EVLA / EVLT - Endovenous Laser Ablation Treatment For Varicose Veins Information

Endovenous Thermal Ablation or Endothermal Ablation (ETA) is the generic term for all methods of treating refluxing superficial veins using heat energy delivered from inside the vein under local anaesthesia. 

When laser is used as the energy source the treatment is called Endovenous Laser Ablation (EVLA) and one of the first systems manufactured to use a laser was named EVLT®. In fact EVLT® (Endovenous Laser Therapy™) is a registered trademark that only refers to one product from a company called Diomed. Radiofrequency may also be used as a form of ETA, but EVLA which uses a laser is currently more popular with vein specialists in the UK.

According to a study by CJ Evans et al in 1999, varicose veins are present in approximately 1 in 3 adults in the Western world. 

Treatment of varicose veins is generally considered to be a medical matter, although the main implications are usually cosmetic, in that people don’t like to live with the appearance of them, usually on their legs. Pain and discomfort are also a factor. Sufferers are often referred by their GP to a vascular or vein specialist for diagnosis of the problem and to discuss treatment options.

Unlike thread or spider veins, varicose veins are situated beneath the skin, being skin coloured or bluish-green and more than 2mm in diameter. They are more serious than thread veins and they can be painful (or achy) and are a sign of leg pump or venous failure, almost always superficial venous reflux.

Different treatment options are available for varicose veins. Traditional treatment is ligation or tying of the affected veins and stripping them from the leg. This a surgical procedure which requires general anaesthetic and up to six weeks ‘down time’ away from work. As well as being painful, this also leads to the veins growing back again in the majority of cases, a process known as neovascularisation. Although still available on the NHS, this is considered by many vascular specialists to be an outdated and unnecessary form of treatment. Other options include foam sclerotherapy where a sclerosant substance is injected in the vein causing the vein walls to collapse.

In 1999, Consultant Vascular Surgeon, Prof. Mark Whiteley became the first person in the UK to perform ETA using radiofrequency (RF) energy to generate the heat inside a vein, thus destroying it and allowing it to be reabsorbed by the body without any regrowth. The procedure was performed using ultrasound guidance, via a tiny keyhole incision of 2 or 3mm.

Following on from the success of this method of treating superficial venous reflux, several other doctors came up with the idea of using a laser (initially an 810nm diode laser) to generate the heat inside the varicose vein which destroys it, instead of RF energy. The first results, which were extremely encouraging, were published in the Dermatologic Surgery Journal in 2001 by Navarro et al in a clinical paper entitled ‘Endovenous laser: a new minimally invasive method of treatment for varicose veins--preliminary observations using an 810 nm diode laser’. This culminated in a technique trademarked as EVLT® or Endovenous Laser Therapy™ using a device manufactured by Diomed which used the 810nm wavelength.

Endovenous Laser Ablation or EVLA is now the recognised generic term for using a laser to treat veins using heat. EVLA covers all systems, and the differing wavelengths used, rather than just the EVLT technique and device at 810nm, and is therefore the generic term we will refer to in this FAQ as vascular surgeons can use a variety of equipment for this procedure.

If you are considering Endovenous Laser Ablation for varicose veins, the following information will give you a basic understanding of the procedure. It can't answer all your questions, since a lot depends on your individual diagnosis. Please ask your vascular specialist about anything you don't understand.

There are two sets of veins within the leg, deep or femoral veins near the bones within the muscles and superficial or saphenous veins which are just under the skin.

The saphenous veins join the femoral veins at various points along the leg. Most of the blood flowing back towards the heart is carried by the femoral veins with very little blood flowing in the superficial veins.

When a person is standing the blood must therefore flow uphill towards the heart. As muscles in the legs contract, they squeeze the femoral veins and thus push the blood up the leg. As the muscles relax, blood is prevented from flowing back down the leg by the action of valves within the veins. The combined action of the muscles and the valves keeps blood flowing up the leg.

Venous reflux

Problems with these valves can lead to venous reflux and varicose veins. Venous reflux is where the valves in the veins and at the junctions between veins have failed and are not functioning properly, thus allowing blood to fall the wrong way down the leg, i.e. back down towards the feet. This back pressure damages valves further down the leg and stretches the veins under the skin; manifesting as varicose veins.

Left untreated venous reflux can cause aching in the legs, swelling of the ankles, thrombophlebitis, venous bleeding, venous eczema, lipodermatolsclerosis, haemosiderin deposition and eventually leg ulceration.

