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Understanding Laser Vein Treatment: EVLT

By Dr Ken Seifert – Follow me on +

My name is Ken Seifert, M.D. I work at Optima vein care and I will be publishing in this blog weekly to help inform the public about the work we do and the help we can provide you with your varicose and spider veins.

In the last blog, I said that lasers get all the glory, but the real hero of the modern era of vein treatment is ultrasound. It’s true, but lasers do deserve some credit too.

A laser is a device that can produce a high intensity light at one wavelength. The color of the light that you see is determined by it’s wavelength. Red is a longer wavelength, and purple is shorter. Humans see only a narrow band of wavelengths. Lasers can be built that produce light that cannot be seen but is still very powerful. Light of a wavelength longer than red is called “infrared” and you may know of infrared lamps that produce heat. Infrared lasers also produce heat.

In addition to the high intensity, the fact that the light is all of one wavelength makes it possible to easily direct it. The light can be directed down a fiber optic bundle and the heat can be placed in a precise location at the end of the fiber optic bundle. This is the technique used to heat veins.

The operation we now do, that has replaced the dreaded vein stripping, is referred to as “EVLT”, that is “EndoVenous Laser Therapy”. In that operation, I introduce a needle into the vein using local anesthetic to make it painless and using ultrasound to guide the placement of the needle in the vein. I then pass a soft tipped wire into the vein and guide the wire up the vein to the groin, again using ultrasound to help me. Next, I remove the needle and leave the wire in the vein. You cannot feel the wire, it is too small and too soft. I then put a soft plastic catheter, a tube, over the wire, remove the wire and put the fiber optic bundle through the tube. The fiber optic bundle is too stiff to advance unprotected up a vein, it would easily puncture the side of the soft vein, but by putting the soft wire up the vein in the catheter, I can put the fiber optic bundle up the vein without hurting you or your vein.

Next, I carefully locate the tip of the fiber at a precise spot in the vein, again using ultrasound. This step is so important that I want to talk about it in a future blog. But back to the operation. I put a lot of local anesthetic around the vein using a small needle and, you guessed it: ultrasound! Now, I can use the infrared laser to precisely heat the vein. This will seal it shut.

The repeated mention of the ultrasound shows you, I hope, how important it is. The diagnosis, and the EVLT, would be impossible without ultrasound.

In the next blog, I will describe how the heat from the laser seals the vein shut and why this method of treatment is superior to other methods.

The History of Treating Varicose and Spider Veins

By Dr Ken Seifert – Follow me on +

My name is Ken Seifert, M.D. I work at Optima vein care and I will be publishing in this blog weekly to help inform the public about the work we do and the help we can provide you with your varicose and spider veins.

Until last week, I wrote an article every week to help you understand the problem and the treatment of varicose and spider veins. Last week, I was in Florida to see my son graduate from the University of South Florida School of Medicine. He is starting his internship in July.

Anyway, I need to pick up where I left off. I last talked about vein stripping, a surgical procedure that physically removed the vein from the leg. There were two problems with that procedure: It was painful, and, prior to the development of ultrasound, it was occasionally not the right thing to do.

We no longer do vein stripping. It has been supplanted by minimally invasive, minimally painful procedures involving methods of heating the vein to seal it shut. The heat is provided by a laser or by a microwave heating device.

I want to emphasize that while lasers get all the glory, the real credit for the modern improvement in the treatment of varicose veins goes to ultrasound. Prior to ultrasound, we either had to guess as to which veins were the problem, or get a venogram. Venograms are a radiology study. A needle is but in a vein in the ankle and radiology contrast material, commonly called “dye” was put in the leg. It wasn’t really a dye, it was colorless, but it partly blocked X rays so the veins would show up on a photographic plate. By taking a series of X rays as the “dye” flowed up the leg, and by tilting the patient up and down, one could sort of tell which veins were incompetent, that is, which veins had valves that were not working. However, if the radiologist didn’t catch the flow at just the right time, the venogram could be misleading or not helpful. Furthermore, there was a lot of X rays involved, exposing the patient to a lot of radiation, and the “dye” was painful. To make maters worse, the whole thing was very expensive. All of these problems conspired to make doctors reluctant to get a venogram, so some vein stripping operations were done on the presumption that the saphenous vein was incompetent. Lots of times, that was true, but sometimes it wasn’t. If it wasn’t, then the patient went through a painful procedure and it didn’t work!

Around 1990, a new era in surgery started and rapidly spread. It emphasized variations on old procedures that could be done through small incisions or through no incisions at all, this minimizing the pain that people experienced but still achieving the goals of the previous operations. I started my surgical career in a time when the emphasis was on the ultimate outcome and not much thought was given to how much pain we inflicted to achieve that outcome. There was initially some resistance to the new techniques and some appropriate skepticism, but the enthusiastic reception by the public pushed this revolution forward. Vascular surgery followed, and alternatives to vein stripping were tried. This was especially appropriate as varicose veins are painful, but usually not life threatening. Sometimes, but usually not. That made painful treatments difficult to justify.

Next week I want to review the short history of the progression from vein stripping to the current methods of treating varicose veins.

Alternatives to Vein Surgery & Vein Stripping

By Dr Ken Seifert – Follow me on +

My name is Ken Seifert, M.D. I work at Optima vein care and I will be publishing in this blog weekly to help inform the public about the work we do and the help we can provide you with your varicose and spider veins.

Every week I will write a short article that I hope will help you understand the problem and the treatment of varicose and spider veins.

Last week I wrote about variations in the main veins of the superficial vein system, the great and small saphenous veins.

In most people who have varicose veins, the great or small saphenous veins, or both, have incompetent incompetent valves. Valves cannot be repaired, and the saphenous veins can be closed without causing any circulation problems. The deep veins can easily handle all the blood flow in the leg.

Until about 15 years ago, the method used to close the saphenous vein was the famous “vein stripping” operation. It was a surgical removal of the vein. It was painful and frankly, kind of brutal. Under general anesthesia, the saphenous vein at the knee or ankle was exposed through an incision and the vein was tied off and divided. A wire was passed up the vein to the groin, where another incision was made. The vein was tied and divided here and the vein could be tied around the wire. The wire was then used to pull the vein out of the patient. The operation required general anesthesia and it often took several weeks to recover from the operation. The operation was usually effective, but it was a drastic solution to a problem that is usually annoying, but not life threatening. Furthermore, if the source of the varicose veins was not the great saphenous vein, as is still occasionally true, then it didn’t even relieve the problem!

These factors gave vein treatment a bad reputation, and some of that bad reputation persists today. I still hear patients tell me that they are worried I’m going to recommend a vein stripping and that some relative, maybe their grandmother, had it done and it was terrible. And it was, but we no longer do that. Less forgivable is the occasional patient who tells me that his or her doctor told her not to get treatment because a vein stripping was terrible. Starting around 1995, vein stripping was replaced by several alternatives, and it is disheartening to learn that that fact has not reached all physicians. I am involved in local efforts to bring the word to all the primary care physicians that no, we don’t do that anymore.

Vein stripping has been replaced by procedures that are just as effective, or even more so, and are done in our office under local anesthesia, or no anesthesia at all, that do not hurt and allow the patient to return to normal activities that day, or sometimes the next day, with minimal or no scars, and with minimal expense.

I will tell you about the development of these procedures in the next article.