Version May 2024
INTRODUCTION — Endovenous laser ablation (EVLA) is a percutaneous technique that uses laser energy to ablate incompetent superficial veins. The axial veins are the primary target for this therapy and include the great saphenous vein (GSV), small saphenous vein (SSV), and accessory saphenous veins (ASVs).
Although vein ligation/stripping was once the standard for the management of lower extremity varicose veins and venous reflux, randomized trials have found that minimally invasive therapies (eg, thermal, non-thermal), including EVLA provide similar or improved clinical outcomes compared with GSV ligation and stripping [1-3]. No significant differences in measures of venous symptom severity (eg, Venous Clinical Severity Score (calculator 1), Aberdeen Varicose Vein Symptom Score) and quality-of-life scores (eg, Medical Outcomes Study Short Form-36) have been found at short-term (one to three months) [2,4,5] or longer-term (two- [6] and five-year) follow-up in comparisons of EVLA and GSV ligation versus vein ligation/stripping in several clinical trials [7]. Compared with other forms of venous ablation, a systematic review and meta-analysis suggested that the pooled success rate for EVLA at three years was significantly higher compared with radiofrequency ablation, vein excision, or sclerotherapy (94 versus 84, 77, and 78 percent, respectively) [1]. A more detailed comparison of EVLA with other vein ablation techniques is provided separately. (See "Comparison of methods for endovenous ablation for chronic venous disease", section on 'Outcome comparisons' and "Approach to treating symptomatic superficial venous insufficiency", section on 'Endovenous versus surgical ablation'.)
The indications, perioperative care, and outcomes of EVLA are reviewed. Alternative approaches to the treatment of chronic venous disease using other minimally invasive thermal and non-thermal techniques, and open surgery are discussed separately.
●(See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease".)
●(See "Approach to treating symptomatic superficial venous insufficiency", section on 'Surgical options'.)
ANATOMY
Venous anatomy — The veins of the lower extremity are divided into superficial, perforating, and deep veins (figure 1A-B). The superficial veins lie superficial to the muscle fascia. The perforating veins cross the fascia and connect the superficial veins to the deep veins that are located beneath the fascia. The deep veins are never treated with endovenous ablation therapies.
The major superficial veins of the lower extremity include the great and small saphenous veins. These and the accessory saphenous veins are collectively referred to as the axial or truncal veins. (See "Classification of lower extremity chronic venous disorders", section on 'Superficial venous system (As)'.)
●The great saphenous vein (GSV) is one of the two main superficial veins in the lower extremity. It is the longest vein in the body and originates on the medial aspect of the dorsal foot. It crosses anterior to the medial malleolus and ascends along the medial aspect of the leg and thigh. Just below the inguinal ligament, it enters the fossa ovalis and terminates in the common femoral vein at the saphenofemoral junction.
●The small saphenous vein (SSV) originates laterally from the dorsal venous arch of the foot, crosses posterior to the lateral malleolus, and ascends in the posterior calf (figure 1A-B). In the upper calf, the SSV passes through the deep muscle fascia and terminates in the popliteal vein; however, the anatomy at the sapheno-popliteal junction is variable (figure 2) [8-11]. The SSV can join an intersaphenous vein that is a superficial cephalad extension in the posterior thigh (ie, vein of Giacomini), connect to both the popliteal vein and the posterior thigh vein, or join the popliteal vein with no major tributaries near the junction (figure 2). Anatomic variations in the SSV have implications for SSV ablation [11]. (See 'Small saphenous vein' below.)
●The accessory saphenous veins (ASVs) are any of several venous segments that ascend parallel to the GSV. Anterior ASVs are located anteriorly and can be found in the thigh or leg (figure 1A-B) [12].
The deep veins of the lower extremity are contained within the deep muscle compartments bounded by the muscle fascia (figure 3). (See "Classification of lower extremity chronic venous disorders", section on 'Deep venous system (Ad)'.)
Perforating veins are those veins that traverse the muscular fascia to connect superficial veins with the deep veins. They are located anteriorly, posteriorly, laterally, and medially in both the thigh and calf. (See "Classification of lower extremity chronic venous disorders" and "Classification of lower extremity chronic venous disorders", section on 'Perforator veins (Ap)'.)
In the lower extremity, normal flow in the perforating veins is from superficial to deep; however, in the foot the flow is from the deep to superficial. Many perforating veins demonstrate bidirectional flow. When the blood flow is reversed greater than 0.5 seconds, perforating veins are considered incompetent. The most clinically significant perforating veins connect the posterior arch vein to the posterior tibial vein. These veins, termed posterior tibial perforators, were formerly known as Cockett perforators.
Saphenous nerve — The saphenous nerve is the largest cutaneous branch of the femoral nerve. It lies near the superficial femoral artery in the thigh, exiting the adductor canal, traveling deep to the sartorius muscle (figure 4A-B). It typically becomes superficial after it emerges medially between the tendons of the sartorius and gracilis muscles at the knee and then travels adjacent to the GSV. The saphenous nerve provides sensory innervation to the medial aspect of the leg and foot. The saphenous nerve is adherent to the saphenous vein in the distal third of the calf [13].
Sural nerve — Identification of the relative anatomy of the sural nerve to the SSV is important for avoiding damage to the sural nerve during EVLA.
The sural nerve is a cutaneous nerve coursing along the SSV and traversing posterior to the lateral malleolus toward the fifth toe (figure 5). The sural nerve provides cutaneous innervation to the posterior-lateral calf and lateral foot. In an autopsy study, the sural nerve was separated from the SSV by the deep muscular fascia above the inferior border of the gastrocnemius muscle, but below the inferior border of the gastrocnemius muscle, the sural nerve perforated the deep fascia to run in close proximity to the SSV, where it can easily be injured [14]. The sural nerve can vary in its course from the usual anatomy in up to one-half of patients and can usually be identified using ultrasound [15].
INDICATIONS
Symptomatic superficial venous reflux — The indications for EVLA are the same as for other vein ablation therapies, including radiofrequency ablation, sclerotherapy, nonthermal adhesive ablation, and open surgical stripping. Venous ablation is indicated in patients with symptoms and signs of venous disease that persist despite a trial of medical management, and documented reflux in the target superficial vein (ie, retrograde flow >0.5 seconds). The patient's symptoms should directly relate to the incompetent veins being treated. (See "Approach to treating symptomatic superficial venous insufficiency", section on 'Candidates for venous intervention'.)
