LASER ENDO-VEINEUX
Mise à jour SFLM-JANVIER 2013
Vasa. 1998 Feb;27(1):43-5
Arteriovenous fistula after endoscopic dissection of the perforant vein of the
lower leg with the neodymium:YAG laser in chronic venous stasis syndrome
Folsch C, Rauber K, Langer C
The endoscopic dissection of the perforating veins has been invented by Hauer in
the last decade. He introduced the videoendoscopy to this surgical procedure.
The avoidance of operative access through areas of trophic changes is very
beneficial for reducing postoperative complications. Although postoperative
thermic lesion have been reported on. Following an endoscopic laser coagulation
of a Cockett perforating vein an arterio-venous fistula between the posterior
tibial artery and vein developed by the mechanism mentioned. Persisting pain and
the persistence of the ulcer led to several diagnostic measures including
phlebography, digital subtraction angiography and CT-scan. After the fistula had
been closed successfully by percutaneous embolization with four platin wires the
ulcer disappeared.
Dermatol Surg 2001 Feb;27(2):117-22
Endovenous laser: a new minimally invasive method of treatment for varicose
veins--preliminary observations using an 810 nm diode laser.
Navarro L, Min RJ, Bone C.
BACKGROUND: Long-term success in the treatment of truncal and significant branch
leg varicosities, when the saphenofemoral junction (SFJ) and the greater
saphenous vein (GSV) are involved, depends on the elimination of the highest
point of reflux and the incompetent venous segment, and is best achieved by
surgical ligation and stripping. Minimally invasive alternatives in the
treatment of varicose veins with SFJ and GSV incompetence have been tried over
the years to increase patient comfort, reduce cost and risk, and allow
implementation by a wide variety of practitioners resulting in varying degrees
of success depending on the fulfillment of the above two premises and the
effectiveness of the method used. OBJECTIVE: To demonstrate a novel way to use
laser energy through an endoluminal laser fiber for the minimally invasive
treatment of truncal varicosities that eliminates the highest point of reflux
and the incompetent segment. METHODS: Patients were treated with 810 nm diode
laser energy administered endovenously through a bare-tipped laser fiber
(400-750 microm). Vein access for endoluminal placement of the fiber through a
catheter was achieved by means of percutaneous or stab wound incision under
ultrasound guidance and local anesthesia. Exact placement of the fiber was
determined by direct observation of the aiming beam through the skin and by
ultrasound confirmation. RESULTS: Preliminary short-term postprocedure results
(up to 1 year, 2 months after treatment) in the endovenous laser treatment of 40
greater saphenous veins in 33 patients indicate a 100% rate of closure with no
significant complications. In addition, a 2-year experience of 80 cases of
isolated branch varicosities (Giacomini, anterolateral branch, etc.) also shows
a 100% rate of closure. CONCLUSION: Early results of our endoluminal laser
methodology indicate a very effective and safe way to eliminate SFJ incompetence
and close the GSV. With proper patient selection, the ease of methodology and
the reduced risk and cost associated with endovenous laser treatment may make it
a successful minimally invasive alternative for a wide group of patients that
previously would have required ligation and strippi
14 Th World Congress of International Union of Phlebology,
Rome 9-14 Sept 2001, Abstract P 9
Endovenous laser: light at the end of the tunnel ?
R. Min
The newest minimally invasive technique for treatment of varicose veins is endovenous laser. Endovenous laser treatment (EVLTTm) allows delivery of laser energy directly into the blood vessel lumen in order to produce vein wall damage with subsequent fibrosis. Results of the first 100 GSVs treated by the above investigator with an 810 nm wavelength diode laser (Diomed, Inc., Andover, MA) are summarized in Table 1. Other than selflimiting ecchymoses and mild discomfort along the treated GSV, there have been no minor or major complications. The early results from more than 400 GSVS treated worldwide with EVLT have been impressive with very effective occlusion of incompetent GSV segments. We eagerly await longerterm followup results from patients already treated with EVLT and additional evaluation of this promising new technique, which may offer a good alternative to ligation and stripping for those patients wishing to avoid surgery.
