Linear Endovenous Energy Density Research Articles

Endovenous laser ablation (EVLA): a review of mechanisms, modeling outcomes, and issues for debate

Endovenous laser ablation (EVLA) is a commonly used and very effective minimally invasive therapy to manage leg varicosities. Yet, and despite a clinical history of 16 years, no international consensus on a best treatment protocol has been reached so far. Evidence presented in this paper supports the opinion that insufficient knowledge of the underlying physics amongst frequent users could explain this shortcoming. In this review, we will examine the possible modes of action of EVLA, hoping that better understanding of EVLA-related physics stimulates critical appraisal of claims made concerning the efficacy of EVLA devices, and may advance identifying a best possible treatment protocol. Finally, physical arguments are presented to debate on long-standing, but often unfounded, clinical opinions and habits. This includes issues such as (1) the importance of laser power versus the lack of clinical relevance of laser energy (Joule) as used in Joule per centimeter vein length, i.e., in linear endovenous energy density (LEED), and Joule per square centimeter vein wall area, (2) the predicted effectiveness of a higher power and faster pullback velocity, (3) the irrelevance of whether laser light is absorbed by hemoglobin or water, and (4) the effectiveness of reducing the vein diameter during EVLA therapy.

Comment to: Six-year follow-up of endovenous laser ablation for great saphenous vein incompetence, by Spreafico G, Piccioli A, Bernardi E, Giraldi E, Pavei P, Borgoni R, Ferrini M, Baccaglini U. J Vasc Surg 2013;1:20-5.

A prospective cohort study to assess the efficacy of endovenous laser ablation (EVLA) for treatment of great saphenous vein (GSV) insufficiency over a 6-year follow-up period was conducted at the Multidisciplinary Centre of Outpatient Surgery - University Hospital, Padua (Italy). Patients were recruited between January 2003 and July 2004, and the follow-up phase lasted until July 2010. Two hundred and four patients underwent EVLA procedure at the outpatient surgery unit. A 980-nm diode laser and tumescent echo color doppler (ECD) guided perivenous anesthesia were used. The most prominent varices were treated with stab-vein avulsion immediately after the EVLA procedure. All patients had to wear 35-mm Hg elastic compression stockings for 24 h daily during the first week after EVLA, and then switch to second-class graduated elastic compression stockings for 4 weeks more. Patients were scheduled for clinical and ECD assessments at 3, 7, 30, and 90 days after EVLA; and thereafter once a year, for 6 years. The main outcome of the study was the incidence of clinical (e.g., lack of improvement or worsening of leg symptoms) and ECD-confirmed (e.g., finding of measurable venous reflux in the treated segment) EVLA failures (ECEFs) during the planned 6-year follow-up period. The ECEFs were categorized as type 1 (venous reflux limited to the junction and/or the residual saphenous stump, for a maximum length of 5 cm from the junction, without reflux in its collaterals); type 2 (reflux also in a collateral vein without clinically evident recurrent varices ); or type 3 (same as 2 with clinically evident recurrent varices, either symptomatic or asymptomatic). One hundred and twenty four patients (60.8%) underwent stab-vein avulsion as well; and 65 patients (32.8%) with residual varicose veins received sclerotherapy within 12 weeks from the procedure. Fourteen (6.8%) out of 204 patients were lost for follow up. No deep vein thrombosis was detected during the follow-up period. After 6 years, 168 (88.4%) patients reported a symptomatic improvement; of them, 87 patients had no residual symptoms, and 81 experienced a significant reduction of their leg complaints. Fourteen patients complained of persistent symptoms, six reported unsatisfactory aesthetic results, and two patients had worsened skin alterations. Of these 22 patients, only two had an ECEF as well. Patients with a competent saphenous junction and a persistently occluded saphenous trunk were 70.0% (133/190); therefore, 57 (30.0%) had an ECEF. Of them, 20 patients had a type 1 ECEF, 18 had a type 2 ECEF [three of which were at the anterior accessory saphenous vein (ASSV)], and 19 had a type 3 ECEF (12 of which were at the ASSV). An atypical junction or one with a diameter ≥8 mm and a mean trunk diameter ≥8 mm, were highly significantly associated with ECEF. Expected EVLA results, either from a clinical or technical (ECD) perspective, were obtained in 88.4% and 70.0% patients, respectively, and persisted throughout the 6-year follow-up period. All failures were observed within the first 2 years from EVLA. The unexpectedly high (57/190; 30.0%) rate of ECEF is possibly due to the systematic application of the Valsalva maneuver during ECD; this probably accounts for the high rate of type 1 ECEF. It is likely that most of the technical failures observed will soon be eliminated thanks to the use of adequate linear endovenous energy density (LEED) (at least 70 joules/cm), which was not in use in the period studied, and to the latest implements now available.

