Linear Endovenous Energy Density Research Articles

Satisfactory result of great saphenous vein endovenous laser ablation until below the knee on active venous leg ulcer: a case series

Background Active venous leg ulcer (VLU) is the most severe manifestation of chronic venous disease which not only affects patients’ health, but also decreases the quality of life, and delivers economic burdens. Treatment of superficial venous reflux with early endovenous laser ablation (EVLA) has been associated with reducing ulcer recurrence levels and promoting faster VLU healing. We reported three cases of patients with active VLU undergoing EVLA with different approaches. Case illustration Three patients came with complaint of leg ulcer, diagnosed with C6sEpAsdPr, with venous clinical severity scores (VCSS) of 15, 23, and 22 respectively. Severe great saphenous veins (GSV) reflux was found in all patients by duplex ultrasound examination. The second patient had undergone above-the-knee EVLA. All patients underwent EVLA using 1470-nano meter wavelength laser device and ELVeS radial fiber (Biolitec, Bonn, Germany). The laser energy protocol used was 6 W linear endovenous energy density (LEED) 50 J/cm for proximal until media ATK GSV ablation, 5 W LEED 40 J/cm for media ATK until proximal below-the-knee (BTK) GSV, and 2 W LEED 20 J/cm for proximal until distal BTK GSV. The third patient was also treated with EVLA for small saphenous vein severe reflux. Follow-up until 6 months post-EVLA showed significant healing of the ulcer with 14, 16, and 17 VCSS reduction consecutively without any complication. Conclusion We’ve reported three cases of patients with active VLU undergoing EVLA until BTK with significant results. The EVLA of GSV until BTK where there is still significant reflux is safe and provides satisfactory results in patients with VLU.

Satisfactory result of great saphenous vein endovenous laser ablation until below the knee on active venous leg ulcer: a case series

Background Active venous leg ulcer (VLU) is the most severe manifestation of chronic venous disease which not only affects patients’ health, but also decreases the quality of life, and delivers economic burdens. Treatment of superficial venous reflux with early endovenous laser ablation (EVLA) has been associated with reducing ulcer recurrence levels and promoting faster VLU healing. We reported three cases of patients with active VLU undergoing EVLA with different approaches. Case illustration Three patients came with complaint of leg ulcer, diagnosed with C6sEpAsdPr, with venous clinical severity scores (VCSS) of 15, 23, and 22 respectively. Severe great saphenous veins (GSV) reflux was found in all patients by duplex ultrasound examination. The second patient had undergone above-the-knee EVLA. All patients underwent EVLA using 1470-nano meter wavelength laser device and ELVeS radial fiber (Biolitec, Bonn, Germany). The laser energy protocol used was 6 W linear endovenous energy density (LEED) 50 J/cm for proximal until media ATK GSV ablation, 5 W LEED 40 J/cm for media ATK until proximal below-the-knee (BTK) GSV, and 2 W LEED 20 J/cm for proximal until distal BTK GSV. The third patient was also treated with EVLA for small saphenous vein severe reflux. Follow-up until 6 months post-EVLA showed significant healing of the ulcer with 14, 16, and 17 VCSS reduction consecutively without any complication. Conclusion We’ve reported three cases of patients with active VLU undergoing EVLA until BTK with significant results. The EVLA of GSV until BTK where there is still significant reflux is safe and provides satisfactory results in patients with VLU.

Safety and Efficacy of Combining Saphenous Endovenous Laser Ablation and Varicose Veins Foam Sclerotherapy: An Analysis on 5500 Procedures in Patients With Advance Chronic Venous Disease (C3-C6).

endovenous laser ablation (EVLA) represents the gold standard in treating both great and small saphenous veins (GSV and SSV) incompetence. To achieve a "no-scalpel" procedure in patients with chronic venous insufficiency (CVI, CEAP C3-C6), concomitant phlebectomies could be replaced by ultrasound-guided foam sclerotherapy (UGFS) into varicose tributaries. The aim of this study is to present a single-centre experience on EVLA + UGFS for patients with CVI secondary to varicose veins and saphenous trunk incompetence, analysing ling-term outcomes. all consecutive patients with CVI and treated by EVLA + UGFS from 2010 to 2022 were included in the analysis. EVLA was performed using a 1470-nm diode laser (LASEmaR® 1500, Eufoton, Trieste, Italy), adapting the linear endovenous energy density (LEED) depending on saphenous trunk diameter. Tessari method was used for UGFS. Patients were evaluated clinically and by duplex scanning at 1, 3 and 6months, and annually up to 4years, to assess treatment efficacy and adverse reactions. 5500 procedures in 4895 patients (3818 women, 1077 men) with a mean age of 51.4years were analysed during the study period. A total of 3950 GSVs and 1550 SSVs were treated with EVLA + UGFS (C3 59%, C4 23%, C5 17% and C6 1%). Neither deep vein thrombosis nor pulmonary embolism were detected during follow-up, as well as superficial burns. Ecchymoses (7%), transitory paraesthesia (2%), palpable vein induration/superficial vein thrombosis (15%) and transient dyschromia (1%) were registered. Saphenous and tributaries closure rate at 30days, 1 and 4years were 99.1%, 98.3% and 97.9%, respectively. EVLA + UGFS for an extremely minimally invasive procedure appears to be a safe technique, with only minor effects and acceptable long-term outcomes, in patients with CVI. Further prospective randomized studies are needed to confirm the role of this combined therapy in such patients.

