Laser Venous Interventions
- Volume 6 - Issue 2 - March/April 2009
- Posted on: 3/16/09
- 0 Comments
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Daniel Carradice, MD and Ian Chetter, MD
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: firstname.lastname@example.org
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.
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
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
1. Callam MJ. Epidemiology of varicose veins. Br J Surg 1994;81:167–173.
2. Kurz X, Lamping DL, Kahn S, et al. Do varicose veins affect quality of life? Results of an international population-based study. J Vasc Surg 2001;34:641–648.
3. Kaplan RM, Criqui MH, Denenberg JO, et al. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg 2003;37:1047–1053.
4. MacKenzie RK, Paisley A, Allan PL, et al. The effect of long saphenous vein stripping on quality of life. J Vasc Surg 2002;35:1197–1203.
5. Lees TA, Beard JD, Ridler BM, et al. A survey of the current management of varicose veins by members of the vascular surgical society. Ann R Coll Surg Engl 1999;81:407–417.
6. Michaels JA, Campbell WB, Brazier JE, et al. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). HTA 2006;10:13.
7. Lurie F, Creton D, Eklof B, et al. Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and stripping (EVOLVeS): Two-year follow up. Eur J Vasc Endovasc Surg 2005;29:67–73.
8. Morrison C, Dalsing MC. Signs and symptoms of saphenous nerve injury after greater saphenous vein stripping: Prevalence, severity and relevance for modern practice. J Vasc Surg 2003;38:886–890.
9. Proebstle TM, Paepcke U, Weisel G, et al. High ligation and stripping of the long saphenous vein using the tumescent technique for local anaesthesia. Dermatol Surg 1998;24:149–153.
10. Jones L, Braithwaite BD, Selwyn D, et al. Neovascularisation is the principal cause of varicose vein recurrence: Results of stripping the long saphenous vein. Eur J Vasc Endovasc Surg 1996;12:442–445.
11. Kotoed SC, Qvamme GM, Schroeder TV, et al. Causes of need of reoperation following surgery for varicose veins in Denmark. Ugeskr Laeger 1999;8:779–783.
12. Fischer R, Linde N, Duff C, et al. Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein. J Vasc Surg 2001;34:236–240.
13. Dwerryhouse S, Davies B, Harradine K, et al. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: 5-year results of a randomised trial. J Vasc Surg 1999;29:589–592.
14. Turton EP, Scott DJ, Richards SP, et al. Duplex-derived evidence of reflux after varicose vein surgery: Neoreflux or neorevascularisation? Eur J Vasc Endovasc Surg 1999;17:230–233.
15. Royle JP. Recurrent varicose veins. World J Surg 1986;10:944–953.
16. Negus D. Recurrent varicose veins: A national problem. Br J Surg 1993;80:823–824.
17. Davies AH, Steffen C, Cosgrove C, et al. Varicose vein surgery: Patient satisfaction. J R Coll Surg Edinb 1995;40:298–299.
18. Carradice D, Chetter I. Endovenous laser ablation in the management of varicose veins. In: Greenhalgh RM (ed.) Vascular and Endovascular Consensus Update. London, U.K.: BIBA Medical (30th Symposium Book); 2008, pp. 581–584.
19. Proebstle TM, Lehr HA, Kargl A, et al. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: Thrombotic occlusion after endoluminal thermal damage by laser generated steam bubbles. J Vasc Surg 2002;35:729–736.
20. Luebke T, Brunkwall J. Systematic review and mata-analysis of endovenous radiofrequency obliteration, endovenous laser therapy and foam sclerotherapy for primary varicosis. J Cardiovasc Surg 2008;49:213–233.
21. van den Bos R, Arends L, Kockaert M, et al. Endovenous therapies of lower extremity varicosities are at least as effective as surgical stripping or foam sclerotherapy: Meta-analysis and meta-regression of case series and randomised clinical trials. J Vasc Surg 2009;49:230–239.
22. Theivacumar NS, Dellagrammaticas D, Darwood RJ, et al. Fate of the great saphenous vein following endovenous laser ablation: Does re-canalisation mean recurrence? Eur J Endovasc Surg 2008;36:211–215.
