LAS VEGAS – Endovenous laser therapy is replacing ligation and vein stripping for many patients with superficial venous incompetence, especially in the legs.

"The endovenous laser has been a major revolutionary advance in the treatment of medical varicose veins of the lower extremities," Dr. Neil S. Sadick said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Endovenous laser fibers are inserted in the vessel under ultrasound guidance to eradicate truncal varicosities in the short and lower saphenous veins. The laser heat transfer causes shrinkage of the vein wall collagen and decreased lumen, with the shrinkage proportional to the delivered linear endovenous energy density.

"This is an extremely easy procedure," that takes about 15 minutes, said Dr. Sadick, a dermatologist at Weill Cornell Medical Center in New York. "It’s almost bloodless. Patients can go back to work that day" wearing light compression hose, and "there’s very little discomfort after" the procedure.

Recurrence rates with endovenous laser therapy also are lower, compared with conventional invasive surgical ligation and stripping procedures, he added. Studies by Dr. Sadick and his associates showed that recurrence rates after treatment of superficial venous incompetence with a combination of endovascular laser and ambulatory phlebectomy were approximately 6% at 1 year, 4% at 2 years, 3% at 3 years, and 4% at 4 years.

Endovenous laser therapy "induces an endothelial type of thrombosis, and then the vein gets dissolved by the body," he said.

Treatment Algorithm

Dr. Sadick developed an algorithm for treatment based on the type of leg varicosity. He uses endovenous laser therapy or endovenous radiofrequency technology to treat large varicose veins of the axial junctions, such as in the long or short saphenous veins. Most intermediate-size varicose veins, such as truncal varicosities or perforations, can be treated by either ambulatory phlebectomy or foam sclerotherapy.

For reticular veins, he prefers to treat with an external 1064-nm Nd:YAG (neodymium YAG) laser or sclerotherapy with or without foam. Microtelangiectasia, or "very, very small vessels," can be treated with microsclerotherapy via very dilute concentrations of sclerosant, "but this is where an external 1064-nm Nd:YAG laser plays an important role" and may suffice without microsclerotherapy, he said.

"Not all leg veins are treated equally," he added. Red telangiectasias measuring less than 1 mm in tiny, oxygenated, red vessels usually are superficial and are "hit hard" with short pulse durations of high-fluence external laser energy in small spot sizes of 1-2 mm.