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Canadian Experience with the 980 nm Biolitec
Laser
| Thursday,
20 September 2007 |
Start
8:50am |
Salon 1 |
Duration:
15mins |
Louis Grondin MD MBA FACPh
Introduction:
In Canada, as in most industrialized countries approximately one in three adult develops varicose veins. Conventional varicose vein surgery by stripping and high ligation, although still considered gold standard in some circles, carries a high recurrence rate and an unacceptable morbidity over time. In the past 10 years Endo-Venous Laser Ablative (EVLA) procedures have emerged as an alternative treatment. EVLA initially utilized diode lasers of 810 nm, 940 nm, and 980 nm; and later 1,320-nm Nd:YAG lasers were introduced. Some controversy arose regarding the ideal laser wavelength. A mathematical model comparing the 980 nm and the 1,320 nm lasers concluded that the 1,320 nm laser would require less energy to achieve venous wall damage; but within their respective parameters both lasers produce similar results and, side effects. Other studies comparing the 980 nm laser with the 810-nm have demonstrated similar effectiveness with no major complications and minimal adverse outcomes. We propose that the concomitant use of foam sclerotherapy with EVLA may maximize the laser energy delivery to the endovein (regardless of the wavelength) and reduce the post-operative treatment sessions, without significantly increasing the treatment risks.
Method:
We utilize a biolitec (980 nm) laser and modified the procedure by delivering laser energy to a vein filled with foam. We present at this meeting a review of our first 200 patients. We position by ultrasound assistance a laser fiber percutaneously into an truncal varix (GSV, SSV, linear collateral veins). Foamed sclerosant (3-5cc) is injected via the catheters. We use medical grade CO2 gas, and 5-micron luer-lock filters to ensure microfoam creation. Following perivenous tumescent infiltration, thermal energy (10 Watts in continuous mode) is applied to the endo-vein. Our patients are examined 1 week, 1month, 6 months, and yearly following the procedure.
Results:
Our overall closure rate is 98%. In the case of the GSV the average closure-distance to the femoral vein is 1.3 cms. The average treatment sessions, following the EVLA, to complete the elimination of truncal varices was 1.8 session/leg. Patient satisfaction by follow up survey is high (95%).
Complications:
We had one systemic allergic reaction, (0.39%) that required resuscitation. This was likely due to the sclerosant. We observed no DVT and no thrombo-embolic event. We found two asymptomatic proximal greater saphenous thrombus protrusion into the femoral vein (0.78%). Superficial phlebitis and paresthesias were uncommon: 1.55% and 0.78% respectively. Matting and staining were also uncommon: (1.94% each) and self resolved within 12 months except in one case ((0.39%). We observed no cutaneous burn.
Conclusion:
The combination of EVLA with surgical procedures has been described, but to date there has been no published report of EVLA in combination with microfoam sclerotherapy. Apart from the inherent advantages of the EVLA procedure, the adjunction of foam sclerosants may reduce the recurrence rate and the course of treatment, without significantly increasing the risk of thromboembolic events. Although in all GSV cases the laser tip was positioned at a distance of 3-5 cms from the SFJ, the average closure site was 1.3 cm from the femoral vein. In the case of the SSV and non-saphenous truncal varices, the laser tip was consistently kept out of the popliteal fossa and at times at a considerable distance from the vein termination. Post-operative ultrasound showed consistent closure of multiple and complex proximal branches where laser energy was not delivered. The more serious complications of deep venous thrombosis or extension of thrombus into the femoral vein have been previously reported as 0% to 2.3% of limbs treated. We observed no DVT or PE, which we attribute to our thrombo-prophylaxis protocol (given in 13 patients) (5%). In the two cases of thrombus protrusion: the pre-surgical diameter of the proximal saphenous vein exceeded 15mm, the protrusion was detected at 24 hours, and resolved without treatment in 2-3 weeks. Others have postulated that clot extension is related to proximal vein size. In the future we propose to evaluate the role of thromboprophylaxis in large diameter veins.
References
i Perrin M, Guexx JJ, Ruckley CV, de Palma R, Royle JP, Eklof B, Nicolini P, Jantet G, and the REVAS group; Recurrent varices after surgery a consensus document; Cardio Vasc Surg; 2000 Vol 8 No 4 p:233-38
ii Beresford JJ, Smith L, Brown RM, Greenhalgh, Davies AH; A comparison of health-related quality of life of patients with primary and recurrent varicose veins; Phlebology 2003; 18: 35-37
iii Mordon SR - Mathematical modeling of 980-nm and 1320-nm endovenous laser treatment. - Lasers Surg Med -2007; 39(3): 256-65
Kabnick LS - iv Outcome of different endovenous laser wavelengths for great saphenous vein ablation. - J Vasc Surg -2006; 43(1): 88-93
v Sadick NS - Combined endovascular laser plus ambulatory phlebectomy for the treatment of superficial venous incompetence: a 4-year perspective. - J Cosmet Laser Ther -2007; 9(1): 9-13
vi Huang Y - Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity: a report of 208 cases. - J Vasc Surg -2005; 42(3): 494-501; discussion 501
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