Prospects of Endovenous Laser Ablation (EVLA) Standardization-Mid-Term Results of a Four-Zone Dosimetry Guiding Tool for 1940 nm Laser.

Heterogeneity regarding dosimetry and reporting of endovenous laser ablation (EVLA) mandates the development of a standardized protocol. This study presents the mid-term results of EVLA with 1940 nm-laser and radial-fibre, supported by a four-zone dosimetry tool. Four anatomical dosimetry zones for great saphenous veins (GSV) and two for small saphenous veins (SSV) were defined with set power levels. Zone-1G (4 W) extended from the inguinal ligament to the apex of femoral triangle, Zone-2G (4 W) from the apex of femoral triangle to the upper border of patella. Zone-3G (3 W) from the patella to the tibial tuberosity. Zone-4G (2 W) extended from the tibial tuberosity to the ankle. Zone-1S from the sapheno-popliteal junction to the tibial tuberosity. Zone-2S from the tibial tuberosity to the ankle. Power was increased by 1 W for veins >10 mm and decreased by 1 W when fibre sticking was encountered. Pullback-velocity was max. 1 mm/s. A total of 152 consecutive patients (185 procedures) were recruited. Mean follow-up time was 11.9 months. Mean linear endovenous energy density for GSV was Zone-1G:42 J/cm, Zone-2G:33 J/cm, Zone-3G:27 J/cm, Zone-4G:22 J/cm, Zone-1S:34 J/cm, Zone-2S:27 J/cm. Occlusion rates were 98.9% (1-month) and 93.7% (12-months). Complications at 1 M were low, namely laser-induced paraesthesia (LIP) 2.2% and endovenous heat-induced thrombosis (EHIT) 1.6%. Persistent LIP (12 M) was observed in 0.5%. The proposed four-zone guiding tool is a step towards standardizing dosimetry and documentation for EVLA with 1940 nm. This strategy shows good mid-term results with minimal complications. Long-term follow-up and application in further centres are necessary to prove its reproducibility. Such a guiding tool could improve the ability to analyse, compare and review different EVLA wavelengths and fibre types.

Ultrasound-guided percutaneous laser ablation of tributary varicose veins using a slim-type radial fiber.

This study presents the efficacy of ultrasound-guided percutaneous laser ablation of tributary varicose veins using a slim-type radial 2-ring fiber. One thousand consecutive patients who underwent endovenous laser ablation (EVLA) of incompetent saphenous veins were included. The tributary varicose veins were punctured with a 16G venule needle and ablated with a 1470nm laser system and a slim-type radial 2-ring fiber with a diameter of 1.27mm. The EVLA was performed with a power of 5W and linear endovenous energy density of around 30J/cm. Percutaneous varicose ablation was safely performed in 939 legs with an average of 5.9 times punctures per leg. No skin burn or nerve injury was observed after varicose ablation. Ultrasonography revealed complete occlusion of the treated veins 1month after EVLA. This study suggests that percutaneous varicose ablation with a slim-type radial 2-ring fiber is a safe and effective alternative to cover the weak point of ambulatory phlebectomy.

A randomized clinical trial to assess the impact of laser power with constant linear endovenous energy density on outcomes of endovenous laser ablation (SLEDGE trial)

