Endovenous Laser Ablation
What is Endovenous Laser Ablation (EVLA)?
EVLA is a non-invasive or keyhole method of treating varicose veins without surgery. Instead of cutting, tying and removing the abnormal veins, they are heated from the inside using laser energy.
The laser energy heats the vein to a temperature at which the vein closes and is cauterised. All the living cells that make up the vein wall are sterilised and the vein cannot recover, regrow and rejoin.
Over the course of a few weeks the body then naturally absorbs the vein. Microscopic cells such as white cells and macrophages autodigest the vein and carry it away. When the treated area is examined with ultrasound a few months after treatment, the abnormal vein has gone.
Endovenous Laser Ablation achieves the same outcome as surgical tying and stripping but without the need for major surgical cuts and painful removal under general anaesthetic. Endovenous Laser Ablation can be carried out in a simple treatment room rather than an operating theatre.
In addition, after Endovenous Laser Ablation, unlike surgical stripping there are no “raw ends of living vein” that can regrow or rejoin. The risk of veins coming back after Endovenous Laser Ablation is much lower than with surgery.
Are my veins suitable for EVLA?
Nearly all patients with varicose veins are suitable for EVLA. Those few who are not suitable (usually those with small recurrent veins after previous surgery) can usually be treated with Foam Sclerotherapy.
What does the procedure involve?
An ultrasound scan is performed on the day of your treatment and the veins to be treated by EVLA are marked with a pen on the skin. You lie on a treatment couch and your leg is cleaned with antiseptic and covered with drapes. Depending on which veins are to be treated, you may be on your back or your front.
At our clinic we monitor your heart with electrodes on your chest and we monitor your oxygen levels with sensor on your finger. A nurse is at your side to offer reassurance and to monitor your wellbeing.
Dr Gajraj and his nurse assistant carry out the procedure. Three members of the team are with you in the treatment room. You wear a surgical gown and Dr Gajraj and his assisting nurse will wear gloves and a gown.
In line with COVID-security measures, eye protection and masks are worn. The treatment room is ventilated. Fresh air is brought into the room from outside through a medical-grade filter and after circulating around the room, it is vented to the outside again.
Endovenous means inside the vein, so the next thing Dr Gajraj has to do is to insert the fine laser fibre into the vein. A small amount of local anaesthetic is injected into the skin and once the skin is numb, a needle is inserted into the vein. The needle is the same size as one that might be used for a blood test. Through this needle, a fine laser fibre is inserted into the vein to be treated. These steps in the procedure are guided by ultrasound.
Once the laser fibre is in the correct position, as judged by ultrasound, the vein is numbed by a series of local anaesthetic jabs.
All staff and the patient put on laser safety goggles as a precaution. The laser is then activated. As the laser fibre is gently withdrawn along the length to be treated, the vein is sealed, cauterised and sterilised.
The laser equipment gives out an activation signal when it is on. You will hear a buzzing noise and you may smell or taste something but won’t feel any pain.
If you are having both legs treated the process is repeated on the other leg. The laser is removed and the needle puncture covered with a small dressing.
The EVLA treatment takes about 20-30 minutes per leg. If you have large varicose veins, you may benefit from Foam Sclerotherapy or Phlebectomy or a Combination of all three (EVLA, Foam Sclerotherapy and Phlebectomy). After your leg is treated, a compression stocking is then put on.
In this photograph, you can see Dr Gajraj performing EVLA in the treatment room. The skin has been numbed with local anaesthetic and a fine laser fibre has been inserted into the unhealthy (refluxing) vein.
Dr Gajraj uses ultrasound to check the progress of the procedure and everyone is wearing Laser Safety Goggles.
The surface lumpy varicose veins have already been marked with a skin pen.
Once the EVLA procedure has been completed, the varicose veins will be treated. In this case, Dr Gajraj has decided to remove the veins by phlebectomy.
Safety and Comfort During EVLA
At the Veincare Centre, we believe that vein procedures are best carried out under local anaesthetic on a walk-in walk-out basis. By avoiding general anaesthetics and a prolonged recovery period, there is virtually no risk to the heart and breathing and deep vein thrombosis is vanishingly rare.
We also believe that it is important to look after the comfort of our patients and to reassure them at every stage of the procedure.
What happens after treatment?
After treatment, we monitor your blood pressure, check you are comfortable and we check your stocking and dressings. Our nurse discusses what you can expect after going home and she gives you a written advice sheet with telephone numbers you can ring if you have any concerns. Approximately 3-4 hours after you enter the clinic, you will be allowed home. It is advisable not to drive after your treatment and we recommend that you are driven home by a friend or relative.
There are very few restrictions after your treatment. We advise that you start driving when you feel confident to perform an emergency stop. Most people experience a tightening sensation along the length of the treated vein and some get pain in that area around 5 days later but this is usually mild. Normal anti-inflammatory drugs like Ibuprofen are normally sufficient to relieve it.
Will I have stitches?
No. There are no stitches. The treatment is carried out through small pricks or punctures in the skin. These punctures are only 1mm and they are covered by a small adhesive dressing which you remove 48 hours later.
Will I need to wear stockings?
Yes. We advise that you wear stockings for 2 days continously.
After 2 days, you can take the stocking off and discard any bandages underneath. At this time, it is a good idea to have a shower, remove the “plasters”, and wash your legs gently.