Comparing cold and warm tumescent anesthesia for pain perception during and after the endovenous laser ablation procedure with 1470 nm diode laser

The aim of this study was to compare the pain perception and side effects during and after endovenous laser ablation with a 1470 nm diode laser using cold or room temperature tumescence anesthesia. One hundred and one patients were randomly assigned in two groups. Group A received room temperature (+24℃) and Group B received cold (+4℃) tumescence fluid, which was used for local anesthesia in the track of great saphenous vein. A visual analog score was recorded immediately after the procedure. Patients were asked to register pain scores and the amount of pain medication consumed during the week. There was no significant difference concerning gender, age, Clinical Etiological Anatomical Pathological Classification, body mass index, or diameter of the treated vein. In Group A, the mean linear endovenous energy density was 59.5 J/cm and in Group B, it was 60.4 J/cm. The average visual analog score after the endovenous laser ablation procedure in Group A was 5 and in Group B was 2. Third day after the procedure, the average visual analog score in Group A was 3 and in Group B was 1. Patients in Group B needed significantly less analgesics compared with patients in Group A (p<0.05). The most frequent side effects in both groups were ecchymosis, induration, and minor paraesthesia, all of which were more common in Group A (p < 0.001). To date, most published endovenous laser ablation series describe the use of room temperature tumescence fluid infiltration of the perivenous stroma for tumescent analgesia and protection against thermal injury to the nearby structures. We describe an alternative technique using cold tumescence fluid infiltration, which is equally effective as, but safer than, room temperature tumescence fluid infiltration, and which yields better visual analog scores.

Endovenous Ablation of Incompetent Saphenous Veins with a New 1,540-Nanometer Diode Laser and Ball-Tipped Fiber

Endovenous laser ablation (EVLA) is an efficient method to treat incompetent saphenous veins with high occlusion rates. The major side effects are postoperative pain and bruising. Laser systems with higher wavelengths, associated with new energy delivery devices, have recently shown excellent short-term results, while reducing the previously reported side effects. The aim of this study is to show the first outcome after EVLA of incompetent saphenous veins with a newly developed ball-tipped fiber and a new wavelength 1,540-nm diode laser. Forty-five incompetent saphenous veins in 35 patients (27 women) were treated: 33 great saphenous veins, 6 short saphenous veins, and 6 anterior saphenous veins. The gravity of chronic venous disease was determined according to the clinical-etiology-anatomy-pathophysiology (CEAP) classification, and the severity of symptoms was scored according to the revised Venous Clinical Severity Score. Patient satisfaction was assessed on a 0-3 scale. The average linear endovenous energy density was 63.5 J/cm of vein length. Patients returned to daily activities after a mean of 1.7 days (SD: 2) after treatment. The modified CEAP clinical severity score improved drastically from a preintervention mean of 4.9 (SD: 2.6) to 0.17 (SD: 0.38) at day 30. During the follow-up period (mean: 168 days [range: 90-240 days]), all the veins were occluded. All patients except 1 were satisfied or very satisfied with the method. No severe complications occurred. Two patients (5%) developed mild paresthesia in the treated area, which spontaneously resolved after 3 months. Postoperative ecchymoses are frequent (83%). Sixteen patients (43%) experienced pain, but only 5 patients (14%) described it as quite intense and required analgesic therapy. EVLA of saphenous veins with a 1,540-nm diode laser using a ball-tipped fiber is a safe and efficient therapy option, with a high success rate in the early postoperative period.

