Endovenous Laser Treatment
Endovenous laser treatment, also referred to as EVLT, is the primary method of closing the abnormal, refluxing superficial veins in the treatment of venous insufficiency.
EVLT belongs to a group of venous treatments called Endovenous Thermal Ablation. Basically, this refers to the use of heat to “ablate” (i.e., to close off) the inside of the vein. The heat—used to “cauterize’ or “ablate” the vein to close—is commonly generated by laser (Light Amplification by Stimulated Emission of Radiation) or radiofrequency waves transmitted through a long catheter to its tip placed inside of the vein. Sometimes a mechanical and chemical closure is used. At Advanced Vein Care Center, we primarily use the laser-generated EVLT to treat venous insufficiency.
Chronic venous insufficiency is caused by the underlying abnormal veins that are usually significant in size, usually located from 1 cm to 3 cm under the skin in a non-obese patient. These are called the “saphenous veins,” and they are usually not visible to the eye and require an ultrasound imaging. Visualizing the vein with an ultrasound, the vein specialist performs the EVLT to “ablate” these veins, thereby closing the source of the abnormal veins that give rise to the visible varicose veins on the skin. In sum, EVLT shuts off the source of chronic venous insufficiency symptoms, the saphenous veins, and the varicose veins are removed by hand during phlebectomy (see Phlebectomy section).
EVLT: General Questions & Answers
What happens to the blood flow when the long saphenous vein is shut off? Will other veins "take over"?
Benefits and Risks of the Procedure
How rare is DVT or PE after the EVLT procedure? Some of the early studies of EVLT reported the risk in a wide range, from one in 100 to one in 400. However, as the definition of DVT was clarified, and as the laser technology switched to a low-energy laser machine the incidence has become very, very low. Recent studies on low-energy laser therapy involving many patients (studies involving between 200 to over 1,100 patients) did not report any incidence of DVT or PE. We also use low-energy laser therapy, and our experience has been similar to that of the literature, very rare.
There are minor risks such as post-procedural leg pain, skin nerve irritation and damage, appearance of tiny red “blush” of spider veins, and other minor or statistically rare “risks” of the procedure, which will be explained during your office visit with Dr. Lee.
EVLT: Before, During, and After Questions & Answers
Before the Procedure: Preparation
- During the day prior to this procedure, you should increase the amount of fluids you drink. Stay well-hydrated. Avoid any food, liquid or physical activity that might cause dehydration.
- Avoid caffeine-containing products such as soft drinks, coffee, or tea.
- On the day of your procedure have a normal breakfast and/or lunch, again avoiding caffeine products.
- Take all your regular medications.
- In the end, your EVLT procedure should not cause you to change your normal dietary activity significantly.
- Remember to stay well-hydrated and avoid caffeine products.
- If you have a prior history of inability to take over-the counter anti-inflammatory medications because of stomach ulcer or reflux condition.
- If you have a kidney condition or are prone to inadequate kidney function
- If you are aged 65 years or greater
- If you are on any major blood thinner medication (Coumadin, Plavix, Pradaxa, etc.)
- If these cases apply to you, you may take Extra Strength Tylenol instead
- If you are taking a “baby-aspirin” daily as part of your usual regimen, you should stop taking them while you are taking Ibuprofen. You should also stop taking Vitamin E pills, fish oil, herbal or home remedies. Multivitamin pills are okay. If you have any question on these points, please call us.
- Ativan (Lorazepam) is a sedative, and we prescribe three 0.5 mg tablets.
- Please take 2 tablets at bedtime the night before your procedure and 1 tablet approximately 2 hours before your scheduled procedure.
- The purpose is to “calm” your nerves prior to your procedure. It is somewhat discretionary on your part. If you do not wish to take the sedatives because you feel you do not need them, you do not have to take them.
- If you feel that you are uniquely predisposed to anxiety attacks and feel additional medication is required, please call us and we will discuss ways to help you further. If you feel that you are particularly sensitive to the effects of sedatives and are concerned about taking these pills, please call us and we will guide you with alternatives. We are here to help you and accommodate to your individual needs.
- ‘EMLA Cream’ stands for a medical term, “Eutectic Mixture of Local Anesthetic”. Our prescription contains 2.5% Lidocaine and 2.5% Prilocaine.
- The purpose of EMLA cream is to “dull” the skin to decrease discomfort during the procedure. While it is not expected to render the leg completely numb, it will make the skin slightly less sensitive to injections during the procedure. If for some reason you fail to apply EMLA cream prior to the procedure, do not worry. Many patients have undergone EVLT without EMLA Cream and have done fine. It is just an additional relief of discomfort during the procedure.
- Two hours before your procedure, you should apply the prescribed EMLA cream to the leg designated to undergo procedure.
- The area of the leg to be applied with the Cream should be where the abnormal veins are. Apply to the inner thigh from the groin down to the inside of knee and down to the inner aspect of the calf down to the ankle. If you are scheduled to undergo treatment of the back of the calf, apply there from the back of the knee to the back of the ankle as well.
- You should only use up to about one tube of cream to the leg, not more.
