1. EndoVenous
Laser Ablation
DR DILIP S.RAJPAL
MS, MAIS, FICS(USA), FMAS,
Dipl. In Laproscopic surgery,
Fellow in Robotic & Adv Lap. Colo-Rectal Surgery (korea univ.)
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
HON. SURGEON NOVA MEDICAL CENTER
HON. SURGEON GODREJ MEMORIAL HOSPITAL
HON. ASS PROF GRANT MED.COLLEGE & HON. SURGEON JJ HOSPITAL
EX-ASST. PROF L.T.M.GEN. HOSPITAL

2. Definition
 Telangiectasias - are a confluence of dilated
intradermal venules less than one millimeter in diameter.
 Reticular veins - are dilated bluish subdermal veins,
one to three millimeters in diameter. Usually tortuous.
 Varicose veins - are subcutaneous dilated veins three
millimeters or greater in size. They may involve the
saphenous veins, saphenous tributaries, or
nonsaphenous superficial leg veins.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

3. Abnormal Veins
Telangiectasias
Varicose vein
Reticular veins
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

4. Common Questions
 Are they dangerous?
 How do they form?
 Why does it happen?
 Did I inherit it?
 What tests can we use?
 What treatments are available?
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

5. Superficial veins
Great saphenous – formed by the union of the
dorsal digital vein of the great toe and the dorsal
venous arch.
 Ascends anterior to the medial malleolus,
posterior to the medial condyle of the femur. It
freely communicates with the small saphenous
vein.
 Proximally it traverses the saphenous opening in
the fascia to enter the femoral vein.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

6. Small saphenous vein
 Formed by the union of the dorsal digital
vein of the 5th digit and distal venous
arch.
 Runs posterior to the lateral malleolus,
lateral to the calcaneal tendon.
 Runs superiorly medial to the fibula and
penetrates the deep fascia of the popliteal
fossa, ascends between the heads of the
gastrocnemius muscle to join the popliteal
vein.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

7. Perforating veins
 Penetrate the deep
fascia, tributaries of the
saphenous veins, valves
are located just distal to
penetration of the deep
fascia.
 Veins cross the deep
fascia obliquely
 Muscle contraction
causes the valves to
close prior to venous
compression so blood is
forced proximally
(musculo-venous pump).
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

8. Deep Veins
 Usually paired with named arteries inside a
vascular sheath, this allows arterial pulsation to
force blood proximally.
 The popliteal vein joins the femoral vein in the
popliteal fossa
 Femoral vein is joined by the deep vein of the
thigh. The femoral vein passes deep to the
inguinal ligament to become the external iliac
vein.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

9. Etiology
 Reflux 80%
 Venous obstruction 18-28%
 Resultant edema and skin changes =
Postthrombotic syndrome
 Muscle Pump Dysfunction
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

10. Stasis Pathophysiology
 Usually associated with venous
incompetence
 Primary and secondary reflux
 Edema
 Vein wall dilatation
 Inflammation/Pigmentation (Hemosiderin
deposits)
 “Fibrin cuffing”
 Ulceration
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

11. Risk factors
 Age: Aging causes wear and tear. Eventually,
that wear causes the valves to malfunction.
 Sex: Women > Men. Hormonal changes during
pregnancy or menopause. Progesterone
relaxes venous walls. OCP may increase the
risk of varicose veins.
 Genetics
 Obesity: Increases venous HTN.
 Standing for long periods of time. Prolonged
immobile standing impairs venous return.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

12. Strong familial component
 Not well studied
 Twin studies 75%
identical, 52% non
identical
 If both parents VVS -
90% of children VVs
 If one parent was
affected 25 percent for
men and 62 percent for
women
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

13. Symptoms
 Achy or heavy feeling,
burning, throbbing,
muscle cramping and
swelling.
 Prolonged sitting or
standing tends to
intensify symptoms.
 Pruritis
 Painful skin ulcers
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

14. Complications
 Extremely painful ulcers
may form on the skin
near varicose veins,
particularly near the
ankles.
 Brownish pigmentation
usually precedes the
development of an ulcer.
 Occasionally, veins deep
become enlarged.
 Bleeding
 Superficial
thrombophlebitis
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

15. Indications for EVLT or RFA: lessons from the
American Venous Forum
February of 1994 and the creation of CEAP
Clinical
C0: No visible or palpable signs of venous disease
C1: telangiectases or reticular veins
C2: varicose veins
C3: edema
C4: skin changes ascribed to venous disease
Most
a. pigmentation or eczema
Common
b. lipodermatosclerosis or atrophie blanche
C5: skin changes as defined previously with healed ulcer
C6: skin changes as defined previously with active ulcer
Etiologic: congenital, primary, secondary or none
Anatomic: superficial, perforator, deep
or none
Pathophysiologic: reflux, obstruction, both or none