Endovenous laser treatment of the great saphenous vein: Measurement of the pullback speed of the fiber by magnetic tracking

Endovenous laser treatment (ELT) is a minimally invasive technique used to treat varicose veins. In this technique, an optical fiber is inserted into the vein to be treated and the laser lights while the optical is slowly withdrawn. The average linear endovenous energy density (LEED) delivered during the procedure is determinant in the success of this therapy. Recanalization and side effects are energy-dependent. Thus, the success of the therapy is mainly related to the pullback speed of the fiber. Ideally this speed has to be 1mm/s. The purpose of this investigation was to evaluate in real time the fiber pullback speed. In order to measure in real time the motion of the fiber inside the saphenous vein, magnetic tracking was used. The system was evaluated during the treatment procedures for 18 patients. The mean pullback speed was 1.02±0.15mm/s similar to the speed the physician wanted to obtain. Based on quality control, safety standards, and regulations official documents for medical lasers, where a 20% accuracy is admitted; only one patient was treated with an average pullback speed inferior to 0.8mm/s (0.77cm/s) and two patients were treated with an average pullback speed superior to 1.2mm/s (1.26mm/s and 1.32mm/s). Consequently, even for a well-trained physician, variations can be observed. These variations could easily explain why complications (too low speed and consequently too high LEED) or recurrences (too fast speed and consequently too low LEED) are sometimes reported in clinical studies. A standardized or an automatic withdrawal of the fiber could possibly improve this technique but remains to be carefully evaluated.

A comparison between two different linear endovenous energy density (LEED) for great saphenous vein ablation using 1470-nm diode laser

Introduction: The immediate success rate of endovenous occlusion of the great saphenous vein (GSV) and its durability after endovenous laser ablation (EVLA) was postulated to be the matter of a dose-response relationship to the amount of laser energy used. Patients and methods: Patients presenting with varicose veins with incompetent GSV scheduled for EVLA were randomized into Group A who received low linear endovenous energy density (low LEED), and group B who received high linear endovenous energy density (High LEED) using the new 1470-nm diode laser. Patients were followed up for 6 months for the durability ofGSV occlusion and the occurrence of unwanted side effects after the procedure. Results: Between April 2011 and May 2012, we treated 63 legs in 58 patients. We had no statistically significant difference between the two groups regarding the occurrence of early post-operative side effects as pain, paraesthesia, and ecchymosis. Regarding ultrasound proven durability ofGSV occlusion after 6 months, data showed total occlusion of the treated GSV segment in 24 out of 32(75%) legs in group A versus 30 out of 31(96.7%) legs in group B. This data indicates a statistically significant difference (P= 0.04) regarding the failure of treatment in the treated GSV segment in group A patients who had the Low LEED 35J/cm in comparison to group B patients who had the High LEED 50J/cm. Conclusion: The use of the 1470-nm diode laser radial fiber (ELVeS-radial kit) with a high laser energy dose (LEED 50J/cm) was optimum in achieving a durable GSVocclusion without a significant increase in unwanted side effects when compared to lower laser energy dose (LEED 35J/ cm).

Local cooling effect on perforation rates comparing the 980–1470 nm laser wavelengths used with endovenous laser ablation: double blindin vitroexperimental study

Endovenous laser treatment (EVLA) is fast gaining acceptance as an alternative to open surgery for the treatment of saphenous vein incompetence. The method of action of these techniques is based on heat, making tumescence anaesthesia necessity. Heat-induced complications may occur with inadequate application of tumescent anaesthesia. Our hypothesis was, local cooling effect of tumescent anaesthesia on tunica adventitia might be kept undamaged from disruption due to the thermal injury. We experimented with two popular laser wavelengths (980 and 1470 nm) and with two different thermal media (+4 and +24) in vitro for perforation. Twenty different 12 cm length vein pieces were numbered randomly to set up four groups of the experiment. Endovenous laser procedures were applied in same manner in a unique design test tube with same energy density per pieces on same duration (10 W/second) (linear endovenous energy density 60 J/cm). Procedure video was recorded for macroscopic perforations. All postprocedure vein segments were examined microscopically. Activities of both wavelengths were much better in cold medium (P < 0.05). Cold tumescent anaesthesia reduces the bleeding complication rate. But the performance of 1470 nm laser was better than that of 980 nm in cold environment (P = 0.0136). It can be commented that reducing the ambient temperature is more beneficial than modifying the laser wavelength on perforation rates. Therefore we suppose tumescent anaesthesia temperature is effective on perforation independently from the wavelengths or type of the laser fibre.

Which is More Important for Postoperative Recovery: Laser Wavelength or Fibers?