ObjectiveTo date, conflicting evidence has been reported regarding the energy settings to use during endovenous laser ablation (EVLA). In the present study, we evaluated the outcomes of EVLA of the great saphenous veins (GSVs) using different power settings with the same linear endovenous energy density (LEED) of ∼70 J/cm. MethodsWe performed a single-center, randomized, controlled noninferiority trial with a blinded outcome assessment of patients with varicose veins of the GSV who underwent EVLA with a wavelength of 1470 nm and a radial fiber. The patients were randomly assigned to three groups according to the energy setting: group 1, 5 W power and an automatic fiber traction speed of 0.7 mm/s (LEED, 71.4 J/cm); group 2, 7 W and 1.0 mm/s (LEED, 70 J/cm); and group 3, 10 W and 1.5 mm/s (LEED, 66.7 J/cm). The primary outcome was the rate of GSV occlusion at 6 months. The secondary outcomes were pain intensity along the target vein the next day and at 1 week and 2 months after EVLA, the necessity for analgesics, and the occurrence of significant complications. ResultsFrom February 2017 to June 2020, 245 lower extremities of 203 patients were enrolled. Groups 1, 2, and 3 included 83, 79, and 83 limbs, respectively. At 6 months of follow-up, 214 lower extremities were examined with duplex ultrasound. GSV occlusion was observed in 72 of 72 limbs (100%; 95% confidence interval [CI], 100%-100%) in group 1 and 70 of 71 limbs (98.6%; 95% CI, 97%-100%) in groups 2 and 3 (P < .05 for noninferiority). No difference was found in the pain level, necessity for analgesics, or rate of any other complications. ConclusionsThe technical results, pain level, and complications of EVLA were not associated with the combination of energy power (5-10 W) and the speed of automatic fiber traction when a similar LEED of ∼70 J/cm was reached.

Satisfactory result of great saphenous vein endovenous laser ablation until below the knee on active venous leg ulcer: a case series

Background: Active venous leg ulcer (VLU) is the most severe manifestation of chronic venous disease which not only affects patients’ health, but also decreases the quality of life, and delivers economic burdens. Treatment of superficial venous reflux with early endovenous laser ablation (EVLA) has been proven to reduce ulcer recurrence levels and promote faster VLU healing. We reported three cases of patients with active VLU undergoing EVLA with different approaches. Case illustration: Three patients came with complaint of leg ulcer, diagnosed with C6sEpAsdPr, with venous clinical severity scores (VCSS) of 15, 23, and 22 respectively. Severe great saphenous veins (GSV) reflux was found in all patients by duplex ultrasound examination. The second patient had undergone above-the-knee EVLA. All patients underwent EVLA using 1470-nano meter wavelength laser device and ELVeS radial fiber (Biolitec, Bonn, Germany). The laser energy protocol used was 6 W linear endovenous energy density (LEED) 50 J/cm for proximal until media ATK GSV ablation, 5 W LEED 40 J/cm for media ATK until proximal below-the-knee (BTK) GSV, and 2 W LEED 20 J/cm for proximal until distal BTK GSV. The third patient was also treated with EVLA for small saphenous vein severe reflux. Follow-up until 6 months post-EVLA showed significant healing of the ulcer with 14, 16, and 17 VCSS reduction consecutively without any complication. Conclusion: We’ve reported three cases of patients with active VLU undergoing EVLA until BTK with significant results. The EVLA of GSV until BTK is safe and provides satisfactory results in patients with VLU.

Linear endovenous energy density (LEED) should always be quoted with the power used in endovenous thermal ablation - results from an in-vitro porcine liver model study.

Linear Endovenous Energy Density (LEED) is the energy used per cm of vein in endovenous thermal ablation (EVTA) but does not include time. This study examines the effect of time during EVTA. EVTA was performed in a previously validated porcine liver model. LEEDs of 40, 60, 80 and 100J/cm, using different powers were repeated 5 times each. Thermal spread, tissue carbonisation and device-tissue sticking during treatment were recorded. LEED positively correlated to thermal spread and carbonisation of the tissue. Power was correlated with carbonisation but not thermal spread. Pullback had no correlations with thermal spread or carbonisation. Catheter sticking found occurred in powers >= 15W or LEED >= 80J/cm. LEED is a good measure of EVTA but does not include time. Power, which does include time, correlates with carbonisation and with device-tissue sticking. The power used must be quoted with the LEED.

Rate of saphenous vein occlusion and side effects at 1 year follow up after 1470 nm endolaser.

Use of endolaser for chronic venous disease involves choosing the laser wavelength and optical fiber to use and the quantity of energy to be administered. Efficacy is assessed by the venous occlusion rate and safety is evaluated in terms of side effects. To determine the incidence of total post-endolaser saphenous vein occlusion at 1-year follow-up. To describe side effects and their incidence and rates of reintervention or supplementary treatment during the postoperative period. A retrospective, observational cohort study with a quantitative approach, enrolling patients with saphenous vein incompetence treated with intravenous 1,470 nm laser ablation. Data were input to an MS Excel 2019 spreadsheet, calculating means and standard deviations with the software's Power Query supplement. 38 patients and 104 venous segments were eligible for the study. 100% were occluded at 30 days and 99.04% were still occluded at 1 year after the procedure. Mean Linear Endovenous Energy Density administered to the internal saphenous vein was 2,040.52 W/cm/s with standard deviation of ± 1,510.06 W/cm/s and 1,168.4 W/cm/s with standard deviation of ± 665.011 W/cm/s was administered to the external saphenous vein. Pain along the saphenous path was the most common side effect, with eight cases (21.05%), followed by one case of paresthesia (2.63%). The total occlusion rate at 1-year follow-up suggests the technique is promising and is currently applicable in this sample. The incidence of pain and paresthesia may be caused by the high mean energy delivered in some cases. It is recommended that multicenter studies be conducted with larger and more uniform samples in terms of their Clinical-Etiological-Anatomical-Pathological classifications.