Based on the available studies, bilateral GSV ablations can be performed safely in a single setting using tumescent anesthesia (maximum dose 15 mg/kg). In a review of data from the Vascular Quality Initiative that compared staged EVLA in 939 patients with concomitant bilateral EVLA in 308 patients, overall complications were similar [16].
There may be some concern over the administered dose of local anesthetic that occurs when the bilateral saphenous vein EVLA is performed. Larger doses of lidocaine are tolerated when a diluted solution of tumescent anesthesia is used compared with the subcutaneous injection (ie, maximal subcutaneous dose: 5 mg/kg for lidocaine without epinephrine; 7 mg/kg with epinephrine) [17,18]. (See 'Instill tumescent anesthetic' below.)
Patients with lower extremity ulceration should be assessed to ensure the adequacy of the arterial circulation since patients with chronic venous disease complicated with ulceration can have coexistent peripheral artery disease. If the arterial circulation is inadequate for wound healing, the arterial disease should be addressed prior to treating the venous disease. (See "Clinical features and diagnosis of lower extremity peripheral artery disease".)
Endovenous ablation is associated with a very low risk of infection; thus, it is generally not necessary to wait for venous ulcers to heal prior to proceeding with EVLA. Faster ulcer healing occurs following endovenous management of associated superficial venous reflux. In a trial that randomly assigned 450 patients with active venous ulcers to compression therapy and early endovenous ablation or to compression therapy and delayed intervention (ie, until ulcer healing or six months after randomization), ulcer healing was faster, and time free from ulcers was longer in the early intervention group [19]. (See "Comparison of methods for endovenous ablation for chronic venous disease", section on 'Ulcer healing'.)
For patients with ulceration who are refractory to management or in whom ulceration recurs, evaluating for obstruction of the iliac vein should be considered. (See "Overview of iliocaval venous obstruction".)
Also, ablation of perforators can be considered, but treatment of perforating veins has not been demonstrated to improve ulcer healing [20].
Contraindications — EVLA is contraindicated in patients with acute deep venous thrombosis and in pregnant patients due to the risk of developing a new deep vein thrombosis (DVT) [21]. We prefer to wait a minimum of six weeks after delivery in pregnant patients before performing EVLA. Circulating volume and uterine size will normalize by six weeks, diminishing the intensity of varicose vein symptoms. Post-partum, the incidence of thromboembolic events is significantly increased for the first six weeks but continues to be elevated for up to three months [22].
Patients with congenital venous abnormalities (eg, Klippel-Trenaunay syndrome, Parkes Weber syndrome) should generally not undergo ablation of major superficial veins. Selected patients may, however, benefit from localized management of symptomatic segments (sclerotherapy, stab phlebectomy). (See "Overview of vascular intervention and surgery for vascular anomalies" and "Approach to treating symptomatic superficial venous insufficiency", section on 'Ambulatory phlebectomy'.)
Relative contraindications to EVLA for a given vein segment that may result in failure to perform the procedure or subsequent failure of the procedure include:
●Chronic or recurrent phlebitis in the target vein, since formation of synechiae in the vein can prevent passage of the laser sheath.
●Severe tortuosity in which passage of the device may not be possible.
●Target veins that are not at least 1 cm deep to the skin dermis after tumescent anesthesia is administered. Ablation of veins closer to the skin may lead to skin burns.
●Target great saphenous vein segments that are aneurysmal (>2.5 cm in diameter) may have a greater risk of failure.
PATIENT COUNSELING — The indications for the procedure, alternatives (eg, continued medical management, vein stripping), risks, and benefits (relief of symptoms attributable to the venous insufficiency) should be discussed with the patient. The patient is informed that:
●Unforeseen anatomic issues may result in failure (ie, the inability to perform an endovenous procedure), in which case the patient may need to be rescheduled for a repeat or alternative procedure.
●In spite of successful technical application of the endovenous device, nonclosure of the vein or late vein recanalization can occur and may be more common in larger diameter veins. In these cases, EVLA may be repeated or an alternative procedure performed. (See 'Saphenous ablation' below.)
●Associated varicosities that have not been treated at the time of the EVLA should become less noticeable but may not completely disappear. Supplemental procedures may be needed to achieve the desired cosmetic result [23,24]. Whether simultaneous versus delayed sclerotherapy or phlebectomy is being performed should be understood prior to the procedure. (See 'Perform supplemental procedures' below.)
●Other risks of the procedure may include bleeding, infection, phlebitis, deep vein thrombosis, and cutaneous nerve injury leading to numbness or paresthesias. (See 'Complications' below.)
Alternatives to EVLA include no therapy, compression therapy, sclerotherapy, radiofrequency ablation, chemical ablation, mechanochemical ablation, nonthermal adhesive ablation, or surgical removal of refluxing superficial veins. (See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins" and "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease" and "Approach to treating symptomatic superficial venous insufficiency", section on 'Surgical options'.)
PATIENT PREPARATION — The diagnostic evaluation is performed by taking a careful history, performing a physical exam, and obtaining noninvasive vascular laboratory studies. A venous duplex ultrasound of the affected lower extremity should evaluate the deep veins, great saphenous vein, accessory saphenous veins, if present, and small saphenous vein for patency as well as the presence of reflux. The clinical evaluation of lower extremity chronic venous insufficiency is discussed elsewhere. (See "Clinical manifestations of lower extremity chronic venous disease" and "Diagnostic evaluation of lower extremity chronic venous disease".)
●Antithrombotic therapies — Aspirin, antiplatelet agents, and nonsteroidal anti-inflammatory drugs (NSAIDs), direct oral anticoagulants (DOACs) are sometimes discontinued to limit postoperative bruising, but this is not necessary.
For patients who are therapeutically anticoagulated, cessation of anticoagulation is not necessary prior to EVLA. Perioperative anticoagulation with low-molecular-weight heparin, warfarin, or direct oral anticoagulants does not appear to affect the success of endovenous closure [25-29]. If cessation is selected, the timing of interruption depends on the agent. (See "Perioperative management of patients receiving anticoagulants", section on 'Warfarin interruption' and "Perioperative management of patients receiving anticoagulants", section on 'DOAC interruptions (overview)' and "Perioperative management of patients receiving anticoagulants", section on 'Bridging anticoagulation'.)
