Laser ablation

Laser ablation also known as photoablation, is the process of removing material from a solid (or occasionally liquid) surface by irradiating it with a laser beam. At low laser flux, the material is heated by the absorbed laser energy and evaporates or sublimates. At high laser flux, the material is typically converted to a plasma. Usually, laser ablation refers to removing material with a pulsed laser, but it is possible to ablate material with a continuous wave laser beam if the laser intensity is high enough. Excimer lasers of deep ultra-violet light are mainly used in photoablation; the wavelength of laser used in photoablation is approximately 200 nm.

Chronic venous insufficiency endovenous laser treatment

Endovenous laser ablation is a new technique to remove varicose veins without surgery. A small tube is inserted into the varicose veins and heat from a laser is delivered inside it to heat up the blood vessel wall so that it collapses and seals shut. Endovenous laser ablation causes scar tissue to form within the vessel. This seals off the vein. Blood then flows through other nearby veins instead. Endovenous laser ablation is routinely done under under local anesthesia with or without supplemental oral anxiolytics, in an office setting ¹. Endovenous laser ablation is well recognized as the first-line treatment for superficial venous reflux with varicose veins in adults ². The literature to date regarding endovenous laser ablation has focused on its applications in adults, in whom endovenous laser ablation has been demonstrated to be effective and safe in the treatment of greater saphenous vein reflux with a long-term occlusion rate of 93% ³. Clinical outcomes from endovenous laser ablation and surgical treatment for varicose veins related to sapheno-femoral reflux seem equal ⁴, and endovenous laser ablation has become the first-line treatment option for varicose veins in adults ⁵.

Your healthcare provider may suggest endovenous laser ablation if your varicose veins are sore, or red and swollen (inflamed). Endovenous laser ablation may also be recommended if the skin over your varicose veins is irritated.

Varicose veins are not usually a serious health problem, but they can be painful. You may also not like how they look.

Endovenous laser ablation for varicose vein mechanism of action

Several mechanisms result in an increase in vein wall temperature, including the direct contact of the fiber tip, the optical-thermal interaction of laser light and surrounding tissues, the heat flow from carbonized blood around the fiber tip and the heat transfer from steam bubbles produced during endovenous laser ablation ⁶. This results in collagen contraction and denudement of the endothelium, stimulating vein wall thickening with eventual luminal contraction and vein fibrosis. The laser energy is distributed along the length of the vein to be treated by retracting the laser fiber along the vein. This results in non-thrombotic vessel occlusion ³. It is now understood that the efficacy of endovenous laser ablation is influenced less by the target chromophore (hemoglobin) and the wavelength of the laser light than was previously thought. Although laser energy at 810 nm wavelength, delivered via a 600 μm laser fiber, is widely used in clinical practice in adults, it is recognized that many wavelengths between 810 nm and 1,470 nm are effective in vein obliteration ⁷. The efficacy of endovenous laser ablation is determined by several factors including the laser power (i.e. the fluence rate and not the laser energy), the pullback velocity and the vein diameter ⁷.

What happens during endovenous laser ablation for varicose vein surgery?

Endovenous laser ablation doesn’t require a hospital stay. It may be done in your healthcare provider’s office. The endovenous laser ablation procedure usually takes less than an hour. Endovenous laser ablation procedure times are dependent on the length of segment treated, experience of the operator, and whether ancillary procedures, such as ambulatory phlebectomy, are done. Regardless of how underlying saphenous incompetence is treated, ancillary treatments are typically needed to treat residual varices. You can likely go home the same day. Bring loose-fitting clothing to wear right after your endovenous laser ablation surgery.

Generally, laser ablation varicose veins surgery follows this process:

• You’ll change into a hospital gown and lie down on an exam table. The table may be tilted in different positions during the procedure. You may be given special goggles or eyeglasses to wear during the surgery. This is to protect your eyes from the laser light.
• Your healthcare provider will numb the area where the tube or catheter will be put into your vein. Your healthcare provider will also give you a shot or injection of numbing medicine along the length of the vein that will be treated.
• Your healthcare provider will use a Doppler ultrasound device to check the vein before and during the procedure. This process uses sound waves to make an image of the vein on a computer screen.
• Your healthcare provider will make a small cut or incision in your skin and insert the catheter. It will be guided into the varicose vein. A laser fiber will be put into the catheter. As your healthcare provider slowly pulls out the catheter, the laser will heat up the length of the vein. The vein will close up and should eventually shrink.

The endovenous laser ablation procedure usually takes less than an hour. The cut where the catheter was inserted will likely be small enough that you won’t need stitches. A bandage will be put on the site.

What happens after laser ablation varicose veins surgery?

You will be encouraged to walk right after the procedure, for about 30 to 60 minutes.

Your leg may have some bruising. The bruises should go away in about 2 weeks.

You’ll need to have someone drive you home after your endovenous laser ablation.

