Laser
surgery in venous insufficiency: E.L.A.V. personal technique
Carlos
Lisbona, Paulina Pérez, Juan Segura, Xavier Puncernau
*
*
Angiology, Vascular and Endovascular Surgery, Angio Vascular Projects
(AVP), Centro Médico Teknon, Barcelona, Spain.
Correspondence:
Carlos Lisbona
E-mail: karlister@yahoo.com
ABSTRACT
Objectives:
To show our experience in the treatment of varicose veins with a
newly developed laser treatment technique: E.L.A.V (Endo Laser Ablation
Veins), a novel application of laser in venous insufficiency pathology.
Method:
We have created a new application that consists of the treatment
of either long or short saphenous veins. It is also possible to
treat both legs at the same time associating miniphlebectomies and
transdermic laser treatment of all small varicosities, if necessary.
Duplex scanning evaluation was undertaken in every patient so that
it provided the causes of venous insufficiency and the highest point
of reflux. It was an accurate and individualized duplex scanning
study.
Results:
Patients treated with E.L.A.V. method presented excellent occlusion
postoperative rate, low morbidity and underwent a more comfortable
postoperative.
Conclusion:
E.L.A.V. method applied by an expert vascular surgeon becomes a
valid alternative to conventional surgery of varicose veins.
Key-words:
laser surgery, varicose veins.
J
Vasc Br 2004;3(4):403-6
Since 1996,
our team has been analyzing closely the works published about minimally
invasive treatment of varicose veins. Radiofrequency, angioscope, subfascial
ligatures and endovenous laser treatment are of special interest for
us because they are sophisticated techniques with important effects
on the hemodynamics. Yet, they avoid the inconvenient postoperative
of the classic techniques.1-3
In the
present article, we show the results of a 24-month analysis of 295 patients
managed with the E.L.A.V.TM technique, in a private hospital.
MATERIAL
AND METHODS
All patients
were approached in the operating room and submitted to regional anesthesia.
After surgery they were not hospitalized. Diodo laser DiomedTM
with 810 nm and 15 W was used in all patients (approved by FDA in 1996
and CE in 1999).
All patients
included in the study belonged to C2-C6 of CEAP classification and were
studied by eco-Doppler. They had long or short saphenous reflux with
or without varicose veins and were uni- or bilaterally approached, if
needed. The highest diameter of long saphenous vein was 16 mm. Patients
did not present any signs of deep venous thrombosis (DVT) and, after
operation, showed long or short saphenous reflux under Valsalva maneuvers.
We operated all the saphenous veins with diameters between 4.5 and 16mm
and reflux.
Pregnant
patients, with DVT, saphenous diameter > 16 mm and with saphenoctomy
were not included in this study.
All patients
were given an information sheet with a precise explanation of the different
techniques that could be employed to their case.
From October
2002 to October 2003 we operated 295 patients with the E.L.A.V.TM technique:
182 unilateral long saphenous; 71 bilateral long saphenous; 27 unilateral
short saphenous; three bilateral short saphenous and 12 long and short
saphenous. In all of them, Müller phleboextraction was associated.
All patients
were submitted to duplex scanning evaluation so that the reflux origin
(saphenofemoral junction versus pelvic veins) and the start and end
points of reflux (Figure 1) could be determined.
 Figure
1 - Duplex scan mapping.
Description
of the technique: E.L.A.V.
The patients
were submitted to regional anesthesia in cases of bilateral or severe
venous insufficiency. The insufficient saphenous vein was catheterized
through a small incision. A guide wire was entered through it and 5
French catheter was passed up to the saphenofemoral junction. We used
a 400 or 600 m optic fiber. Laser was applied to the entire extension
of the saphenous vein (Figure 2). Shunt types 1 and 3 (insufficiency
or not of saphenofemoral junction) were treated with ligature of insufficient
saphenofemoral junction and its collaterals (Figure 3). In shunt types
2 and 4 this procedure was not necessary. The catheter was placed 2
cm below the saphenofemoral junction (duplex scan guided position).
810 nm laser energy were liberated, with 12-14 watts, one second duration
and 0.5 seconds between shoots (Figure 4).4-7
Figure
2 - Catheterization of the long saphenous vein (middle 1/3 leg).
Figure
3 - Saphenofemoral junction ligature.
Figure
4 - Laser procedure.
A total
of 80-110 pulses were needed in every leg, depending on the length of
the treated vein (Figure 4).4,5,7 Müller
phlebectomy was made in the varicose veins (Figure 5) and transdermic
laser treatment was applied to the small varicosities, telangiectases
and reticular varicose veins if needed. After cleaning the leg, a sterile
dressing is applied to the incisions and an elastic bandage must be
used during 48 hours. After that, stockings must be worn for 4 more
days.
Figure
5 - Muller phlebectomies.
Prophylactic
heparinization (low molecular weight heparin) and antibiotic therapy
were used in all patients to prevent DVT and infections because the
next medical control would not be before 48 hours after the procedure.
Hemodynamic
control study by duplex scanning was carried out after 48 hours, 8 days,
1, 3, 6 and 12 months. Elastic stocking support was required for no
more than 15 days.
RESULTS
Immediate
results were considered to be within 1 month after the procedure. They
were: absence of burnings, cellulites, paresthesias or thrombosis; hematomas
were found only in cases of phlebectomy. There were two cases of incomplete
occlusion portions of the long saphenous vein combined with correct
occlusion of the rest. No important postoperative pain (no need of major
analgesic therapy) was reported.
Patients
came back to their normal routine in 72 hours (average).
Late results
were: 5% Periphlebitis (cellulites) successfully treated with diclofenaco,
1.3% of partial asymptomatic revascularization of the long saphenous
vein, one total revascularization in a patient with a big hematoma in
the thigh, 48 hours postoperative probably because extravasations of
the laser fiber, two cases with partial long saphenous vein reflux,
none in short, and 0.6% cases of low paresthesia in short saphenous
vein treatment, all of them transitory.
DISCUSSION
E.L.A.V.TM
is able to treat venous insufficiency and varicose veins uni- or bilaterally
in an ambulatory procedure that is really comfortable for the patient.8
In case
of saphenofemoral junction insufficiency, its ligature has no recidives
nor neoangiogenesis in our experience.
Under regional
anesthesia we were able to treat global insufficient saphenous veins,
uni- or bilaterally, associating long phlebectomies, all at one time
in an operating room and with optimal surgical conditions.
The use
of this laser method does not require tumescence anesthesia because
no injuries presented in the proximal structures.
It offers
non-systemic complications and the locals are clean and easily treated.
Phlebectomy
of varicose veins, telangiectasis and varicosities transdermic laser
treatment provide a very aesthetical result that satisfies patients,
both man and woman.
Only longer
series and prospective studies can really tell us the function and applicability
of this new technique as it happens with other new procedures.
Finally,
in our opinion, laser surgery must be applied in an individualized hemodynamic
study by a specialist in vascular surgery who has the appropriate knowledge
on these techniques and of course it must take place in an adequate
atmosphere and operating room. Revascularizations are probably due to
an incorrect application of the laser method.
Laser treatment
E.L.A.V.TM gives us the opportunity to heal without harm;
it includes a very trustful technique with both hemodynamic and aesthetic
good results.9-13
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