●Prophylactic antibiotics — Infection is rare following endovenous ablation procedures, and antibiotic prophylaxis is generally not needed prior to EVLA [30]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
●Thromboprophylaxis — EVLA is a brief outpatient procedure with an overall low risk of deep vein thrombosis (DVT). DVT prophylaxis is needed only for high-risk patients. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
●Vein mapping/marking — On the day of the procedure, the veins to be ablated may be marked (ie, marked with indelible ink), with duplex ultrasound to aid in the administration of tumescent anesthesia, but it is generally not necessary.
●Scheduled follow-up — A prescheduled appointment should be made for follow-up duplex examination within seven days after EVLA. We prefer to obtain our duplex ultrasound two to four days following EVLA, since most endovenous heat-induced thrombus are believed to form within 72 hours; however, practice patterns reported in the literature vary [31] to assess for deep vein thrombosis. (See 'Postoperative duplex ultrasound' below and 'Endovenous heat-induced thrombus' below and 'Deep vein thrombosis' below.)
MECHANISM OF ACTION AND LASER DEVICES — Lasers emit a single, coherent wavelength of light (figure 6). Laser therapy of venous structures is based upon the concept of selective photothermolysis (ie, selective thermal confinement of light-induced damage) [32]. The wavelength of light is chosen based upon the chromophore (the part of a molecule responsible for its color) of the target tissue. Vein wall injury is mediated directly by absorption of photon energy by the vein wall (thermal radiation) and indirectly by thermal convection from steam bubbles and thermal conduction from heated blood [32-35]. (See "Basic principles of medical lasers".)
Commercially available devices for EVLA are manufactured by Angiodynamics (810 and 1470 nm diode lasers), Dornier MedTech (940 nm diode laser), Sciton (1319 nm Nd:YAG laser), CoolTouch (1320 nm Nd:YAG laser), and Biolitec (980 and 1470 nm diode lasers). The wavelength of laser may impact outcomes [36-40]. (See 'Closure rates and recurrence' below.)
In addition to wavelength, some have speculated that the type of fiber tip may affect the depth of tissue injury, postoperative pain, and bruising during EVLA [41]. As an example, the use of a bare laser fiber may lead to inhomogeneous vein wall destruction due to a tendency of the tip to become located eccentrically within the vein. Diminished postprocedure pain and bruising were found in patients treated with the 1470 nm laser catheters with a radial fiber compared with the bare-tip fiber [42]. A flared tip (Tulip Tip, Tobrix), designed to center the laser and promote more homogeneous heating, is commercially available in Europe but not in the United States. One trial using this device noted reduced postoperative ecchymosis and pain; however, the differences demonstrated were small and likely not clinically significant [43].
PROCEDURE — EVLA can be performed in a clinic, office, or other outpatient surgery setting with oral diazepam and local anesthesia with or without supplemental venous procedures [44]. If moderate sedation is used, a nurse should be dedicated to monitoring the patient's level of consciousness, heart rate, blood pressure, and oxygen saturation. Local tumescent anesthesia is required for the procedure to reduce the incidence of nerve injury and skin necrosis (if the vein is superficial), regardless of other forms of anesthesia such as general or regional anesthesia. Regional anesthesia (eg, femoral nerve bloc) may be a good option if the patient will undergo extensive concomitant phlebectomy [45].
It is important that the patient is relaxed and well hydrated. An oral anxiolytic can be given approximately one hour prior to the procedure to help the patient relax. (See "Acute procedural anxiety and specific phobia of clinical procedures in adults: Treatment overview", section on 'Benzodiazepines as first-line medication'.)
Preparation
Equipment
●Duplex ultrasound machine – The procedure can be performed with a portable ultrasound machine (gray scale imaging); however, color duplex imaging with a vascular probe is ideal.
●Laser generator – The machine should be checked for proper functioning and calibrated, if necessary.
●Tilt table – The ability to adjust the patient's position between Trendelenburg and reverse Trendelenburg is highly desirable. Alternatively, a venous tourniquet can be used to assist engorgement of the vein during access.
●Pump for tumescent anesthesia (eg, Klein pump) – The pump is used to infuse tumescent anesthesia but is not essential. If a Klein pump is not available, the tumescent anesthesia can be injected by hand.
Medications
●Local anesthetic for puncture site: 1% lidocaine without epinephrine. The addition of bicarbonate may help diminish the pain of injection.
●Tumescent anesthetic (a mixture of saline, epinephrine, bicarbonate, and lidocaine for subcutaneous injection). Dosing for tumescent anesthesia is discussed below. (See 'Instill tumescent anesthetic' below.)
Materials
●Preparation materials: skin prep, gown, mask, and sterile gloves
●Draping materials: sterile drape, bag, or towel for foot
●Tubing for tumescent
●10 mL syringe with 16- to 20-gauge needle to draw up anesthetic, 25- to 30-gauge needle to inject
●Micropuncture sheath kit: micropuncture wire (0.035"), 4F device dilator/sheath
●Echogenic 21-gauge micropuncture needle
●Additional guidewires: glidewire (0.018")
●Wound dressing: gauze and elastic wrap or thigh-high elastic stocking with gauze pads, or adhesive strips or bandages
General technique — EVLA is performed according to the manufacturer's recommendations. The general technique is described below.
The patient is positioned supine for treatment of the great saphenous vein (GSV) or accessory saphenous veins (ASVs). The prone position is preferred for treatment of the small saphenous vein (SSV), but it can be successfully treated in the supine position. The leg should be prepped to include the saphenofemoral junction (for treatment of the GSV) or the saphenopopliteal junction (for treatment of the SSV) since these areas must be imaged with ultrasound.
Place the device sheath — The patient is placed in reverse Trendelenburg position to engorge the target vein and facilitate venous access. Using ultrasound guidance, a micropuncture cannula is introduced into the vein near the mid-calf for GSV ablation or near the ankle for SSV ablation and a long guidewire advanced toward the saphenofemoral junction (or saphenopopliteal junction).
On occasion, the vein may develop spasm during venipuncture. Carefully selecting an accessible portion of the vein and successfully obtaining access upon the first attempt greatly reduces the risk of vasospasm. Placement of a venous tourniquet just cephalad to the vein or the application of 2% nitroglycerin paste over the vein may break the spasm and prevent the need for a second venipuncture. Alternatively, a cutdown to access the vein can be performed.
Difficulty advancing the wire or the sheath into the vein more cephalad may be encountered in the presence of a tortuous vein, venous aneurysms, or vein segments that are sclerotic or occluded. Severely tortuous vein segments cannot be treated, though this should be recognized in advance on preoperative duplex ultrasound. Mildly tortuous venous segments, sclerotic segments, and venous aneurysms can usually be crossed with straightening the leg, manual manipulation of the overlying skin, or by using a hydrophilic wire (eg, glidewire). Segmental occlusions can be managed with two treatments administered through two separate sheaths placed cephalad and caudal to the occlusion.
