Role of Duplex Imaging in Endovenous Obliteration for Primary Venous Insufficiency

Olivier Pichot, MD; Carmine Sessa, MD; James G. Chandler, MD; Michel Nuta, MD; and Michel Perrin, MD
J Endovasc Ther 2000;7;451-459

Conclusions: "Duplex scanning is indispensable for selecting patients, guiding the procedure, and defining the morphological maturation and hemocynamic changes that appear to characterize successful endovenous obliteration."

Phlebectomy. Technique, indications and complications.

Ramelet AA.
Int Angiol 2002 Jun;21(2Suppl 1):46-51

Phlebectomy  was first described by Celsus, and was reinvented 40 years ago by Dr. Robert Muller of Neuchatel, Switzerland.  "This safe, esthetic, effective and economical operative technique has now been fully developed and adopted all over the world.  Phlebectomy hooks enable venous extraction through minimal skin incisions (1-3mm) or even needle punctures, assuring complete and definite eradication of the veins.  The small size of the skin incisions usually results in little or no scarring, contrary to that found in classical venous surgery, and avoids the possible complications of sclerotherapy, such as skin necrosis or residual hyperpigmentation."

Surgical and endovascular treatment of lower extremity venous insufficiency

John J. Bergan, N. H. Kumins, E.L. Owens
J Vasc Interv Radiol 2002 Jun;13(6):563-8 

Pub Med Abstract

"Lower extremity venous insufficiency is a highly prevalent condition.  Now it is understood that telangiectasias, reticular varicosities, and true varicose veins are physiologically similar and etiologically identical.  The four main influences causing these abnormalities are heredity, female sex, gravitational hydrostatic forces, and hemodynamic muscular compartment pressure.  There are clear indications and goals for intervention.  A cornerstone in the treatment of venous insufficiency is elimination of sources of venous hypertension. One of these is the refluxing greater saphenous vein.  Minimally invasive saphenous ablation can be achieved by radiofrequency energy and laser light energy. These new techniques eliminate the psychological barrier to treatment caused by the term  stripping and allow the objectives of surgery to be achieved with minimal invasion and quick recovery.  Endovenous techniques show great promise.  They provide minimal invasion, often under local anesthesia and intravenous sedation, thereby eliminating  the need for general anesthesia.  Objectives of venous insufficiency have been established and the endoluminal minimally invasive techniques developed in recent years appear accomplish their goals."

(Dr. Bergan is an experienced academic surgeon, former Chief of the Division of Vascular Surgery at Northwestern Medical School, and now at the Vein Institute of La Jolla)

Endovascular laser therapy of lower extremity venous insufficiency 

Endovenous Laser: A New Minimally Invasive Method of Treatment for Varicose Veins-Preliminary Observations Using an 810 nm Diode Laser

Luis Navrro, MD, Robert J. Min, MD, and Carlos Bone , MD
Dermatol Surg 2001;27:117-122

Results: 100% rate of closure in 33 patients with 40 greater saphenous veins with no significant complications at up to 14 months.  A 24 month experience of 80 cases of branch varicosities showed 100% closure rate.

Conclusion: Endovenous Laser is a  very effective and safe way to eliminate SFJ incompetence and close the GSV.   

Treating Saphenous Vein Insufficiency with a 940 nm Laser

Ronald G. Bush, MD, FACS,  Karin A. Hammond, RN, BSN
Published in: 

Dr. Bush and Ms. Hammond were the first in the US to use the 940 nm laser for endovenous laser ablation. I had the pleasure of visiting Dr. Bush at his Midwest Vein Treatment Center in Toledo, Ohio.   They report on the treatment of their first 120 patients using the 940 nm endoluminal laser. The first 20 had high ligation of the GSV, the subsequent 100 did not.  There was no reca nalization in any patient treated with over 10 watts at 1-second duration or 8 watts at 2-second duration. 

Histologic examination  of veins treated at 8-12 watts for 1 second  showed no endothelium or sub-endothelium present.  At six weeks there was continued absence of the endothelium and sub-endothelium, organized thrombus in the lumen, and inflammatory changes in the muscularis.

Ultrasound examination showed gradual obliteration of the lumen of the GSV over a six month period.

There were no complications with this procedure.

Conclusion: "In our opinion, this minimally invasive and safe technique will replace high ligations and strippings in 85% of those patients with SFJ reflux."

Thermal Damage of the Inner Vein Wall During Endovenous Laser Treatment: Key Role of Energy Absorption by Intravascular Blood

T. M. Proebstle, MD, MSc, M. Sandhofer, MD, A. Kargl, MD, D. Gul, MD, JW. Rother, PhD, J. Knop, MD, PhD, and H. A. Lehr, MD, PhD
Dermatol Surg 2002;28:596-600

This was an ex-vivo study of 940 nm laser energy (15J/pulse) in 5 veins filled with blood, and 5 with normal saline.  The saline filled veins showed vein wall injury confined to the direct site of laser impact.  The blood filled veins showed thermal damage in more remote ares including the vein wall opposite to the laser impact.  Steam bubbles were generated in hemolytic blod by all three lasers, while no bubbles could be produced in normal saline or plasma.