Morphological changes of veins and perivenous tissues during endovenous laser coagulation using 2-μm laser radiation and various types of optical fibers

ObjectiveTo determine the morphological changes in veins and perivenous tissues after endovenous laser coagulation (EVLC) using laser radiation with a wavelength of 1910 nm and different types of fibers (bare tip and radial). MethodsThe EVLC procedure was carried out on 22 surface veins of six sheep. The radiation source was a diode-pumped solid-state laser, which was based on a LiYF4:Tm crystal and had an emission wavelength of 1910 nm and a maximum output power of 10 W. Two types of optical fibers were used: (1) bare tip and (2) radial or radial with two rings. Histological and morphometric methods were used, and the statistical digital data were analyzed. ResultsThe use of a linear endovenous energy density of 20 J/cm and optical bare fibers for veins with diameters of 3-4 mm resulted in a slit-shaped or wide venous wall perforation. A thermal effect was observed on the perivenous connective tissue (PVCT), which caused damage to its structures. Wide perforations were accompanied by complete destruction of the PVCT in the projection of the formed defect. The distance between the remaining vein wall fragment, located opposite to the perforation, and injured small vessels was 257.7 ± 23.6 μm. The radius of thermal damage increased to 2073.5 ± 8.0 μm near the vessel perforation. Using optical radial fibers for veins with diameters of 3.9 ± 0.5 mm did not lead to perforations. The destructive effect of the laser on small vessels of the PVCT extended to a distance of 425.7 ± 22.0 μm. ConclusionsAnalysis of thermal vessel damage in perivenous tissue after EVLC with bare-tip fiber shows that in the projection of a wide perforation, the damaged vessels of the PVCT are located at a large distance from the coagulated vein wall. On the opposite side of the perforation, the distance from the coagulated vein wall to the damaged vessels of the PVCT is significantly reduced because of the minimal output of laser radiation energy through the poorly damaged part of the wall. Using an optical radial fiber facilitates the application of a uniform distribution of thermal energy to the vein wall and damage to all its layers; at the same time, it minimizes the thermal energy that extends beyond the vein wall and damages the surrounding tissue. Clinical RelevanceThe use of radiation with a wavelength of 1910 nm will make it possible to carry out endovenous laser coagulation of varicose veins at lower power values compared with radiation in the micron and one and a half micron regions of the spectrum. Understanding of morphological changes of veins and perivenous tissues after endovenous laser coagulation with 1910-nm laser radiation and different types of optical fibers (bare-tip, radial, radial 2ring) help predict possible complications and reduce their rate.

A randomized controlled trial to evaluate the safety and efficacy of transluminal injection of foam sclerotherapy compared with ultrasound-guided foam sclerotherapy during endovenous catheter ablation in patients with varicose veins

ObjectiveWe compared the safety, need for additional foam sclerotherapy, and 1-year venous clinical severity score (VCSS) improvement in the limbs of patients with chronic venous disease and great saphenous vein (GSV) reflux. These patients had undergone endovenous laser ablation (EVLA) using a 1470-nm diode laser and concurrent foam sclerotherapy (1% polidocanol) through the access sheath (transluminal injection of foam sclerotherapy [TLFS]) or EVLA and concurrent direct-puncture ultrasound-guided foam sclerotherapy (UGFS). MethodsIn the present study, we screened 467 patients (577 legs) with symptomatic primary GSV reflux for randomization to either TLFS with EVLA (n = 103 legs; TLFS group) or UGFS with EVLA (n = 94 legs; UGFS group). The exclusion criteria were (1) recurrent varicose veins after previous intervention; (2) hypersensitivity reaction to sclerotherapy; (3) acute deep vein thrombosis; (4) serious lower limb ischemic disease; (5) a coagulation disorder; and (6) simultaneous EVLA of both GSVs and small saphenous veins. The correlations of the VCSS changes with the clinical features, such as age, sex, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, total amount of sclerosant used at the original procedure, multiple punctures (more than two) for sclerotherapy at the original procedure, the use of TLFS, and linear endovenous energy density, were estimated using logistic regression. ResultsNo significant differences in the distribution of the CEAP classification were observed between the two groups. After 12 months of follow-up, all truncal veins were occluded. The VCSS had significantly improved in the TLFS group compared with the UGFS group (UGFS, −7.4 ± 1.8; TLFS, −8.7 ± 1.5; P < .0001). Multivariate analysis revealed that TLFS was the only significant factor for an improved VCSS (hazard ratio, 0.63; 95% confidence interval, 0.32-0.96; P < .0001). The need for additional second-stage sclerotherapy was significantly avoided in the TLFS group (n = 10; 10%) compared with the UGFS group (n = 51; 54%; P < .0001). ConclusionsTLFS combined with EVLA is a safe and feasible procedure that improves the VCSS and reduces the need for additional second-stage interventions compared with UGFS combined with EVLA.