Position the catheter — A 4 French laser sheath is advanced over the wire and positioned in the vein. Correct catheter position is critical to reduce the risk of deep vein thrombosis. The tip of the laser should be placed at least 2 cm below the saphenofemoral (or saphenopopliteal) junction and the position confirmed with ultrasound. Ideally, the catheter tip should be just caudal to at least one tributary vein to ensure continued flow in the more cephalad vein. Be aware of arteries in close proximity to the vein to minimize the possibility of creating an arteriovenous fistula [46]. Examples include a deep external pudendal artery coursing posterior to the GSV near the saphenofemoral junction and sural artery branches in proximity to the SSV or perforators.
Patients with variant SSV anatomy with no tributaries to the SSV in the popliteal region may be at a higher risk for deep venous thrombosis [9]. (See 'Venous anatomy' above and 'Small saphenous vein' below.)
Once the sheath is in place, the patient should be placed in the Trendelenburg position. This serves to empty the vein and allow better contact of the laser catheter to the wall of the vein, which may help reduce postprocedure pain.
The laser sheath is backed out to expose the tip of the laser catheter. The position of the tip of the catheter should be rechecked with ultrasound and correct placement confirmed. This is a critical portion of the procedure. Sometimes air bubbles in the gel or hair around the groin can reduce visibility. Also, imaging the catheter in patients with obesity can be a challenge. If technical issues obscure the catheter, and its position cannot be positively ascertained, the procedure should be aborted and an alternative procedure performed (eg, vein stripping, sclerotherapy).
Instill tumescent anesthetic — With ultrasound imaging, an echogenic micropuncture needle is used to inject tumescent anesthesia into the tissue surrounding the vein. Tumescent anesthesia has several important functions, including:
●Providing anesthesia during EVLA
●Facilitating contact of the vein wall with the laser tip
●Deepening the vein relative to the skin to protect the skin from damage during laser treatment
●Acting as a heat sink to protect surrounding tissues, especially sensory nerves, from thermal damage during laser treatment
The accepted maximum dose of lidocaine with epinephrine in tumescent anesthesia is between 15 and 55 mg/kg [34,35]. Most available reports evaluating lidocaine toxicity using tumescent anesthesia are in patients undergoing liposuction for which a portion of the lidocaine is theoretically removed during the liposuction. One report used 14 volunteers to perform 41 tumescent anesthetics with varying doses of lidocaine ranging from 19.2 mg/kg to 52 mg/kg. The authors estimated the maximum safe dosage of lidocaine in tumescent anesthesia was 28 mg/kg without liposuction and 45 mg/kg with liposuction [47]. In an observational study of patients undergoing EVLA, 5 of 11 patients experienced symptoms of toxicity when administered 35 mg/kg of tumescent anesthesia in the perivenous space, but none of the eight patients who were administered 15 mg/kg experienced symptoms of toxicity [17]. With undiluted lidocaine with epinephrine (ie, 7 mg/kg max), only 500 mL of tumescent anesthesia could be used, which is roughly the amount required to perform EVLA of a single GSV.
After completion of the tumescent anesthesia, it is important to confirm with ultrasound that a halo of tumescent anesthetic surrounds the catheter, especially in the region of the saphenofemoral junction, and to ensure that the catheter and vein are at least 1 cm deep to the skin.
Ablate the vein — After adequate tumescent anesthesia has been delivered, the vein is ready for treatment. The catheter is slowly pulled back at an initial rate of 1 mm every second for the first 10 cm of treatment length. Thereafter, the catheter can be pulled back 2 to 3 mm every second. A slow, steady pullback provides even heating of the entire vein segment and minimizes the chance of vein perforation.
Perform completion ultrasound — Following completion of the procedure, ultrasound examination of the common femoral vein (or popliteal vein for treatment of the SSV) is performed to confirm patency and exclude thrombus. Closure of the treated vein is confirmed. The vein should appear thickened (ie, hyperechoic doughnut) with thrombus in its lumen with no identifiable venous flow. The vein near the saphenofemoral junction should be compressible and hypoechoic and without the presence of any intraluminal debris, which would appear hyperechoic. If the vein is thickened but has a narrowed lumen with persistent color Doppler flow, we observe these patients. On follow-up, the saphenous vein typically scars down and the vein occludes typically over the next month.
Perform supplemental procedures — Following successful closure of the target veins, the extremity is evaluated for any significant residual varicose veins, which can be managed with phlebectomy or sclerotherapy depending upon their size and operator preference. The supplemental procedures can be performed immediately following EVLA, or as deferred treatment. When we identify large (>8 mm) varicose tributaries, we selectively perform phlebectomy or sclerotherapy at the time of the EVLA to prevent superficial thrombophlebitis, especially if the varicosity is still bulging at the completion of the procedure. The main advantage of supplemental procedures concomitant with EVLA is a reduction in the overall treatment time.
The majority of smaller varicose tributaries (<8 mm) will significantly reduce in size to a new baseline within six weeks due to the reduced venous pressure. The advantage of waiting four to six weeks following EVLA is that the residual veins will be smaller and more amenable to injection sclerotherapy, rather than phlebectomy. In addition, up to 40 percent of patients will require no further treatment [48-52].
●One trial randomly assigned 50 patients to EVLA with concomitant phlebectomy or EVLA with sequential phlebectomy [49]. The concomitant treatment group required longer operative times, fewer subsequent procedures (1 of 25 versus 16 of 25), and a trend toward longer time to return to work (10 versus 3 days). The concomitant treatment group also had a lower health-related quality of life (HRQOL) at six weeks and three months; however, no differences in HRQOL were seen at one year and remained equal at five years [50]. It is important to note that in the sequential treatment group, a supplemental procedure was not needed in one-third of the patients. Similarly, a retrospective study of 80 patients treated with EVLA alone found that supplemental treatment was needed in only 42 percent of patients [51].
●A comprehensive review of over 300 limbs treated with EVLA and sequential phlebectomy identified anatomic and clinical factors associated with lack of regression of superficial varicosities following EVLA [52]. CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification did not affect the need for secondary procedures. An increased likelihood of requiring secondary procedures was found for enlarged (>6 mm) GSV in the distal thigh, patients with clusters of large (>6 mm) diameter varicosities, and patients in whom the cosmetic appearance was very important. These patients might benefit from a combined EVLA and phlebectomy performed as a single-stage procedure.