Conclusion: Intravascular blood plays a key role for homogeneously distributed thermal damage of the inner vein wall during EVLT.    

Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: Thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles

T. M. Proebstle, MD, MSc, H. A. Lehr, MD, PhD, A. Kargl, MD, C. Espinola-Klein, MD, W. Rother, PhD, S. Bethge, MD, and J. Knop, MD, PhD

26 patients with 31 limbs with incompetent GSV were treated by EVLT  with a 940 nm laser, using multiple pulses of 15 J energy.  All GSVs but one were thrombotically occluded at days 1, 7, and 28. All patients showed ecchymoses and palpable induration along the occluded GSV for 2 to 3 weeks. 2 patients developed branch vein thrombophlebitis that was treated with diclofenac.

Conclusion: EVLT of the GSV with a 940-nm diode laser is effective in inducing thrombotic vessel occlusion and is associated with only minor adverse effects. 

Endovenous laser treatment of the lesser saphenous vein with a 940 nm diode laser: early results.

Proebstle TM, Gul D, Kasrgl A, Knop J.
Dermatol Surg 2003 Apr;29(4):357-61

41 LSVs were treated with 940 nm laser using pulsed or continuous pull-back technique.  No recanalization was seen in mean followup of 6 months.

Conclusion: "ELT of the LSV under tumescent local anesthesia is feasible and effective."

Endovenous Laser Treatment of the Incompetent Greater Saphenous Vein 

Robert J. Min, MD, Steven E. Zimmet, MD, Mark N. Isaacs, MD, and Mark D. Forrestal, MD
JVIR 2001; 12(10):1167-1171 

Results: 87/90 greater saphenous veins (97%) were closed at 1 week after initial treatment with endovenous laser.  The remaining three were closed with additional therapy.  89/90 (99%) were still closed at 9 months as determined by duplex exam.

Conclusion: Endovenous laser treatment of the incompetent greater saphenous vein appears to be an extremely safe technique that yields impressive short-term results.

Endovenous laser: a new minimally invasive method of treatment for varicose veins-preliminary observations using an 810 nm diode laser.

Navarro L, Min RJ, Bone C
Dermatol Surg 2001 Feb;27(2):117-22 

40 greater saphenous veins in 33 patients were treated with 810 nm diode laser energy by the endoluminal approach.  100% of veins were closed at up to 14 months.  There were no significant complications.

Conclusion: Endovenous laser is a "very effective and safe way to eliminate SFJ imcompetence and close the GSV."   

2-Year Follow-Up Results on Endovenous Laser Treatment Of the Incompetent Greater Saphenous Vein (Abstract)

Robert Min, MD presenter
Amer College of Phlebology 16th Annual Congress (November 8-10, 2002, Ft. Lauderdale FL)

326 GSVs in 289 patients with varicose veins were treated with endovenous laser.  Successful closure of the GSV was noted in 98% (320/326) of GSVs at 1 to 30 month follow-up.  91% (62/68) of limbs followed for a minimum of 2 years remain closed.  The treated segments of the GSVs were not visible on duplex imaging at 2 years.  All recurrences occurred prior to 9 months.  Most occurred within  months after treatment.  There wer no skin burns, paresthesias, or DVTs.

Conclusions: 2-year follow-up on 68 limbs treated with endvenous laser showed recurrence rate of less than 9%. "These results are comparable or superior to those reportd for the other options available for treament of the incompetent GSV.  Endovenous laser appears to offer these benefits with lower rates of complication and avoidaance of general anesthesia."

Endolaser-A Three Year follow-up Report: Implications on Crossectomy and Ligation and Stripping

Luis Navarro, MD, FACS (presenter), Carlos Bone' Salat, MD
Amer College of Phlebology 16th Annual Congress (November 8-10 2002, Ft Lauderdale FL)

This is a three year follow-up on the first 200 cases of Endolaser treatment of incompetent GSVs with SFJ incompetence treated with diode laser energy at 810, 940, or 980 nm in short pulses.  Concurrrent mini-phlebectomy or subsequent sclerotherapy completed the treatments.

Results: In the first 200 endolaser patients followed for up to three years (mean: 23.6 months), showed a recanalization rate of 2.6%, all occurring within the first 6 months.  To date, all 200 cases show absence of SFJ reflux.

Conclusion: "At three years, the safety and low recanalization rates of Endolaser are superior to the safety and recurrence of ligation and stripping, making it an effective alternative or possibly the current primary treatment choice."  

New Endolaser Venous system (980) Treatment of Long Saphenous Vein Reflux: Efficacy and Safety (Abstract)

Lowell S. Kabnick, MD, FACS (presenter)
Amer College of Phlebology 16th Annual Congress (November 8-10 2002, Ft Lauderdale FL)

A 980 nm diode laser was used to treat 20 consecutive Long Saphenous Veins .
RESULT(s): 20/20 limbs (LSV) were closed and showed no SFJ reflux.
Complications inclcuded ecchymosis, discomfort/pain, and superficial phlebitis. All discoloration disappeared in less than 3 weeks. All Pts. had minimal discomfort. All Pts. resumed activities of daily living on day one.