Table 1. Post-Post-EVLTTM FolIow-U of GSVsFollow-U / Ratio (%) Closed / % Area Reduction
1 month / 100/100 (100%) / 41 %
3 months / 72/72 (100%) / 76 %
6 months / 54/55 (98%) / 90¨%
9 months, / 40/41 (98%) / >95 %
12 months / 25/27 (93%) / >95 %
* / Evaluated with Duplex Ultrasound
Phlébologie 2001,54(3): 293-300
L’énergie laser intraveineuse dans le traitement des troncs veineux variqueux : rapport sur 97 cas
Navarro L, Boné C
Objectif: Éradiquer les varices des troncs et le reflux de la grande veine saphène (GVS) en obstruant la GVS de l'aine au genou par l'énergie laser délivrée par voie intraveineuse au moyen d'une fibre laser à embout nu.
Méthodes : Après un test diagnostique approfondi utilisant l'ultrasonographie couleur, un cathéter est placé dans la GVS sous la jonction saphénofémorale. L'introduction du cathéter dans la veine est effectuée sous anesthésie locale et guidée par ultrasonographie soit par une ponction souscutanée, soit par l'approche « stab wound Muller Hook ». Une fibre laser à embout nu est introduite dans le cathéter et placée à 12 cm sous la jonction saphénofémorale. La position exacte de la fibre est appréciée par ultrasonographie et par observation directe de la lumière transcutanée. Une anesthésie locale périveineuse est réalisée sur toute la longueur de la GVS et l'énergie de la diode laser est appliquée par pulsions d'une seconde toute (s) la (les) 13 mm depuis la jonction saphénofémorale jusqu'au point d'introduction de la sonde.
Résultats : Les résultats des 97 grandes veines saphènes traitées chez 79 patients indiquent une absence de reflux et l'oblitération de la GVS dans chaque cas, avec un suivi moyen de 7,0 mois. Le taux de recanalisation a été de 0 % et aucune complication grave n'a été observée.
Conclusion : Les résultats à court terme de cette méthode démontrent qu'il s'agit d'un procédé sûr et efficace pour oblitérer la GVS et pour éliminer les reflux des jonctions saphénofémorales et d'une alternative au traitement chirurgical habituel de patients présentant des varices des troncs.
Phlébologie 2001, 54(4): 367-370
Petit fait clinique, grand retentissement potentiel: l’arrivée du laser endoveineux
Gorny P, Chahine D, Tran-Duy S
Nous rapportons ici la première expérience en France de traitement de la maladie variqueuse avec le laser endoveineux (LE). Le LE est une nouvelle méthode d'occlusion de la grande veine saphène à l'étage crural. Elle recourt à la chaleur dégagée par une source laser diode 810 nm. La procédure est simple, sûre, bien tolérée, rapide (30 mn) et réalisable en cabinet médical. Elle est menée sous anesthésie locale. Les résultats à court terme (1 à 9mois) sont excellents (99 à 100 % d'occlusion). Les résultats à long terme restent inconnus. Ceux fournis par les diverses techniques d'occlusion ayant précédé cellelà ne soutiennent pas la comparaison, en termes de qualité et de taux de récidives, avec les résultats de la chirurgie d'exérèse bien exécutée. Par suite, opposer le LE directement à la chirurgie semble pour l'instant prématuré. Néanmoins cette technique miniinvasive apparaît comme une option thérapeutique intéressante, qui permettrait de retarder le recours à une chirurgie d'optique plus radicale. A cet égard le LE pourrait concerner un grand nombre de patients et se révéler une bonne indication chez ceux désireux d'éviter la chirurgie d'exérèse en première approche ou chez ceux désireux de choisir une solution thérapeutique offrant un rapport confort/ bénéfice élevé.
J Vasc Interv Radiol 2001 Oct;12(10):1167-71
Endovenous laser treatment of the incompetent greater saphenous vein.
Min RJ, Zimmet SE, Isaacs MN, Forrestal MD.
