Since cessation of therapy is unnecessary it should provide a valuable alternative to surgery in these patients.

Photomed Laser Surg. 2009 Aug;27(4):655-8.Endovenous laser therapy of the small saphenous vein: patient satisfaction and short-term results.Trip-Hoving M, Verheul JC, van Sterkenburg SM, de Vries WR, Reijnen MM.

OBJECTIVE: Conventional surgical treatment for small saphenous vein (SSV) reflux is associated with high recurrence rates and complications. Endovenous laser ablation (EVLA) is a treatment modality with promising results. This study reports patient satisfaction and short-term results after EVLA of SSV reflux. METHODS: Fifty-two legs of 49 consecutive patients were treated with EVLA for reflux of the SSV. Patients were investigated clinically and by duplex scanning before and 6 weeks after treatment. Patient records were studied and a questionnaire was completed. RESULTS: Technical success was accomplished in all patients. After 6 weeks the occlusion rate was 100% and after 6.5 months no recurrent varicosities were reported. Complications consisted of bruising (51%), induration (39%), delayed tightness (16%), phlebitis (2%), and temporary paresthesia (6%) and were all self-limiting. One deep venous thrombosis occurred in a patient with a protein C deficiency. Ninety-two percent (45/49) of patients were satisfied with the results and in 98% symptoms had significantly improved or completely disappeared. Working activities were resumed after a mean of 4 days. Forty-three patients (88%) would consider having endovenous laser treatment again if indicated. CONCLUSIONS: EVLA of the SSV seems to be a safe modality with excellent short-term results and high

patient satisfaction. Controlled studies assessing the effectiveness of EVLA in comparison to conventional treatment of SSV reflux are crucial before considering EVLA as the standard treatment.

Cardiovasc Intervent Radiol. 2009 Sep;32(5):1067-70. Epub 2009 Jul 16.Endovenous laser ablation of incompetent perforator veins: a new technique in treatment of chronic venous disease.Ozkan U.

The aim of this study was to assess the feasibility of endovenous laser ablation of incompetent perforator veins in a patient with incompetency of the small saphenous vein and multiple perforator veins. Two different methods were used to ablate seven perforator veins with a laser giving 50-60 J/cm energy. Total occlusion was observed in six perforators, and partial ablation in one perforator, at 1-month follow-up. To our knowledge, endovenous laser ablation of incompetent perforator veins is easy and a good therapeutic method.

Eur J Vasc Endovasc Surg. 2009 Aug;38(2):199-202.Endovenous laser ablation of the small saphenous vein: prospective analysis of 150 patients, a cohort study.Huisman LC, Bruins RM, van den Berg M, Hissink RJ.

OBJECTIVE: To evaluate treatment of the small saphenous vein (SSV) by endovenous laser ablation. STUDY DESIGN: A cohort study, occlusion of the vein and safety of the procedure was analysed prospectively. PATIENTS: 150 consecutive patients (169 limbs) were treated between August 2006 and January 2008 in an outpatient clinic setting. The average age was 57 years (range 23-87); 82% female; 31% had serious varicose disease (CEAP 3-6). Treated length averaged 23 cm (range 6-53 cm). METHODS: All patients underwent a standardised assessment comprising digital questionnaire, physical examination and duplex ultrasonography. The SSV was cannulated percutaneously under ultrasound control and perivascular local anaesthesia (tumescent) was injected. An 810 nm diode laser was used, delivering 70 J/cm. Three months post-treatment all patients received a duplex ultrasound of the treated vessel. RESULTS: Complete occlusion of the SSV after 3 months was achieved in 98% of the cases. Two patients (1.3%) had sural nerve paraesthesia. Six patients developed superficial thrombophlebitis. Serious complications did not occur. CONCLUSIONS: Endovenous laser ablation for treating the incompetent small saphenous vein is a safe, effective and technically feasible technique.

Phlebology. 2009 Aug;24(4):151-6.Effects of eccentric compression by a crossed-tape technique after endovenous laser ablation of the great saphenous vein: a randomized study.Lugli M, Cogo A, Guerzoni S, Petti A, Maleti O.

