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
The vein that is treated by EVLT remains closed for the rest of your life, and as time passes, it gets absorbed to a certain extent by the body. Sometimes, an ultrasound performed months or years later can see the vein remain closed as a “cord” without a lumen. Other times, the ultrasound cannot even locate the closed off veins.
The fact of the matter is that there are already “other veins” that are currently directing the blood flow back to the heart, because the refluxing veins are currently sending the venous blood back down the leg (when standing or sitting for long time). When the abnormal vein is shut off, these other veins will have an “easier time” carrying the blood out of the leg.
An important innovation about the EVLT is that it can be performed with the patient wide awake. It does not require general anesthesia. It only requires local anesthesia, i.e. injections with lidocaine-containing solution. You will be given “sedative pills” such as Lorazepam the night before and 2 hours before the procedure, but for most patients, even these are not necessary. You will also be prescribed an anesthetic “cream” as a way of making the skin sensitivity “dull” to minimize the discomfort associated with needle injections. But then again, for many patients, even this is not necessary. General anesthesia is a potentially dangerous undertaking for patients, and it is completely unnecessary for this procedure. In fact, in Advanced Vein Care Center, we have performed over 3,000 EVLT’s in the past several years. We have never had to use anything more than local anesthesia to perform those procedures, even in the most anxious patients prone to panic attacks.
No. No stitches. No coming back to get stitches removed.
We do all our EVLT procedures in one-hour sessions. We have learned from performing over 3,000 procedures that one hour is the optimal time for completing the procedure. Beyond one hour, there arises a greater chance of issues arising from patient’s back pain, hip pain, bladder incontinence, fatigue, etc. If you have very complex venous reflux anatomy where there are more than 2-3 veins that need to be treated, you may require two EVLT sessions.
For the same reason as above, we treat one leg at a time, one month apart. Treating both legs in the same setting takes too much time and discomfort during the procedure. There are tissue trauma, post procedural pain and discomfort that follow each EVLT procedure, such that treating both legs simultaneously can be overwhelming for most patients.
There can be mild to moderate pain associated with post-procedural inflammation. We use a low-frequency laser technology to minimize post-procedural pain. Usually most patients tolerate pain with anti-inflammatory analgesics such as Ibuprofen alone, or Ibuprofen with small amounts of opioid analgesic such as oxycodone or hydrocodone (active ingredients of Percocet and Vicodin). We seldom have patients who require re-fill of these pain medications.
Time off from work depends on two things: (a) Degree of physical activity required in your job that would be a stress on the newly treated leg; (b) Your desire to return to work and your ability to endure mild to moderate pain/discomfort during work. If your job consists of low-level physical activity (e.g., office work), and if you are motivated to return to work (e.g., self-employed), you can return to work the following day. Even if your job requires moderate degree of physical activity (e.g., nurse or hair stylist), if you are able to tolerate mild to moderate discomfort (equivalent discomfort to a moderate cold or flu), then you can also return in 1-2 days. If your job requires strenuous physical activity (e.g., construction work or mail-carrier) or if you are unable to tolerate mild or moderate discomfort well, then you should take off between 1-3 days plus the weekend and return to work the following Monday. If minimizing time-off from work is important to you, then you should let us know, and we will schedule your procedures accordingly to meet your needs.
The veins that we treat with EVLT will stay closed with a success rate of 95 to 98 %, long-term. If your leg pain and discomfort are caused by venous insufficiency, then EVLT will result in significant improvement in pain and discomfort in over 80% of patients. If your concern is that of leg swelling, the following is what we have observed. After EVLT, the pain and discomfort and the “pressure” associated with your swelling in the leg will improve in greater than 80% of the time. But the “disappearance” of swelling will depend on the nature of your swelling, such as the cause of your leg swelling above and beyond the refluxing veins (such as obesity, heart/liver/kidney conditions, etc.), the duration of your leg swelling, etc. In some patients, the appearance of swelling does not return to normal even though the pain and discomfort is alleviated.
The chance that the vein that was closed by EVLT will open again is less than 2-5% (1-2% at the Advanced Vein Care Center). However, the chance that other veins in the leg will develop venous insufficiency because of on-going risk factors (hereditary, obesity, standing long periods), is about 25%. Venous insufficiency is a life-long condition, and it needs to be monitored by the patient, so that when the symptoms of pain and varicose veins return, you should seek help from the vein specialist right away.