16. Patient Assessment
 History

History of symptoms and onset

History of venous complications

Desire for treatment
 Comorbidities

Rule out secondary cause including DVT and HEART Failure
 Examination

Patient in general

Pedal pulses

Groins
 Veins
Trendelenburg Test
Venous claudication
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

17. Investigation
 All get a Duplex scan
 Examines
– Deep veins
– Superficial veins
– Incompetence and
patency
Other Tests
Physiologic testing
Phlebography
Intravascular Ultrasound
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

18. Duplex scan
 Vast majority have superficial
incompetence only.
 Sensitivity 95 % for identifying the
competence of the saphenofemoral and
saphenopopliteal junctions.
 Less sensitive for identifying incompetent
perforators (40 to 60 percent)
.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

19. Treatment
 Conservative
Leg elevation
Exercise
Compression stockings
Treatment of other underlying conditions
Nothing
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

20. Vein ablation therapies
Classified by method of vein destruction:
1. Chemical (sclerotherapy)
2. Thermal (laser or endovenous ablation)
3. Mechanical (surgical excision or
stripping)
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

21. Who gets sclerotherapy
 Small non-saphenous varicose veins (less
than 5 mm),
 Perforator veins
 Residual or recurrent varicosities following
surgery
 Telangiectasia
 Reticular veins
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

22. Who gets Sclerotherapy
 Who else
– Good control with Trendelenburg
– Recurrent veins
– Frail with resistant/healed ulcers
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

23. Sclerosing Agents
 Sodium tetradecyl sulfate
 Hypertonic Saline
 Polidocanol
 Monoethanolamine oleate
 Glucose combinations
 Damage endothelium leading to thrombosis of
the vein.
 Pressure to try and reduce the amount of
thrombus.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

24. Microsclerotherapy
 30 g butterfly needle
 0.2% STD
 Several courses required
benefit compression
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

25. Telangiectasias
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

26. Foam Sclerotherapy
 1:4 Sclerosant (1% or
3%): Air
 Why foam?
– Induces spasm
– Disperses further
– Enhanced sclerosis
Breu, FX, Guggenbichler, S. European Consensus Meeting on Foam Sclerotherapy, April, 4-6, 2003,
Tegernsee, Germany. Dermatol Surg 2004; 30:709.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

27. DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

28. Spider veins
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

29. Foam Sclerotherapy:
Complications
 Phlebitis
 Skin staining
 Failure
 Residual lumps
 Matting
 Embolus (CVA)
 DVT
 Ulceration (rare)
 Anaphylaxis (very rare)
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

30. Foam Sclerotherapy Results
 Variable depending on series
 Long-term recurrence rates are as high as
65 percent in five years, however, patients
can also be retreated when veins recur
 Large veins can be a problem
 Currently randomized trial
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

31. Catheter-based Treatments
 Endovenous laser EVLA
 Radiofrequency ablation RFA
 Primarily to treat saphenous insufficiency
(great or small)
 EVLA and RFA, are equally efficacious &
have similar recanalization rates.
DR DILIPEndovascular Surg 2008; 42:235. JT. High ligation of the saphenofemoral junction in endovenous obliteration of varicose
RAJPAL
Boros, MJ, O'Brien, SP, McLaren, JT, Collins,
veins. Vasc
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

32. Radiofrequency ablation
Radiofrequency ablation devices (ClosureFast™, RFiTT®, ClosureRFS™) generate a
high frequency alternating current in the radio range of frequency.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

33. Mechanism RFA
- By directing resistive radiofrequency energy
through a vein, a narrow rim of tissue less than
1mm is heated by an electrode.
- The amount of heating is modulated using both a
microprocessor and manual movement, resulting in
controlled collagen contraction, thermocoagulation
and absorption of the vein.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

34. Endoluminal radiofrequency ablation of
the great saphenous vein: methods
Percutaneous access to
the greater saphenous
vein most commonly at
the level of the knee
under duplex ultrasound
guidance
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

35. Endoluminal radiofrequency ablation of
the great saphenous vein: methods
1) A guidewire is advanced to the SF junction over
which the closure catheter is passed
2) catheter prongs are extruded to contact the intimal
lining of the vessel wall
3) radiofrequency generator allows the tip of the
catheter and the prongs to attain a temperature of 85
degrees C.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

