Laser Venous Interventions
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author affiliations:
From the Academic Vascular Surgical Unit, Hull Royal Infirmary, E. Yorks, United Kingdom.
Disclosure: Dr. Carradice and Dr. Chetter disclose that Diomed (Cambridge, U.K.) provided research grants (50% of a research nurse’s salary over a 12-month period) to facilitate trials at Hull Royal Infirmary, but had no involvement or influence in the drafting, or decision to publish this or any other paper.
Manuscript submitted September 12, 2008, provisional acceptance given December 2, 2008, accepted December 11, 2008.
Address for correspondence: Daniel Carradice, MD, Academic Vascular Surgical Unit, Hull Royal Infirmary, Anlaby Rd, Hull, E Yorks HU3 2JZ, United Kingdom. E-mail: dan1@doctors.org.uk
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Abstract
Varicose veins are a common problem, affecting 10–23% of men and 30–40% of women, and are known to impair health-related quality of life. Surgery is the most commonly employed treatment in the U.K. It has been shown to improve quality of life overall and is highly cost effective. Negative aspects include quality of life impairment in the immediate post-operative period and disappointingly high long-term recurrence rates.
Three new minimally invasive treatments have emerged to try to address these shortcomings: foam sclerotherapy, radiofrequency ablation (RFA) and endovenous laser treatment (EVLT).
This review describes the principles of these treatments, with particular emphasis on EVLT. Current best evidence is presented and discussed with specific references to key outcomes of anatomical success, safety, quality of life and economic impact.
Evidence suggests that EVLT is the most efficacious procedure currently available for the treatment of varicose veins in the short and medium term. This is based upon enhanced anatomical success, 95.4% at 5 years (cf. surgery, 75.75%, RFA, 79.9% and foam, 73.5%), and improved quality of life up to 3 months, featuring reduced pain, an earlier return to function and few significant complications.
Further evidence is required and large randomized clinical trials (RCTs), centered on quality of life and offering economic analysis, are eagerly awaited.
Introduction
Varicose veins (VVs) are a common problem, with a prevalence of 10–23% in men and 30–40% in women.1 VVs are not solely a cosmetic concern, but impair health-related quality of life (QoL).2–4 Most patients suffer symptoms (aches, discomfort, pruritis and muscle cramps) and a proportion will develop complications, including edema, eczema, lipodermatosclerosis, ulceration, phlebitis and bleeding.
Surgery is the most commonly employed treatment in the United Kingdom.5 The REACTIV trial6 clearly demonstrated that surgical treatment results in significant improvements in QoL and is cost effective (incremental cost-effectiveness ratio of £1,936 (USD 2,845) per quality-adjusted life-year over 10 years). VVs therefore can and should be treated (Table 1).
Surgery is not ideal. It results in a temporary deterioration in postoperative QoL (as seen with most invasive treatments).4,7 This is likely due to the local morbidity associated with groin dissection and the trauma of vein stripping. Surgery leads to painful and prolonged recovery in some patients, and poses the risks of infection, hematoma and nerve injury.8,9
Recurrence following surgery is significant, with persistent reflux in up to 30% of cases at 1 year, 40% at 2 years and up to 60% beyond 10 years on duplex scanning.10–14 Many centers, however, find that their figures are lower and one must be cautious when interpreting duplex outcomes, as symptomatic recurrence is much lower. Despite this, approximately 20% of procedures are performed for recurrent VVs.15,16
The decline in QoL, complications and recurrence of symptoms, perhaps coupled with an element of unrealistic expectations, results in dissatisfaction with surgical treatment in up to a quarter of National Health Service (NHS) patients.17
Endovenous treatment
A range of minimally invasive treatments have been developed, which are planned and performed under ultrasound guidance.
Liquid sclerotherapy has been performed for many years. It uses a chemical irritant injected into the vein, initiating inflammation in the vein wall. The results of liquid sclerotherapy were disappointing and led to a decline in its use; however, the mixture of the sclerosant (polidocanol or sodium tetradecyl sulphate) with air or carbon dioxide to produce a foam injected into the vein under ultrasound guidance seems to yield much better results. Foam sclerotherapy is now used to treat both truncal and segmental VVs.
Radiofrequency ablation (RFA) utilizes thermal energy to occlude the vein. An electrode is inserted into the vein and passes an electrical current through the wall, directly heating it to around 80˚C. Another similar device (VNUS ClosureFAST, San Jose, California) uses indirect thermal energy via the introduction of a heated coil into the vein. The temperature of the coil is automatically regulated to 120˚C. A problem with RFA techniques is that prior to the vessel wall, the blood is also heated, causing thrombosis. This thrombus insulates the wall from the heating effect and if insufficient energy is transmitted to the vessel wall, a thrombotic occlusion of the vessel, rather than destruction of the vein wall, results. The thrombus may later recanalize, causing recurrence.
Finally, endovenous laser therapy (EVLT) was developed and has since become the frontrunner of the new modalities.18
Principles of EVLT
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