Benefits and Risks of the Procedure
The main benefit is the improvement of leg pain and discomfort. Sometimes the appearance of swelling improves, but this depends on the patient’s specific clinical factors. EVLT procedure should also decrease the future chance of thrombophlebitis/blood clots, bleeding, and worrisome venous stasis dermatitis and leg ulcers. EVLT should also decrease the likelihood of rapidly worsening and progressive appearance of varicose veins—as well as ugly spider veins—in the lower legs.
The most feared risk is also the most rare – formation of deep vein blood clots (“deep vein thrombosis” or “DVT”) and/or pulmonary embolism (“PE”–travel of blood clots to the lungs, potentially a life-threatening complication.)
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
Yes. Between two to four weeks prior to the scheduled date, you should receive in the mail an package in an envelop with specific information as to all your appointments for EVLT, Phlebetomy, and post-EVLT ultrasound. If you do not receive them at least by two weeks prior to the scheduled date, please be sure to call our office. This packet of information should also have prescriptions for medications to be taken in preparation for the procedure.
- 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.
Yes. Three medications: Ibuprofen, Ativan (Lorazepam), and EMLA Cream
It is for Pain Management.Two days before the procedure begin taking Ibuprofen 600 mg tablets as prescribed. Taking anti-inflammatory medications prior to a procedure has been found to decrease post-procedural pain and discomfort in other surgical procedures. Be sure to take the medication with meals. You should NOT take Ibuprofen if you have the following conditions:
- 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.
Yes. You should receive in your package a prescription for the appropriate antibiotic prophylaxis. If you do not, please call our office and let us know.
For EVLT, you do not have to stop your blood thinner before the procedure. EVLT can successfully close the vein despite the anticoagulation. However, if you also have Phlebectomy scheduled following EVLT, you have to have stopped your blood thinners for a number of days prior to your Phlebectomy (see the Phlebectomy section), otherwise your Phlebectomy will have to be cancelled and re-scheduled.
No. It is not necessary to stop aspirin before the EVLT procedure.
Yes, you must bring your compression stockings to the procedure. Wearing compression stockings immediately after the procedure is an essential after-care in order to optimize the clinical outcome from the procedure. Bring your compression stockings to all your appointments. If you have a problem obtaining them prior to the procedure, be sure to let us know beforehand.
Bring loose clothing to the procedure and remove all foot/toe jewelry because these steps make the task of undressing and dressing in the procedure room much easier. You do not have to bring an extra set of clothes, other than your underwear. Bring an extra pair of underwear because sometimes the sterile solutions used to prep the groin area can stain or wet the underwear.
No. Do NOT shave your leg within 72 hours of the procedure, as it increases the risk of post-procedure skin infection.
PLEASE ARRIVE 30 MINS PRIOR TO PROCEDURE TIME.This is necessary in order for you to review and sign forms such as the consent form, visit the Restroom, enter the procedure room, disrobe, and help us choose your choice of music for 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.
No. You must have a friend or family member to drive you to and from your appointment. While the EVLT procedure will not impair your ability to walk, the oral sedative, the local anesthetics in the leg and wrapping of your leg — all of these make it best not to drive immediately after the procedure.
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
Yes. We have two Restrooms for the patients you can use as soon as you arrive in our office, so you do not delay your appointment time.
We do not allow someone to stay in the room with the patient because our experience has been that, despite their best intention, their presence in the room distracts from the focus and the flow of the procedure. In special circumstances where their presence is absolutely required, we make an exception, but not commonly.
Yes, you may bring your own music on your iPod or a similar device for your private listening. However, we have a wonderful In-Room Wi-Fi on-demand music system, and you will be able to choose your own music from either Pandora or our iTune library.
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.)
A medical assistant will bring you into the procedure room. You should have used the Restroom while in the waiting room beforehand. Patient takes off the pants/dress, shoes and socks, and puts on a gown over whatever clothing is comfortable for your upper body and the underwear. Our ultrasound technologist performs ultrasound exam to map out the refluxing veins that need to be treated, standing or on the procedure bed as appropriate. Dr. Lee will then come in, ask questions to update and confirm clinical information as needed, and proceed with the procedure.
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.
No. Intravenous sedation is completely unnecessary for this procedure. We do provide a prescription for “sedative pills” (Ativan/Lorazepam) prior to the procedure, but for most people, even this is not necessary. We have never had to stop the laser procedure because of anxiety or pain intolerance, after 3,000 to 4,000 EVLT procedures in our office so far.
No, the laser does not hurt at all. The vein is completely anesthetized when the laser is performed. One part of the procedure that hurts is when initially we try to access the vein. This is similar to getting an IV placed, which is a relatively minor discomfort. The other part is when the vein is being “numbed” with local anesthetic injections. For most people, this, too, is relatively a minor discomfort. Otherwise, there is no other pain associated with the procedure.