PURPOSE: To assess the safety and preliminary efficacy of endovenous laser
treatment (EVLT), a novel percutaneous technique for occlusion of the
incompetent greater saphenous vein (GSV). MATERIALS AND METHODS: Ninety GSVs in 84 patients with reflux at the saphenofemoral junction (SFJ) into the GSV were
treated endovenously with pulses of laser energy and evaluated in a prospective,
nonrandomized, consecutive enrollment multicenter study. Patients were evaluated
at 1 week and at 1, 3, 6, and 9 months to determine efficacy and complications.
RESULTS: Eighty-seven of 90 GSVs (97%) were closed 1 week after initial
treatment with endovenous laser. The remaining three GSVs were closed after
repeat treatment. Eighty-nine of 90 GSVs (99%) remained closed for as long as 9
months according to serial duplex ultrasonography. Sonographic evaluation
demonstrated 73% reduction in GSV diameter at 6 months (61 patients) and 81%
reduction in GSV diameter at 9 months (26 patients) after EVLT. One patient
developed a transient localized skin paresthesia. There have been no other minor
or major complications. CONCLUSIONS: EVLT of the incompetent GSV appears to be
an extremely safe technique that yields impressive short-term results. Long-term
follow-up is awaited.
Dermatol Surg 2002 Jan;28(1):56-61
Comparison of endovenous radiofrequency versus 810 nm diode laser occlusion of
large veins in an animal model
Weiss RA
BACKGROUND: Endovenous occlusion using radiofrequency (RF) energy has been shown
to be effective for the elimination of sapheno-femoral reflux and subsequent
elimination of varicose veins. Recently, endovenous laser occlusion has been
introduced with initial clinical reports indicating effective treatment for
varicose veins. However, in our practice we note increased peri-operative
hematoma and tenderness with the laser. Little is known regarding the mechanism
of action of this new laser vein therapy. OBJECTIVE: To better understand the
mechanism of action of endovenous laser vs. the endovenous RF procedure in the
jugular vein of the goat model. METHODS: A bilateral comparison was performed
using 810 nm diode laser transmitted by a bare-tipped optical fiber vs. the RF
delivery by engineered electrodes with a temperature feedback loop using a
thermocouple (Closure procedure) in three goat jugular veins. Immediate and
one-week results were studied radiographically and histologically. Temperature
measurements during laser treatment were performed by using an array of up to
five thermocouples, spaced 2 mm apart, placed adjacent to a laser fiber tip
during goat jugular vein treatment. RESULTS: Immediate findings showed that 100%
of the laser-treated veins showed perforations by histologic examination and
immediate contrast fluoroscopy. The RF-treated side showed immediate
constriction with maintenance of contrast material within the vein lumen and no
perforations. The difference in acute vein shrinkage was also dramatic as laser
treatments resulted in vein shrinkage of 26%, while RF-treated veins showed a
77% acute reduction in diameter. At one week, extravasated blood that leaked
into the surrounding tissue of laser treated veins acutely, continued to occupy
space and impinge on surrounding structures including nerves. For the laser
treatment, the highest average temperature was 729 degrees C (peak temperature
1334 degrees C) observed flush with the laser fiber tip, while the temperature
feedback mechanism of the RF method maintains temperatures at the electrodes of
85 degrees C. CONCLUSION: Vein perforations, extremely high intravascular
temperatures, failure to cause significant collagen shrinkage, and intact
endothelium in an animal model justify a closer look at the human clinical
application of the 810 nm endovenous laser technique. Extravasated blood
impinging on adjacent structures may theoretically lead to increased
peri-operative hematoma and tenderness. Further study and clinical investigation
is warranted.