Conslusion: Early results using ELVS employing continuous energy with rapid laser fiber pull back, appears efficacious and safe. Long term observation and trials with decreasing continuous energy are planned.

Radiofrequency Closure

Twelve and Twenty-four Month Follow-up After Endovascular Obliteration of Saphenous Vein Reflux-A report from the Multi-Center Registry

Lowell S Kabnick and Robert F Merchant
JP 2001; 1; 17-24

Results:  87% freedom from saphenous reflux on 235 limbs from 23 centers.

Conclusions: Endovenous radiofrequency obliteration without ligation of the sapheno-femoral junction is an effective treatment for saphenous vein reflux, with persistent relief of clinical signs and symptoms at 12 months.  Paresthesia is temporary in nature and less frequent when th treatment is limited to the thigh and just below the knee.  This minimally invasive technique is a practical and efficacious alternative to surgical stripping and ligation. 

Controlled Radiofrequency Endovenous Occlusion Using a Unique Radiofrequency Catheter Under Duplex Guidance to Eliminate Saphenous Varicose Vein Reflux: A 2-Year Follow-Up

Robert A. Weiss and Margaret A. Weiss
Dermatol Surg 2002;28:38-42

Results: 98% of 140 veins were found occluded by duplex at 1 week.  At 12 months reflux was absent in 90%.  No reflux developed after 6 weeks.

At 24 months, 90% (19/21) of  patients had complete disappearance of the saphenous vein .

Conclusion: RF endovenous occlusion is effective. The rate of recurrent reflux and morbidity is low. There is no need for general anesthesia, or the extensive convalescence associated with vein stripping and ligation surgery.  98% of patients were willing to recommend the procedure to a friend or family member.  

Closure of the Greater Saphenous Vein with Endoluminal Radiofrequency Thermal Heating of the Vein Wall in combination with Ambulatory Phlebectomy:  50 Patients with More than 6-Month Follow-up

Mitchell P. Goldman and Syed Amiry
Dermatol surg 2002;28:29-31

Results: 41 legs were evaluated. 68% were completely closed.  22% had an open and refluxing GSV.  3 of 41 legs had recurrent varicose veins.  Only 1 leg had recurrent symptoms.

Conclusion.  Endoluminal RF thermal heating of an incompetent GSV has been shown to be easily accomplished and effective over a 24 month followup.  

Endovascular obliteration of saphenous reflux: a multicenter study.

Merchant RF, DePalma RG, Kabnick LS
J Vasc Surg. 2002 Jun;35(6):1292-4

This is a prospective study including 286 patients from 30 different clinical sites.  319 limbs with saphenous vein reflux were treated with temperature controlled radiofrequency heat, without high ligation of the saphenofemoral junction.  83.% were completely occluded at 12 months and 10,8 were recanalized.  At 24 months, 85.2% wer completely occluded 11.3% were recanalized. 91.4% of 232 limbs followed to 12 months and 90.1% of 142 limbs at 24 months were free of saphenous reflux. Paresthesia was reported in 3.9% of limbs at 1 year and 5.6% at 2 years.

Conclusion. "Endovenous vein obliteration without high ligation dramatically reduces the presence of varicosities and reflux and, when performed with the prescribed pull-back methodology, is comparable with vein stripping at 1 and 2 years." 

Endovenous laser photocoagulation (EVLP) for varicose veins.

Chang CJ, Chua JJ.
Lasers Surg Med 2002 Oct;31(4):257-262

141 patients with 244 legs were treated.  96% showed remarkable improvement.  [Note: the early complication rate was significant, no doubt due to the extraordinarily long pulse duration of 10 seconds using a 1,064 nm (Nd:YAG) laser and power of 10 or 15 W.-OVC ed.] Nevertheless,  the final outcome showed no significant morbidity or mortality.  All patients recovered completely.

Conclusions: EVLP is a simple effective treatment modality for varicose veins.

Deep vein thrombosis and superficial venous thrombosis

Frequency and prevention of symptomless deep-vein thrombosis in llong-haul flights: a randomised trial

ScurrJH, Machin SJ, Bailey-KingS, Mackie IJ, McDonald S, Smith PD.
Lancet 2001 May 12;357(9267):1485-9

This is a prospective study of 231 patients traveling by long-haul economy class air travell.  All flights were at least 8 hours; the median duration was 24 hours.  12/116 passengers (10%) developed asymptomatic calf DVT; none wore compression hose; two were heterozygous for Factor V Leiden. Four patients who wore elastic compression hose, had varicose veins and developed SVT; one was heterozygous for both Factor V Leiden and prothrombin G20210A.  None of the passengers who wore class I compression hose developed DVT.