Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity: A report of 208 cases
Article Outline
Background
We assessed the safety and efficacy of endovenous laser treatment (EVLT) of the saphenous vein combined with a surgical strategy for treatment of deep venous insufficiency in the lower extremity.
Methods
Two hundred thirty venous insufficiencies of the lower limbs in 208 consecutive patients (93 men and 115 women; mean age, 54.15 years) were treated with EVLT combined with surgical strategies. All patients were symptomatic. There were 84 limbs (36.5%) in C2, 25 (10.9%) in C3, 109 (47.7%) in C4, 1 (0.4%) in C5, and 9 (3.9%) in C6 (CEAP), and Klippel-Trenaunay syndrome was present in 2 limbs. A total of 119 (51.7%) had perforator vein incompetence. Four therapeutic methods were included in this series according to symptoms, CEAP classification, and venous reflux. Simple EVLT was performed for 15 patients with only great saphenous vein (GSV) incompetence or Klippel-Trenaunay syndrome in 19 lower limbs. EVLT combined with high ligation of the GSV and open ligation of perforators was performed for 5 patients with GSV and perforator incompetence in 5 lower limbs. EVLT was combined with high ligation of the GSV for 76 patients with GSV incompetence in 94 lower limbs. EVLT was combined with external banding of the first femoral venous valve and high ligation of the GSV for 112 patients with primary deep venous insufficiency in 112 lower limbs. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks, 6 months, and 1 year after operation.
Results
All patients tolerated the procedure well and returned to normal daily activities immediately, achieving a 100% immediate clinical success rate. Spot skin burn injuries occurred in 2 patients (1.0%). Paresthesia in the gaiter area was noted in 15 patients (7.2%). No postprocedural symptomatic deep venous thrombosis or pulmonary embolism occurred. Three patients had local recurrent varicose veins in the calf (1.4%) during a 2- to 27-month follow-up (mean, 6.12 months). Postoperative clinical classes were significantly improved between 2 weeks and 24 months (P = .0001 at 2 weeks and 3 to 18 months; P = .0055 at 24 months compared with before operation), especially in preoperative C2 to C3 stage patients, who achieved complete amelioration.
Conclusions
EVLT is a novel minimally invasive treatment with advantages of safety, effectiveness, and simplicity, and it leaves no scars. Its indications can be expanded by combining EVLT with surgical strategies.
Superficial varicosity in the lower extremity is a common disorder in the Chinese population. Its most frequent causes are primary deep venous insufficiency (PDVI) and great saphenous vein (GSV) incompetence. The classic surgical strategies include reconstruction of the deep venous valve, high ligation and ablation of the GSV, ligation of perforators, excision of superficial varicosities, and so on. The drawbacks of surgery include risks associated with surgical complications, increased in-hospital costs, and prolonged recovery periods. Also, surgery does not ensure freedom from recurrence.1, 2 In recent years, with the development of minimally invasive techniques and the advent of new surgical apparatus, less invasive alternatives to surgical treatment of superficial varicose veins have emerged. From June 2001 to September 2003, 208 consecutive patients were successfully treated by endovenous laser treatment (EVLT) combined with surgical interventions in our department. Herein we report our experience and a retrospective study to evaluate the safety and efficacy of this method.
Methods
Patients
All patients were selected from our department as they came for their symptomatic varicosities. Thorough history and physical examinations were performed. All patients were first screened by air plethysmography and ankle-brachial index measurement, and only those with normal venous outflow in air plethysmography and an ankle-brachial index greater than 0.9 underwent further testing. Duplex scanning was performed to document patency of the deep veins and to evaluate the valve reflux time. Venous reflux was defined as reverse flow of more than 0.5 seconds.3 Combined with the reflux index, a value greater than 2.5 would be considered as severe reflux.4 Perforators were considered incompetent if the diameter was 4 mm or more and/or had an outward directional flow exceeding 0.5 seconds. On account of certain limitations in the above-mentioned testing, ascending venography was performed to confirm the diagnosis and further exclude postthrombotic syndrome with total recanalization and the May-Thurner syndrome, which might be missed in ultrasonography.