23. Brookes R. EuroQol: The current state of play. Health Policy 1996;37:53–72.
24. The EuroQol Group. EuroQol — A new facility for the measurment of health-related quality of life. Health Policy 1990;16:199–208.
25. Brazier J, Jones N, Kind P. Testing the validity of the EuroQol and comparing it with the SF 36 health survey questionnaire. Qual Life Res 1993;2:169–180.
26. Smith JJ, Garratt AM, Guest M, et al. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg 1999;30:710–719.
27. McHorney CA, Ware JE, Raczek AE. The MOS 36 item short-form health survey: II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medl Care 1993;31:247–263.
28. Garratt AM, Macdonald LM, Rutna DA, et al. Towards measurement of outcome for patients with varicose veins. Qual Health Care 1993;2:5–10.
29. Garratt AM, Rutna DA, Abdalla MI, et al. Responsiveness of the SF-36 and a condition specific measure of health outcome for patients wth varicose veins. Qual Life Res 1996;5:1–12.
30. Mekako AI, Hatfield J, Bryce J, et al. A nonrandomised controlled trial of endovenous laser therapy and surgery in the treatment of varicose veins. Ann Vasc Surg 2006;20:451–457.
31. Rasmussen LH, Bjoern L, Lawaetz M, et al. Randomzed trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose vens: Short term results. J Vasc Surg 2007;46:308–315.
32. Darwood RJ, Theivacumar N, Dellagrammaticas D, et al. Randomised clinical trial comparing endovenous laser ablation with surgery for the treatment or primary great saphenous varicose veins. BJS 2008;95:294–301.
33. Jia X, Mowatt G, Burr JM, et al. Systematic review of foam sclerotherapy for varicose veins. BJS 2007;94:925–936.
34. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: Long term results. J Vasc Int Rad 2003;14:991–996.
35. Theivacumar NS, Dellagrammaticas D, Beale RJ, et al. Factors influencing the effectiveness of EVLA in the treatment of great saphenous vein reflux. Eur J Vasc Endovasc Surg 2008;35:119–123.
36. Timperman PE, Sichlau M, Ryu RK. Greater energy delivery improves treatment success of endovenous laser treatment of incompetant saphenous veins. J Vasc Interv Radiol 2004;15:1061–1063.
37. Timperman PE. Prospective evaluation of higher energy great saphenous vein endovenous laser treatment. J Vasc Interv Radiol 2005;16:791–794.
38. Proebstle TM, Moehler T, Herdemann S. Reduced recanalization rates of the great saphenous vein after endovenous laser treatment with increased energy dosing: Definition of a threshold for the endovenous fluence equivalent. J Vasc Surg 2006;44:834–839.
39. Desmyttère J, Grard C, Wassmer B, et al. Endovenous 980-nm laser treatment of saphenous veins in a series of 500 patients. J Vasc Surg 2007;46:1242–1247.
40. Yang CH, Chou HS, Lo YF. Incompetent great saphenous veins treated with endovenous 1,320-nm laser: Results for 71 legs and morphologic evolvement study. Dermatol Surg 2006;32:1453–1457.
41. Chang CJ, Chua JJ. Endovenous laser photocoagulation (EVLP) for varicose veins. Lasers Surg Med 2002;31:257–262.
42. Proebstle TM, Moehler T, Gül D, et al. Endovenous treatment of the great saphenous vein using a 1,320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Dermatol Surg 2005;31:1678–1683.
43. Kabnick LS. Outcome of different endovenous laser wavelengths for great saphenous vein ablation. J Vasc Surg 2006;43:88–93.
44. Mordon SR, Wassmer B, Zemmouri J. Mathematical modeling of 980-nm and 1320-nm endovenous laser treatment. Lasers Surg Med 2007;39:256–265.
45. Carradice D, Mekako AI, Hatfield J et al. Endovenous laser therapy with concomitant or sequential phlebectomy: A randomised controlled trial. Brit J Surg (in press).
46. Proebstle TM, Herdemann S. Early results and feasibility of incompetent perforator vein ablation by endovenous laser treatment. Dermatol Surg 2007;33:162–168.
47. Proebstle TM, Lehr HA, Kargl A, et al. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: Thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles. J Vasc Surg 2002;35:729–736.