Rapid progression in technique and technology has characterized the growth of endovenous laser ablation since its inception. Moreover, the treatment parameters that have demonstrated significance in altering patient outcomes including: power, wavelength, linear endovenous energy density (LEED), and type of fiber-tip. Postoperative outcomes concerning pain and bruising have been attributed to vein wall perforation. This study presents an in-vitro method to quantify the potential for pain and bruising by comparing the degree of perforation of vessels with regard to wavelength and fibers.

What Is the Optimal Energy Density of 1,470 nm Diode Laser in the Treatment of the Varicose Veins?

Purpose: This study was done to determine the suitable level of energy for the elimination of saphenous veins. Methods: A randomized comparative study was done to determine the optimal linear endovenous energy density (LEED) for EVLT of incompetent great saphenous veins. Between October 2009 and September 2010, in 268 (173 women, 95 men) patients with a mean age of 43.1 (range 20∼80) were treated, using a 1,470 ㎚ diode laser at 10 watts in continuous mode. Patients were randomized to undergo EVLT with 100 J/cm (Group A) or 80 J/㎝ (Group B), respectively. They were evaluated clinically and by duplex at 1, 3, and 6 months and 1 year. Results: There was no significant difference concerning gender, age, C of CEAP or diameter of the treated veins. Successful occlusion rates of the GSV, defined as the absence of flow on color doppler imaging, were 92% in Group A and 91% in Group B. There was no deep vein thrombosis, superficial burns or thrombophlebitis. In group A, visual analog scale was 3.7.6, which was higher than group B (2.3.2). The area of ecchymosis was 37.5% in group A, but 12.5% in group B. Conclusion: There was no significant difference between 80 J/㎝ group and 100 J/㎝ group in terms of occlusion rate within 1 year. Long-term results will be required to determine the optimal level of energy.

Does Puncture Site Affect the Rate of Nerve Injuries Following Endovenous Laser Ablation of the Small Saphenous Veins?

Objectives The small saphenous vein (SSV) lies in close relationship with sural nerve and is at risk of damage during surgery or vein ablation procedures on this vein. The aim of this study was to compare the effect of puncture site for SSV endovenous laser ablation (EVLA) on the rate of post-operative sural nerve injury. Design Randomised controlled study. Patients and Methods Sixty patients with isolated SSV varicose veins (68 limbs) were randomised into two groups. All patients were treated with endovenous laser ablation procedures using radial fibres and a 1470 nm diode laser. In Group 1, SSVs were canulated from lateral malleolar part of the SSV. In Group 2, SSVs were canulated in the mid-calf. EVLA procedures were performed by using 12 W energy and 70 J cm −1 LEED (linear endovenous energy density). Local pain, ecchymosis, induration and paraesthesia in treated regions, vein diameter, treated vein length, tumescent anaesthesia volume, delivered energy were recorded. Follow-up visits were arranged on the 2nd post-operative day, 7th day, 1st, 2nd, 3rd and 6th months. Results The mean SSV diameters at sapheno-popliteal junction (SPJ) and calf levels were Group 1 SPJ: 6.6 S.D. 1.2 mm, Calf: 5.1 S.D. 1.1 mm, and Group 2 SPJ: 6.8 S.D. 1.6 mm, Calf: 4.9 S.D. 1.3 mm. Adverse events after treatment were 1 patient with induration, 3 with ecchymosis and 6 minimal paraesthesia in Group 1 (malleolar) and 1 local pain, 4 minimal ecchymosis or induration and 1 paraesthesia in Group 2 (mid-calf). In Group 1 in two patients the paraesthesia lasted 2 months and then resolved spontaneously. In the remaining four patients’ paraesthesia resolved in less than 1 month without treatment. In Group 2 paraesthesia resolved spontaneously in two weeks. Induration, ecchymosis and local pain also resolved in less than 2 weeks in both groups. There was no recanalisation or reflux in the treated SSV of either group during the follow-up period. Conclusion Treatment of the SSV by endovenous laser ablation using a 1470 nm laser and a radial fibre is safe and effective. Puncturing the vein at mid-calf level causes less post-operative nerve injury without affecting the recanalisation rates.