Endovenous laser ablation of incompetent great saphenous veins with 1470-nm laser using bare tip and radial fibers results in similar short-term outcomes

ObjectiveThe common side effects of endovenous laser ablation (EVLA) are pain and discomfort in the treated leg. We compared the pain and outcomes after EVLA using a 1470-nm laser with bare tip or radial fibers in the treatment of incompetent great saphenous veins (GSVs). MethodsA total of 86 patients with primary varicose veins of the GSV were randomized to treatment using a 1470-nm laser and bare fiber (BF; n = 43) or radial fiber (RF; n = 43) during a 12-month period from January to December 2019. Patients were assessed clinically and using venous Doppler ultrasonography at 24 hours, 1 week, and 1 month. The periprocedural parameters and short-term outcomes of pain after the procedure, improvement in the Venous Clinical Severity Score (VCSS), and vein occlusion at 1 month were compared and analyzed. ResultsThe linear endovenous energy density (65.7 J/cm vs 65.2 J/cm), tumescent local anesthetic solution used (627.4 mL vs 661.4 mL), treated GSV length, and number of hook phlebectomies were similar in both groups. The pain score at 8 hours (2.77 vs 2.70) and 1 week (2.81 vs 2.74) were similar in the BF and RF groups, respectively. The improvement in the VCSS was significant in both groups and was slightly better in the BF group, although the difference was not statistically significant. Both fiber types had 100% efficacy in terms of closure of the treated vein at 1 month. ConclusionsEVLA using a 1470-nm laser with a BF had similar outcomes in the short term compared with a RF of the same wavelength. Both fibers were associated with significant improvement in the VCSS at 1 month.

Comparison of laser power output from the fiber tip during endovenous laser ablation against displayed power and the “first treatment” effect

ObjectiveInternational guidelines recommend endovenous laser ablation as one of the first-line treatments for truncal venous reflux associated with varicose veins. Clinicians use linear endovenous energy density to measure the energy used during treatment. The aim of this study was to investigate the power output from the fiber tip and to see if this changed with use. MethodsWe placed 15 mL of water in a thermally insulated 25-mL beaker. Two thermocouples were placed equidistantly adjacent to the laser fiber tip. A 1470-nm laser was fired at 5W for 2 minutes and the temperature change was measured. Three fibers were used on different days to allow the laser to cool for 24 hours between fibers. Each fiber was tested three times in a row. We also tested the “first treatment” effect by comparing the power output when the fiber was fired immediately after the laser was switched on, compared with treatments when the laser had been switched on for 1 hour. To assess whether this was due to the console being “cold” on the first firing of the day, we repeated the experiment having switched on the laser console 1 hour before firing to “prewarm” the console. However, the diode was not fired during this hour. To measure fiber degradation, three runs of the experiment were performed successively before firing the laser continuously for 20 minutes, then three more runs were conducted, resulting in delivery of approximately 10,000 J. ResultsThe actual power output seemed to be lower than the console suggested. The power output from the first fiber used in a succession of three with the same laser had a significantly lower power output than the following two runs (P = .0004 and P < .0001, respectively). When the laser was prewarmed for 1 hour without firing, no change in this output pattern was noted (P = .293). Fiber degradation was not found in any of the fibers that were tested within the maximum recommended for the fiber (10,000 J). ConclusionsThe first use of a fiber in a treatment session has a significantly lower power output from the treatment tip than subsequent uses, even if the machine is prewarmed and the console displays the same power for each. The authors believe that this phenomenon is due to the diode being less efficient when first used after switching it on. Clinicians need to be aware that the true power output at the fiber tip may not be as indicated by the console display and may be variable during a treatment session.