The contour of deep veins, valves, and perforators could be visualized, and the function of the first valve of the femoral vein was tested by the Valsalva maneuver. Perforators could be localized under duplex scanning combined with venography. The severity of venous insufficiency was categorized according to the CEAP classification.5 On the basis of duplex scanning, ascending venography, and CEAP classification, patients with PDVI were stratified into mild, moderate, and severe groups to simplify the choice of therapeutic modalities. The mild group was defined as patients at stage C2 to C3, with venous reflux to the knee level in ultrasonography, mild reflux but nearly normal contour in the first valve of the femoral vein, mildly dilated deep veins, and nearly normal configuration of other valves in the deep veins as visualized by venography. The moderate group were patients at stage C4 to C5, with venous reflux to below the knee level in ultrasonography, moderate reflux in the first valve of the femoral vein (with its valve contour being retained), dilated deep veins, and less definitive visualization of the contours of the other valves in deep veins on venography. The severe group were patients at stage C6, with venous reflux to the ankle level in ultrasonography, severe reflux in the first valve of the femoral vein (with obscure valve contour), more dilated deep veins, and other valves in the deep veins poorly visualized by venography. Patients with acute superficial thrombophlebitis, aneurysmal veins larger than 2.0 cm in diameter, nonpalpable pedal pulses, or deep venous thrombosis (DVT) and those who were pregnant, breast-feeding, or in poor general condition were not candidates for EVLT.
Procedures
All patients were treated with EVLT or EVLT combined with surgery under epidural or lumbar anesthesia. The 810-nm diode laser (Diomed, Ltd, Cambridgeshire, United Kingdom) was used to generate heat sufficient to cause thermal damage to the venous endothelium. Four therapeutic strategies were included: simple EVLT was performed for 15 patients with GSV incompetence or Klippel-Trenaunay syndrome (KTS) in 19 lower limbs during our early stage of EVLT. Procedures were followed as previous reported6 and were based on the techniques of Navarro et al.7 In some patients who had significant enlargement of the saphenous trunk, the technique was improved for the treatment of GSV trunk. After introduction of the optical fiber to the GSV from the ankle level to the groin, the involved limb was elevated 30°, and blood in the varicose veins was fully evacuated. A laser-emission power of 12 or 14 W in continuous mode was chosen to treat GSV from below the saphenofemoral joint (SFJ) to the knee level, and then 12 W and 1 pulse duration was used in the GSV from the knee level to the ankle level. A wavelength of 810 nm of diode laser energy was delivered along the course of the GSV as the laser fiber and catheter were slowly withdrawn in 3- to 5-mm increments. During the procedure, manual compression was applied over the red aiming beam, which could be visualized through the skin, to improve the vein wall apposition around the laser fiber tip; thus, better laser fiber–endothelial contact and even emission by laser energy were achieved to completely shrink and occlude the venous trunk. For mild or moderate varicosities caused by tributaries of the GSV, EVLT with multiple percutaneous introductions of laser fiber through an 18-gauge needle was performed.
EVLT was combined with high ligation of the GSV and open ligation of perforators for 5 patients with GSV and perforator incompetence in 5 lower limbs. This intervention was performed after we realized that pulmonary embolism (PE) might occur though the SFJ and that the perforator could be obliterated by direct EVLT through an 18-gauge needle. EVLT was combined with high ligation of the GSV for 76 patients with GSV incompetence in 94 lower limbs. EVLT was combined with external banding of the first femoral venous valve and high ligation of the GSV for 112 patients with PDVI in 112 lower limbs. Femoral banding was indicated for patients of C4 to C6 with axial reflux in duplex and venography examinations or with complex skin changes but in whom the configuration of the first valve had not been totally destroyed. Among those, 25 limbs underwent additional phlebectomy because of extensive varicose masses in the calf region. The indications for intervention are shown in Table I. All operated limbs were managed with compressive bandaging after the procedure. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks, 6 months, and 1 year after operation.