Endovenous laser ablation of great saphenous veins using a 1470 nm diode laser and the radial fibre – follow-up after six months

Endovenous laser ablation (EVLA) is an efficient method to treat insufficient great saphenous veins (GSV) with high occlusion rates. Most studies used 810, 940 or 980 nm diode lasers and a bare fibre. Moderate postoperative pain and bruising are frequent findings. Laser systems with higher wavelengths like 1470 nm with a higher absorption in water show less pain and bruising after the procedure. A newly-developed fibre (radial fibre, Biolitec) emits the laser energy radially around the tip directly into the venous wall contrary to the bare fibre.(9) The aim of this study was to demonstrate the outcome and side-effects after EVLA of GSV with a 1470 nm diode laser (Ceralas E, Biolitec) by using the radial fibre. Non-randomized, prospective study including 50 unselected limbs of 50 patients with a duplex sonographically verified incompetent GSV. EVLA was performed with a 1470 nm diode laser (Ceralas E, Biolitec) and a radial fibre. In the same session all insufficient tributaries were treated by phlebectomy. Tumescent local anaesthesia with 0.05% lidocaine was applied perivenously. Laser treatment was carried out in a continuous mode with a power of 15 W. Compression stockings (30 mmHg) were applied for one month. Postinterventional checkups took place one, 10, 30 days and six months after the procedure. Three patients were lost to follow-up. The average linear endovenous energy density (LEED) was 90.8 J/cm vein (SD 35.3). At the six month follow-up all treated veins remained occluded and no new reflux in the treated segments occurred. No recurrent varicose veins had occurred so far. No severe complications such as deep venous thrombosis could be detected. In four patients at 30 days and three patients at six months local paresthesia occurred in the region of EVLA. Forty-four percent of patients did not have any pain after the treatment and 50% did not take any analgesic tablets at any time after the procedure. Postoperative ecchymoses in the track of the treated GSV was rare. In 80% of the limbs, no ecchymoses was observed after the treatment. EVLA of GSV with a radially emitting laser fibre by using a 1470 nm diode laser is a safe and efficient treatment option.

Outcomes Using a 1470-nm Laser for Symptomatic Varicose Veins

The aim of this study was to evaluate safety and effectiveness of the laser fiber with wavelength of 1470 nm for ablation of symptomatic varicose veins. This was a prospective study carried out from November 2007 to October 2009. Seventy-six limbs in 72 consecutive patients were treated by endovenous laser ablation (EVLA). Baseline preprocedural clinical and ultrasonic grading of varicose veins was done. Endovenous laser ablation was done under ultrasonic guidance, and prior superficial venogram was taken if required. After the procedure all the patients were followed up with for 1 year with duplex ultrasound scan, and improvement in grading of venous disease was assessed. One hundred eight treated veins of 76 limbs were followed up on day 2, 1 month, 6 month, and 12 months postprocedurally. At the end of 1-year follow-up, venous occlusion rate and ulcer healing rate were 98.61% and 85%, respectively. The average preoprocedure clinical grade and venous disability score improved significantly at 12 months. Most of the postprocedure complications were transient and self limiting; the most common complication was paresthesia (10.53%). No major complications, such as deep vein thrombosis, occurred. When the authors compared legs treated with linear endovenous energy density below or above 100 J/cm, the paresthesia rate and postoperative pain was significantly higher in the second group, with energy density more than 100 J/cm. EVLA, using 1470-nm laser, is a minimally invasive, safe, outpatient department (OPD) procedure that causes less postprocedural pain with linear endovenous energy density (LEED) less than 100J/cm.

1470 nm diode laser for endovenous ablation (EVLA) of incompetent saphenous veins - a prospective randomized pilot study comparing warm and cold tumescence anaesthesia