Apply compression — Following the completion of the procedure, a light bandage is placed over the EVLA puncture site and any phlebectomy sites, and compression is applied. The type of compression prescribed and duration of compression vary widely [53,54]. Generally, either previously prescribed thigh high compression stocking, or wraps, are placed.
Specific anatomic sites — The technical aspects of the EVLA procedure vary with the anatomic site. Venous anatomy is described above. (See 'Venous anatomy' above and 'Anatomy' above.)
Great saphenous vein — Treating the saphenous vein in the lower calf is rarely necessary because most patients obtain adequate relief of their venous symptoms without extending the ablation below the mid-calf. Doing so may increase the risk of saphenous nerve injury. (See 'Nerve injury' below.)
●One trial randomly assigned 65 patients with above- and below-knee GSV reflux into three groups: above-knee GSV EVLA, mid-calf to groin (extended) GSV EVLA, or above-knee EVLA plus below-knee GSV foam sclerotherapy [55]. All patients experienced significant improvements in symptoms; the extended EVLA group had the highest patient satisfaction and the lowest requirement for subsequent sclerotherapy, and the below-knee foam sclerotherapy group was a close second. The need for additional sclerotherapy was 61 percent in the above-knee EVLA group versus 17 and 36 percent in the extended GSV EVLA and above-knee plus below-knee GSV foam group, respectively.
●The same group of investigators evaluated 69 below-knee GSV segments with duplex ultrasound six weeks following above-knee GSV EVLA and found 59 percent had no or minimal reflux [56]. All patients experienced significant improvement in symptoms, but patients with persistent reflux in the below-knee GSV more often required sclerotherapy for residual symptomatic varicose veins.
Studies have evaluated alterations in technique to improve closure rates in large diameter GSV. One study reviewing the evolution of their management reported on 88 patients treated for large-diameter GSV (mean 22 mm; range 15 to 34 mm) using a 1560 nm wavelength laser [36]. The first third underwent open ligation of the saphenofemoral junction combined with EVLA and had no failures. The second third underwent EVLA using 90 J/cm for the more cephalad vein; among these, type 2 failure (recanalization) occurred in four patients (13.2 percent) with body mass index (BMI) >40. A second EVLA in these patients was ultimately successful. The last third underwent a personalized EVLA procedure: for patients with vein diameters 15 to 20 mm, the energy used was 100 J/cm for the more cephalad vein; for vein diameters 20 to 30 mm, the energy used was 150 J/cm for the more cephalad vein. The third group had no failures and included five patients with BMI >40.
Accessory saphenous vein — Clinical failure following EVLA of the GSV can be due to large refluxing accessory saphenous tributaries (figure 1A-B). As a result, we prefer to treat ASVs that demonstrate significant reflux at the same time as GSV ablation. The second sheath needs to be placed in the ASV prior to instillation of tumescent anesthesia. We treat the GSV first since it is usually the larger vein.
Small saphenous vein — Anatomic variation in the saphenopopliteal junction is common [11]. In approximately 30 percent of patients, the SSV does not communicate with the popliteal vein; rather, it drains cephalad, continuing as the intersaphenous vein (vein of Giacomini). In some individuals, the SSV drains into the popliteal vein directly with no significant tributaries. These patients have a higher risk of developing deep venous thrombosis with SSV endovenous ablation [9]. (See 'Deep vein thrombosis' below.)
Compared with puncture at the ankle level, puncture of the SSV at the midcalf level in one trial of 60 patients resulted in fewer postoperative paresthesias without affecting the success of closure at six months follow-up [57]. (See 'Nerve injury' below.)
Perforator veins — Although there are special catheters designed to treat incompetent perforating veins (eg, Venacure), there are no studies showing that treatment of incompetent perforating veins leads to faster ulcer healing or a decreased incidence of ulcer recurrence. Studies that have evaluated patients undergoing treatment for incompetent perforating veins almost universally include patients with combined treatment of an incompetent GSV, making analysis of the clinical utility of adding the treatment of perforating veins difficult to determine.
FOLLOW-UP CARE
Pain management — Pain can usually be controlled with over-the-counter pain medications (eg, acetaminophen). Extensive concurrent vein excision (phlebectomy) may require stronger analgesics (eg, codeine). In one study, 85 percent of patients complained of no or minimal pain [58]. Moderate to severe pain is experienced in 4 to 9 percent of patients [59,60]. Pain gradually resolves with time and is improved by wearing compression stockings. (See 'Duration of compression therapy' below.)
Nonsteroidal anti-inflammatory drugs can be added for patients who develop a significant phlebitic reaction. An ice pack can also be applied to the affected areas for comfort. (See 'Superficial thrombophlebitis' below.)
Patient instructions — In the absence of concerning symptoms, the patient should be seen in the office within six weeks of the procedure to reevaluate the clinical symptoms/signs of venous disease and determine the need and timing for any possible supplemental procedures. (See 'Perform supplemental procedures' above.)
Concerning clinical symptoms that should prompt the patient to call their physician include:
●Swelling or excessive pain that is not relieved with the prescribed pain medications may be a symptom of deep vein thrombosis.
●Numbness, tingling, coolness, or discoloration of the toes of the treated extremity. The compression bandages/stockings may be too tight and need to be removed.
Our routine instructions include:
●Ambulate normally and take short (20 minute) leisure walks three times daily.
●Avoid prolonged standing and sitting; when seated, elevate the treated extremity.
●Refrain from strenuous cardiovascular activities (eg, heavy aerobic exercise) for one to two weeks; thereafter, resume normal activities.
●Resume normal job duties within three to four days; however, jobs requiring prolonged standing and/or heavy lifting may require additional time off.
●Maintain the postoperative dressing and elastic bandages/stockings until the postoperative duplex examination, which should occur within two to three days following the procedure. (See 'Postoperative duplex ultrasound' below.)
●Reinforce any areas of bleeding that occur through the dressing, but patients should call their physician if excessive bleeding occurs. This is more commonly associated with vein excisions performed at the same time as the endovenous ablation.
●Wear thigh-high graded compression stockings day and night for one to two weeks following the procedure. However, the optimal compression regimen following EVLA has not been well studied, and differing types and duration have been used successfully [53]. (See 'Duration of compression therapy' below.)