Whole-length great saphenous varicose veins thermochemical ablation, a novel technique: safety, efficacy, and mid-term follow-up results

Background Despite all advances in the treatment of varicose veins, recurrence rates are still high, and multiple factors have been incriminated. This study aims to evaluate the safety and efficacy of whole-length great saphenous vein ablation, starting flush with the saphenofemoral junction down to the ankle, using a new technique combining laser and chemical ablations. Patients and methods A prospective study was conducted that included patients with varicose veins who presented to the Vascular Surgery Department, Dr. Soliman Fakeeh Hospital, KSA, in the period from May 2016 to February 2018. All patients were treated with endovenous laser ablation of the whole great saphenous vein starting flush at the saphenofemoral junction using radial fiber combining low-level laser energy with truncal injection sclerotherapy for the below-the-knee vein segment with adjusted linear endovenous energy density. Patients were followed up for 18 months. Chronic venous disease quality of life questionnaire-20 (CIVIQ-20) was obtained before treatment and after 6–12 months. Results This study included 125 patients (132 limbs), their mean age was 40.4±11.8 years, male to female ratio was 1 : 2.4, Clinical, Etiological, Anatomical, Pathological (CEAP) classification was 2–6, the presentation was bilateral in seven (5.6%) patients, technical success was achievable in 99.3% of patients, need for extra-truncal treatment at the same time of ablation (laser, injection, or phlebotomy) in 64 (48.5%) patients, postoperative deep vein thrombosis was seen in 0%, saphenous nerve injury was seen in one (0.7%) case, recanalization at 6–12–18 months was seen in two (1.5%) cases, and improvement in CIVIQ-20 from 71.25±9.6 to 32.4±4.6 and 29.7±1.2 was seen at 6 and 12 months, respectively. Conclusion The use of the radial laser fiber allows safe flush thermal ablation of the great saphenous vein, with the anticipated decrease in groin recurrence, combined with thermochemical ablation of the below-the-knee segment has promising result in short-term and mid-term follow-up.

Endovenous Laser Ablation of Saphenous Veins Larger than 2 cm: a Prospective Study

Background. The current catheters and fibres used for endovenous laser and radiofrequency ablation of varicose veins have a radial energy emission. This gives an opportunity to treat veins of a large diameter which was previously considered to be challenging. The majority of studies categorise veins of more than 1 cm in diameter as large (Chaar C.I., et al. 2011; Florescu C., et al. 2014). Many patients have saphenous veins 1–2 cm in diameter, which can be occluded in almost 100% of cases. Treating veins more than 2 cm in diameter with tumescent anaesthesia may be associated with formation of a “blind pocket”. This means that a part of the vein does not have appropriate contact with the fibre. This can be one of the reasons for recanalisation. The aim of this study was to investigate the results of endovenous laser ablation (EVLA) of saphenous veins larger than 2 cm in diameter. Methods. This was a prospective non-comparative study that included 231 patients who underwent 261 EVLA of the great saphenous vein (GSV) between November 2014 and June 2019. EVLA was performed using 1470 nm laser, radial fibres, and an automatic pull back device. All procedures were performed under tumescent anaesthesia. The average diameter of the veins at the saphenofemoral junction was 24 ± 6 mm (range 21–43 mm). EVLA was administered at the average power of 8–10 W. The linear endovenous energy density in dilated segments was 83–147 J/cm. The follow up period was 178 ± 67 days (range 61–540 days). Duplex ultrasound was performed on days one and seven, and months two and six after the treatment. Results. Two hundred and thirty (88%) veins were occluded the day after EVLA. In 31 (12%) cases there were non-occluded segments of dilated parts of the saphenous vein on the day after the procedure. These segments were found to be occluded in 21 of 31 patients at seven days. In 11 (4%) cases, ultrasound guided foam sclerotherapy (UGFS) was performed. Short stumps of GSV (19 ± 6 mm) were found in 12 (5%) patients at six month follow up, with no reflux in these stumps. Recanalisation of a long segment of the GSV with reflux was found in two (0.8%) cases, which was treated by EVLA and UGFS. Conclusion. EVLA using radial fibres is effective for a GSV more than 2 cm with a 99% occlusion rate in the early follow up period.

Endovenous laser ablation: A comprehensive review.

To provide an evidence-based overview of endovenous laser ablation and describe its role as an effective and durable technique for the management of superficial venous insufficiency. The published literature on the treatment of varicose veins using endovenous laser ablation was reviewed. The literature search focused on the history of endovenous laser ablation, its safety and durability, known complications, and differences in outcomes based on the iterations of fiber type and laser wavelength. Treatment safety and efficacy of endovenous laser ablation appear to be based on the amount of energy administered over a defined distance, or the linear endovenous energy density. The ideal linear endovenous energy density varies with the laser wavelength and fiber-type. Post-operative pain and bruising may be reduced by the use of higher wavelength fibers or the use of radial or jacket-tip fibers as compared to bare-tip fibers. The incidence of endothermal heat-induced thrombosis remains low and has declined with increasing experience. Reports have demonstrated a greater than 90% technical success rate with saphenous endovenous laser ablation, long-term durability of ablation, and commensurate improvement in quality of life. Endovenous laser ablation is a safe and durable treatment option for the management of incompetent superficial and perforator veins of the lower extremities. As an endothermal technology, it remains a key component of the standard of care for the treatment of chronic venous insufficiency.