Major side effects after endovenous laser ablation (EVLA) are pain and bruising. Low temperature of the tumescence fluid might cause additional venous constriction and a cooling effect around the vein. The aim of this study was to show outcome and side effects after EVLA of incompetent great saphenous veins (GSV) with a 1470 nm Diode laser (Ceralas E, biolitec) using cold or warm tumescence fluid for anaesthesia. Between August and November 2007, 85 consecutive patients (85 legs) with an incompetent GSV were treated by EVLA. The patients were randomized in two groups. In 42 patients (Group A) a warm (37 degrees C) and in 43 patients (Group B) a cold (5 degrees C) tumescence fluid (TF) was used for local anaesthesia in the track of GSV. All patients were re-examined after 1, 10 and 30 days clinically and by duplex for complications and occlusion in the treated vein segment. Patient's satisfaction was assessed on a 0 to 4 points scale. In each group one patient was lost to follow-up. There was no significant difference concerning gender, age, C of CEAP, BMI or diameter of the treated vein. In Group A a mean of 462 ml TF and in Group B a mean of 428 ml TF were used. In Group A the mean LEED (average linear endovenous energy density) was 114 J / cm and in Group B 115 J / cm. In both groups occlusion of the treated veins was achieved for all patients. The diameter of the GSV at 3 cm below the sapheno-femoral junction shrunk from 1.0 to 0.7 cm in both groups. The modified CEAP clinical score improved in Group A from 2.9 to 0.7 (mean value) and in Group B from 3.0 to 1.1. The mean pain score on a scale from 0 to 4 during day 2 to day 10 was 1.2 in Group A and 1.0 in Group B. At this time patients in Group A took a mean of 3.4 and in Group B 1.7 analgetic tablets. Ecchymoses were rare in both groups (4 in Group A, 7 in Group B). In this prospective randomized comparative study the temperature of the tumescence fluid did not influence the occlusion rate when a high LEED was used. In both groups pain and ecchymoses are less frequent in this study with a 1470 nm diode laser than reported in studies with 810-980 nm systems. Cold tumescence fluid reduced pain slightly and reduced the intake of analgetics significantly.

Endovenous laser ablation of varicose veins with the 1470-nm diode laser

Endovenous laser ablation (EVLA) is one of the most accepted treatment options for varicose veins. In previous studies conducted with a laser at 810 to 1320 nm, paresthesia, pain, and ecchymosis were common adverse effects. We hypothesized that a lower linear endovenous energy density (LEED), as used with 1470-nm diode laser fibers, would lead to a reduction in adverse events. We conducted a prospective, nonrandomized observational cohort study of 312 consecutively treated lower limbs legs in 286 patients. Of these, a bare laser fiber (ELVeS-plus kit) was used to treat 168 legs in 150 patients (group 1), and a radial fiber (ELVeS-radial kit) was used in 144 legs in 136 patients (group 2). Laser treatment was performed in the great saphenous vein. Follow-up for all patients was 3 months. The primary end point was the occurrence of ecchymosis and bruising. This was correlated to the reduced LEED needed with the 1470-nm diode laser. Laser fiber (odds ratio [OR], 22.3; 95% confidence interval [CI], 20.2-24.5) and body mass index (OR, 0.35; 95% CI, 0.15-0.55) were identified as independent parameters for LEED. In group 2 compared with group 1, LEED in the great saphenous vein could be reduced from 79.4 +/- 9.1 to 57.4 +/- 10 J/cm (P < .0001). LEED was an independent parameter for skin bleeding (OR, 1.04; 95% CI, 1.017-1.058). Ecchymosis and bruising were significantly less frequent in group 2 than in group 1 (P < .0001). The need for analgesia was low, with 103.08 +/- 15.34 mg diclofenac-sodium in group 1 vs 82.08 +/- 18.86 mg in group 2 (P < .04). Occlusion with elimination of reflux was achieved in 100% of group 1 and group 2 (P < 1). No recanalization occurred at follow-up. Endovenous laser treatment of varicose veins in the great saphenous vein with the 1470-nm diode laser is safe and highly effective. The lower energy level needed using the radial laser fiber significantly minimized adverse effects compared with the bare laser fiber.

Endovenous Laser Ablation (980 nm) of the Small Saphenous Vein in a Series of 147 Limbs with a 3-Year Follow-up

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 10 W. The pulse duration (1.5–3 s) was chosen to deliver a linear endovenous energy density (LEED) depending on the SSV diameter measured 1.5 cm below the sapheno-popliteal junction (SPJ) with the patient standing. For SSV diameters between 2 and 4.5 mm, the LEED applied was 50 J cm−1. The LEED was 70 J cm−1 for 4.5–7 mm, 90 J cm−1 for 7–10 mm. 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 9 mm. 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.