Venous reflux problems are also somewhat hereditary, in that if you have one parent with a history of venous problems, then you have a 50% chance of suffering yourself, two parents and the likelihood rises to 80%. Additionally men tend to have more vascular problems than women. Pregnancy and weight gain can indeed make vascular problems appear worse but they are generally not factors for actually making the problem worse in itself.

EVLA is a ‘walk-in, walk out’ procedure, performed under local anaesthetic.

A variety of laser wavelengths are now available, including devices offering 810nm, 940nm, 941nm, 1064nm, 1320nm and 1470nm. It is felt by many vein specialists that the higher wavelengths are associated with less pain following the procedure as these wavelengths more specifically target the vein wall rather than the blood within the vein. However evidence for this is anecdotal and there are no randomised clinical trials of EVLA comparing the differing wavelengths.

EVLA is used to treat the underlying venous reflux in the saphenous veins which is contributing to the presence of varicose veins and thread veins rather than treating those veins themselves, hence it is treating veins much higher up and deeper up the leg.

Although early techniques for EVLA used a general anaesthetic it soon became clear that this could be performed under local anaesthetic using a tumescent liquid injected around the vein which also helps to reduce the heat damage potential of the laser and provides pain relief. The vein itself is free of blood at the point of treatment.

The advantage of EVLA is that it offers a ‘walk-in, walk-out’ option for treating varicose veins and venous reflux problems, without a need for operating theatres and overnight stays. However, it is not a one size fits all solution and can often be combined with other treatment techniques, including sclerotherapy and microsclerotherapy to truly address an individual’s problems.

The results of EVLA have been shown to last longer than those which can be achieved through vein stripping, while research has shown that veins which have been stripped grow back in almost a quarter of cases.

Although most of the time a venous reflux problem is visible through the presence of the distended varicose veins close to the skin’s surface, in some people the problem still exists but with no apparent signs on the surface of the leg. Such people may simply have visible thread veins or in some cases nothing at all.

Most vascular surgeons and vein specialists therefore advocate the use of ultrasound diagnosis as best practice when dealing with a person who presents either with a visible problem or any symptoms associated with vascular problems. Without being able to see the underlying venous system a practitioner cannot properly assess whether there is an issue with venous reflux which is causing the cosmetically unattractive varicose or thread veins which you have asked them to treat.

Sometimes you can pay for just this ultrasound scan separately; expect to pay about £150, in order to correctly diagnose the problem and to help you and the practitioner decide if EVLA is a suitable treatment option for you or if something else would be better suited.

On consultation with a vascular specialist a detailed discussion will take place which should clearly highlight your expectations of the EVLA treatment. The practitioner should then be able to explain the treatment and potential results to you.

A medical history will be taken to make sure that there are no reasons why you are not suited to be treated with EVLA. Then you would normally be asked to sign a consent form, which means that you have understood what the treatment may do, and the potential side effects.

Photographs may also be taken by the practitioner that can be used as a “before and after” comparison to show you how successful your treatment has been from a cosmetic perspective.

The procedure
An ultrasound scan is used to mark the position of the veins and identify the problematic areas.

Local anaesthetic is then injected around the vein to ease any discomfort that might be created through the treatment. A small needle is first inserted into the targeted vein through a very small incision and a fine probe or thin laser fibre is then inserted through the needle up the vein; the incision is usually close to the knee. The laser energy is delivered in short or continuous pulses to seal the faulty vein so that blood can no longer flow through it. The incision point is then sealed with surgical tape and will heal over quickly.

A compression stocking is then applied on the leg to reduce subsequent swelling and bruising. You will normally be asked to stand and walk immediately after the procedure.

The procedure usually takes between half an hour to a couple of hours to perform, depending on how many veins and how many legs are being treated. Afterwards you can go home without the need for a hospital stay. The treatment removes both the appearance of the varicose veins and the discomfort caused by their presence.

EVLA is a ‘walk-in, walk out’ procedure so you will be able to leave the clinic after treatment. You will be advised to wear compression stockings after treatment because these apply constant pressure to the legs. This will reduce bruising post-treatment and will ensure the treatment effectively targets the unwanted veins to offer results that are long lasting.

Aside from wearing support or compression stockings for about 2 - 3 weeks, you should be able to return to your day to day routine immediately.

You will normally be asked to return to the clinic for a follow-up check after a few weeks to have an ultrasound scan and discussion to assess the success of the treatment.