●Do not be alarmed if there is a pulling sensation or tightness over the treated vein. This is due to the scarring of the vein, which adheres to the surrounding tissues. Gentle stretching exercises in the region of the treated vein may be helpful. For great saphenous ablation, stretching the inner thigh region is accomplished by sitting on the floor with the feet pressed together and leaning forward. For the small saphenous vein, stretching the vein is accomplished by leaning forward against a wall with the affected leg placed behind the hips with the foot flat on the floor.
Postoperative duplex ultrasound — All patients should undergo duplex ultrasound within seven days following the procedure to rule out deep vein thrombosis [59,61]. The main purpose of the postoperative duplex study is to carefully evaluate the extent of the ablated vein for thrombus and to determine whether any thrombus extends into the deep veins. (See 'Endovenous heat-induced thrombus' below and 'Deep vein thrombosis' below.)
When patients treated with EVLA for venous ulceration develop recurrence, we reevaluate them with duplex ultrasound, looking for residual/recurrent superficial venous reflux. In the absence of significant superficial venous reflux, we consider obtaining a computed tomographic venogram to evaluate for central vein obstruction in the iliac veins. (See "Overview of iliocaval venous obstruction".)
Duration of compression therapy — The duration of compression following EVLA varies widely in the literature [57]. We suggest one week of compression following EVLA. We recommend a second week of wearing compression if it improves postprocedure pain.
Several trials have addressed this issue and have randomized patients to wearing compression stockings for one to two weeks compared with zero to two days following EVLA [58-60]. Most of these trials have found diminished edema, pain, and use of pain medication for the first one to two weeks in patients who wore compression stockings longer. There was no difference in time to return to work, vein closure rates, or deep venous thrombosis. One trial found no difference in pain or bruising in patients who wore compression stockings following the procedure compared with patients who did not wear compression stockings. This trial evaluated 85 limbs, 91 percent of which underwent radiofrequency ablation; only 9 percent underwent EVLA with an 890 nm wavelength laser [58].
Return to normal activities — We usually suggest that patients wait three to five days before going back to work. Patients who stand or walk more as part of their work typically need to take off more time.
The time to return to normal activities or return to work has varied among the available clinical trials. One trial of 99 patients reported a decreased time to return to normal activity (2 versus 7 days) and return to work (4 versus 17 days) for EVLA compared with GSV ligation and stripping [61].
On the other hand, two trials involving 200 and 121 patients found no significant differences in return to normal activity or work (average, seven days) [62,63]. Yet another trial found a longer time until return to work for EVLA compared with GSV ligation and stripping (20 versus 14 days) [64].
CLOSURE RATES AND RECURRENCE
Saphenous ablation — Initial technical and short-term success for treatment of the great saphenous vein (GSV) ranges from 90 to 100 percent [1,4,7,60,62-66]. Most reports demonstrate 97 to 98 percent short-term success rates. In large retrospective studies, varicose vein recurrence was reported in 7 to 14 percent of patients long-term (two to seven years) following EVLA [5,67-72]. Varicose vein recurrence is reported with long-term follow-up at rates that are similar to radiofrequency ablation [7].
Large veins — Whether vein diameter is a significant factor in determining closure rates is debated [60,62,63]. In the author's experience, failures are rare but are more common with very large vein diameters, typically greater than 2 cm in patients with high BMI. A BMI >40 has also been reported to affect closure rates. Some have suggested that veins with a diameter >8 to 10 mm are associated with a higher risk of nonocclusion [60,62,63]. As an example, in a review of 500 patients treated with EVLA, 98 percent of GSVs were successfully closed on the initial postprocedure duplex ultrasound. After four years, the closure rate had decreased to 97 percent. All failures occurred in patients with a saphenofemoral junction >11 mm or a GSV diameter >8 mm [60]. In another study, initial success for EVLA of the GSV was 95 percent [62]. In the successfully treated veins, the average maximum vein diameter was 11 mm, whereas for the failures, the mean maximum vein diameter was 21 mm. In a review that included 287 patients treated with either radiofrequency ablation or EVLA, higher rates of recanalization were more common in patients with GSV diameter >10 mm [63].
Other reports demonstrate equal effectiveness for treating very large GSVs compared with smaller veins. One study found no significant differences in the failure rates of EVLA in 732 patients with large diameter veins >10 mm compared with smaller diameter veins (4.5 versus 3.4 percent) [73]. Large veins constituted 12 percent of the total veins treated, and 1 percent of the veins had a diameter >20 mm. The vein obliteration rate in the largest veins (20 to 24 mm) was 100 percent. In another study of 38 consecutive ablations, 20 GSVs measured >1 cm in diameter, and four measured >2 cm in diameter [74]. Successful ablation was achieved in 100 percent of veins, independent of vein diameter. A third study evaluated 49 EVLA procedures on large GSVs (mean diameter 17 mm; range 15 to 26 mm diameter) and noted a failure rate of 2.1 percent, which was similar to the rate for EVLA of smaller GSVs [75].
Accessory saphenous ablation — Short-term results of EVLA of the accessory saphenous vein (ASV) and small saphenous vein (SSV) have shown closure rates similar to GSV EVLA with minimal complications [67,76-80]. The primary success rates are 87 to 98 percent for the anterior ASV and 91 to 93 percent for the SSV [67,73,81,82]. However, in one single-center retrospective review of 732 EVLAs, the rate of failure to close was significantly higher for the ASV and SSV compared with the failure rate for the GSV (8.8 percent and 13.2 percent versus 1.6 percent, respectively) [73]. In a trial that randomly assigned 106 patients with unilateral, primary SSV reflux to EVLA or surgery, reflux was eliminated in significantly more patients treated with EVLA compared with surgery (96 versus 72 percent) [83]. The high failure rate in the surgery group was primarily due to an inability to strip the SSV because of tortuosity or vein breakage. Despite the increased incidence of persistent axial reflux in the SSV, the symptomatic improvement was the same in both groups and remained the same after two years.
Perforator ablation — Studies are not available looking at long-term success or clinical outcomes (eg, ulcer healing) of EVLA for perforators. Feasibility studies have shown that EVLA is technically possible and appears safe [84-86]. In a trial that randomly assigned 69 patients to EVLA of incompetent thigh perforators draining into the GSV or EVLA of the GSV, technical success rates for perforator ablation were significantly lower compared with great saphenous ablation (77 versus 100 percent) [86]. Both groups experienced similar clinical success, and both groups had a single recanalization of the GSV between one week and one month.
