Veins: EndoVenous Laser Therapy (EVLT)
EndoVenous Laser Therapy (EVLT) is the new, minimally invasive treatment for patients with varicose veins.
There are 2 main veins in the legs which function to bring blood from the legs back to the heart. The superficial venous system comprises of veins that are close to the skin surface. The deep venous system is the set of veins present inside the muscles of the legs.
Valves within the veins prevent the blood from flowing back down the leg, or refluxing. The refluxing veins cause build up of pressure within the veins, causing them to become distended and swollen.
This procedure is done for patients with varicose veins and chronic venous hypertension who have reflux in the superficial veins, such as the Long Saphenous Vein (LSV).
This procedure involves delivering laser energy within the Long Saphenous Vein (LSV) to cause it to shrink over time. Once the LSV has sclerosed, blood will no longer be able to flow in the vein. This will prevent any venous reflux and will reduce the pressure in the veins in the legs.
In this procedure, the LSV is not removed or stripped. Over time, the vein will shrink and become non-functional.
This procedure is usually performed under Local Anaesthesia with Monitored Sedation. The anaesthetist will administer medication intravenously to keep the patient sedated and unaware during the procedure.
A General Anaesthetic may be considered if the patient is not suitable for monitored sedation or if the patient requests for a GA.
- The Long Saphenous Vein (LSV) in the inner thigh is localised with an ultrasound scanner.
- A local anaesthetic injection is given and a sheath is placed inside the LSV.
- The laser fibre is then introduced into the sheath and passed up to the Sapheno-Femoral Junction (SFJ) at the groin.
- A solution of saline and some medication will be injected around the LSV under ultrasound guidance. This helps to prevent skin burns.
- Once the tumescent injections are completed, pulses of laser energy are fired along the laser fibre.
- At the tip of the fibre, the laser energy converts to heat. This causes damage to the inner lining of the vein. The inflammation that is triggered in the LSV will cause it to eventually shrink and sclerose.
- The prominent varicosities in the lower thigh and calf are then surgically removed through small incisions measuring about 5mm.
- These small wounds are then closed with special Steri-strip dressings. No sutures or stitches are required.
- After the procedure, the leg will be bandaged with crepe bandage.
This surgery is usually performed as a Day Surgery, which means the patient does not need to be admitted overnight after the surgery.
The bandages can be removed after 48 hours and changed for post-op compression tube stockings that will need to be worn for the first 2 weeks. The stockings will prevent leg swelling and reduce the risk of bruising after the surgery.
During this period, the patient is encouraged to walk around to avoid deep vein thrombosis (DVT). Generally, the patient will be advised to walk around at home for the first 2 weeks after surgery. Excessive physical activity may lead to increased bruising along the medial thigh.
After 2 weeks, patients can gradually increase their activity level back to normal.
Avoidance of strong sun exposure and ultraviolet (UV) radiation is advised for the first 2 weeks as this may cause permanent darkening of the surrounding skin, or hyperpigmentation.
With EVLT, the laser energy causes the LSV to become inflamed. Therefore, for the first 6 to 8 weeks after the procedure, the patient may feel a hardened cord-like vein along the inner thigh, especially in the lower half where the LSV is closer to the skin.
The common complications associated with this procedure include:
- Bruising especially along the inner thigh
- Palpable cord-like Long Saphenous Vein (LSV) along the inner thigh
- Skin burn from heat transmission from the laser fibre to skin
- Saphenous nerve injury, leading to patchy numbness along the lower inner thigh
- Bleeding and haematoma (clot) formation at the stab wounds
- Wound infection
- Recurrence of varicose veins, approximately 3-5% in 5 years
- Deep vein thrombosis (DVT)
The traditional approach to treating Long Saphenous Vein (LSV) incompetence is to surgically remove the LSV via two incisions, one in the groin and another in the lower thigh. This is usually done under a General Anaesthetic. Post-operative pain is usually higher after surgery, compared to Endovenous Laser Therapy (EVLT).
An alternative minimally invasive approach to treating LSV incompetence is to use radiofrequency energy as the energy source to create heat. Radiofrequency Ablation of the LSV is performed using the ClosureFast system.