Varicose Veins – Endovenous Laser Ablation (EVLA)
Varicose veins are a condition that occurs when the superficial veins no longer function properly for reasons that are poorly understood. The walls of the veins lose their elasticity and become dilated and elongated. The tissues surrounding the veins cannot effectively support the vein, so the vein becomes large and tortuous. Valves inside the veins, which are designed to return the blood back to the heart, become incompetent, and the blood passes backwards down the leg instead of returning to the heart.
These changes result in pooling of blood, increased venous pressure and the accumulation of fluid in your legs. This may progress to clotting in the veins, bleeding from superficial veins, thickening of the skin and may eventually lead to ulceration in the lower leg (uncommon in uncomplicated varicose veins).
Endovenous Laser Ablation (EVLA)
Endovenous laser ablation (EVLA) is a minimally invasive procedure for the treatment of varicose veins, and has been used in the USA since the late 1990’s and in Australia since early 2000. It is considered the primary treatment for saphenous incompetence related varicose veins in the UK (NICE Guidelines) and USA and in these countries surgery is only rarely performed now when the veins are unsuitable for EVLA and/or sclerotherapy.
EVLA involves closure of incompetent (abnormal) saphenous veins from the inside, using heat generated by laser energy. Saphenous veins are the main superficial veins of the legs, and handle less than 10% of your leg blood flow. Saphenous veins are not deep veins and when the incompetent veins are sealed off, backward leak of blood is abolished and other veins that have been “swamped” with their usual flow and the incompetent flow from the leaking saphenous vein have less work to do and the venous drainage of the leg actually improves. The saphenous veins can be used for bypasses later in life but please be assured that they cannot be used for bypasses if they are varicose and as such you will not be losing a conduit that may be used down the line.
EVLA involves a combination of laser and ultrasound technology and does not usually require admission to hospital or general anaesthesia. Research performed on a large number of patients over >5 years has shown results that parallel and often outperform surgical stripping.
Prior to the laser procedure, local anaesthetic cream (EMLA) is applied to the skin under an occlusive dressing for at least 45 minutes along the ultrasound marked saphenous trunk/s to be treated. You are then brought into the procedure room and prepped so the skin is sterilised. A small amount of local anaesthetic is then injected at the knee and/or lower calf and a sheath placed. A thin laser fibre is then inserted through the skin and directly into the vein that is causing the often painful and unattractive varicose veins. Tumescent local anaesthesia (lignocaine, adrenaline, bicarb in cool saline) is used to directly anaesthetise the tissue surrounding the vein being treated. This tumescent also squeezes the vein shut around the laser fibre expelling any blood and achieving better application of the laser to the vein wall. It also provides a cylinder of cooled tumescent that surrounds the vein prevention the sensation of heat or thermal injury to perivenous tissues such as skin or small nerves.The laser heats the lining within the vein, damaging it and causing it to close and seal shut.
Although treatment with EVLA will resolved pressure symptoms and often reduce the size and number of visible varicose tributaries in the thigh and calf, it is often necessary to treat any residual veins by sclerotherapy or phlebectomy for perfect cosmesis. If sclerotherapy is required, this is not performed on the day of the laser treatment as this increases the risk of painful phlebitis and skin staining. When you have had your laser procedure and your 3 month follow up scan, the doctor will advise you of any subsequent treatment that may be required.
Preparing for EVLA
- The Oral Contraceptive Pill or Hormone Replacement Therapy should be stopped at least 2 weeks before your EVLA treatment. It is also important not to schedule a long distance trip (more than 4 hours) within 4 weeks of the procedure.
- Aspirin and/clopidogrel can be continued but please advise the nurse of this on commencing – you will have a little more bruising but it is much safer to continue these medications.