OBJECTIVES: To evaluate the effect of eccentric compression applied by a new crossed-tape technique on procedure-related pain occurrence after endovenous laser ablation (ELA) of the great saphenous vein (GSV). METHODS: From April 2005 to June 2006, 200 consecutive ELA procedures were randomized to receive (group A: 100) or not (group B: 100) an eccentric compression applied in the medial aspect of the thigh. Patients were scheduled for a seven-day examination to assess the level of pain experienced. Pain intensity was measured using a visual analogue scale giving a numerical grade from 0 (no pain) to 10 (worst pain ever). RESULTS: The intensity of postoperative pain was significantly reduced (P < 0.001) in the eccentric compression group as compared with the non-compression one. CONCLUSIONS: This technique of eccentric compression greatly reduces the intensity of postoperative pain after ELA of the GSV.

Phlebology. 2009 Aug;24(4):166-75.Endovenous laser treatment: a morphological study in an animal model.Vuylsteke M, Van Dorpe J, Roelens J, De Bo T, Mordon S.

OBJECTIVES: The destruction induced during endovenous laser treatment (ELT) of the saphenous vein and the perivenous tissue in an animal model (goats) was analysed. Differences in vein wall destruction produced by two

laser types, the 980 and 1500 nm diode lasers, were evaluated histologically. METHODS: In 14 goats, 28 lateral saphenous veins were treated with ELT. In 14 veins we used the 980 nm diode laser and in the remnant a 1500 nm laser. Postoperatively the veins were removed at different stages and sent for histological examination. RESULTS: Immediately removed veins after ELT show an uneven destruction of the vein wall. Veins harvested one week postoperatively show inflammatory tissue at their periphery. Two and three weeks postoperatively, organization is very extensive. In some cases, recanalization begins in a semi-lunar manner at the contralateral side of the laser hit. Veins treated with a 980 nm laser show deeper ulceration with more perivenous tissue destruction compared with veins treated with a 1500 nm diode laser. CONCLUSIONS: The ELT of veins produces an unevenly distributed damage. The cell necrosis is far more extensive than expected. Uneven vein wall destruction can lead to recanalization. Using a 1500 nm laser correlates with less penetrating ulcerations and more circumferential damage.

Vasc Endovascular Surg. 2009 Oct-Nov;43(5):467-72. Epub 2009 Jul 23.Saphenous Laser Ablation at 1470 nm Targets the Vein Wall, Not Blood.Almeida J, Mackay E, Javier J, Mauriello J, Raines J.

The 2 primary objectives of this study were to investigate whether the 1470-nm wavelength can close a saphenous vein painlessly and determine safety, efficacy, and side effects of the 1470-nm laser. In all, 26 limbs were treated in the Dominican Republic, with a radially-emitting fiber at low energy ranging from 20 J/cm to 30 J/cm. Perivenous anesthesia was used selectively. Then 41 veins were treated with the 1470-nm laser at 30 J/cm at 5 watts, using standard perivenous tumescent anesthesia in Miami and compared to a historical control (980 nm, 80 J/cm, and 12 watts). We demonstrated that the 1470-nm wavelength endovenous laser system could not close saphenous veins without use of anesthesia. Closure with a dramatic reduction in energy when compared to a 980-nm wavelength control demonstrated a marked reduction in postoperative pain and ecchymosis; this implies that vein-wall perforations are minimized with this system.

Int Angiol. 2009 Aug;28(4):281-8.New wavelength for the endovascular treatment of lower limb venous insufficiency.Soracco JE, López D'Ambola JO.

AIM: The aim of this research was to show the efficacy of the 1 470-nm wavelength diode laser for endovenous laser treatments and the clinical results obtained. METHODS: Patients with varicose veins stratified by CEAP classification (clinical) in C2-6 and low-flow venous malformations were treated with and without crossectomy. Endolaser venous system with Ceralas E 1 470 nm diode laser (ELVeS(R) PainLess, Biolitec AG, Jena, Germany) was used. The average power applied was in the range of 2-6 W, continuous mode and pull-back of 10 mm/5 s. Two optical fibres were used; frontal emission bare fibre of 400 mu (ELVeS(R)) and radial emission fibre of 600 mu (ELVeS(R)). All patients were evaluated with Duplex ultrasonography (US) before, intraproceeding, immediately after, at 48 hours, 7 and 30 days after the initial procedure. An average follow-up of twelve months was attained. In 15% of the cases, the endovenous laser proceeding was also evaluated during the treatment with thermographic images, direct thermography and direct venous angioscopy to assess the local temperature increase. After the treatment histopathological studies were also performed. RESULTS: Between 30% and 50% of the vein's initial diameter was immediately reduced in 100% of patients and fibrosis was observed by histopathological analysis. Thirty days post-treatment all cases presented venous obliteration observed by Duplex US. Clinical symptoms were resolved. Side-effects were: minimal discomfort, local pain, postpuncture ecchymosis and minimal fibrosis of the treated veins. Nevertheless, there was absence of hyperpigmentation in all patients and absence of neuritis in 98.6% of patients. Popliteal thrombosis was presented 24 hours after the procedure in 2.9% of the patients (these patients did not receive heparin). CONCLUSIONS: With this laser wavelength, which is new in phlebology applications, remarkable effective results were achieved with lower power comparing to the results currently obtained by using higher power and shorter laser wavelengths. This development provides the benefit of potentially better therapeutic results with less collateral damage.