At home

After you go home, be sure to follow any instructions from your provider. You may be told to:

• Put an ice pack over the area for 15 minutes at a time, to help reduce swelling.
• Check the incision sites every day. It’s normal to see light pink fluid on the bandage.
• Keep the incision sites out of water for 48 hours. You may need to take a sponge bath until the bandages are removed.
• Wear compression stockings for a few days or weeks, if advised. These stockings gently squeeze your legs. This helps to prevent swelling in your legs. It can also help stop your blood from clotting or pooling.
• Not sit or lie down for long periods of time. Keep your leg raised when sitting.
• Not stand for long periods of time.
• Walk about 3 times a day for 10 to 20 minutes each time. Do this for 1 to 2 weeks.
• Keep active, but don’t run, jump, or lift heavy things for 1 to 2 weeks.
• Not take hot baths for 1 to 2 weeks.

When it comes to medicine, be sure to:

• Take over-the-counter pain medicine as needed, and only if advised by your healthcare provider. Some medicines can increase bleeding.
• Ask your healthcare provider when it will be safe to take blood-thinning medicine again, if you stopped taking it for the surgery

Your healthcare provider may want to give you an exam at a follow-up visit. He or she may use ultrasound to make sure the laser procedure worked.

Call your healthcare provider if you have:

• Signs of infection in the treated area. These include redness, warmth, or fluid leaking from the incision.
• Swelling that gets worse, or new swelling
• Any pain that keeps you from doing your normal activities

Your healthcare provider may give you other instructions, depending on your situation.

Endovenous laser ablation for varicose vein contraindications

Contraindications to endovenous laser ablation technique include:

• Allergy to local anesthetic
• Hypercoagulable state
• Infection of the leg to be treated
• Lymphedema
• Nonambulatory patient
• Peripheral arterial insufficiency
• Poor general health
• Pregnancy
• Recent or active thromboembolism
• Thrombus or synechiae in the vein to be treated
• Tortuous great saphenous vein (it may be difficult to place the laser fiber)

Endovenous laser ablation for varicose vein risks and side effects

All surgeries have some risks. Some possible risks of laser ablation for varicose vein include:

• Infection
• Pain over the vein
• Bleeding
• Bruising
• Nerve damage
• Redness or swelling (inflammation) of the vein
• Blood clots
• Changes in skin color over the treated vein
• Burns

You may have other risks, depending on your general health. Be sure to talk with your healthcare provider about any concerns you have before your procedure.

Short-term pain and ecchymoses have been commonly observed after endovenous laser ablation. Intermittent-pulsed laser fiber pullback has been reported, in a retrospective review, to cause significantly greater levels of post-operative pain and bruising, compared with a continuous pullback protocol ⁸. Adding a short-stretch bandage for 3 days following intermittent mode endovenous laser ablation substantially reduced patient-reported bruising and pain. Employing continuous mode pullback further reduced the severity of pain and bruising to such an extent that levels were similar to those reported by patients treated with radiofrequency ablation. Preliminary reports suggest there may be some differences in postoperative course depending on wavelength used to perform endovenous laser ablation ⁹. However, this is based on sparse data with short-term follow-up.

References

1. Endovenous laser ablation. https://www.phlebolymphology.org/endovenous-laser-ablation/
2. Patel PA, Barnacle AM, Stuart S, Amaral JG, John PR. Endovenous laser ablation therapy in children: applications and outcomes. Pediatr Radiol. 2017;47(10):1353–1363. doi:10.1007/s00247-017-3863-4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574964
3. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol JVIR. 2003;14:991–996. doi: 10.1097/01.RVI.0000082864.05622.E4
4. Nesbitt C, Bedenis R, Bhattacharya V, et al. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2014;7
5. Dexter D, Kabnick L, Berland T, et al. Complications of endovenous lasers. Phlebol Venous Forum R Soc Med. 2012;27:40–45. doi: 10.1258/phleb.2012.012s18
6. Poluektova AA, Malskat WSJ, van Gemert MJC, et al. Some controversies in endovenous laser ablation of varicose veins addressed by optical-thermal mathematical modeling. Lasers Med Sci. 2014;29:441–452. doi: 10.1007/s10103-013-1450-y
7. Malskat WSJ, Poluektova AA, van der Geld CWM, et al. Endovenous laser ablation (EVLA): a review of mechanisms, modeling outcomes, and issues for debate. Lasers Med Sci. 2014;29:393–403. doi: 10.1007/s10103-013-1480-5
8. Zimmet SE. Pain, bruising and short-term efficacy after endovenous laser treatment of the greater saphenous vein: the effect of operative technique and postoperative care. Paper presented at the 16th Annual Congress of the American College of Phlebology; Nov 7-10, 2002; Fort Lauderdale, Florida, USA.
9. Proebstle TM, Moehler T, Gul D, Herdemann S. Endovenous treatment of the great saphenous vein using a 1320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Dermatol Surg. 2005;31:1678-1683