Table I. Indications for intervention
| Variable | Indication | No. limbs (%) |
|---|---|---|
| EVLT | C2-C3, simple GSV incompetence, segmental reflux in duplex scan and venography, and KTS | 19 (8.3%) |
| EVLT + GSV high ligation + open perforator ligation | C2-C4, GSV and perforator incompetence, segmental reflux | 5(2.2%) |
| EVLT + GSV high ligation | C2-C4, GSV with or without perforator incompetence, segmental reflux in duplex scan and venography, patients in mild group with segmental reflux | 94(40.9%) |
| EVLT + external banding of the first femoral venous valve + GSV high ligation | C4-C6, axial reflux and the first femoral venous valve was not totally destroyed in duplex scan and venography, complex skin changes, patients in mild group with axial reflux and patients in moderate and severe group | 112(48.7%) |
| No phlebectomy | No extensive varicose mass | 87(77.7%)⁎ |
| Phlebectomy | Extensive varicose mass | 25(22.3%)⁎ |
⁎ Percentage in total limbs performed on EVLT combined with external banding of the first femoral venous valve and high ligation of the GSV. |
Parameters
The diode laser fiber in the treatment of GSV and superficial varicosities is normally 400 to 600 μm in diameter; the 600-μm-diameter fiber and a wavelength of 810 nm were chosen in our series. Pulses ranging from 80 to 500 seconds were used for the entire procedure, with a mean of 205. According to the severity of varicosities, it took 0.5 hours to 1 hour to perform the entire procedure, with a mean of 50 minutes.
Postoperative management
Ambulatory activities were encouraged after operation. Elastic compressive bandaging was instructed for at least 14 days or was changed to graduated compression stockings 3 days after operation. A thigh or pantyhose stocking was recommended. Oral administration of aspirin 75 mg was recommended for 1 to 2 months.
Statistical analysis
SAS software (SAS Institute, Cary, NC) was used. Statistical analysis of the data was performed with descriptive statistics and the Wilcoxon rank sum test for comparison of preoperative and postoperative C classes.
Results
Patient characteristics
Two hundred thirty venous-insufficient lower limbs (115 in the right and 115 in the left) in 208 consecutive patients (93 men and 115 women) were included in this series. Among those, two limbs had had previous treatment of sclerotherapy, and another three had had GSV and varicose vein ablation. Their ages ranged from 7 to 79 years, with a mean of 54.15 years. Their courses of disease were 1.5 to 30 years, with a mean of 12.61 years. According to the CEAP classification, all involved lower limbs had superficial varicose veins, and more than half had a class 4 or higher clinical stage (51.7%). Patients’ demographic data and CEAP classifications are listed in Table II, Table III.
Table II. Demographic and CEAP classification for 208 patients (230 limbs) treated with EVLT
| Variable | Data |
|---|---|
| History | |
| Mean age, y (range) | 54.15(7-79) |
| Women/men | 115/93(55.3%/44.7%) |
| Limb (right/left) | 115/115 |
| Course of disease, y (range) | 12.61(1.5-30) |
| Previous treatment | |
| Sclerotherapy | 2(0.9%) |
| Ablation | 3(1.3%) |
| CEAP classification | |
| Clinical | |
| Class 2 | 84(36.5%) |
| Class 3 | 25(10.9%) |
| Class 4 | 109(47.4%) |
| Class 5 | 1(0.4%) |
| Class 6 | 9(3.9%) |
| Etiology | |
| Primary | 228(99.1%) |
| Secondary | 0 |
| Anatomy/pathology | |
| Superficial reflux | 228(99.1%) |
| Deep reflux | 112(48.7%) |
| Perforator | 119(51.7%) |
| Others | 2(0.9%)⁎ |
⁎ Klippel-Trenaunay syndrome. |
Table III. Clinical presentation in CEAP distribution for 208 patients (230 limbs) treated with EVLT
| CEAP classification/symptoms | No. limbs (%) | |
|---|---|---|
| Clinical | ||
| Class 2: varicose veins | 84 | |
| Class 3: varicose veins with edema | 25 | |
| Class 4 | 109 | |
| Focal pigmentation | 7(6.4%) | |
| Hyperpigmentation | 45(41.3%) | |
| Indurated skin | 37(33.9%) | |
| Lipodermatosclerosis | 20(18.3%) | |
| Class 5: healed ulceration | 1 | |
| Class 6: active ulceration | 9 | |
| Anatomy/pathology | ||
| Superficial reflux | 228 | |
| Deep reflux | 112 | |
| Hyperpigmentation | 45(40.2%) | |
| Indurated skin | 37(33.0%) | |
| Lipodermatosclerosis | 20(17.9%) | |
| Healed ulceration | 1(0.9%) | |
| Active ulceration | 9(8.0%) | |
| Perforator | 119 | |
| Focal pigmentation | 7(5.9%) | |
| Hyperpigmentation | 45(37.8%) | |
| Indurated skin | 37(31.1%) | |
| Lipodermatosclerosis | 20(16.8%) | |
| Healed ulceration | 1(0.8%) | |
| Active ulceration | 9(7.6%) | |
| Others | 2⁎ |
⁎ Klippel-Trenaunay syndrome. |
Therapeutic effects
Successful percutaneous access and endovenous placement of laser fibers were achieved in all patients. All patients tolerated the procedure well and recovered uneventfully, with disappearance of varices. Patients without venous banding were encouraged to undertake ambulatory activities the day after operation. They returned to their normal daily activities 3 days after the operation and returned to work 14 days after operation. The durations for patients with venous banding were 3, 14, and 28 days after operation, respectively. Patients who received only EVLT had no incision, and the others had stage I wound healing. Gaiter ulcerations in all 9 patients were healed in 2 to 5 weeks after the procedure. On the basis of a questionnaire that measures preoperative and postoperative venous symptoms (including heavy legs, swelling, heat or burning sensation, numbness, tingling, and itching), all patients had relief of their symptoms and were satisfied with EVLT and the corresponding combined surgery.
