Vascular and Endovascular Sciences

Vice President:
Vascular Access Society of India

Editorial Board:
Annals of Vascular Surgery

Asian Society of Vascular Surgery

Medanta Hospital, Gurugram, Haryana 122001

Dr. Tarun Grover
Dr. Tarun Grover
Peripheral Vascular & Endovascular Sciences

Laser Treatment

What is EndoVenous Laser treatment (EVLA/EVLT)?

EVLA stands for Endovenous Laser Ablation. It is often called EVLA or endovenous Laser Ablation. It is a method of managing varicose veins using laser.

What does EVLA (Endovenous Laser Ablation) mean?

‘Endovenous’ means ‘inside the veins’ ie its a minimally invasive procedure . No cuts or incisions are made during this treatment.

‘Ablation’ is a term meaning to cause thermal damage to the vein endothelium.

How is the procedure performed ?

EVLA is performed as a Day care which means ‘Walk-in, walk-out’.

Patient can walk back home in the same evening.

To perform EVLA, the surgeon needs delineate the veins to show which ones are the one causing problem. This is done using Duplex Ultrasound ( Colour Doppler ).

At the EVLA procedure, the surgeon uses Duplex to find the target veins to be treated. The veins that can be treated are the main venous trunks of the legs:

EVLA does NOT treat the large tortuous veins on the skin surface (the blow outs ). These are treated either with sclerotherapy or after the EVLA by other methods.

Under Duplex guidance , a small needle is used to gain access into the vein near the knee or ankle. A guide wire is passed into the vein and a long ‘sheath’ is passed up the vein to the top.

Local anaesthetic ( Tumescence ) is injected around the vein – again using Duplex guidance.

The local anaesthetic fluid has following advantages :

Once the anaesthetic is in place, the laser fibre is passed up inside the sheath until it comes out of the top. The fibre position is confirmed with Duplex and the laser is fired.

The sheath and laser are then gradually pulled back, making sure the vein is completely ablated.

The treatment takes about 20-30 minutes per leg. You may also have some foam sclerotherapy or some avulsions undertaken and a compression bandages are then put on.

Why use EVLA?

Varicose veins are often thought to be the large dilated tortuous veins on their legs. Although these veins can be seen in some people with vein problems, these visible varicose veins are not the real problem. They are just the tip of an Iceberg! – Venous Incompetence.

Hence management of varicose veins and the other Sequel (such as phlebitis, venous eczema, lipodermatosclerosis, Non healing venous leg ulceration and even many people with spider veins of the legs), the underlying main veins that aren’t working.

Unfortunately, when the valves become incompetent in these truncal veins, the valves cannot be repaired or replaced. Therefore, to stop the blood refluxing in the faulty direction and causing damage, we need to ablate the veins completely.

For the last few decades, surgeons have operated on patients with varicose veins and venous diseases by ligating the veins and then stripping them.

However, the advancement in the technology has made these major interventions almost obsolete .The varicose veins are now destroyed by thermal energy for example by using EVLA – the veins are closed in a way that makes them sclerosed and never grow back again.

Will I need further treatment?

If you are having treatment just to relieve symptoms then no further treatment is usually necessary. Most patients however wish also to improve the appearance of their veins and of these about 80% will require further treatment. The varicosities normally become less obvious after EVLA but rarely disappear completely.

Additional treatment for the varicosities can be either by avulsions or foam sclerotherapy. These additional treatments can be undertaken at the time of the EVLA or more usually after a delay of 4-6 weeks.

Avulsions are undertaken after giving small incisions over the veins and they are pulled out with a crochet hook. These small incisions heal easily without stitches and with minimal scarring.

Foam sclerotherapy is the commonest means of dealing with residual varicose veins after EVLA and is highly effective for these.

What are the complications?

Serious complications after EVLA are very rare.

Thrombophlebitis: EVLA works by causing thermal damage to the vein and an inevitable response to the heat is an inflammation of the vein wall. One may experience the vein that has been ablated become hard and Nodular. Varicose veins that feed from the treated vein may also become hard as some thrombus forms within them. This clot is not dangerous and the body on its own eventually resorbs it over a few weeks.

Nerve damage: As nerves lie alongside the veins these may also become damaged by the heat energy. Few patients notice small patches of numbnes or parenthesis on their legs . These usually resolve over a few months.

ThermalBurns: It is a possibility to burn the skin with the laser during the procedure but this is very rare indeed.

DVT: A DVT is a blood clot in the deep veins in the leg. It is a recognised complication of surgery and can be dangerous if the clot breaks away and travels to the lungs. The risk of getting a DVT after EVLA is very low but has been reported.