ENDOLUMINAL TREATMENT OF VARICOSE VEINS (EVLT, ELVES)The endovenous laser treatment of varicose veins (EVLT or ELVES) has completely changed the management options for venous insufficiency. The traditional surgical treatment of varicose veins was ligation and stripping of the vein under either spinal or general anesthesia. EVLT allows the clinician to treat the problem in the office setting under local anesthesia with excellent results and minimal downtime. It has significantly chnages the way I now manage patients with vein problems.WHAT IS EVLT? EVLT is the use of a laser that is threaded into the vein under Doppler ultrasound guidance. Lasers have been used for numerous medical applications throughout the body. Recently, a novel technique utilizing laser energy delivered endovenously (directly inside the vein) has been developed to treat varicose veins. An 810 nm diode laser will be used to deliver the laser energy via a small laser fiber. EVLT is performed under local anesthesia in the doctor’s office. There is very little scarring, and a relatively short recovery period after the surgery as compared to conventional vein stripping. During the procedure, you will be given special eye goggles to protect your eyes against accidental exposure to laser light. Next, the treatment area will be marked and anesthetized with Lidocaine. A sterile laser fiber will be inserted into the vein and positioned under ultrasound guidance. Laser energy will be delivered to selectively treat the target vein. A compression dressing will be applied and must be worn for 2 days following the procedure. The dressing can be removed at home, but compression hose should be worn for at least 2 weeks following the treatment. You will return to the office in 2 weeks and the doctor will examine the vein with ultrasound and physical examination.
Illustration of the endoluminal treatment of a varicose vein
AM I A CANDIDATE FOR EVLT?
EVLT can be performed if the superficial venous sytem is incompetent. That means that the main valve in the greater saphenous vein is not working well, and blood is flowing backwards and into the large, ropy varicose veins. It cannot be used for the deep vein valve problems. Infact, there is no good surgical treatment for deep vein valve problems. Years ago, we used to try and repair the deep valve system with valve repair surgery, but the results were poor. In the future, this technology might develop and be beneficial, but at this time, it is not available.
There complications of EVLT are very infrequent. The possible risks included the following:
1. Deep venous thrombosis (probably less than 0.5% chance) WHAT ARE THE ADVANTAGES OF EVLT OVER CONVENTIONAL VEIN STRIPPING? Vein stripping was the gold standard for management of varicose veins in the past. The process involves general or spinal anesthesia, followed by an incision in the groin and ankle. The greater saphenous vein was then cannulated with a device that was used to essentially avulse the vein from the leg. This was a brutal procedure, and the recovery time was painful and porlonged, with significant bruising and pain. There was a high incidence of saphenous neuritis, or pain along the inside part of the leg due to injury to a nerve that runs beside the saphenous vein that is being removed. EVLT is performed in the office under local anesthesia, avoiding the potential pitfalls of general or spinal anesthesia. The whole process takes 45-90 minutes. We use tumescent local anesthesia around the vein. That means under ultrasound guidance, a very dilute mixture of local anesthesia in infiltrated around the vein. This blocks the pain sensation fibers around the vein, and moves the nerve that travels close to the vein away. In addition, the anesthetic solution acts like a reservoir to collect heat from the laser, and not allow it to penetrate deeper into the other tissues. Trauma to the surrounding tissues is minimized. The actual lasering process takes only a few minutes, depending on the length of vein being treated. Once the laserng process is completed, the side branches are removed throught tiny 1 mm incisions that heal without stitches. At the conclusion of the procedure, the patient walks out of the room. The dressings are removed in 2 days, and a compressive bandage is reapplied daily until compression hose can be worn. I advise patients to take an inbuprofen 200 mg 3 time daily for one week, starting day 1. The worst part of the recovery process is usually day 2-3, when the inner thigh will develop a hard, red line that is tender and hot. This is a normal finding and is a sign that the treatment was effective. It feels like a pulled thigh muscles, and last 5-6 days,improving over time. A follow-up appointment is made in 2 weeks to recheck the veins with Doppler ultrasound. Some patients choose to return to work a day or two after the procedure, depending on their level of activity at work. EVLT is such a superior procedure to vein stripping because it is performed in the office under local anesthesia, the results are excellent both in terms of relief from varicose veins, and from the cosmetic perspective. The downtime and discomfort is significantly less, and patients are far happier with the results. DOES INSURANCE COVER THE TREATMENT OF VARICOSE VEINS AND EVLT? Most insurance companies will cover treatments for varicose veins that are causing problems despite conservative management. Conservative management means a trial of compression hose for 3-6 months. If you continue to have pain or swelling despite wearing compression hose, then most insurance carriers will cover EVLT or microphlebectomy. Insurance does not usually cover the treatment of spider veins, and these treatments are paid for by the patient.
|