Complications
Symptoms such as induration, pain, paresthesia, skin burn injury, leg swelling, cough, thoracic pain, hemoptysis, and fever were investigated after operation and in follow-up to evaluate operation-related complications. If any symptoms suggestive of DVT or PE occurred, further investigations including duplex scan, pulmonary radiograph, computed tomography, and isotope scan were performed to diagnose and guide treatment. In patients who experienced ecchymosis along the course of treated veins, this symptom usually abated in 2 weeks. Most patients had striplike or thrombuslike indurations over the treated veins that caused slight or moderate pain and resolved in 3 to 6 weeks. Paresthesia in the gaiter area was noted in 15 patients (7.2%) and recovered in 1 to 2 months. Spot skin burn injuries occurred in 2 patients (1.0%) and resolved in 2 to 4 weeks. There have been no other minor or major complications such as DVT, PE, or allergic reactions.
Follow-up
Patients were followed up from 2 to 27 months, with a median of 6 months. Duplex ultrasonography was performed 2 weeks after operation with the finding that there was no detectable flow and that total closure of the GSV was achieved in all 230 limbs (100%; Fig 1). Three patients had local recurrent varicose veins in the calf (1.4%) 3 weeks after operation and were successfully treated with EVLT under local anesthesia. No recurrence was seen in other patients. No patient experienced symptoms of DVT or PE. Postoperative clinical classes of patients are listed in Table IV. They were significantly improved between 2 weeks and 24 months (P = .0001 at 2 weeks and 3 to 18 months; P = .0055 at 24 months compared with before operation), especially preoperative C2 to C3 patients, who achieved complete amelioration at a mean of 6 months of follow-up. Duplex ultrasonography 1 year after operation demonstrated a thin, fibrous cord along the original GSV (Fig 2).
Fig 1.
Duplex ultrasonography showed an enlarged great saphenous vein (GSV) with detectable flow before endovenous laser treatment (EVLT) (left, indicated by NGSV) and a GSV with a smaller diameter and no detectable flow 2 weeks after EVLT (right, indicated by OPSV).