Journal des maladies vasculaires Mars 2002 (27); Suppl 1: IS 18
Laser endo-veineux: résultats
Anastasie B
De mai à décembre 2001 63 patients ont étés traités; 43 femmes et 20 hommes de 24 à 89 ans. 82 axes veineux ont subi le traitement, soit 71 en territoire des grandes saphènes dont 4 récidives récurrentes et 11 petites saphènes. 58 ont eu un abord par ponction percutanée à la malléole ou à la jarretière, 11 ont nécessité une crossectomie saphène interne, ce qui a permis un cathétérisme rétrograde; 13 autres ont eu un mini abord chirurgical par crochet de phlébectomie. Cette technique a été adaptée à partir de celle du Dr RJ Min en utilisant un laser 810 Diomed (12-14 W, 1 s) et 980 nm Biolitec (8 –12 W, 1,5 – 2,5 s). Les tirs laser sont effectués tous les 3 mm. La reprise d’une activité complète était obtenue en 6 jours en moyenne. Deux patients (2,4 %) au début de la phase d’apprentissage ont eu une endo-sclérose incomplète au hunter, sclérosée ensuite sous échographie. Il est à noter que les territoires occlus sont restés stables chez ces deux patients. Un abcès du scarpa fut à déplorer, 2 patients présentèrent un érythème douloureux et inflammatoire résolutif en 15 jours avec un traitement AINS local et général. Nous n’avons pas noté d’hématomes, ni d’infection cellulitique, thrombose ou embolie pulmonaire, perforation vasculaire. 97,6 % sont occlus jusqu’à 6 mois de suivi. La réduction de diamètre vasculaire mesurée échographiquement était de 40 % à J8 et 60 % à J90 en moyenne. Del giglio (980 nm) obtient, après avoir traité des branches puis des grandes et petites saphènes, 94 % d’occlusion à 24 mois sur 34 membres inférieurs. Boné (810 et 940 nm Dornier) sur 97 grandes saphènes aboutit à 100 % d’occlusion à 7 mois de suivi moyen. Min (810 nm) publie ses résultats sur 90 grandes saphènes; 99 % des vaisseaux sont occlus sur un suivi moyen de 9 mois. A 24 mois, 97 % des saphènes traitées restent occluses. Aucun effet indésirable important (hématome, infection, thrombose, embolie pulmonaire, perforations) n’était noté dans ces travaux.
J Vasc Surg 2002 Apr;35(4):729-36
Endovenous treatment of the greater saphenous vein with a 940-nm diode laser:
thrombotic occlusion after endoluminal thermal damage by laser-generated steam
bubbles
Proebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge S, Knop J
PURPOSE: Despite a rapid spread of the technique, very little is known about the
laser-tissue interaction in endovenous laser treatment (EVLT). We evaluated EVLT
of the incompetent greater saphenous vein (GSV) for efficacy, treatment-related
adverse effects, and putative mechanisms of action. METHODS: Twenty-six patients
with 31 limbs of clinical stages C(2-6), E(P), A(S,P), P(R) with incompetent GSV
proven by means of duplex scanning were selected for EVLT in an outpatient
setting. A 600-microm fiber was entered into the GSV via an 18-gauge needle
below the knee and proceeded to the saphenofemoral junction (SFJ). After
infiltration of tumescent local anesthesia, multiple laser pulses of 15 J energy
and a wavelength of 940 nm were administered along the vein in a standardized
fashion. D-dimers were determined in peripheral blood samples 30 minutes after
completion of EVLT in 16 patients and on postoperative day 1 in 20 patients. One
GSV that was surgically removed after EVLT was examined by means of
histopathology. Additionally, an experimental in vitro set-up was constructed as
a means of investigating the mechanism of laser action within a blood-filled
tube. RESULTS: A median of 80 laser pulses (range, 22-116 laser pulses) were
applied along the treated veins. On days 1, 7, and 28, all limbs except one
(97%) showed a thrombotically occluded GSV. In one patient, the vessel showed
incomplete occlusion. The distance of the proximal end of the thrombus to the
SFJ was a median 1.1 cm (range, 0.2-5.9 cm) in the remaining patients. Adverse
effects in all 26 patients were ecchymoses and palpable induration along the
thrombotically occluded GSV that lasted for 2 to 3 weeks. In two limbs (6%),
thrombophlebitis of a varicose tributary required oral treatment with
diclofenac. D-dimers in peripheral blood were tested with normal results in 14
of 16 patients 30 minutes after completion of the procedure and elevated results
in 7 of 20 patients at day 1 after EVLT. However, an increase of D-dimers from
day 0 to day 1 was observed in 15 of the 16 patients undergoing tests 30 minutes
after EVLT and on day 1. The 940-nm laser was demonstrated by means of in vitro
experiments and the histopathological examination of one explanted GSV to act by
means of indirect heat damage of the inner vein wall. CONCLUSION: EVLT of the
GSV with a 940-nm diode laser is effective in inducing thrombotic vessel
occlusion and is associated with only minor adverse effects. Laser-induced
indirect local heat injury of the inner vein wall by steam bubbles originating
from boiling blood is proposed as the pathophysiological mechanism of action of
EVLT.