- Anticoagulants such as warfarin or the new/novel oral anticoagulants (NOAC’s) such as pradaxa, eliquis, xarelto and others coming onto the market monthly can be continued but Dr Bray will advise you and the team how this is to be managed around the time of your procedure and whether clexane is needed on the day of treatment. Once again, bruising will be more common but it is far safer to continue these medications for their indicated reason than to cease them for this minimally invasive procedure.
- General anaesthesia is not required and sedation is avoided unless absolutely necessary and discussed with Dr Bray at the time of booking. Your leg may be a little “tight” and numb from the tumescent and tight stocking. For this reason, it is essential that you organise for someone to drive you home or plan to catch public transport.
- It is recommended that you take the day off work.
- On the day of your treatment, do not apply moisturiser to your legs.
- Wear slacks or loose trousers, and sandals or loose shoes to the clinic to allow for the thickness of the stockings.
The EVLA procedure
- You will be asked to arrive ½ to one hour prior to your procedure. Our sonographer will perform an ultrasound scan to mark the position of your vein prior to treatment, and will apply an anaesthetic cream (EMLA) along the vein. The anaesthetic cream is optional but will minimise your discomfort during the subsequent local anaesthetic injections (tumescent).
- An injection of enoxaparin (Clexane) may be given to you prior to the procedure to reduce the risk of thrombosis. Occasionally in high risk patients this may be continued for 2-10 days.
- Photographs for medical record purposes and future comparison may be taken before treatment.
- The EVLA procedure is performed with you lying down on an examination bed. Dr Bray and the sonsographer will need access to your groin if treating the great/long saphenous vein so you will be asked to change into disposable underwear that can be untied one one side to be able to sterilise the area to be insonated and the entire leg with cetrimide and reduce the risk of infection. This can be a little embarrassing for a minute until the sterile drapes are applied but necessary to avoid infective complications down the line. Ultrasound is used to guide the puncture through an anaesthetised site, usually on the inside of the thigh or knee for the great saphenous vein (GSV) or the posterior calf for the small saphenous vein (SSV). When treating the GSV you will be reclined flat on your back but when treating the SSV you will be prone (face down on your front). Using the introducer needle, a small wire then catheter is fed into the vein and is accurately positioned using ultrasound guidance. Tumescent local anaesthetic is infiltrated around the vein at several levels along the length of the saphenous vein, using fine needles guided by ultrasound.
- The laser tip is then positioned using ultrasound guidance just below the level the saphenous vein enters the deep veins. The laser probe is activated and then slowly withdrawn, thus “heat sealing” the vein. As microbubbles are created when this process begins a funny taste can often be noted for which mints are available. As a local anaesthetic is used prior to the procedure, most patients experience no discomfort during the procedure but patients are always asked to advise Dr Bray immediately if any pain is felt as it is quite safe to halt the procedure at any time, infiltrate more local anaesthetic and then continue.
- Compression stockings and bandages are applied after treatment.
- Patients should be aware that on the day of the procedure, there is a very small chance that the Endovenous Laser Ablation cannot proceed due to the veins being technically not suitable for the endovenous laser (scarring/clot/tortuosity), or the vein going into spasm prior to or during the procedure. Before scheduling a patient for an Endovenous Laser procedure, every effort is made to fully assess the patient’s suitability for Endovenous Laser, using appropriate clinical review together with diagnostic vascular ultrasound. However, patients should be aware that if for any reason the doctor determines that the Endovenous Laser procedure cannot be fully or safely performed on the day scheduled, the doctor will not proceed with the Endovenous Laser procedure.
What you should do after EVLA
Physical Activity :
- You will be asked to go for a 30 minute walk immediately after the procedure, and you will then need to have a 30 minute walk every day.
- You should maintain your normal daytime activities but avoid standing still for long periods. You should also avoid strenuous physical activity, such as aerobics, weight lifting or running, for 3-4 weeks after your treatment.
- Most occupations may be resumed the day after EVLA, although in heavy manual occupations, 3-5 days off work is recommended.
