Ultrasound Guided Laser

What is Ultrasound Guided LASER?

Ultrasound Guided Laser is where thermal energy generated by a Laser machine is used to treat Varicose Veins below the surface of the skin. To treat Varicose Veins under the skin requires an ultrasound to visualise the Varicose Veins so the treating doctor is able to accurately place the catheter needed to deliver the Laser energy inside the Varicose Vein.

What is Endovenous Laser Ablation?

EndoVenous Laser Ablation (EVLA) is the more technical term used for the Ultrasound Guided Laser treatment of Varicose Veins. The term EndoVenous refers to a treatment on the inside of a vein, Laser refers to the use of thermal energy from a Laser machine and Ablation refers to sealing off and destroying the Varicose Vein.

The term EndoVenous Laser Therapy (EVLT) is sometimes still used as it was the first term used to refer to the procedure. However, EVLT is in fact a registered trademark for a specific laser kit produced by the company DIOMED, who were the first company to introduce the internal vein Laser procedure.

The generic name of EndoVenous Laser Ablation is the preferred term now to describe the insertion of a laser fibre inside a Varicose Vein, as the procedure can be performed with a number of different laser machines using a number of different types of laser fibres.

How established is the EVLA treatment?

Internal laser treatment to close large veins was first described by Navaroo and Min in 2001. The EVLA procedure has been used in Australia since 2002.

Why can’t an external laser be used?

Applying a laser to the outside of the skin is only effective for very small superficial veins which is called Surface Laser Treatment. To effectively try and close larger and deeper veins the thermal energy from the laser has to be delivered to the inside of the vein. To get the laser energy to the inside of a deep vein a small incision is made in the skin and a catheter containing the laser fibre is inserted and guided by Ultrasound to the area to be treated.

What type of laser is used for EVLA?

There are 2 main groups of lasers used for EVLA. One group is DIODE Lasers at a wavelength of 810 or 940nm which produce Laser light that concentrates in the haemoglobin of the blood. The second group is YAG Lasers at a wavelength of 1320nm which produce Laser light that is more strongly absorbed in the collagen of the vein wall.

What are the advantages of EVLA?

The main advantage of EVLA is that it can very effectively treat large deep Varicose Veins that in the past required removal by surgical stripping in hospital. EVLA is minimally invasive with no need for General anaesthesia and no surgical scarring. The treatment can be done in a Leg Vein Clinic without requiring hospital admission. The treatment can be performed in 1 or 2 hours with immediate walking after the procedure and return to work and normal activities the next day. EVLA has a very good safety profile and long term follow up studies have shown very low recurrence rates.

How is EVLA done?

Topical anaesthetic cream is applied to the skin and an injection of blood thinning medication (Clexane 40mg) is given subcutaneously. A small puncture wound (~4mm) is made under local anaesthetic at the knee or ankle depending on which Varicose Vein is being treated. With guidance from an Ultrasound scanner a thin guidewire is passed up the Varicose Vein before a catheter (~45 cm) is passed over the wire. The Laser fibre is then introduced through the catheter to the inside of the Varicose Vein. Local anaesthetic is injected around the Varicose Vein at several levels using a fine needle (25gauge) directed by Ultrasound. The tip of the Laser fibre is precisely positioned in the Varicose Vein and then the Laser is activated and the Laser fibre is slowly withdrawn destroying the full length of Varicose Vein.

Are there any requirements before EVLA?

All treatments are performed on an outpatient basis in our Leg Vein Clinic and there is no specific preparation required before treatment. We do recommend not shaving or waxing the legs in the 24 hours before any Leg Vein treatment including EVLA. We do recommend wearing loose fitting clothing and comfortable footwear as patients need to be able to wear compression stockings after treatment and be ready to walk for at least 30 minutes after treatment. We advise not applying any leg moisturiser on the day of treatment as some small dressings may need to be applied to the skin. Patients can elect to bring shorts to wear during the procedure.

What needs to be done after EVLA treatment?

Walking after EVLA is very important to stimulate blood flow through the deep veins and reduce any risk of Deep Vein Thrombosis. The usual recommendation is a 30 minute walk immediately after treatment and at least 30minutes daily for two weeks. Usual daytime activities can be resumed immediately after treatment. It is advised to avoid strenuous physical activity such as aerobics for one week after treatment and avoid standing still for long periods. Long haul (over 4 hours) Airline flight should be avoided for 4 weeks post therapy. If a plane flight is unavoidable then cover with a blood thinning injection may be advised. Stockings are usually advised to be worn continuously for 7 days and then for a further 7 days during the day only. It is routine to perform a check ultrasound scan at 14 days after EVLA.

What is noticed after EVLA treatment?

It is common to have bruising down the length of the treated vein and some mild pain for several days which can persist for up to 2 weeks. It reflects inflammation in the treated vein and that the treatment is working. Pain is managed with walking, Anti-inflammatories (eg Naprosyn) and mild analgesics (eg Paracetamol) as necessary.

Some skin discolouration is usual early on and tender lumps due to “trapped blood” in the treated vein are not uncommon and can persist for the first few weeks. Inflammation (phlebitis) of the treated veins can occur resulting in red, raised areas developing over branch veins which usually disappear within 4-6 weeks. If post treatment inflammation persists and causes undue discomfort, management includes further compression stockings, anti-inflammatory medication, regular walking and if necessary treatment by needle puncture in the clinic.

What are the possible complications of EVLA?

Possible complications from EVLA can occur even with perfect technique. Pigmentation from the iron in the blood can occur along the treated veins and whilst this typically disappears within 12 months, permanent staining can occur in about 5% of patients. This staining can be of cosmetic significance but can respond well to surface Laser treatment with Q Switch or Picosecond Lasers.

Deep Vein Thrombosis are clots extending into the deep leg veins and can occur after EVLA but fortunately this potentially serious complication is quite rare if the protocol of compression and regular daily walking is followed. Women at higher risk of Deep Vein Thrombosis are sometimes advised to stop oral contraceptives prior to EVLA to reduce the risk of Deep Vein Thrombosis.

The sensory nerves next to the Varicose Veins being treated can suffer heat damage when the Laser treats the Vein. Nerve damage can result in numbness but this is usually mild and lasts only a few weeks but rarely can be long lasting.

What are the costs of EVLA?

The cost of the Mapping Scan that needs to be performed before the EVLA procedure qualifies for a Medicare rebate, with the out of pocket expense to the patient of about $160. The Mapping Scan is performed in our Leg Vein Clinic by our Vascular specialist and not by a Radiographer at an outside Ultrasound clinic.

The EVLA procedure, as is the case with the VENEFIT, is more expensive than injection based Varicose Vein procedures because of the additional time and costs of the single use catheters and equipment that need to be used. Private Health Insurance does not cover out of Hospital procedures such as the EVLA. The EVLA procedure does qualify for a Medicare rebate and as a medical procedure with a Medicare rebate GST is not applicable. The Medicare Safety Net can apply when out of pocket medical expenses exceed a certain threshold, however Medicare has placed a cap on the out of pocket expenses for Varicose Vein treatments that can contribute to the Medicare Safety Net. In some circumstances an income tax rebate can be claimed for out of pocket health expenses exceeding a certain threshold but this varies with individual circumstances and would need an Accountants advice.

The cost of EVLA does vary according to whether one or two legs are being treated but expect the out of pocket expense to be around $2500 for EVLA treatment on one leg and around $4500 for EVLA treatment if both legs are treated.