Endovenous Laser Ablation (980nm) of the Small Saphenous Vein in a Series of 147 Limbs with a 3-Year Follow-up

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. 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 1.5 cm below the sapheno-popliteal junction (SPJ) with the patient standing. For SSV diameters between 2 and 4.5mm, the LEED applied was 50 Jcm(-1). The LEED was 70 Jcm(-1) for 4.5-7 mm, 90 Jcm(-1) for 7-10mm. Patients were evaluated at 1-week, 1-month, 1-year, 2-year and 3-year follow-up. 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 9 mm. 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. 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.

Use of a New Endovenous Laser Device: Results of the 1,500 nm Laser

A new endovenous laser wavelength (1,500 nm 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. In 129 patients, 158 GSVs were treated using the 1,500 nm diode laser. An average linear endovenous energy density of 53.4 J/cm and an average endovenous fluence of 32.21 J/cm(2) were administrated to the vein. 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. Endovenous laser treatment of the GSV using a 1,500 nm diode laser is effective and safe. The marked shrinkage of the treated veins can guarantee good long-term results.

Endovenous 980-nm laser treatment of saphenous veins in a series of 500 patients

In recent years, endovenous laser treatment (ELT) has been proposed to treat incompetent great saphenous veins (GSV). This study reports the long-term outcome of ELT in a series of 500 patients. Incompetent GSV segments 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 diode laser (Pharaon, Osyris, France). The GSV diameter was measured by Duplex examination in an upright position in different GSV segments (1.5 cm below the saphenofemoral junction, crural segment, condylar segment, and sural segment). These measurements were used to determine the optimal linear endovenous energy density (LEED) for each segment. During treatment, patients were maintained in the Trendelenburg position. Patients were evaluated clinically and by duplex scanning at 1 and 8 days, 1 and 6 months, and at 1, 2, 3, and 4 years to assess treatment efficacy and adverse reactions. A total of 511 GSVs were treated. The mean diameter was 7.5 mm (range, 2.4 to 15.0). The LEED was tuned as a function of the initial GSV diameter measured in the orthostatic position, from 50 J/cm (3 mm) up to 120 J/cm (15 mm). At the 1-week follow-up, 9.3% of the patients reported moderate pain. In the immediate postoperative period, the closure rate was 98.0% and remained constant during the 4-year follow-up to reach 97.1%. After 1 year, a complete disappearance of the GSV or minimal residual fibrous cord was noted. Major complications have not been detected; in particular, no deep venous thrombosis. Ecchymoses were seen in 60%, transitory paresthesia 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 junction diameter >1.1 cm or for GSV truncular diameter >0.8 cm) ELT of the incompetent GSV with a 980-nm diode laser appears to be an extremely safe technique, particularly when the energy applied is calculated as a function of the GSV diameter. It is associated with only minor effects. Currently, ELT has become the method of choice for treating superficial veins and has almost replaced the treatment of traditional ligation and stripping.

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

Limited data are available about treatment-related side effects with respect to laser wavelength in endovenous laser treatment (ELT) of the great saphenous vein (GSV). To compare the results and side effects of a 940 nm diode and a 1,320 nm neodymium:yttium-aluminum-garnet (Nd:YAG) laser. Three patient cohorts (A, B, and C) received ELT of the GSV using a 940 nm diode laser at 15 W (group A) or 30 W (group B) or using a 1,320 nm laser at 8 W (group C). In all cases, energy was administered continuously with constant pullback of the laser fiber under perivenous tumescent local anesthesia. 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/cm and an average endovenous fluence equivalent of 12, 30, and 33 J/cm2 were administered 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), and 97% (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%) were significantly 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). ELT of the GSV using a 1,320 nm Nd:YAG laser causes fewer side effects compared with 940 nm diode laser ELT.

Endovenous Treatment of the Great Saphenous Vein Using a 1,320 nm Nd

Background Limited data are available about treatment-related side effects with respect to laser wavelength in endovenous laser treatment (ELT) of the great saphenous vein (GSV). Objective To compare the results and side effects of a 940 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 940 nm diode laser at 15 W (group A) or 30 W (group B) or using a 1,320 nm laser at 8 W (group C). In all cases, energy was administered continuously with constant pullback 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/cm and an average endovenous fluence equivalent of 12, 30, and 33 J/cm2 were administered 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), and 97% (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%) were significantly 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 1,320 nm Nd:YAG laser causes fewer side effects compared with 940 nm diode laser ELT.