LOCAL ADVERSE REACTIONS — EVLA is generally well tolerated. EVLA is associated with variable levels of pain, and randomized trials have found more pain [87,88], less pain [4,89], or no difference in pain [6,58,90] in patients undergoing great saphenous EVLA compared with other ablation therapies. Similar results have been noted for small saphenous vein EVLA [91].
Bruising/hematoma — Approximately 60 percent of patients treated with EVLA have ecchymosis to some extent [4]. The median time to resolution is approximately two weeks. Lower and higher incidences of bruising have also been reported [4,6,58] compared with vein stripping. More severe bruising is probably related to perforation of the treated vein, which may have been due to contact of laser tip with the vein wall.
Hematoma occurs in 1 to 5 percent of patients undergoing EVLA of the great saphenous vein (GSV) [6,44,59]. One trial that randomly assigned 200 patients to EVLA or GSV ligation and stripping found significantly more hematomas in patients who underwent GSV ligation and stripping (12 versus 5) [6]. Another trial found that the size of hematomas that occurred was significantly smaller at one week for EVLA compared with surgical stripping [4].
Skin burns — Skin burns are a preventable complication and should be a rare occurrence following EVLA. The infusion of adequate amounts of tumescent anesthesia should be performed to ensure that the treated vein is more than 1 cm below the skin surface. Investigators performing EVLA without tumescent anesthesia have reported an incidence of skin burns of approximately 5 percent [38]. (See 'Instill tumescent anesthetic' above.)
Superficial thrombophlebitis — A mild superficial thrombophlebitis is anticipated along the course of the ablated vein [92]. In addition, varicose veins that are in direct communication with the treated vein may thrombose or collapse and scar down. The reported incidence of symptomatic phlebitis following EVLA ranges from 0 to 5.2 percent and does not appear to be related to whether or not concomitant phlebectomy was performed [4,38,58-60,93].
Superficial thrombophlebitis is managed conservatively. Thrombosed veins that are painful and tender can be treated with cold compresses and nonsteroidal anti-inflammatory drugs (eg, ibuprofen). More significant signs or symptoms of pain or edema warrant ultrasound examination to evaluate for thrombus extending from the saphenous vein into the common femoral vein.
COMPLICATIONS — Although EVLA is generally well tolerated, a variety of complications can occur. The most important are thrombus extension (ie, endovenous heat-induced thrombus [EHIT]), deep vein thrombosis (DVT), and nerve injury. Local adverse reactions, such as skin bruising/hematoma, skin burns, and superficial thrombophlebitis, are discussed above. (See 'Local adverse reactions' above.)
A review from the National Surgical Quality Improvement Program (NSQIP) included 1786 patients undergoing EVLA [94]. Surgical site infection was less common for EVLA compared with vein stripping (0.5 versus 1.4 percent); however, deep venous thrombosis occurred more frequently with EVLA (1.6 versus 0.8 percent).
Anatomic failure — Following saphenous ablation, duplex ultrasound can show procedural failure, but some of these patients have clinical improvement that is maintained long-term. Anatomic failure is a useful term to distinguish these patients from those with clinical failure (ie, recurrent clinical symptoms and/or varicose veins) [95] (table 1). (See 'Closure rates and recurrence' above.)
Endovenous heat-induced thrombus — Thrombus propagating from the ablated superficial vein into the deep vein cephalad to the level of the ablation can lead to DVT, although DVT is uncommon [59]. This process has been termed EHIT.
EHIT classification — Several classification systems have been proposed to provide an accurate description of the level of EHIT following great saphenous venous ablation for the purpose of guiding clinical therapy and further research [31,96,97]. Much of the literature refers to the Kabnick classification (figure 8B). The latest classification scheme from the American Venous Forum/Society for Vascular Surgery is a minor modification of the Kabnick classification subdividing EHIT 1 depending on the degree of propagation of the thrombus (figure 7 and figure 8A-B) [31].
Risk factors for EHIT — Many factors have been purported to increase the risk for EHIT [31]. Among those suggested, larger vein diameter, less than 2.5 cm distance of the tip of the catheter from the saphenofemoral junction, history of thrombophilia, and possibly prior deep vein thrombosis or superficial vein thrombosis appear to be the most relevant following EVLA [59,93,96,98-105].
Larger vein diameter may be a risk factor for great saphenous vein (GSV) EHIT. In a retrospective review of 312 perioperative vein mappings, patients with valvular incompetence at the saphenofemoral junction or a large proximal GSV diameter had a significantly increased risk of developing EHIT [106]. Patients who developed EHIT had a mean great saphenous diameter of 13.1 mm, and 11 percent had saphenofemoral junction incompetence. By comparison, those who did not develop EHIT had a mean diameter of 8.4, and only 0.44 percent had saphenofemoral junction incompetence.
A review of over 4000 EVLA treatments supported the notion that increasing the distance of the laser tip from the saphenofemoral junction reduces the risk of EHIT [107]. In this study, there was a trend toward a decreased incidence of EHIT when the tip of the catheter was ≥2.5 cm compared with 2 cm from the junction (2.3 versus 1.3 percent).
However, a separate review that included 519 great or anterior saphenous vein EVLA procedures did not identify vein diameter, short distance of the catheter tip to saphenofemoral junction, type of endovenous ablation (radiofrequency versus EVLA), concomitant treatments (sclerotherapy, phlebectomy), or perioperative anticoagulation as risk factors for EHIT [98]. Rather, on multivariate analysis, male sex and Caprini thrombosis risk score (calculator 2) were the only significant risk factors.
EHIT treatment and follow-up — Consensus guidelines from the American Venous Forum/Society for Vascular Surgery recommended the following treatments based on the unified EHIT classification scheme (figure 7) [31]:
●Class I: No treatment, no routine follow-up imaging needed.
●Class II: Weekly surveillance ultrasound until the thrombus has retracted from the deep vein, consider treatment with antiplatelet agents or anticoagulation for high-risk patients.
●Class III: Therapeutic anticoagulation and weekly surveillance until the thrombus has retracted from the deep vein.
●Class IV: Treatment is individualized, but in general, therapeutic anticoagulation per guidelines for treatment of deep venous thrombosis.
Superficial venous thrombosis due to EHIT is thought to be more benign than spontaneous thrombus in this location. Nevertheless, we typically treat Class II EHIT with therapeutic anticoagulation and have noted that in most cases, the thrombus retracts from the deep vein within one to two weeks. (See "Superficial vein thrombosis and phlebitis of the lower extremity veins", section on 'Treatment of SVT'.)