Int Angiol. 2009 Aug;28(4):289-97.Experience with concomitant ultrasound-guided foam sclerotherapy and endovenous laser treatment in chronic venous disorder and its influente on Health Related Quality of Life: interim analysis of more than 1000 consecutive procedures.King T, Coulomb G, Goldman A, Sheen V, McWilliams S, Guptan RC.

AIM: The aim of this paper was to evaluate the efficacy of the concomitant use of endovenous laser treatment (ELT) and ultrasound-guided foam sclerotherapy (USGFS) in the management of chronic venous disorder and to objectively analyze the influence of the combination therapy on the Health Related Quality of Life (HRQL) of the treated patients. METHODS: In this prospective series, 1 114 varicose veins in 924 consecutive subjects were treated either with a 980 nm (7-15W) or a 1320 nm (3-10W) endovenous laser. Inclusion criteria: informed consent, clinical, etiologic, anatomical, and pathophysiological (CEAP) clinical class 2, and an accessible vein. Exclusion criteria: coagulation disorder, pregnancy, lactation, current thrombosis, systemic disease, poor general health, or allergy to sodium tetradecyl sulfate (STS). ELT was performed on refluxing saphenous truncal and non-saphenous veins, including incompetent perforators. USGFS was utilized to treat selective refluxing, symptomatic varicose tributaries that were not amenable to ELT alone. The Venous Dysfunction Score (VDS) and Health Related Quality of Life (HRQL) were assessed. All of the patients were strictly monitored and had Duplex ultrasound scanning to evaluate for deep vein thrombosis (DVT) at 24-72 hours. Thorough Duplex scanning was done at 1 week, 1 month, 3 months, 6 months, 12 months, and 24 months. RESULTS: At 1 month, there was continued reflux (> 0.5 seconds) in 26 SFJs (3.0%, N=824) and 4 SPJ s (2.5%, N=155) and at 3 months in 15 SFJs (1.8%), 5 SPJ s (3.7%). At 6 months, reflux was present in 10 SFJs (1.2%) and 4 SPJs (2.5%). At a mean of 12+/-10 months of post-treatment follow-up, 4 SFJ (1.9%, N=207) and 1 SPJ (1.9%, N=52) had reflux. Overall, there was elimination of reflux in 98% of junctions. The posterior accessory saphenous veins (PAV: N=117) had 100 % elimination of reflux at 1 month, a result that remained unchanged for more than a year (P<0.001). Similarly, anterior accessory saphenous veins (AAV: N=56), cranial, caudal, or thigh, extensions of the small saphenous vein (CESSV: N=31), and non-saphenous veins and incompetent perforators (NSV, IP: N=31) all had sustained and statistically significant response (P<0.001). Sequentially assessed VDS showed significant improvement (P<0.001). The Aberdeen Varicose Vein Questionnaire (AVVQ) revealed significant improvement in HRQL at 1-2 year (P<0.001). Failed ELT attempts occurred in six cases due to vein spasm (N=4, 0.36%) or fiber/laser machine malfunction (N=2, 0.18%). These veins were successfully treated with ultrasound-guided foam sclerotherapy. Thirty-two patients (2.9%) complained of a small area of numbness at one month. There was complete resolution in 6 (18.8%) of the patients by 6 months. There were four cases of a localized cellulitis at laser venous access sites. These resolved uneventfully with oral antibiotics. There were also two skin reactions, with localized urticaria, due to dressing tape. These required no additional treatment. There were two cases of superficial phlebitis that resolved with continued compression and NSAIDs. There was one asymptomatic popliteal DVT and one uncomplicated superficial skin burn that both resolved uneventfully with no treatment other than observation. No pulmonary embolism (PE), thrombophlebitis, or visual disturbance occurred. CONCLUSIONS: Ultrasound-guided foam sclerotherapy given concomitantly with ELT is safe and highly efficacious in the management of GSV, SSV reflux and in their tributaries or in non-saphenous veins. CVD patients treated with combination therapy given in this manner demonstrated significant improvement in their HRQL.