Phlébologie 2002; 55 (3): 239-43
Traitement de l’insuffisance veineuse de la grande saphène par photocoagulation laser endoveineuse: technique et indications
Guex JJ; Min RJ; Pittaluga P
Les procédures de traitement endovasculaires sont devenues extrêmement communes en pathologie vasculaire, le mouvement s'étend également au traitement de certaines varices. Les méthodes endovasculaires déjà connues sont : la sclérothérapie échoguidée, avec ou sans cathéter (et son dernier avatar la mousse), le clip endoveineux (V Clip°) et la radiofréquence (VNUS").
La méthode la plus récente (EVLT Diomed°) emploie un générateur Laser Diode de 15 W et d'une longueur d'onde de 810 nm dont l'énergie est délivrée in situ par une fibre optique de 600 µm.
La procédure est strictement ambulatoire, sous anesthésie locale semitumescente, et sous contrôle échographique. Il n'y a ni hospitalisation ni arrêt de travail.
La fibre optique est montée dans la grande veine saphène à travers un cathéter introduit au genou selon la méthode de Seldinger, puis positionnée grâce à l'échographie. La photocoagulation de la veine variqueuse est obtenue en retirant progressivement la fibre optique, sous compression manuelle, en appliquant des impulsions laser d'une puissance de 12 W et d'une durée de 1 sec suivies d'une pause de 1 sec. Les soins postopératoires se limitent au port d'une compression pendant une semaine.
La technique est simple, rapide et efficace.
Dermatol Surg 2002 Jul;28(7):596-600
Thermal damage of the inner vein wall during endovenous laser treatment: key
role of energy absorption by intravascular blood
Proebstle TM, Sandhofer M, Kargl A, Gul D, Rother W, Knop J, Lehr HA
BACKGROUND: Despite the clinical efficacy of endovenous laser treatment (EVLT),
its mode of action is incompletely understood. OBJECTIVE: To evaluate the role
of intravascular blood for the effective transfer of thermal damage to the vein
wall through absorption of laser energy. METHODS: Laser energy (15 J/pulse, 940
nm) was endovenously administered to explanted greater saphenous vein (GSV)
segments filled with blood (n = 5) or normal saline (n = 5) in addition to GSVs
under in vivo conditions immediately prior to stripping. Histopathology was
performed on serial sections to examine specific patterns of damage.
Furthermore, in vitro generation of steam bubbles by different diode lasers
(810, 940, and 980 nm) was examined in saline, plasma, and hemolytic blood.
RESULTS: In saline-filled veins, EVLT-induced vessel wall injury was confined to
the site of direct laser impact. In contrast, blood-filled veins exhibited
thermal damage in more remote areas including the vein wall opposite to the
laser impact. Steam bubbles were generated in hemolytic blood by all three
lasers, while no bubbles could be produced in normal saline or plasma.
CONCLUSION: Intravascular blood plays a key role for homogeneously distributed
thermal damage of the inner vein wall during EVLT.
Lasers Surg Med 2002;31(4):257-62
Endovenous laser photocoagulation (EVLP) for varicose veins
Chang CJ, Chua JJ
BACKGROUND AND OBJECTIVES: Untreated varicose veins have significant morbidity
and potential mortality. Treatment aims to relieve symptoms, improve appearance,
and to prevent deterioration. Current therapeutic options include graduated
compression stockings, sclerotherapy, ambulatory phlebectomy, surgical ligation,
and stripping. Results of laser photocoagulation of vascular anomalies have been
encouraging. Applying these concepts of laser-tissue interactions, we developed
a new method of treatment for varicose veins of the lower extremities.
STUDY DESIGN/MATERIALS AND METHODS: One hundred and forty-nine patients with 252 varicose greater saphenous veins underwent endovenous laser photocoagulation