Increasing the Effectiveness of Laser Thread Vein Treatment

A recent study by German researchers has shown that the addition of indocyanine green (ICG) a medical pigment increased the results achievable with diode laser therapy in the treatment of telangiectatic leg veins, thread veins present in the legs, without incurring any short term to medium term side effects.

The study published in Lasers in Surgery and Medicine in April 2012, entitled ‘Indocyanine green-augmented diode laser therapy of telangiectatic leg veins: a randomised controlled proof of concept trial’ was carried out at University Hospital Regensburg by lead investigator Dr. Annette Klein, with a diode laser device, MeDioStar supplied by Asclepion.

Thread veins in the legs affect between 40-50% of the adult population and are seen as a cosmetic problem more so than a medical one, generally treated with microsclerotherapy and the application of laser energy, although complete clearance of the thread veins isn’t always possible in all cases, with either treatment option due to the individual nature of each patient’s venous structure. The study set to see if it was possible to increase the effectiveness of laser therapy on leg thread veins by adding a green medical dye in combination with a 808nm diode laser.

ICG was intravenously given to 15 female patients who presented with thread veins in their legs which were between 0.25 and 3mm in diameter (based on a dose of 2mg/kg of body weight), then immediately afterwards the diode laser was administered in one single treatment at various different settings. The patients were then reviewed at 1 and 3 months. Control treatments were also done on patients using the diode laser without ICG for comparison.

The German researchers concluded that the addition of ICG to the treatment showed better results than using the diode laser alone. Additionally, even with the addition of ICG, the success of the treatment was very much dependent on the power settings employed on the laser, with exposure between 100 J/cm2 and 110 J/cm2 resulting in good clearance of the veins, increasing to excellent, according to the authors, when double pulses were applied.

We asked Consultant Vascular Surgeon, Mr. Haroun Gajraj from The VeinCare Centre in Dorset for his thoughts on this clinical trial and its results.

“Indocyanine green is a medical dye that is used in a number of medical investigations. It binds to proteins in the blood and therefore when injected it stays in the blood vessels. It absorbs energy at the same wavelength as the diode laser emits, so after injecting it, the laser energy more efficiently heats the blood in the thread veins. The idea is that the laser then zaps the blood vessels more selectively more effectively. The blood boils and the boiling blood destroys the vein.

Thread vein example in the leg - Courtesy Dr. Gajraj

My experience and the experience of most vein specialists is that laser does not compare favourably with sclerotherapy. The reason is that the thread veins nearly always have deeper "feeder" veins that laser cannot reach without burning the skin. So cooling the skin has been tried in association with turning up the power. Results have been disappointing. Now this technique tries to get round the problem of skin burns by sensitising the thread veins with this dye. However, the problem of deeper feeder veins still remains I suspect.

This is a very small study. The follow up is short and although the results appear impressive, I doubt whether this treatment will beat sclerotherapy by a skilled injector. The reason why laser has appeal is that it doesn't require any real skill. It can be delegated to a non-medically trained person. Sclerotherapy is difficult and requires knowledge, training and years of practice. Some people don't like the idea of having a substance injected into their veins and laser has a lure that it is without risk therefore. However, I have seen people who have suffered skin damage after attempts to clear thread veins by laser.”

As is often the case with breakthrough clinical papers, more research with increased patient numbers is certainly needed on the exact protocols required for this to be seen as a truly more effective option than laser therapy alone in the treatment of leg thread veins, or indeed to supersede the use of microsclerotherapy for this indication. Long-term follow-up studies will also be required to determine if the clearance of the thread veins is wholly achievable or if, as Mr Gajraj stated, the problem simply resurfaces due to the deeper feeder veins which ultimately produce the visible thread veins which are generally not targeted with laser therapy.

Aside from the actual efficacy of this treatment option, the practical aspects will not be to the liking of most medical aesthetic clinics or patients either in terms of the additional requirement for intravenous application of the dye and the additional resources, costs, skills and patient discomfort this would incur. It will be interesting to see if more studies are done in this area.