Table IV. Comparison of patients in preoperative and postoperative C classes (CEAP)
| Variable | C class | Total | ||||
|---|---|---|---|---|---|---|
| C2 | C3 | C4 | C5 | C6 | ||
| 2 wk after operation | ||||||
| No. of limbs seen (preoperative C) | 84 | 25 | 109 | 1 | 9 | 228 |
| No. of limbs improved to C0 | 84 | 25 | 0 | 0 | 0 | |
| No. of limbs improved to C4 | — | — | 109 | 0 | 0 | |
| No. of limbs improved to C5 | — | — | — | 1 | 4 | |
| No. of limbs improved | 84(100%) | 25(100%) | 0(0%) | 0(0%) | 4(44.4%) | 113(49.6%) |
| No. of limbs unchanged | 0(0%) | 0(0%) | 109(100%) | 1(100%) | 5(55.6%) | 115(50.4%) |
| 3 mo after operation | ||||||
| No. of limbs seen (preoperative C) | 84 | 25 | 105 | 1 | 9 | 224 |
| No. of limbs improved to C0 | 84 | 25 | 1 | 0 | 0 | |
| No. of limbs improved to C4 | — | — | 104 | 0 | 0 | |
| No. of limbs improved to C5 | — | — | — | 1 | 9 | |
| No. of limbs improved | 84(100%) | 25(100%) | 1(1.0%) | 0(0%) | 9(100%) | 119(53.1%) |
| No. of limbs unchanged | 0(0%) | 0(0%) | 104(99.0%) | 1(100%) | 0(0%) | 105(46.9%) |
| 6 mo after operation | ||||||
| No. of limbs seen (preoperative C) | 84 | 25 | 105 | 1 | 9 | 224 |
| No. of limbs improved to C0 | 84 | 25 | 5 | 0 | 0 | |
| No. of limbs improved to C4 | — | — | 100 | 0 | 0 | |
| No. of limbs improved to C5 | — | — | — | 1 | 9 | |
| No. of limbs improved | 84(100%) | 25(100%) | 5(4.8%) | 0(0%) | 9(100%) | 123(54.9%) |
| No. of limbs unchanged | 0(0%) | 0(0%) | 104(95.2%) | 1(100%) | 0(0%) | 101(45.1%) |
| 12 mo after operation | ||||||
| No. of limbs seen (preoperative C) | 70 | 16 | 81 | 0 | 2 | 169 |
| No. of limbs improved to C0 | 70 | 16 | 3 | — | 0 | |
| No. of limbs improved to C4 | — | — | 78 | — | 0 | |
| No. of limbs improved to C5 | — | — | — | — | 2 | |
| No. of limbs improved | 70(100%) | 16(100%) | 3(3.7%) | — | 2(100%) | 91(53.8%) |
| No. of limbs unchanged | 0(0%) | 0(0%) | 78(96.3%) | — | 0(0%) | 78(46.2%) |
| 18 mo after operation | ||||||
| No. of limbs seen (preoperative C) | 48 | 3 | 39 | 0 | 0 | 90 |
| No. of limbs improved to C0 | 48 | 3 | 1 | — | — | |
| No. of limbs improved to C4 | — | — | 38 | — | — | |
| No. of limbs improved to C5 | — | — | — | — | — | |
| No. of limbs improved | 48(100%) | 3(100%) | 1(2.6%) | — | — | 52(57.8%) |
| No. of limbs unchanged | 0(0%) | 0(0%) | 38(97.4%) | — | — | 38(42.2%) |
| 24 mo after operation | ||||||
| No. of limbs seen (preoperative C) | 15 | 1 | 8 | 0 | 0 | 24 |
| No. of limbs improved to C0 | 15 | 1 | 0 | — | — | |
| No. of limbs improved to C4 | — | — | 38 | — | — | |
| No. of limbs improved to C5 | — | — | — | — | — | |
| No. of limbs improved | 15(100%) | 1(100%) | 0(0%) | — | — | 16(66.7%) |
| No. of limbs unchanged | 0(0%) | 0(0%) | 8(100%) | — | — | 8(33.3%) |
Fig 2.
Duplex ultrasonography showed a thin, fibrous cordlike remnant of the original great saphenous vein (GSV) 1 year after endovenous laser treatment (EVLT). The common femoral vein (solid arrow) and GSV (dashed line arrow) are shown. A, GSV below the saphenofemoral joint, with detectable flow in the common femoral and femoral veins. B, GSV in the thigh: a thin, fibrous cordlike remnant.
Discussion
Compared with classic surgery for PDVI and GSV incompetence, the objective of less invasive treatment alternatives is to reduce risk, morbidity, and cost while leading to acceptable short- and long-term results; cosmetic reasons are important as well. Techniques such as miniphlebectomy, cryotherapy, sclerotherapy, ultrasonography, transcatheter-guided sclerotherapy, and electrocautery have been developed as less invasive means for the treatment of superficial varicosities in the lower extremities. Among all minimally invasive treatments, subfascial endoscopic perforator surgery, endoluminal radiofrequency, and EVLT have shown promise. EVLT seems particularly promising in the minimally invasive treatment of varicose veins.6, 7 EVLT consists of percutaneous transvenous catheter-guided laser fiber introduction, a minimal access site size, transmission of laser energy through a small-diameter and flexible fiber, and direct operation through skin visualization of the laser tip by its red aiming beam light. This causes a thrombotic occlusion of laser-treated veins. All of these contribute to procedural ease and safety, improved effectiveness, and an absence of surgical scarring.