Many people find it comfortable to wear the surgical stocking in the daytime for another week or two. However, if you feel more comfortable without the stocking, leave it off.
How long will I need off work?
The recovery after EVLA is very rapid and most people can get back to work within a day or two.
If the varicose veins are very extensive and if phlebectomy is performed at the same time, it may be appropriate to arrange a week off work.
What will my legs look like after Endovenous Laser?
This question is frequently asked.
Of course, initially, when you take off the stockings, the treated areas may be bruised, tender and lumpy. Some people bruise a lot, some hardly at all. Bruising will settle quickly over the next few days. In addition, some areas may be a little lumpy and tender. This is all part of the healing process and lumpy areas will gradually disperse over the next few weeks.
Sometimes, the skin overlying the veins that have been treated by laser becomes very sensitive and a little red a few days after the treatment. If this happens, you may be surprised because you didn’t experience this straightaway. Once again, this is all part of the healing process which leads to the vein being successfully absorbed by your body.
If you experience lumpiness, tenderness or sensitivity, try rubbing an anti-inflammatory cream or gel such as Voltarol or Ibuprofen into the area (but please check with a pharmacist if you are unsure whether these are suitable for you). Some people also find Arnica cream soothing.
We routinely take photographs of our patients before treatment and after treatment.
This photo-documentation is an important part of the assessment of our treatments. Many patients are surprised when they see the dramatic change in their legs after vein treatment.
Will I need further treatment?
If you are having treatment just to relieve symptoms or to treat a complication such as varicose eczema, phlebitis or leg ulceration, then no further treatment is usually necessary.
Most patients however wish also to improve the appearance of their veins and of these about 90% will require further treatment. The lumpy veins normally become less obvious after EVLA but rarely disappear completely.
Additional treatment for the visible lumpy varicose veins can be removed either by Phlebectomy or Foam Sclerotherapy. These additional treatments can be undertaken at the time of the EVLA or more usually after a delay of 4-6 weeks. If you have extensive varicose veins on both legs it is very unlikely that you will be able to have all the additional treatment undertaken at the time of the EVLA.
Phlebectomies are undertaken after a local anaesthetic solution has been injected around the veins to numb the area. Small incisions are made over the veins and they are gently extracted with a micro-instrument. You may require many small incisions but they heal quickly without stitches and they are hardly noticeable after 3-6 months.
Foam sclerotherapy in combination with Phlebectomy is the commonest means of dealing with varicose veins after EVLA.
EVLA is not usually performed on its own
It may surprise you to know that if we only treated your varicose veins by laser, they may not go away completely. When the appearance after treatment is important, EVLA by itself may not be enough. One lady from the USA contacted us at the Veincare centre to ask for advice. She had had EVLA by her specialist in the USA. EVLA had been performed successfully but her varicose veins did not change. She contacted us to ask why.
Superficial venous reflux – down flow of blood in the incorrect direction is the cause of varicose veins. First thing in the morning when we get out of bed and stand up, gravity tends to pull the blood down the veins in the wrong direction. If the valves in the veins are not working, reflux occurs, filling visible side branches under the skin. Even when the reflux is abolished, these side branches will not disappear. Over time they have been stretched beyond their elastic recoil. After laser, they remain baggy and visible. That’s why an adjunctive procedure such as Phlebectomy or Foam Sclerotherapy is required. EVLA cannot treat these very superficial varicose veins under the skin for 2 reasons. Firstly, varicose veins are tortuous, and a straight laser fibre cannot be inserted along them. Secondly, the varicose veins are very superficial and close to the skin: laser energy might injure the skin. That’s why adjunctive procedures in addition to EVLA are needed to get the best results for varicose veins.
What are the complications of EVLA?
Serious complications after EVLA are very rare. Compared to traditional surgical stripping, EVLA has the following advantages:
- Avoidance of general anaesthetic with less risk to breathing and less strain on the heart
- No major incisions or cuts with very low risks of infection
- Lower risk of DVT
- Lower risk of nerve injury
- Avoidance of admission and overnight stay in hospital
- Lower risk of vein recurrence (the risk of veins returning)
- Phlebitis: EVLA works by heating the wall of the vein and an inevitable and deliberate response to the heat is an inflammation of the vein wall. You may feel the vein that has been treated become hard and tender. Varicose veins that feed from the treated vein may also become hard and lumpy as part of the healing process. The phlebitis will resolve over a few weeks.
- Nerve damage: As nerves can lie alongside the veins these may also become damaged by the heat or by Phlebectomies and a few patients notice small patches of numbness on their skin. These usually resolve over a few months.
- Burns: Although it is possible to burn the skin with the laser in practice this is very rare indeed. Some sensitivity of the skin overlying the treated vein is quite common. This settles within a few days. The sensitivity may be associated with a degree of redness and some have incorrectly described this as a skin burn.
- DVT: A DVT is a blood clot in the deep veins in the leg. It is a recognised complication of surgery and can be dangerous if the clot breaks away and travels to the lungs. The risk of getting a DVT after EVLA is very low but has been reported. Avoidance of general anaesthetic, good hydration and physical activity reduce this risk.
Summary
Endovenous Laser Ablation (EVLA) is an endothermal ablation treatment that is the treatment of choice for superficial venous reflux, varicose veins and complications of superficial venous reflux such as superfical venous thrombosis (phlebitis), varicose eczema and venous leg ulceration (NICE CG168).