36. Varicose veins
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

37. Endovenous Laser
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

38. Endovenous Laser
 Devices (EVLT®, ClosurePlus™)
 Use a bare tipped optical fiber which
applies laser light energy to the vein.
 Therapy based on photothermolysis (light
induced thermal damage).
 Laser light heats the target tissue inducing
thermal injury
 Wavelength of light is chosen based on
the target structure's chromophore.
Bush, RG, Shamma, HN, Hammond, K. Histological changes occurring after endoluminal ablation with two diode
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON changes to 4 months. Lasers Surg Med 2008; 40:676.
lasers (940 and 1319 nm) from acute
LAPROSCOPIST &

39. Endovenous laser therapy
(EVLT): mechanism
- Thermal reaction after laser exposure is essential.
- Damages endothelial, intimal internal elastic
lamina, and to some degree the media. Adventitia is
rarely affected.
- In vitro studies suggest that energy results in
‘boiling of blood’ and generation of ‘steam bubbles’
that indirectly, homogenously affect the varicose
vein.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

40. Endovenous laser therapy:
methods
1) GSV entered at the knee
2) Guidewire passed through hollow needle into the vein
can be difficult if:
a. tortuosities
b. local venous spasm
c. sclerotic fragments
3) Needle removed
4) 3mm cutaneous incision made
5) Introducer sheath placed over guide wire
6) Guidewire removed when at the SFJ
7) Longitudinal US visualization of sheath 1-2 cm distally to
the SFJ

41. Endovenous laser therapy and
radiofrequency: methods
Tumescent anesthesia (5 ml epi, 5 ml bicarb, 35ml
1% lidocaine in 500ml saline) is administered to the
perivenous space resulting in
a) reduction in pain
b) protection of perivenous tissue through cooling
c) increase in surface area of laser tip
and vein wall

42. Wavelengths of light used for
venous laser therapy
DR DILIP RAJPALCarmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous
Mozes, G, Kalra, M,
CONSULTANT GEN. SURGEON
ablation techniques. J Vasc Surg 2005; 41:130.
LAPROSCOPIST &

43. Endovenous laser therapy and
radiofrequency: specifics
Pulsed vs. continuous:
pulsed mode is associated with higher adverse events
Wavelengths:
Higher wavelengths (1320nm) reported less postoperative
pain, and less likely to have ecchymoses
Fluence (J/ cm2):
Single most important parameter to quantify
above 60-100 J/ cm2 for durable GSV occlusion
Wattage:
high, short duration wattage vaporizing effect
low prolonged wattage coagulating effect
Pullback Speed:
if performed at fixed wattage then energy is
solely dependent on pullback speed

44. Surface laser therapy
 Telangiectasias,
reticular veins and
small varicose veins
<5mm
 Not used for larger
varicose veins
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

45. Post op care
 Graduated compression stockings are
worn following the procedure.
 F/U duplex ultrasound is performed within
one week to evaluate for thrombus in the
common femoral vein.
 Pt recovery averages two and four days
 Significantly shorter interval than is seen
with surgical ligation and stripping
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

46. Endovenous complications
 Pain, bruising, hematoma
 Skin changes: burns, induration,
pigmentation, matting, dysesthesia, &
superficial thrombophlebitis.
 Nerve injury
 DVT
 Wound infection
Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation
DR DILIP RAJPAL 41:130.
techniques. J Vasc Surg 2005;
CONSULTANT GEN. DE Roos, SP, Nijsten, T. Endovenous laser ablation-induced complications: Review of the literature and new
VAN DEN Bos, RR, Neumann, M,
SURGEON
LAPROSCOPIST
cases. Dermatol Surg 2009; &

47. Which is Better ???
 Endoluminal thermal ablation versus
stripping of the saphenous vein: Meta-
analysis of recurrence of reflux.
 ES Xenos, G Bietz, DJ Minion, et al
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

48. Endoluminal thermal ablation versus stripping of
the saphenous vein: Meta-analysis of recurrence
of reflux.
 Method: Systematic search of
Medline/Pubmed, OVID, EMBASE,
CINAHL, Clinicaltrials.gov and Cochrane
central register

1966-2009 in all lanuages
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

49. Method
 Randomized prospective clinical trials with
> 365 days f/u.
 Analyzed outcomes included recurrence
of varicosities and reflux, as documented
by duplex ultrasound, and recurrence of
signs and symptoms
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

50. Results
 8 randomized controlled trials were
included
 497 patients total
 226 L/S
 271 endoluminal thermal ablation
 F/U 584 SD182 days.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

51. Conclusion
 Catheter-based treatments and traditional
venous stripping with high ligation have similar
long-term results
 Catheter-based treatments have a decreased
post op pain, shorter recovery time to work
and normal activity.
DR DILIP RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST &

52. Questions
?