Endovenous Laser Ablation with and Without Concomitant Phlebectomy for the Treatment of Varicose Veins: A Retrospective Analysis of 954 Limbs

Endovenous laser ablation (EVLA) with concomitant phlebectomy is commonly performed in many institutions. However, phlebectomy is associated with cosmetic complications such as surgical scarring, hemorrhage, and hematoma. This study aims to compare the need for additional sclerotherapy during follow-up after EVLA with and without concomitant phlebectomy. Between November 2013 and December 2018, we performed EVLA on 1,363 limbs in 1,009 patients with symptomatic primary varicose veins, of which 954 limbs in 771 patients with great saphenous vein (GSV) or small saphenous vein (SSV) insufficiency were included in this study. Data were collected prospectively and supplemented with retrospective medical record review. Demographic and clinical characteristic profiles were collected. The outcomes of EVLA with or without concomitant phlebectomy were compared. Logistic regression was used to assess predictors for additional sclerotherapy after EVLA. CEAP classification (P<0.001), operative time (P<0.001), laser device type (P<0.001), length of the treated vein (P<0.001), linear endovenous energy density (P<0.001), and tumescent local anesthesia volume (P<0.001) differed significantly. Pain after EVLA was significantly more frequent in the nonphlebectomy group than in the phlebectomy group (P=0.005). During follow-up, 34 of 954 limbs (3.6%) underwent additional sclerotherapy for residual visible varicose veins after EVLA. No statistical difference was found in the rate of additional sclerotherapy between the groups (P=0.849). Logistic regression showed that female sex (odds ratio [OR], 6.18; 95% confidence interval [CI], 1.86-20.6; P=0.003) is significantly associated with additional sclerotherapy, and concomitant phlebectomy is not a significant predictor of additional sclerotherapy (OR, 0.844; 95% CI, 0.375-1.90; P=0.682). Patient preference for additional sclerotherapy was comparable between those who underwent EVLA with and without concomitant phlebectomy. This result supports our present strategy of avoiding simultaneous phlebectomy at the time of primary EVLA.

Effect of Transluminal Injection of Foam Sclerotherapy Combined with Endovenous Thermal Ablation of Varicose Veins

ObjectiveThe combination of endovenous therapies with stab avulsion or ultrasound guided foam sclerotherapy is widely performed. However, these conventional techniques tend to result in incomplete avulsions or persistent varicosities.MethodsOne hundred and thirteen legs in 97 consecutive patients who underwent 1470 nm laser ablation for great saphenous varicose veins were enrolled. The foam sclerosing agent was injected via the sheath after endovenous laser ablation (EVLA). Patients were divided into two groups: EVLA only group (Control; n = 50) and EVLA and transluminal injection of foam sclerotherapy (TLFS) group (SCL; n = 63).ResultsAt three month follow up, reflux was abolished throughout all treated great saphenous veins (GSVs) when assessed with Duplex ultrasound. Thrombophlebitis was observed in two patients in the SCL group (p = .13). Additional second stage sclerotherapy was needed in the Control group (n = 33, 66%) vs. SCL group (n = 2, 3%; p < .0001). The venous clinical severity score (VCSS) was significantly improved in the SCL group (changes of VCSS, Control −3.3 ± 1.7 and SCL -4.4 ± 1.0; p < .0001). Univariable and multivariable analyses revealed that, among age, sex, Clinical-Etiology-Anatomy-Pathophysiology classification, linear endovenous energy density, and TLFS, TLFS was the only significant factor of improved VCSS (hazard ratio = −0.96; 95% confidence interval = −1.4 to −0.58; p < .0001).ConclusionsTLFS combined with EVLA may be an easy, safe, and effective procedure with acceptable complications vs. EVLA alone and reduces additional second stage interventions.

The Use of Micronized Purified Flavonoid Fraction for Postoperative Symptoms Regression After Endovenous Thermal Ablation. A Randomized Controlled Study