J Endovasc Ther. 2009 Aug;16(4):500-5.Endovenous thermal ablation of superficial venous insufficiency of the lower extremity: single-center experience with 3000 limbs treated in a 7-year period.Ravi R, Trayler EA, Barrett DA, Diethrich EB.

PURPOSE:To demonstrate that endovenous thermal ablation is not only effective and safe but also a durable treatment in patients with symptomatic varicose veins. METHODS:From February 2002 to February 2009, 2354 patients (1836 women; mean age 53 years, range 15-95) with symptomatic varicose veins in 3000 limbs underwent endovenous laser ablation (EVLA) or radiofrequency ablation (RFA). The majority of treated vessels were the great saphenous veins (GSV; 2619, 87.3%); 269 (8.9%) small saphenous veins (SSV) and 112 (3.8%) accessory saphenous veins (ASV) were also treated, all in outpatient procedures under local intra-compartmental anesthesia. An ultrasound evaluation was performed within 2 weeks of the procedure to evaluate vein occlusion, vein wall thickness, and clot extension into the deep vein. In a long-term evaluation involving the first 165 patients treated from February 2002 to January of 2003, 105 (64%) patients [126 (67%) of the 188 eligible limbs] were followed annually with clinical evaluation, duplex ultrasound, and symptom/satisfaction assessment over a mean 6.7 years. RESULTS:Treatment of 3000 limbs involved the use of EVLA in 2841 (2460 GSVs, 269 SSVs, and 112 ASVs) and RFA in 159 GSVs. Post-procedure duplex ultrasound found 57 (2.0%) veins recanalized or incompletely occluded [51 (2%) treated with EVLA and 6 (3.7%) with RFA] in patients treated for GSV or ASV incompetence. In the 269 SSVs treated (all with EVLA), 18 (6.7%) limbs demonstrated incomplete occlusion. Overall, both EVLA and RFA procedures were well tolerated, with minimal complications. In the longitudinal assessment of the 105 patients (126 limbs) participating in annual follow-up for a mean 6.7 years, the overall rate of satisfaction, symptom relief, and absence of varicosities was 86%.

CONCLUSION:Endovenous ablation of saphenous vein has proven to be an effective, safe, and very durable procedure.

Dermatol Surg. 2009 Sep 1. [Epub ahead of print]Histopathologic Studies of the Below-the-Knee Great Saphenous Vein after Endovenous Laser Ablation.der Kinderen DJ, Disselhoff BC, Koten JW, de Bruin PC, Seldenrijk CA, Moll FL.

BACKGROUND There has been hesitation to use endovenous laser ablation (EVLA) for the treatment of incompetence of the below-the-knee great saphenous vein (GSV). OBJECTIVE To assess early pathologic changes in the below-the-knee nonvaricose GSV and adjacent tissue after EVLA in legs scheduled for below-the-knee amputation. METHODS The below-the-knee GSV in five patients was exposed to EVLA using 14-, 12-, and 10-watt laser power with continuous or intermittent laser exposure using a 600-nm core, bare tip fiber. Six segments (3 x 3 cm) of GSV with adjacent tissue were excised, examined histologically, and compared with non-laser-exposed parts of the vessel. RESULTS Histologic evaluation revealed thermal damage of the intima and the internal part of the media. At the site of the laser tip, carbonization and necrosis was observed. Vascular perforation with subsequent perivascular bleeding was occasionally (<10%) seen in cases treated with 40 to 80 J/cm and in all cases treated with 110 to 200 J/cm. The saphenous nerve was not damaged. CONCLUSION Based on this histopathologic study, acute thermal damage of the below-the-knee GSV after EVLA was limited to the intima and the inner third of the media. No acute damage of perivascular nerve tissue was observed. The authors have indicated no significant interest with commercial supporters.

Ann Vasc Surg. 2009 Sep 10. [Epub ahead of print]Use of a New Endovenous Laser Device: Results of the 1,500 nm Laser.Vuylsteke ME, Vandekerckhove PJ, De Bo T, Moons P, Mordon S.