In a review of 500 EVLA procedures, EHIT occurred in 4.9 percent at the saphenofemoral junction and in 6.3 percent at the saphenopopliteal junction [93]. Using the Lawrence classification system (figure 8A), 25 patients developed EHIT at the saphenofemoral junction, three were classified as level III and seven as level IV, all 10 of which were treated with observation. All patients with level III and three of the patients with level IV EHIT resolved at one week; the other four patients with level IV resolved between two to seven weeks.
Deep vein thrombosis — Thromboembolic complications following EVLA are uncommon. The incidence of DVT varies in the literature depending upon whether routine duplex ultrasound is performed within two to three days following EVLA and how well the saphenofemoral junction is examined. An experienced technician should perform the examination [99,108] (see 'Postoperative duplex ultrasound' above).
Some large series of EVLA with duplex ultrasound follow-up have noted 0 percent incidence of DVT [4,58,60,108], while others report an incidence of 0.9 to 2.3 percent [59,84,93,96,99]. A meta-analysis that included over 16,000 patients reported that the incidence of EHIT level V was 0.3 percent, and pulmonary embolism (PE) occurred in 0.1 percent [109]; the author's experience is consistent with these results. Stroke in a patient with DVT and a patent foramen ovale has also been reported following EVLA [110]. Some of the variation in the incidence of DVT may be related to how well the saphenofemoral junction is examined with duplex ultrasound following EVLA. An experienced technician should perform the examination.
DVT due to endovenous therapies usually resolves quicker compared with spontaneous DVT [59,96]. In the review of 500 EVLA procedures described above [93], of the 12 patients with level V EHIT, six were not treated with anticoagulation and all resolved in one week. The other six patients with level V were treated, and the thrombus retracted between two and six weeks. All three patients with level VI EHIT were treated with anticoagulation, with the DVT resolving within six weeks, at which point anticoagulation was discontinued. None of the patients developed a pulmonary embolism.
Specifically for EHIT, some investigators have used novel oral anticoagulants to avoid subjecting patients to low-molecular-weight-heparin injections [111]. One study included 21 patients with EHIT who were treated using rivaroxaban. Nine patients had level 2 to 3 EHIT and were treated with 20 mg daily; 12 patients had level 4 to 5 EHIT and were treated with 15 mg twice daily. All patients had complete regression of EHIT at 6 to 25 days, and no clinically significant pulmonary embolus developed.
Nerve injury — Sensory abnormalities due to nerve injury following EVLA occur with a reported incidence ranging between <1 to 7 percent [60,108,112]. Symptoms of saphenous nerve injury include pain or numbness along the medial aspect of the calf or medial foot and occasionally a feeling of pressure or tightness around the knee or ankle. These symptoms typically resolve four to six weeks after EVLA. Sural nerve injuries can cause pain or numbness in the posterior-lateral aspect of the distal third of the leg the lateral heel, ankle, and foot.
Because of the close proximity of the saphenous nerve and vein in the distal calf, saphenous nerve injury may be more likely when endovenous ablation occurs below the level of the mid-calf, due to the adherence of the saphenous nerve to the saphenous vein in the distal third of the calf [13]. (See 'Saphenous nerve' above.)
Adequate tumescent anesthesia is probably the most important factor in preventing nerve injuries. In an observational study of patients undergoing EVLA without tumescent anesthesia, the rate of paresthesia was much higher at 36 percent compared with other studies in which tumescent anesthesia was used [38].
Due to the risk for saphenous nerve injury, surgical stripping of the saphenous vein in the mid- to distal calf is no longer recommended. For similar reasons, we prefer not to extend ablation of the GSV below the mid- to upper calf. (See 'Great saphenous vein' above.)
Other complications — Other technical complications have been described in case reports.
Arteriovenous fistula formation is rare but has been reported [46]. The popliteal fossa is felt to be at increased risk for this complication following small saphenous vein ablation due to the proximity of the sural arteries to the vein and may be related to errant placement of the tumescent needle [113,114]. (See "Acquired arteriovenous fistula of the lower extremity".)
Although uncommon, a retained foreign body from a broken laser catheter tip has also been reported [112]. Care in placement of the tumescent needle minimizes the potential of this complication. Device components should be examined carefully after they are removed from the patient to ensure their integrity. If there is any question about the possible loss of a device, radiographs should be obtained.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic venous disorders".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Vein ablation (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Endovenous laser ablation – Endovenous laser ablation (EVLA) is a minimally invasive percutaneous technique using laser energy to ablate incompetent superficial truncal veins of the lower extremity (ie, great, small, or accessory saphenous veins). (See 'Introduction' above and "Overview of lower extremity chronic venous disease".)
●Candidates – Candidates for EVLA are patients with persistent symptoms/signs of venous disease after a trial of medical therapy plus documented superficial venous reflux (ie, retrograde flow >0.5 second duration) as a source of their symptoms. (See 'Indications' above.)
●Procedure – EVLA is typically performed in an office or ambulatory surgery setting with local anesthesia and anxiolytics. If concurrent vein excision (phlebectomy) is performed, moderate sedation may be beneficial for patient comfort. Regional anesthesia is another option. (See 'Procedure' above.)
•Extent of ablation – For great saphenous vein (GSV) ablation, we suggest not extending EVLA below the mid-calf to minimize the risk of saphenous nerve injury (Grade 2C). Symptoms of saphenous nerve injury may include pain or numbness along the medial aspect of the calf or lateral foot. These symptoms typically resolve within four to six weeks of the procedure. (See 'Place the device sheath' above and 'Nerve injury' above.)
•Pain management – Some degree of pain and/or bruising is common following EVLA, and a mild superficial phlebitis is expected. Pain associated with EVLA is usually controlled with over-the-counter pain medications (eg, acetaminophen). Pain gradually resolves over time and is improved by wearing compression stockings. Extensive concurrent vein excision (phlebectomy) may require stronger analgesics (eg, codeine). (See 'Pain management' above and 'Patient instructions' above and 'Duration of compression therapy' above.)
●Postoperative duplex – Duplex ultrasound should be performed within seven days of the procedure to evaluate for deep vein thrombosis and/or endovenous heat-induced thrombus (EHIT). We repeat duplex ultrasound within a week if thrombus is identified at the saphenofemoral/saphenopopliteal junction, extending up to, or into, the deep vein. (See 'Postoperative duplex ultrasound' above and 'Endovenous heat-induced thrombus' above and 'Deep vein thrombosis' above.)
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