Introduction: Micronized purified flavonoid fraction (MPFF) is a venoactive agent with proven positive effects in the treatment of chronic venous disease. The aim of our study was to assess the use of MPFF for the post-operative symptoms relief after endovenous thermal ablation (EVTA) with phlebectomies. Methods: 120 patients undergoing EVTA (Laser 1470nm or Radiofrequency) of the greater saphenous vein with phlebectomies were randomized in two groups: group 1 (60 patients) receiving MPFF 500mg Bid 7 days before and 30 days after the procedure; and group 2 (60 patients) not receiving MPFF (Control group). Demographics (age, gender), intra-operative details such as (type of ablation, linear endovenous energy density, vein diameter and length of ablated vein), Clinical -Etiology- Anatomy- Pathophysiology (CEAP) clinical classification, 10-cm Visual Analog Scale (VAS) for pain, Venous Clinical Severity Score (VCSS) and Chronic Venous Insufficiency Quality-of-Life Questionnaire (CΙVIQ) were recorded. Follow up visits were performed at 7 days prior to ablation and 7 and 30 days post-ablation. Primary outcome was postoperative pain assessement using the VAS scale and CIVIQ pain score. Secondary outcomes included assessemnt of VCSS and CΙVIQ scores. Results: Patients' demographics, CEAP clinical classification and intra-operative details were not different between the two groups. Mean preoperative VAS and CIVIQ pain score were similar in both groups (5±1.9 and 8.7±3 in the group 1 vs. 5.4±1.7 and 9.4±3.4 in the group 2, respectively; p=0.7). At 30-day follow up an improvent of VAS and CIVIQ pain score was recorded in both groups (0.2±0.5 VAS pain score and 4.5±1.1 CIVIQ pain score in the group 1 vs 1.1±1.3 and 5±1 in the group 2, respectively), (p=0.03). The improvement of VAS and CIVIQ pain scores was higher in the group 1 in comparison to group 2 at 7 day and 30 day postoperatively in realtion to pre-operative status [at 7 days: VAS; group 1 from 5±1.9 to 1.5±1.5 vs. group 2 from 5.4±1.7 to 2.6±1.8 (p=00.4); CIVIQ; group 1 from 8.7±3 to 5±1.2 vs. group 2 from 9.4±3.4 to 5.8±1.8 (p=0.04); at 30 days: VAS; group 1 from 5±1.9 to 0.2±0.5 vs. group 2 from 5.4±1.7 to 1.1±1.3 (p=0.04); CIVIQ; group 1 from 8.7±3 to 4.5±1.1 vs. group 2 from9.4±3.4 to 5±1 (p=0.03)]. Both groups showed a significant improvement in all domains of CIVIQ and VCSS compared to preoperative assessment (p=0.02) at 30-days post-operatively, but there was no difference between the two groups in terms of improvement. Conclusion: Administration of MPFF agent in patients undergoing EVTA may improve postoperative pain. Larger studies are needed to confirm these findings. Disclosure: Nothing to disclose

Patency of Anterior Accessory Saphenous Vein Following Endovenous Laser Ablation for Varicose Veins: Bare-Tip Versus Radial Fiber

Introduction - Anterior accessory saphenous vein (AASV) insufficiency is one of the most common causes of late recurrence after endovenous laser ablation (EVLA) for great saphenous vein (GSV) insufficiency1)2). Therefore, reduction of the AASV patency rate after EVLA can be associated with better long-term results. The aim of this study is to compare the patency rate of saphenofemoral junction tributaries after EVLA between bare-tip and radial fibers. Methods - We reviewed 375 limbs in 339 patients undergoing EVLA for GSV insufficiency. The bare-tip fiber with a 980-nm diode laser was used in 299 limbs (group B). The radial fiber with a 1470-nm diode laser was used in 76 limbs (group R). Concomitant ablation of AASV or high ligation of GSV was not included in this study. Patients who had previous EVLA, high ligation and stripping were excluded. Duplex ultrasound scanning was performed 3 months after EVLA to assess occlusion of the ablated GSV and patency of the saphenofemoral junction tributaries including the AASV, the posterior accessory saphenous vein (PASV) and the superficial epigastric vein (SEV) in both groups. Student-t tests and chi square tests were used to compare two groups. Results - The total occlusion rate of the ablated GSV at 3 months after EVLA was 100% in group R and 99% in group B, p = 0.999. The patent AASV was detected significantly (p = 0.004) less in group R (33 limbs, 43%) than in group B (184 limbs, 62%), whereas the PASV patency rate was similar (p = 0.815) in both groups (16% in group R, 15% in group B, p = 0.815). The SEV occlusion rate was 4% in group R and 1% in group B, p=0.101. There was no difference in age, gender, body mass index, CEAP classification and the proximal GSV diameter in both groups. Laser power was smaller in group R (8.9 +/- 0.9 W) than in group B (9.4 +/- 0.6 W), p < 0.001, however, linear endovenous energy density did not differ between the groups (79.9 +/- 13.6 J/cm in group R, 78.3 +/- 9.2 J/cm in group B, p = 0.198). The distance between the tip of the fiber and the common femoral vein was shorter in group R (9.7 +/- 2.4 mm) than in group B (17.5 +/- 4.9 mm), p < 0.001. Conclusion - EVLA using a radial fiber archived better occlusion rates of AASV. This result can be attributed to the position of the laser fiber tip closer to the saphenofemoral junction. Our study suggests that EVLA using a radial fiber will reduce the risk of late recurrence caused by AASV insufficiency in the treatment of GSV varicose veins. References1)J Vasc Surg. 2016; 63: 420-428.2)Eur J Vasc Endovasc Surg. 2011; 41: 685-690.