Complications
evidenced in the endovascular laser treatment for varicose veins
(Portuguese
PDF version)
Jorge
Enrique Soracco,1 Jorge Lopez D'Ámbola,1
José Luis Ciucci,1 José Maria Pereira de
Godoy,2 Cleusa Ema Quilici Belczak3
1.
Phlebology and Lymphology Service, Hospital Militar Central Dr. Cosme
Argerich, Buenos Aires, Argentina.
2. Angiology and Vascular Surgery Service, Faculdade de Medicina
de São José do Rio Preto (FAMERP), São José
do Rio Preto, SP, Brazil.
3. Vascular Center, Maringá, PR, Brazil.
Correspondence:
Jorge Enrique Soracco
Riobamba, 451 2o "A"
Buenos Aires, Argentina
E-mail: jsoracco@fibertel.com.ar
ABSTRACT
Objective:
The aim of the present study is to report the complications seen
in the endovascular laser treatment of varicose veins of the lower
limbs.
Methods:
From June 1999 to December 2002, 250 patients submitted to the endovascular
treatment of varicose veins of the lower limbs using lasers and
suffering from complications, such as skin burns, saphenous neuritis,
hyperpigmentation and fibrosis along the course of the saphenous
vein, were assessed. The diagnosis of the complications was made
clinically based on the signs and symptoms evidenced. Of the 250
patients, aged 25-79 years, treated in the Hospital Militar de Buenos
Aires, 196 were female and 54 were male. High power 810 nm wavelength
laser diodes were applied using semi-rigid 400 and 600-micron fiber-optic
quartz systems in continuous contact with the skin. Percentages
were used for statistical analysis.
Results:
Burn-type injuries were observed in 3.2% of cases, hyperpigmentation
in 9.6%, fibrosis along the course of the saphenous vein over at
least 6 months in 5.6% and saphenous neuritis in 4.8%.
Conclusions: We concluded that the endovascular laser treatment
for varicose veins of the lower limbs is not free from complications;
therefore, all factors involved should be identified and assessed.
Key-words:
lasers, varicose veins, lower extremities.
J
Vasc Br 2005;4(4):333-5
The conventional
surgery is widely accepted as the standard therapy for the treatment
of varicose veins, although it is associated with a high recurrence
rate.1 As an alternative, there is the possibility to use endovascular
procedures, such as radiofrequency endovenous obliteration, endovenous
laser treatment and sclerotherapy, which have the advantage of being
minimally invasive.1
The laser
has received a growing acceptance for the treatment of telangiectasias
and varicose veins, and it is suggested that the approach to these veins,
during the same treatment session, can be complementary in selected
individuals,2,3 besides being effective and safe for the treatment of
saphenous vein incompetence.4-7
However,
the following complications are mentioned: skin burn, saphenous neuritis,
hyperpigmentation and fibrosis in the internal saphenous vein.5-7 The
identification of such complications is an important tool to clear the
factors involved.
The aim
of the present study is to report complications in the endovascular
laser treatment of lower limb varicose veins in our service.
MATERIAL
AND METHOD
We assessed,
from June 1999 to December 2002, the following complications: skin burn,
saphenous neuritis, hyperpigmentation and fibrosis in the saphenous
vein in 250 patients submitted to endovascular laser treatment of lower
limb varicose veins, with follow-up ranging from 1 month to 3 years,
at the Hospital Militar in Buenos Aires, Argentina. The diagnosis
of the complications was clinical, based on signs and symptoms. We assessed
196 female patients and 54 male patients, aged between 25 and 79 years.
Venous insufficiency was diagnosed by color Doppler duplex scanning.
Exclusion criteria were: patients with chronic venous insufficiency
associated with trophic disorders, ulcers, peripheral arteriopathies,
chronic diseases, deep venous thrombosis, pregnancy or lactation.
It was
an outpatient procedure, but the patients remained in the hospital for
3 to 4 hours after the surgery. There were a total of 206 bilateral
procedures and 44 unilateral ones. The ligation of the aortic arch of
the saphenous vein was performed with local anesthesia and intravenous
application of 810-nm high potency diode laser, through a system of
400 and 600- µm semirigid quartz optical fibers, flat contact
tip in continuous surgical mode. We proceeded to the signing of the
insufficient veins with the patients standing and using a dermographic
pencil. The great saphenous vein was punctured at the pre-malleolus
with an 18-G needle, and the 600-µm pre-carbonized semirigid quartz
optical fiber was introduced. When the distal puncture was not possible
to be performed, the pre-malleolar saphenous vein was accessed through
a delicate dissection. We highlight that it is always important to assure
that the optical fiber is inside the vein, and it should ascend it with
no difficulty. The transdermoillumination allowed the verification of
the laser tip progression (red, 635-nm diode) up to the inguinal crease,
emerging through the sectioned or repaired distal saphenous vein or
until the site of reflux that was previously signaled and diagnosed
using the eco-Doppler, such as, for example, the perforating vein of
Hunter's canal. When needed, the procedure was performed under control
using the eco-Doppler.
We proceeded
in a similar manner with the insufficient and perforating collateral
veins, performing the punctures that were required to achieve a full
treatment of the varicose veins and block the sites of reflux, with
potencies ranging from 4 to 10 W. The treatments were usually controlled
using the eco-Doppler.
The development
of this technique was approved by the Bioethics Committee of the Hospital
Militar de Buenos Aires, where all patients were properly informed
about the method and signed a consent form.
For statistical
analysis, the percentages were calculated.
RESULTS
Burns were
seen in 3.2%, hyperpigmentation in 9.6%, fibrosis in the saphenous vein
for more than 6 months in 5.6% and saphenous neuritis in 4.8%.
DISCUSSION
The present
study shows that the endoluminal laser therapy for superficial lower
limb varicose veins presents events, such as skin burn, saphenous neuritis,
fibrosis in the vessel route, hyperpigmentation and hematoma, which
usually disappear through time. Variable events are described from one
service to another.3,5,8,9 Paresthesia is reported in around 8.5% in
the first week, usually with regression within 6 months, persisting
in 0.7% of cases.7 Another study reports paresthesia in 10% of cases
in the sixth postoperative month and skin burn lesion in 3.3%.8 It is
possible that these differences are associated with the team's experience
level.9 Other results show higher frequencies of complications: local
paresthesia in 36.5%, ecchymosis in 23%, superficial burn in 4.8%, superficial
phlebitis in 6% and hematoma in 0.8% of cases. Significant morbidity
or mortality rates were not registered. All patients had a fast recovery,
and the authors think that the complications were minimized after the
endovenous laser treatment (EVLT), comparing to the conventional postoperative
period.10 What can be observed in the literature is a variation in the
frequency of these complications, probably due to several factors. The
choice of the vessel to be treated (higher or smaller caliber), the
laser to be used (diode) and the energy to be expended in each procedure
may be factors that might influence the occurrence of these complications.
As these factors are being identified, it is possible to reduce the
events.
On the
other hand, the endovascular laser has proved to be efficient regarding
the resolvability of the varicose veins,5-7 besides being a less aggressive
intervention in relation to the conventional surgery.3-7 Most events
are reversible through time, although they create a temporary discomfort
for patients.
CONCLUSION
We conclude
that the endovascular laser treatment for lower limb varicose veins
is not free from complications and that the factors that led to such
complications must be identified and reassessed.
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