LAS VEGAS – Endovenous laser therapy is replacing ligation and vein stripping for many patients with superficial venous incompetence, especially in the legs.
"The endovenous laser has been a major revolutionary advance in the treatment of medical varicose veins of the lower extremities," Dr. Neil S. Sadick said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.
Endovenous laser fibers are inserted in the vessel under ultrasound guidance to eradicate truncal varicosities in the short and lower saphenous veins. The laser heat transfer causes shrinkage of the vein wall collagen and decreased lumen, with the shrinkage proportional to the delivered linear endovenous energy density.
Photos courtesy Dr. Neil S. Sadick
This before photo shows a patient prior to leg vein treatments with a 1064 nm laser. This patient was treated three times with 5 mm spot size. First treatment as 130J / 30ms, second and third treatment were 140J / 20ms.
"This is an extremely easy procedure," that takes about 15 minutes, said Dr. Sadick, a dermatologist at Weill Cornell Medical Center in New York. "It’s almost bloodless. Patients can go back to work that day" wearing light compression hose, and "there’s very little discomfort after" the procedure.
Recurrence rates with endovenous laser therapy also are lower, compared with conventional invasive surgical ligation and stripping procedures, he added. Studies by Dr. Sadick and his associates showed that recurrence rates after treatment of superficial venous incompetence with a combination of endovascular laser and ambulatory phlebectomy were approximately 6% at 1 year, 4% at 2 years, 3% at 3 years, and 4% at 4 years.
Endovenous laser therapy "induces an endothelial type of thrombosis, and then the vein gets dissolved by the body," he said.
Treatment Algorithm
Dr. Sadick developed an algorithm for treatment based on the type of leg varicosity. He uses endovenous laser therapy or endovenous radiofrequency technology to treat large varicose veins of the axial junctions, such as in the long or short saphenous veins. Most intermediate-size varicose veins, such as truncal varicosities or perforations, can be treated by either ambulatory phlebectomy or foam sclerotherapy.
The same patient is photographed after leg vein treatments with a 1064 nm laser.
For reticular veins, he prefers to treat with an external 1064-nm Nd:YAG (neodymium YAG) laser or sclerotherapy with or without foam. Microtelangiectasia, or "very, very small vessels," can be treated with microsclerotherapy via very dilute concentrations of sclerosant, "but this is where an external 1064-nm Nd:YAG laser plays an important role" and may suffice without microsclerotherapy, he said.
"Not all leg veins are treated equally," he added. Red telangiectasias measuring less than 1 mm in tiny, oxygenated, red vessels usually are superficial and are "hit hard" with short pulse durations of high-fluence external laser energy in small spot sizes of 1-2 mm.
For more bluish veins that measure 1-2 mm (which he called blue venulectasia) and for larger reticular varicosities that are 2-4 mm, spot sizes and pulse durations increase but with more moderate fluences. External laser settings for blue venulectasia would be a spot size of 2-4 mm with a medium pulse width and moderately high fluence. For reticular veins, he uses an external spot size of 4-6 mm with a long pulse width and moderate fluence.
"You can see excellent results if you use this paradigm of variable pulse moding for treating telangiectasia without even injecting patients," he said.
Lasers are indicated for the cosmetic treatment of leg veins in patients whose veins are too small to cannulize for sclerotherapy, or for the small subset of patients who do not respond to sclerotherapy. Patients with needle phobia or those who have multiple sclerosant allergies also are candidates for cosmetic laser treatment of leg veins.
Leg veins require different treatment than do facial telangiectasias, Dr. Sadick added. Hydrostatic pressure is greater in the legs. Lower extremity vessels are larger, with increased basal lamina, compared with facial telangiectasias. The deeper location of many lower-extremity vessels makes access more difficult.
Caution Is Advised
The longer wavelengths and higher fluences of external laser treatment for leg veins cause a greater inflammatory reaction. "The worst thing you can do is treat patients on a weekly or biweekly basis" with external laser, he said. "You need to wait 6-8 weeks after each laser treatment so all the inflammation can resolve before the next treatment session" in order to avoid complications.
Dr. Sadick cautioned that the external 1064-nm Nd:YAG lasers are "sort of like weapons. They need to be handled very gently and understood, particularly when you’re treating the legs." Complications can include ulceration, purpura, blisters, and hyper- or hypopigmentation. These most commonly are caused by stacking pulses in a given area (especially with longer wavelengths), treating tanned skin, improperly matching wavelength to skin type, and failing to address hydrostatic pressure.