Bandages and Compression Stocking :
- A compression stocking will be fitted at the end of the procedure. Wearing a compression stocking is a very important part of the treatment, as it maintains pressure on the veins, preventing them from re-filling with blood. A compression stocking must be worn continuously for 4 days. This means that the stocking cannot be removed at all, including for bathing and sleeping. A plastic overstocking is available to purchase for showering purposes. If the stocking must be removed it should be done by another person whilst you are reclined flat in bed with the leg raised on pillows where it should remain till the stocking can be re-applied.
- After 4 days you may remove the stocking, wash your leg, wash the stocking and then wear the stocking during the day only for a further 10 days. You are now able to shower and sleep without the stocking.
- You must avoid any flights of more than 4 hours duration for 4 weeks after your treatment.
- If travel is unavoidable, you should have Clexane injections for anticoagulation before departure, and daily Clexane injections for 5 days after arrival. You should discuss any travel arrangements with the doctor.
- An ultrasound will be performed within 1-2 weeks of your treatment to ensure that the treated vein is occluded and to exclude the very small risk of blood clotting (DVT). Dr Bray will only see you with this scan if there is a concern.
- A further ultrasound is performed at 3 months with the option for clinical review if there are any concerns or direct referral to our Phlebologist if there are residual cosmetic veins you want to have treated with sclerotherapy.
- A final 1 year post EVLA scan is performed to ensure you have a great result and to audit our outcomes and is another chance for you to meet Dr Bray to discuss any concerns or be referred directly to our Phlebologists if you have any cosmetic veins you wish to have addressed with sclerotherapy.
- Please note that all standard post-treatment venous duplex studies are bulk-billed.
What to expect following EVLA
The following features are expected, and you do not need to notify our rooms if they occur:
- Bruising down the length of the treated vein is almost invariable, and should not be a cause for concern. The bruising will settle down after a few days. It is important not to use creams such as Lanosil or Hirudoid before or after the treatment.
- Mild to moderate pain invariably occurs a day or two after treatment. Aching in the leg may persist for up to two weeks and shows that the procedure is working. Pain is usually improved by simple analgesia such as paracetamol or ibuprofen (for example, Nurofen) or by walking. You may also experience some soreness behind the knee due to rubbing by the bandage or stockings. Make sure you adjust the stocking and pull it up, to avoid a blister.
- Discolouration usually occurs early on, and is not a cause for concern. Red, raised areas can develop over the treated veins, but these usually disappear within 2-3 weeks.
- Tender lumps due to blood trapped in the treated vein (phlebitis) are common, and may persist for the first few weeks. This is not a complication and not dangerous or a DVT. If it occurs, the doctor may decide to release the trapped blood at the time of your next appointment. This happens by simply pricking the vein and letting the trapped blood out. If it is not released, trapped blood will eventually be absorbed. This may take a few weeks. The doctor may release the trapped blood if it is causing pain, discomfort or discolouration.
Possible Complications from EVLA
Deep Vein Thrombosis (DVT) : Very rarely a clot may form or extend from the site of treatment into the deep veins. This is extremely rare but is potentially serious as a piece of clot may break off and travel to the lungs (pulmonary embolus). The protocol of walking daily and wearing the compression stocking is very important to minimise the possibility of this complication. Signs and symptoms of thrombosis include excessive swelling and pain in the legs and shortness of breath or chest pain may indicate a pulmonary embolus. DVT requires urgent medical treatment with blood thinning injections. Hospital admission may be required for more severe cases. Please advise Dr Bray if you have any personal or family history of thrombosis (“blood clots”), or if you are on hormone treatment such as the oral contraceptive pill or hormone replacement therapy or are a smoker as these are all risk factors for DVT. It is not advisable to have surgery performed for 4 weeks before or after EVLA, nor to schedule a long distance trip. Following the EVLA procedure, if you develop excessive pain and excessive swelling in the legs, shortness of breath or chest pain after the treatment, please inform the doctor immediately. If these symptoms occur outside of business hours, you should present at the Emergency Department at Sir Charles Gairdner Hospital.