BACKGROUND: A new endovenous laser wavelength (1,500nm diode laser) in the treatment of great saphenous vein (GSV) reflux was evaluated. We studied the occlusion rate at 6 months and noted possible side effects. METHODS: In 129 patients, 158 GSVs were treated using the 1,500nm diode laser. An average linear endovenous energy density of 53.4J/cm and an average endovenous fluence of 32.21J/cm(2) were administrated to the vein. RESULTS: The occlusion rate at 6 months postoperative was 93.3%. Some of the nonoccluded veins closed spontaneously. A postoperative foam treatment was necessary in 3.4% of the treated veins. We found a marked shrinkage of the treated veins. There were limited side effects: moderate or severe ecchymosis in 19%, moderate pain in 1%, moderate periphlebitis in 8.2%, with no paresthesias. CONCLUSION: Endovenous laser treatment of the GSV using a 1,500nm diode laser is effective and safe. The marked shrinkage of the treated veins can guarantee good long-term results.

J Vasc Surg. 2009 Sep 24. [Epub ahead of print]Stroke following endovenous laser treatment of varicose veins.Caggiati A, Franceschini M.

This report describes an ischemic stroke following endovenous laser treatment of the great saphenous vein in a patient with a patent foramen ovale. No thrombophilic conditions or other possible sources of emboli could be demonstrated.

Angiol Sosud Khir. 2009;15(1):69-76.Endovascular laser ablation with wavelength 1,560 nm for varicose veinsSokolov AL, Liadov KV, Lutsenko MM, Lavrenko SV, Liubimova AA, Verbitskaia GO, Minaev VP.

In 2002 - 2008 more than 1000 patients with lower limb varicose veins were treated with endovenous laser coagulation (EVLC) of subcutaneous and perforating veins in the Therapeutic Rehabilitation Center. Usually we used laser wavelength between 915 and 980 nm; but recently 1,560-nm laser, which physical properties are quite different, was used for 43 patients, including 49 EVLCs for great (GSV) and lesser (LSV) saphenous veins and 15 EVLCs for perforating veins (PV). Interventional technique was similar to previously used. Postoperative period for 1,560-nm laser ablations was characterized by earlier resolution of mild pain syndrome, more than twice less ecchymosis, and pain absence along the coagulated veins. These resulted of obliteration. in the

decrease of postcoagulative period severity, thus enabling patients to ambulate earlier. No complications occurred. Ultrasonic picture of 1,560-nm laser coagulation showed uniform wall thickening, intimal induration and circular narrowing of venous lumen. Histological examination of GSV revealed significant thickening of venous wall due to edema and circular shrinkage, focal necrobiosis and caryolysis. Twenty three patients (who underwent total 35 EVLCs for GSV, LSV and PV) were followed up for 4-6.5 months. In all cases treated veins were completely obliterated; no segments with preserved blood flow and pathological refluxes were revealed. In conclusion, EVLC with wavelength that is actively adsorbed by water is characterized by mild postoperative period and higher efficacy of obliteration.

Eur J Vasc Endovasc Surg. 2009 Oct 14. [Epub ahead of print]Endovenous Laser Ablation (980nm) of the Small Saphenous Vein in a Series of 147 Limbs with a 3-Year Follow-up.Desmyttère J, Grard C, Stalnikiewicz G, Wassmer B, Mordon S.

AIM: This study aims to demonstrate the treatment outcomes of endovenous laser ablation (EVLA) of incompetent small saphenous veins (SSVs) with a 980-nm diode laser. MATERIALS AND METHODS: Between 1 June 2003 and 30 June 2006, 128 patients (147 limbs) with varicose veins and reflux in the SSV on duplex ultrasound (US) examination were treated with a 980-nm diode laser under US guidance. EVLA was performed using pulsed mode with a power of 10W. The pulse duration (1.5-3 s) was chosen to deliver a linear endovenous energy density (LEED) depending on the SSV diameter measured 1.5cm below the sapheno-popliteal junction (SPJ) with the patient standing. For SSV diameters between 2 and 4.5mm, the LEED applied was 50Jcm(-1). The LEED was 70Jcm(-1) for 4.5-7mm, 90Jcm(-1) for 7-10mm. Patients were evaluated at 1-week, 1-month, 1-year, 2-year and 3-year follow-up. RESULTS: The initial technical success rate was 100% in 147 patients. The SSV remained closed in 114 of 117 limbs (97%) after 1 year, all of 61 limbs after 2 years and all of 30 limbs after 3 years. For the three SSVs where re-canalisation was observed, the diameter was greater than 9mm. Major complications have not been detected and, in particular, there was no deep venous thrombosis (DVT). Ecchymoses were seen in 60% with a median duration of 2 weeks. Temporary paraesthesia (mostly hypoaesthesia) was observed in 40% of treated legs with a median duration of 2 weeks. The maximum duration did not exceed 4 weeks. No skin discolouration, superficial burn, thrombophlebitis or palpable induration was observed. CONCLUSION: EVLA of the incompetent SSV with a 980-nm diode laser appears to be an extremely safe technique. After successful treatment, there is a very low rate of re-canalisation of the SSV. Obliteration of the SSV was confirmed at 1-, 2- and 3-year follow-up; this study suggests that this procedure will provide a lasting result.