- After applying EMLA cream, cover the leg loosely with plastic wrap. Commonly used are Saran wraps. This will prevent your clothing from becoming stained and will aid in the absorption of the medication in the cream.
- If you have any questions about this, please feel free to call us and we will guide you.
I have had knee (or hip) replacement and I always have to take antibiotics for prevention of infection. Will I have to do the same?
I am on a blood thinner (Coumadin, Plavix, Pradaxa, etc.). Do I have to stop it before the EVLT procedure?
Do I have to bring compression stockings to the procedure? Will I have to wear them right after the procedure?
Sometimes there can be a delay, so please bring a book or other reading material to help pass the time. Sometimes the our procedures can run ahead of schedule, so please be sure to be on time 30 minutes prior to procedure time.
If you take the sedatives before the appointment, then it is absolutely mandatory that you do not drive a car or operate any potentially dangerous machinery. If you do not take the sedatives beforehand, we still recommend that you be driven by someone else because of possibly limited ability to operate a vehicle immediately after the procedure.
During the Procedure
You can bring iPad, Kindle, or even a paperback. During the EVLT procedure, our patients have been known to do all kinds of parallel activities, including Googling on their iPad, internet shopping, reading an e-Book, even catching up on their office e-mails, texting or Tweeting. One patient even studied for her state licensure exam during our procedure. (She passed 3 days later.)
The procedure itself consists of:
- Repeating of the ultrasound exam by Dr. Lee for final confirmation
- Sterile prepping and draping of the treatment leg
- Accessing the refluxing abnormal vein with a needle
- Placing the laser catheter to exactly the spot in the vein needed
- Infusion of “numbing medicine” around the vein through a series of local anesthetic injections that will render the vein completely anesthetized
- Then, closing the vein shut with laser treatment. For some people, two to three veins will be treated with these steps during the one hour period.
- Afterward, your treated leg will be cleaned and bandaged, and you will receive verbal instructions on post-procedure care. These instructions are also printed and will be given to you in an envelope. Pain medication instructions are also given, and prescriptions will be discussed and dispensed as appropriate. The subsequent appointments will also be confirmed with you at this time.
- And you will walk out of the room to your friend or family who is awaiting to drive you home.
Some patients have chronic pain in their back or hip due to arthritis. If this is the case, you need to let us know beforehand, so we can use adequate padding or positioning to minimize your discomfort. Most people can tolerate a one-hour procedure quite well, however.
I have Latex allergy. Will that be a problem? How about a surgical prep allergy? How about a tape allergy?
After Procedure Care
After the first week, our recommendation is, the longer you wear the compression stockings, the better – up to 4-6 weeks. However, this is left to the patient’s own discretion. At any point after the EVLT procedure, if wearing the CS causes one of the following “problems,” then CS should be removed and worn again only if the problems disappear.
- Numbness/tingling of toes, foot/ankle, or any part of lower leg
- Skin blisters, or skin discoloration or pressure marks
- Severe focal pain in the toes, foot/ankle, heel, or any part of lower leg
- Undue difficulty or complications of arthritic pain in other areas incurred while donning and doffing the stockings with physical hardship
- Other problems (call us with concerns…)
- There is no overwhelming scientific data for us to be emphatic about the duration of wearing compression stockings after the EVLT.
However, there are some information that suggest the following:
- Main reason for wearing CS is for decreasing post-procedure pain, discomfort and swelling.
- Wearing CS for 48 hours straight and up to one week following the EVLT procedure has been shown to decrease post-procedural pain, discomfort, and swelling.
- By six weeks after the procedure, wearing CS did not seem to make any difference.
- Wearing CS does not seem to affect the “vein closure” rate whether or not CS was worn or not – there is just no clear data on this.
- One thing that most vein specialists agree on, is that there is no clear data to suggest the duration, the type of compression, and the strength of compression stockings to be mandated following the laser treatment.
What if I experience problems with wearing the compression stockings after the procedure? If I don’t wear it, will it "un-do" the effects of the procedure?
Overall, the average pain and discomfort is similar to that of mild to moderate tissue inflammation on a body part. See above for how much time should I take off from work following EVLT?
- Walking leisurely – Immediately with compression stockings on
- Walking on a treadmill at a low to intermediate speed – Immediately with compression stockings on
- “Spinning” on a stationary bike – Immediately with compression stockings on
- Intermediate to high-speed treadmill or running on the road – One week with compression stockings on
- Low-intensity weight lifting – Immediately with compression stockings on
- Moderate to High-intensity weight lifting not involving the treated leg directly – One week with compression stockings on
- Moderate to High-intensity weight lifting which involves the treated leg directly – Two weeks with compression stockings on
“Redness” of the skin in addition to the bruising is also a normal observation following the EVLT treatment, and it may get worse in the first 3-4 days before it begin to resolve. Rapidly spreading redness beyond the area of treatment may be a concern, and if present, you should call our office.
Following the procedure, leg hurts and it is swollen. Can this be the deep vein blood clot that’s potentially life-threatening?
For more information about endovenous laser treatment feel free to get in touch with our informed office staff. Our Springfield, MA office can be reached by phone at (413) 732-4242 or email us.