The endovenous laser generates bursts of heat enough to form steam bubbles, which cause thermal injury to the venous endothelium. This results in thrombotic occlusion of the target vein.8 EVLT is indicated to treat insufficiency of the GSV and its tributaries in which the clinical manifestations are superficial varicose veins. Navarro et al7 reported a 100% rate of GSV closure in 40 limbs after EVLT by using 810 nm with a mean follow-up of 4.2 months. Despite the limitation of small numbers and only short-term data, the efficacy of EVLT for the treatment of incompetent GSV has been reported to be greater than 95%.8, 9 Our results showed the same successful rate. Proebstle et al10 reported a series of 77 patients who received EVLT of 106 GSVs in which 6 GSVs (6%) were not occluded at day 1 after operation, 9 GSVs (9%) were not occluded at 1 month, and 11 GSVs (10%) were not occluded at 3 months and indicated the EVLT failure might be related to the administration of low laser fluence, its unit is J/cm2.
To achieve optimal effects, the selection of patients is most important. Patients with potential risks for DVT and PE should be excluded. Duplex scanning combined with ascending venography was performed routinely, because the latter can directly visualize the configuration of deep veins, valves, and perforators and can compensate for the drawbacks of duplex scanning. The duplex scan has its predominant advantage in reflux detection and quantitative evaluation. Complete recanalization of the deep veins in patients with postthrombotic syndrome and May-Thurner syndrome were excluded in this series to prevent possible postoperative DVT and subsequent PE. Because of examiner preference, some cases were detected only in venography, although it is invasive and requires contrast media.
To decrease the postprocedural recurrence of both the GSV and tributaries for other than technical reasons, we performed different therapeutic strategies according to symptoms, CEAP classification, and venous reflux. Duplex and ascending venography were performed to evaluate the deep vein patency, venous reflux, valve contour, and perforator localization. For patients with PDVI and deep reflux, especially those with obvious skin changes, EVLT combined with external banding of the first femoral venous valve and high ligation of the GSV was performed at one stage. In 1975, Kistner11 advocated the femoral valve repair operation in the treatment of PDVI. In 1982, Jones et al12 reported the method of triangular venous valvuloplasty. From 1982 to 1987, more than 200 patients were operated on with these 2 methods in our department. We found that satisfactory results were most likely to be expected in lower limbs with mild and moderate deep venous reflux.13 In a study of 50 adult cadavers (100 lower extremities),14 it was suggested that the valves of the common femoral vein could withstand a retrograde pressure of 180 to 250 mm Hg; the valves of the femoral vein, 260 to 350 mm Hg (the first valve of this vein is the strongest and acts against 350 to 420 mm Hg); and the valves of the popliteal vein, 210 to 300 mm Hg. Thus, different types of deep venous reconstruction were performed according to the venous reflux detected by ascending and descending venography.13, 15, 16
Reconstruction of the first valve of the femoral vein seemed to be more effective in patients of C4 to C6 with total deep venous reflux only if the valve was not totally destroyed. To avoid the postoperative complication of thrombosis due to intravenous manipulation, this banding valvuloplasty operation was chosen and clinically applied, with excellent results. Camilli and Guarnera,17 Guarnera et al,18 and Belcaro et al19 have reported their successful experiences with external banding valvuloplasty. Thus, external banding of the first femoral venous valve was chosen for valve reconstruction in this series. For both GSV and perforator incompetence, to avoid recurrence, high ligation and ligation were performed, respectively, in our early cases; localization of perforators by ultrasonography and direct puncture to permit EVLT obliteration was used after we gained experience with this technique. Also, multiple puncture of tributary varices for EVLT was performed. For patients who had an enlarged mass in the GSV or its tributaries, phlebectomy was used.
Although the postoperative clinical classes were significantly improved in our follow-up study, especially those in the C2 to C3 classes before operation, limbs in preoperative C4 to C6 showed no significant change in clinical classes after operation. Advanced cases with skin changes are unlikely to change significantly after treatment, and the healing of an active ulcer would drop the patient from C6 to C5. Thus, venous severity scoring20 seems to be more accurate than the CEAP classification for assessing the efficacy of the treatment.