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.
We have treated many patients with Latex allergy. Simply let us know, and we will use Latex-free instruments, gloves, and supplies. Similarly for the surgical prep allergy and tape allergy. We have alternative means to take care of you while avoiding your allergens.
After Procedure Care
Wear compression stockings (CS) for the first 48 hours continuously (day and night). Then continue wearing CS during the day (take off at night when sleeping) for until the end of the first week after the procedure.
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.
No, chances are overwhelming that taking off the compression stockings will NOT “un-do” the closure of vein by the laser. Whatever the benefits maybe from wearing CS following the EVLT procedure, they are not worth the risk of “problems” if you develop them while wearing CS (see above).
Absolutely not. You should not keep your leg elevated after the EVLT. This will increase your chance of deep vein blood clots (DVT). You should walk from time to time as part of your normal physical activity. Get up and “move around” from time to time. This is very important.
We recommend walking around at least 5-10 minutes every hour during awake hours. Obviously you can sleep your normal sleeping hours without having to wake up and walk at night. But during the day, you should walk as much as possible. Avoid sitting with your knee bent at less than 90-dgree angle. If you must sit, sit with your leg as straight as possible, perhaps elevated. Get up and walk as much as possible if you must sit. Avoid standing still.
Mild to moderate. Rarely, severe. Depends on the length, the location, and the number of veins that were treated. Greater pain results if the length of the vein is longer, if the number of treated veins is greater, and if the location of the vein is below the knee and lower in the leg. Lastly, it depends on the pain-tolerance level of the patient: greater if the patient has a history of being more “sensitive” and “anxious” to pain. Usually, the pain and discomfort gets worse in the first 3-4 days before it gets better.
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?
For relatively healthy patients, Ibuprofen (600 mg every 6 hours) suffices to control pain. Extra strength Tylenol is an alternative to Ibuprofen IF you have an issue with kidney function, or if you are more than 65 years of age, or if you have symptoms of stomach ulcer or reflux (GERD). If you have a liver condition, we do not recommend Tylenol. Please consult with us. You will be asked if you are a candidate for post-procedural opioid pain pills in addition to Ibuprofen. They include oxycodone (Percocet), hydrocodone (Vicodin), codeine (Tylenol #3), or tramadol (Ultram), and one of these will be prescribed if appropriate.
You should avoid letting water soak the treated area in the leg where there was a needle puncture, for at least 36 hours to 48 hours. Those wounds are expected to heal over enough to be “water-resistant” by 36 to 48 hours. If you are desperate to take a shower before that time, then you might place a plastic bag over the treated area, then take a shower letting water touch the leg only sparingly. If the white gauze-bandage is wet at all, you should remove it, and replace it with another dry gauze and tape over the treated area. After 48 hours, you can take the shower, then leave the white gauze/tape off the treated area and leave only the steri-strips directly on the wounds. If there is any residual oozing of clear or pinkish-red fluids from the needle puncture wounds, apply more sterile dry gauze & tape over them.
Prolonged submersion in clean bath water or jacuzzi should be avoid for at least one week.
Prolonged submersion in a swimming pool (as in swimming laps or aquatic aerobics) should be avoided for two weeks.
- 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
“Black-and-blue” bruises are normally expected after the EVLT treatments. One may have varying degrees of bruises depending on the size and the length of the vein treated, its location, amount of laser energy used, post-procedural anti-inflammatory pain medications, and other specific factors. It may take days to weeks before the bruises go away.
“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.
No, it is statistically more likely from a normal course of post-procedural inflammatory response. Deep vein blood clot (DVT) is extremely rare (less than one in 500 with our current laser machine).
For a month following the EVLT procedure, we recommend that you avoid long-distance travel with more than an hour transit time, whether in a car or on an airplane. If traveling longer distances in a car, we recommend that you stop every hour and walk around for 5 to 10 minutes. If you have to travel in an airplane for much longer than an hour within the month, you should consult with us, so we can give you a prescription for a blood-thinning medication (or a low-dose aspirin instead if appropriate) as a prophylaxis against blood-clot formation during your air travel. While traveling, you should wear compression stockings, avoid tight spaces where your knees and hips will be flexed at acute angles, and get up and walk around as much as possible.
We recommend one month following the procedure as our experience has served our patients well. But there is little data to support any particular duration.
No, if it is just oozing of blood slowly, then apply sterile dry gauze to the area with some pressure and it is expected to stop.
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.