Superficial Thrombophlebitis : the treated vein may feel tender and lumpy along its course, which reflects the underlying inflammation which is part of the treatment and healing process. Occasionally the vein will become more inflamed, causing heat, redness, pain and swelling along the vein, or in discrete lumps. If this occurs, it is advisable to continue wearing the compression stocking, take anti-inflammatory medications (for example, Naprosyn or Nurofen) and continue walking regularly. Rarely, antibiotics may be prescribed if the area is particularly inflamed, although infection is seldom present. Please notify Dr Bray if you are worried about this problem.
Staining of the skin (pigmentation) : This may occur along the treated veins and is due to deposition of iron pigments (haemosiderin) in the skin. It is important to stop taking iron supplements before your treatment. If this discolouration occurs, the staining will fade in most cases over a 3 – 6 month period, but may persist for over 12 months in a minority of patients. However, there can be permanent staining in approximately 5% of patients. Staining is of cosmetic significance only. Any underlying veins which may contribute to the pigmentation will be identified and treated.
Numbness/Nerve Damage : The heat generated by laser energy can occasionally cause damage to adjacent nerves or other tissues. This may cause numbness which is usually mild and resolves over weeks to months. Very rarely, more severe damage to a nerve may occur, leading to permanent numbness or weakness. Care is taken during treatment to infiltrate adequate local anaesthetic mixed with saline in order to protect surrounding tissue.
Skin Burns : Heat generated by the laser may cause a skin burn. However, meticulous care is taken to inject adequate local anaesthetic and saline around the vein to protect adjacent tissues. Our current state of the art laser is one of the new generation of endovenous laser that uses far less energy to achieve the same results as the old lasers with a subsequent very low risk of thermal injury
Failure of Treatment : This is rare following EVLA. However, occasionally a vein may fail to close down (in less than 2% of cases). The medical term for this is recanalization and it can be treated with repeat EVLA, surgery or ultrasound guided sclerotherapy.
What may happen to untreated varicose veins?
In the case of large varicose veins, spontaneous blood clots may develop in these veins. Also, skin changes including pigmentation, hardening of the skin and underlying fat (lipodermatosclerosis) and, eventually, ulcers may develop in the lower legs. If you decide not to have any intervention, we strongly recommend you wear compression stockings on a regular basis to prevent worsening of your varicose veins.
Spider veins are mostly cosmetic and may get more prominent with time, but rarely cause a problem otherwise.
Recurrence of Veins
EVLA has been shown to be a very effective treatment for varicose veins. Treated correctly, the veins should not reopen following EVLA. However, a low rate of recanalisation has been reported in the literature.
It is important to note that EVLA is treating the trunk of the varicose veins, and not the branches. The branch veins may need ultrasound guided injection in a subsequent session. Quite often following EVLA, the branch veins disappear or may look better. However, follow-up Ultrasound Guided Sclerotherapy is recommended to ensure no recurrence.
New varicose and spider veins may develop over time, as a patient’s underlying tendency to form varicose veins cannot be changed. These recurrent veins can also be successfully treated. Factors which may prevent or delay recurrence include maintaining a healthy weight, avoiding prolonged standing, undertaking regular exercise and using compression stockings. Pregnancy usually has an adverse effect on varicose veins, and hormone therapy may aggravate the situation. It is important to take these factors into consideration, however, the basic underlying weakness in the wall of all the veins cannot be changed.
It is important to follow up the treated vein with ultrasound imaging to detect signs of early recurrence in branch veins. The follow-up protocol includes ultrasound examinations within 1-2 weeks, and then 3 months, 1 year and then yearly. We have a strict follow-up protocol, and all patients are advised to adhere to this protocol.
Dr Bray performs the ultrasound follow ups as a service to his patients, and the ultrasounds are performed at no extra cost to the patient if they have a valid Medicare card and referral.
© Vascular Solutions 2007