ENDOVENOUS LASER ABLATION VEIN TREATMENT (EVLA)

What is Endovenous Laser Ablation (EVLA)?

Endovenous laser therapy for major saphenous reflux has been in use since about 2000-2001, having shown better results than varicose vein surgery.

This is predominantly used to treat large Great and Small Saphenous Veins previously treated by surgical ligation and stripping in hospital under general anaesthetic. Other large veins including the Anterior Accessory Vein or large perforators can also be treated.

Under local anaesthetic, a small skin puncture is made with the laser probe, with the laser fibre being passed up the vein under ultrasound guidance. The vein is then surrounded by a column of anaesthetic. The laser fibre is activated and slowly withdrawn, destroying the vein.

If necessary Ambulatory Phlebectomy and Ultrasound Guided Sclerotherapy can be performed at the same time or in a follow-up session. Any residual issues can receive further treatment about 2 weeks later.

What are the advantages and disadvantages of EVLA?

EVLA is very effective in treating larger veins, especially those larger than 5 mm, and is usually performed on veins such as the Great and Small Saphenous Veins and the Anterior Accessory Vein. Unlike varicose vein surgery, this does not require admission to hospital or anaesthesia. There is usually no need to take time off work and you will be able to continue with your everyday activities. The Small Saphenous Vein often responds better to EVLA than to Sclerotherapy but the cost for laser treatment is often greater than that for Sclerotherapy alone.

What should you do before EVLA?

Do not apply moisturiser to your legs on the day of treatment. Wear loose fitting clothing and sandals or loose shoes to allow for the thickness of the stockings that are applied after treatment.

What happens during EVLA?

You will lie down on a treatment bed and be draped as per a surgical procedure. Usually, a subcutaneous injection of the anticoagulant drug Clexane will be administered. Just before the procedure, a Sonographer will perform a limited scan of the leg, similar to the initial screening scan, so the treatment team can see the current condition of the veins. The vein is punctured through an anaesthetised site, around the knee for the Great Saphenous Vein, and the calf for the Small Saphenous Vein. A wire is passed up the vein, a 20-45 cm long fine tube is passed over the wire, the wire is withdrawn and the laser probe introduced through the tube. Local anaesthetic is infiltrated around the vein at several levels, directed by ultrasound and using extremely fine needles.

Using ultrasound guidance, the laser tip is precisely positioned just below the end of the vein, at the groin for the Great Saphenous Vein, and the knee for the Small Saphenous Vein. The probe is activated and slowly withdrawn, destroying the vein.

Directly following this process, Ultrasound Guided Sclerotherapy and/or Ambulatory Phlebectomy will often be performed to treat the remainder of the diseased veins in the leg.

After completion, a bandage and/or stocking will be applied to each treated leg.

Although the procedure sounds daunting, it involves minimal discomfort.

What should you do after EVLA?

You will be asked to go for a 20-30 minute walk immediately after treatment.

It is essential that you arrange for someone to drive you home.

You will usually be asked to walk for 20-30 minutes each day for 1-2 weeks.

Maintain normal daytime activities and avoid standing still for long periods.

Avoid strenuous physical activity such as aerobics for 48 hours after treatment since this increases the risk of blood flow returning into the treated veins.

You are required to avoid any flights of greater than 2-4 hours duration for 4 weeks and any flights of greater than 4 hours duration for 6 weeks after treatment. If travel is unavoidable, anticoagulants, either oral or subcutaneous, should be administered prior to the flight.

Stockings are to be worn continuously for 4 days and nights. Then they are to be worn through the day, removing them at night and replacing them in the morning after your shower for another 3 days. It is routine practice to perform an ultrasound scan 1 week after treatment to ensure that treatment has been 100% successful and to exclude the very small risk of DVT (Deep Vein Thrombosis). Some patients will require follow-up treatment of residual varicosities by Ultrasound-guided Sclerotherapy, which would be performed about 1-4 weeks later.

What can you expect following EVLA?

The following features are expected, are transitory and may not occur at all:

• Some bruising down the length of the treated vein is almost invariable and shows that the vein has been destroyed to the point where it has disintegrated in parts. This can be very slight or quite extensive
• Mild discomfort invariably occurs, commencing a day or two after treatment. Aching in the leg persists for up to two weeks and shows that the procedure is working. Pain is usually improved by walking or by taking Paracetamol or Ibuprofen. Soreness behind the knee can result from the bandage or stocking rubbing on your skin
• Discolouration is usual early on and is not a cause for concern
• Trapped blood can result in red, raised areas that develop over treated veins and can be tender and uncomfortable, but these usually disappear within two to three weeks
• Phlebitis or inflammation of the treated veins can occur. It is treated by further compression, anti-inflammatories and regular walking

What are the possible complications from EVLA?

Adverse reactions for EVLA are similar to those for UGS. Complications can occur even with perfect technique.

These include:

• Deep vein thrombosis (DVT)
  A blood clot can form and extend into the deep veins. The risk is less than 1:2,000 compared to the background risk of about 1:9,000. This potentially serious complication is very uncommon if the protocol of compression and regular daily walking is followed. Although DVT post procedure is most uncommon, we at Specialist Vein Care perform Duplex scans routinely on all patients post Sclerotherapy/ Endovenous Laser Ablation therapy to exclude this complication.
• Allergic reaction
  Allergy to the anaesthetic solution can occur. This is rare! It can present immediately as an anaphylactic reaction with generalised rash, itchiness or difficulty with breathing. Our practice is equipped and ready to deal with this circumstance if it arises.
• Swelling of the leg or ankle (2:100)
  This is usually a temporary phenomenon and is due to inflammation
• Pigmentation (1:10)
  Brown marks can appear near or along a treated vein and are due to haemosiderin, a form of iron from the blood. Most disappear within 3-12 months but in about 5% of patients, this can persist past 12 months. This is of cosmetic importance only and persistent pigmentation may respond to laser treatment.
• Nerve injury (3:1,000)
  Irritation of surface sensory nerves rarely occurs and will usually disappear within a few weeks.