Expect side effects such as pain, discomfort, itching, swelling and bruising and a feeling of tightness or numbness in the treated leg(s) for up to a few weeks following treatment.

The removal of varicose veins does not affect blood flow. This is because the remaining veins in the leg, particularly the deeper (femoral) veins, take over this role.

Any operation on the leg carries a risk of Deep Vein Thrombosis (DVT). For example, with the old vein stripping method the associated risk was 5%, which is 15 times more that the 0.3% risk with EVLA.

In extremely rare cases small skin burns have been reported with EVLA.

It is important to follow the advice of your vein specialist as closely as possible following EVLA to ensure that you get the full benefit of the treatment and avoid any complications.

Post-treatment advice may include:

• Take over the counter anti-inflammatories or pain killers (ibuprofen or paracetamol) for a few days after the treatment, which will ensure you feel comfortable.
• Wear the supplied or recommended compression stockings for the time period advised.
• Plan for an average of three days off work post treatment although some people do return to work sooner (even on the same day), this depends on how you feel and your type of work.
• Do plenty of walking post-treatment (ideally four miles per day for two weeks).
• Avoid hot baths, Jacuzzis, steam rooms or swimming pools for two weeks after treatment.
• Avoid drinking alcohol for 24/48 hours following treatment.
  

You should not undergo EVLA treatment if you are pregnant and many specialists will not treat patients who are breast feeding.

 If there is a history of past deep vein thrombosis (DVT), the ultrasound scan will need to pay particular attention to the state of the deep veins. If there is significant deep vein obstruction, EVLA may be inadvisable.

Other contra-indications include:

• Active superficial vein thrombosis
• Acute Deep Vein Thrombosis
• Recent Long Haul Flights
• Very superficial veins close outside the fascia and close to the skin
• Very tortuous veins which cannot be negotiated by a straight laser catheter

EVLA is very safe and can be performed in the presence of many medical conditions and without the need to stop medications such as anti-coagulants.

Until recently it was highly unlikely that anyone considering Endovenous Laser Ablation for the treatment of varicose veins would’ve been able to access this free of charge on the National Health Service, as the treatment of choice recommend within the health system was vein stripping.

However the National Institute for Health and Care Excellence (NICE) issued updated guidance at the end of July 2013 which stated that surgery should only be offered to treat varicose veins on the NHS if other less invasive treatments are unsuitable.

Currently there is wide regional variation in the treatment of varicose veins in the UK as there is no definitive system for determining which people would benefit most from treatment. There is also currently no established framework within the NHS for the diagnosis and management of the condition. To help standardise the kind of treatment people can receive, NICE has published a new clinical guideline on varicose veins.

For confirmed cases of varicose veins, it recommends that endothermal ablation, radiofrequency or laser, should be offered. If endothermal treatment is not suitable, then ultrasound-guided foam scleropathy should be offered. Finally, if these others are not suitable, then surgery should be considered.  The guidance is available here.

We would therefore always recommend that you visit your General Practitioner before embarking on private treatment for varicose veins. As well as their advice and guidance they may also be able to refer you to a local NHS Hospital who can treat you with newer techniques, based on this updated guidance.

The cost of EVLA will depend on the number of varicose veins being treated, the severity of them and whether one leg or both legs is being treated. Private prices for EVLA start from around £1,900 up to approximately £4,500.

Endovenous Laser Ablation (EVLA) is a safe, effective and minimally invasive treatment option to remove varicose veins. The technique has been developed and perfected for well over a decade.

It is a ‘walk-in, walk-out’ procedure which produces very little downtime for the individual with good results that last longer than those seen with traditional surgical stripping operations.

With new guidance from NICE, this treatment may be accessible on the NHS as well as through private clinics.

Please note that results of surgery vary enormously, depending upon the patient, their condition and the skill of the individual surgeon.

 (All before and after photographs featured are real patients treated by highly experienced vascular surgeons, your results may differ).

Female right leg before (left) and after (right) EVLA treatment for varicose veins.

Male patient treated for varicose veins with endovenous laser ablation.

Before and after pictures courtesy of The Private Clinic.

Female with varicose veins on the legs before (left) and after (right) EVLA treatment

Man with varicose veins on both legs before (left) and after (right) Endovenous Laser Ablation treatment.

 Before and after pictures courtesy of Dr. Haroun Gajraj at The Veincare Centre.