EVLA is used to block off either main saphenous vein by passing a laser probe up the vein introduced through a puncture needle under local anaesthetic with ultrasound guidance. It has been in use for approximately 10 years in the USA and Europe. It was introduced into Australia by our group in 2002. Our results published in the Medical Journal of Australia and European Journal of Vascular Surgery show a low risk of complications and excellent medium-term results (to view the published article - click here). Both legs can be treated at the one session. Visible varicose veins are usually treated by ultrasound-guided sclerotherapy (UGS) at the same time and again some 2-4 weeks later when they have decreased in size.
What are the advantages and disadvantages for EVLA?
Advantages
- Minimal discomfort.
- No admission to hospital or general anaesthesia.
- Minimal time off work or interference with normal home duties.
- Both legs can be treated at the one session.
- Surface tributaries are treated at the same session with UGS.
Disadvantages
- A further session for UGS is frequently required 2-3 weeks later when the veins have become collapsed and smaller.
- Injected veins may remain inflamed for several weeks and patience is required to allow this to settle.
What should you do before EVLA?
- Do not shave your legs.
- Do not apply moisturiser to your legs on the day of treatment.
- Wear slacks or loose trousers and sandals or loose shoes to allow for the thickness of the bandages and stockings.
- Preoperative sedation is not required.
What happens during EVLA?
- A sonographer or doctor will mark out veins to be treated.
- Anaesthetic paste is spread along the skin over the vein and left for 30 minutes to reduce discomfort from further injections.
- The procedure is performed with you lying on a treatment couch that is tilted at stages through the treatment.
- The vein is punctured through an anaesthetized site at about the knee for great saphenous reflux and back of calf for small saphenous reflux.
- A fine wire is passed up the vein, a long fine tube is passed over the wire, and the laser probe is introduced through the tube.
- Local anaesthetic is infiltrated around the vein at several levels through the anaesthetized skin directed by ultrasound using a fine needle.
- The laser tip is precisely positioned just below the end of the saphenous vein using ultrasound guidance.
- The probe is activated and slowly withdrawn destroying the full length of the vein. The procedure involves minimal discomfort.
- A bandage and stocking are applied after treatment.
What should you do after EVLA?
- Walk for 15 minutes immediately after treatment.
- Arrange for someone to drive you home or go by public transport – it is essential that the patient does not drive on the day of treatment. Driving can resume on the following day.
- Walk or keep the leg elevated as much as possible for the first 24 hours and walk for 30 minutes each day.
- Wear the bandages and stocking continuously for 48 hours. Then wear stockings only through the day, remove them at night and replace them in the morning after the shower. Some find it easier to wear them continuously and wash the stockings in the shower. Continue this for approximately 7-10 days or longer if pain develops after they are discarded.
- Maintain normal daytime activities and avoid standing still for long periods.
- Avoid strenuous physical activity such as aerobics for three weeks after treatment although swimming is acceptable from about 3 days after treatment.
- Avoid flights of greater than 4 hours duration for 6 weeks after treatment. If travel is unavoidable, then the flight should be covered by subcutaneous heparin injections given before departure and after arrival.
- Return for a check ultrasound scan within a few days after treatment to ensure that the treated vein is occluded, determine whether any further veins require treatment, and exclude the small risk of deep vein occlusion.
- Bring your stockings to every follow-up visit.
What can you expect following EVLA?
The following features are expected. They are not a cause for concern although they should be reported at review:
- Mild pain persists for several days and shows that the treatment is working. The degree is related to the initial size of the veins. Pain is usually improved by walking or by Panadol or Nurofen. Soreness can occur behind the knee from rubbing by the bandage or stocking.
- Discolouration and tender lumps over tributaries treated by UGS are usual early on. They usually disappear within 4-6 weeks. This indicates that treatment has been successful. Lumps may need to be pricked to let out “trapped blood”.
- Phlebitis or inflammation can occur at any time after treatment of tributaries by UGS due to reaction to the sclerosant. It is treated by further compression and regular walking. It does not represent infection and does not require treatment with antibiotics.
- Migraine symptoms. Patients with a history of migraine headaches occasionally develop prodromal visual symptoms within a few minutes after treatment. Patients may wish to take their usual migraine treatment an hour or so prior to treatment in the hope of preventing this.
- Recurrence. Treated veins can reopen or new veins can develop. For this reason, ultrasound surveillance is offered at yearly intervals so that recurrent veins can be detected and easily treated by UGS before they become too large.
What are the possible complications from EVLA?
Complications can occur even with perfect technique.
- Deep vein thrombosis. Clots extending into the deep veins can occur. This potentially serious complication is very uncommon if the protocol of compression and regular daily walking is followed. Minor clots develop in deep veins in less than 2% of our patients. If this is demonstrated on the postoperative scan then you may require treatment with daily heparin injections until further scans show the clot is resolving.
- Nerve damage. We are not aware of any reports of damage to major nerves. Irritation of surface sensory nerves can occur rarely and this usually disappears within a few weeks but persisting numbness is a rare late event.
- Skin burns have been reported but have never been encountered in our practice.