Most cases in our study were treated by EVLT combined with surgical strategies. The advantages are as follows. Using a longitudinal incision of 6 to 8 cm at the inner side of the upper thigh for the external banding operation and a 2-cm incision along the dermatoglyph in the groin region just over the SFJ for high ligation of the GSV, placement of the fiber could be accurately confirmed by direct visualization. This is a simple procedure for a vascular surgeon. Intradermic suture was performed with absorbable suture. The incision was sheltered, with no scar left, and was easily accepted by patients. High ligation of the GSV was performed with EVLT except for 15 patients (19 lower limbs) in our early stage. High ligation of the GSV was used to decrease the risk of thrombus in the deep vein and GSV recanalization caused by SFJ reflux and to facilitate complete GSV thrombosis and fibrosis. We had no complications of clinically apparent DVT or PE in our patient cohort and had a low recurrence rate. Because most of our patients had varices in the calf region and more advanced skin changes in the gaiter area than those reported in the literature, we treated the entire incompetent GSV from groin to ankle (not from groin to knee) in all cases. To avoid thermal injury to the saphenous nerve during the procedure, 12 W in discontinuous mode with a 1-second pulse duration, 1-second intervals, and relatively quick withdrawal was used in the GSV from the knee to ankle level, and subcutaneous tumescence of saline along the course of the GSV was recommended. EVLT combined with surgical strategies can be used to broaden the clinical application. For patients with PDVI, especially those with total deep reflux, deep venous valvuloplasty can be performed and followed with EVLT. This combined therapeutic method was performed to achieve better efficacy. In our 208 cases, EVLT combined with external banding of the first femoral venous valve was performed for 112 patients in 112 lower limbs (53.8%). In our experience, EVLT combined with high ligation of the GSV, perforator ligation, and valvular repair, when complicated with PDVI, could reduce recurrence and recanalization due to blood reflux and further enhance the shrinkage and fibrosis of treated varicoses. Reports of clinical results of GSV surgery in the presence of deep reflux are not consistent,21, 22, 23, 24 and recently, the definition of deep axial reflux was advocated25 to be of great importance in the choice of surgery. Two cases of KTS were reported in our series. KTS with superficial varicose veins and patent deep veins is optimal for EVLT.
If the GSV was too tortuous to allow a catheter to pass, multiple puncture was indicated, and ultrasound-guided catheterization was used if necessary. If varicosities were very close or adhered to the dermis, then subcutaneous tumescence of saline over the treated vein was indicated to form a protective barrier between varicosities and the skin, thus preventing skin burn injury. Quick withdrawal was important as well. Two skin burn injuries occurred at an early stage in our series. Because subcutaneous tumescence of saline and the terminal highlight were used, such complications were seldom seen. The diode laser is an endovenous one that has a contact effect. We suggest that elevation of the involved limbs before the emission of laser energy, to fully empty venous blood and collapse the venous wall by compression, will help to obtain better fiber endothelial contact and reduce the postoperative reaction of thrombophlebitis as well. In addition, laser power of 12 to 14 W in continuous mode was used in treatment of the GSV from the groin to knee level for increasing laser energy to completely achieve a therapeutic effect.
Indurations along the course of the GSV or over treated varicose veins will cause local pain. Such a tissue reaction is most distinct 1 to 2 weeks after operation and then gradually subsides and diminishes in 3 to 6 weeks. The more complete the emptying of the vein lumen, the less tissue reaction will be produced, and better results will be achieved. In addition, postoperative compressive bandaging or compressive stockings are most important after EVLT to avoid early recanalization and enhance the therapeutic effect.
Early results with EVLT have been impressive, with very effective closure of incompetent GSV and varicose veins, but its long-term evaluation awaits long-term follow-up and multicenter investigations. On the basis of continuous improvement of this technique, EVLT will render favorable prospects for extensive application because of its advantages of safety, effectiveness, minimal invasiveness, fewer complications, and easy operation.26
For an extraordinarily enlarged GSV, unmatching of the laser fiber caliber to the venous caliber should be considered. Radiofrequency is another endovascular technique for the elimination of saphenofemoral reflux and truncal GSV. Because we now perform both EVLT and radiofrequency in our department, further study to compare EVLT vs radiofrequency in the treatment of GSV is under way to achieve better selection of these two minimally invasive techniques.
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Competition of interest: none.
PII: S0741-5214(05)00883-9
doi:10.1016/j.jvs.2005.02.051
© 2005 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