Eur J Vasc Endovasc Surg. 2009 Oct 23. [Epub ahead of print]Intraluminal Fibre-Tip Centring Can Improve Endovenous Laser Ablation: A Histological Study.Vuylsteke M, Van Dorpe J, Roelens J, De Bo T, Mordon S, Fourneau I.

OBJECTIVE: In this histological study, the lateral saphenous vein of the goat was treated using a laser fibre to which a tulip-shaped, self-expandable catheter had been fixed to achieve endovenous laser ablation (EVLA). The catheter centres the laser fibre in the vein preventing direct contact with the vein wall. This study aims to establish whether prevention of direct contact between the fibre tip and the vein wall prevents ulceration and perforation of the vein wall and perivenous tissue destruction. MATERIALS AND METHODS: Ten lateral saphenous veins were treated, using the tulip catheter, in goats under general anaesthesia. Ten more veins were treated with a normal bare fibre. We used a 980nm diode laser to provide the energy. Postoperatively the veins were removed immediately, at 10 days and after 3 weeks for histological examination. Destruction of the vessel wall was measured and perivenous tissue destruction was quantified using a graded scale. RESULTS: Ulceration and perforation were prevented when using the tulip catheter. It also achieved more even vein wall necrosis. Tulip-catheter-treated veins show a transmural vein wall necrosis in, on average, 80% of the total circumference compared to 64% in bare-fibre treated veins. Less perivenous tissue destruction was seen with the new catheter (perivenous tissue destruction scale: tulip catheter: 1.7 vs. bare fibre: 3.8). Three weeks after treatment, we found regression of the perivenous tissue destruction as the healing process continued. CONCLUSIONS: EVLA using the tulip catheter avoids ulceration and perforation of the vein associated with treatment using a bare fibre. It also results in more even circumferential vein wall necrosis and less perivenous tissue destruction.

J Vasc Surg. 2009 Nov;50(5):1106-13.

Treatment of recurrent varicose veins of the great saphenous vein by conventional surgery and endovenous laser ablation.van Groenendael L, van der Vliet JA, Flinkenflögel L, Roovers EA, van Sterkenburg SM, Reijnen MM.

OBJECTIVE: Varicose vein recurrence of the great saphenous vein (GSV) is a common, costly, and complex problem. The aim of the study was to assess feasibility of endovenous laser ablation (EVLA) in recurrent varicose veins of the GSV and to compare this technique with conventional surgical reintervention. METHODS: Case files of all patients treated for GSV varicosities were evaluated and recurrences selected. Demographics, duplex scan findings, CEAP classification, perioperative data, and follow-up examinations were all registered. A questionnaire focusing on patient satisfaction was administered. RESULTS: Sixty-seven limbs were treated with EVLA and 149 were surgically treated. General and regional anesthesia were used more in the surgery group (P < .001). Most complications were minor and self-limiting. Wound infections (8% vs 0%; P < .05) and parasthesia (27% vs 13%; P < .05) were more abundant in the surgery group, whereas the EVLA-treated patients reported more delayed tightness (17% vs 31%; P < .05). Surgically-treated patients suffered less postoperative pain (P < .05) but reported a higher use of analgesics (P < .05). Hospital stay in the surgery group was longer (P < .05) and they reported a longer delay before resuming work (7 vs 2 days; P < .0001). Patient satisfaction was equally high in both groups. At 25 weeks of follow-up, re-recurrences occurred in 29% of the surgically-treated patients and in 19% of the EVLA-treated patients (P = .511). CONCLUSION: EVLA is feasible in patients with recurrent varicose veins of the GSV. Complication rates are lower and socioeconomic outcome is better compared to surgical reintervention.