Endovenous Thermal Ablation of Prominent Central Forehead Veins (Supratrochlear Veins).

BACKGROUND: Many patients complain of prominent vertical veins in the center of their forehead, worse when smiling, wrinkling the forehead in bright light, leaning forward, and when vasodilated in heat, when exercising, or with alcohol. Previous attempts to treat these with external laser, sclerotherapy, and phlebectomy have not been successful. OBJECTIVE: To describe a new method of treating prominent vertical forehead veins and to report the early results. MATERIALS AND METHODS: We used endovenous laser ablation with a 1470 nm diode laser in 15 patients (F:M 12:3; mean age 38.4 years range 24-69). A bare fiber was used once and a 400-µm single ring radial fiber (Biolitec, Vienna, Austria) in all other cases. Tumescence was placed around the vein and a power of 2 to 3 W with a pullback of 7 to 10 seconds per centimeter. RESULTS: Twelve of the 15 patients (80%) ended up with a good cosmetic result and were satisfied, although 2 needed redo treatment. One patient had minor skin tethering, and 2 (13%) suffered burns-one was the only bare fiber case and the other, the only one where 4 W was used. CONCLUSION: We present a novel technique to treat prominent vertical forehead veins, with apparently good early results.

Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins.

BACKGROUND: New treatment methods have challenged open surgery as a treatment for great saphenous vein (GSV) insufficiency, the most common being ultrasound-guided foam sclerotherapy (UGFS) and endovenous laser ablation (EVLA). This study evaluated the long-term results of surgery, EVLA and UGFS in the treatment of GSV reflux. METHODS: Patients with symptomatic GSV reflux were randomized to undergo either open surgery, EVLA or UGFS. The main outcome measure was the occlusion rate of the GSV at 5 years after operation. RESULTS: The study included 196 patients treated during 2008-2010; of these, 166 (84·7 per cent) participated in the 5-year follow-up. At 5 years, the GSV occlusion rate was 96 (95 per cent c.i. 91 to 100) per cent in the open surgery group, 89 (82 to 98) per cent after EVLA and 51 (38 to 64) per cent after UGFS (P < 0·001). For patients who had received no additional treatment during follow-up, the occlusion rates were 96 per cent (46 of 48), 89 per cent (51 of 57) and 41 per cent (16 of 39) respectively. UGFS without further GSV treatment was successful in only 16 of 59 patients (27 per cent) at 5 years. CONCLUSION: UGFS has significantly inferior occlusion rates compared with open surgery or EVLA, and results in additional treatments.

[EFFICACY OF SURGICAL TREATMENT OF VARICOSE DISEASE, DEPENDING ON ADSORPTION-RHEOLOGIC PROPERTIES OF BLOOD].

Physico-chemical adsorption-rheological properties of venous blood in patients, suffering varicose disease of the lower extremities, and their impact on efficacy of various methods of surgical treatment were studied. Conduction of endovasal laser coagulation in combination with crossectomy have promoted enhancement of operative treatment efficacy in patients in initial terms of observation (in 1 week), in 1 month a complete occlusion of the vein was noted more rarely. Efficacy of a small--power laser ablation with irradiation power of 10 W and less in 4 weeks postoperatively is higher, than of surgical treatment with a laser irradiation power 15 W. In a varicose disease of the lower extremities there were observed the raising of the blood volume toughness, superficial relaxation and superficial stress on background of reduction of the toughness--elasticity module, superficial toughness and superficial elasticity. Crossectomy conduction did not influence the integral dynamics of adsorption--rheological properties of venous blood, but in 1 month after endovasal laser coagulation a normalization of physicchemical parameters of blood was noted. Application of laser irradiation of the 10 W power and less promotes inhibition of the relaxation properties of venous blood; a prognostic meaning owes initial value of the blood volume toughness.

High-risk lead removal by planned sequential transvenous laser extraction and minimally invasive right thoracotomy.

INTRODUCTION: Transvenous pacemaker or implantable cardioverter defibrillator (ICD) lead extraction via mechanical or excimer laser sheath is typically safe and effective. Longer duration from implant, presence of large vegetations or thrombi, fractured leads, and prior failed extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Techniques developed for minimally invasive valve surgery were used in conjunction with laser extraction to refine a "hybrid" technique for lead extraction. We assessed the outcomes of high-risk lead extraction using this hybrid lead extraction technique. METHODS AND RESULTS: Retrospective assessment of clinical parameters and procedural outcomes in patients undergoing planned hybrid lead extraction from February 2008 to September 2012 was performed. We report 8 cases of hybrid lead extraction performed at our institution. We extracted 21 leads with average lead age of 13.8 years since implant. All leads were removed with complete clinical and radiographic success. There were no intraprocedure complications. One patient died of continued sepsis and 1 other had symptoms consistent with pulmonary embolism. CONCLUSIONS: Hybrid lead extraction using this technique is a safe and effective approach for removal of high-risk chronic pacemaker or ICD leads. This method extends the range of approachable leads resulting in complete removal without median sternotomy. Hybrid lead extraction can be scheduled electively facilitating complete lead removal with a low complication rate and short postoperative recovery time, mitigating the risks inherent in midline sternotomy or emergent cardiac surgical rescue.

[Use of laser technologies in treatment of chronic venous insufficiency in patients with a wide ostial segment of the main trunks of subcutaneous veins].

Presented herein is the authors' experience in endovascular laser obliteration of the major trunks of the grate saphenous vein (GSV) with a wide ostial segment (measuring from 15 to 34 mm) in patients presenting with chronic venous insufficiency. Group One patients (n=32) underwent crossectomy followed by endovasal laser obliteration (EVLO) of the GSV's trunk on the femur. Group Two patients (n=46) were not subjected to crossectomy, whereas obliteration of the GSV's trunk was carried out immediately from the ostium. In Group One we managed to achieve obliteration of the GSV's trunk in 32 patients (100%) with no additional interventions, and in Group Two this was achieved in 42 (91.3%) patients. Four patients (8.7%) required performing a secondary procedure of EVLO after which obliteration of the trunk was achieved in all patients of Group Two. There was no evidence of deep-vein thrombosis.

The use of endovenous laser treatment in toddlers.

The use of endovenous laser ablation therapy in children is limited. Klippel-Trenaunay syndrome (KTS) is associated with persistent ectatic anomalous veins within the affected extremity, with increased risk of thromboembolism. The present report describes four toddlers (<20 kg) with KTS of the lower extremity who underwent a total of five endovenous laser procedures for treatment of ectatic anomalous marginal venous system, without complications.

[Endovasal obliteration of the main subcutaneous veins - a mechanism of action].

Active dissemination implementation of endovascular methods has during the past decade been a progressive tendency of the development of surgical treatment management of varicose disease.Amongst these methods, endovasal laser obliteration in Russia occupies the leading place. Despite widespread implementation of this method into clinical practice still there are neither common concepts on the mechanisms of action of laser energy, inducing lesions of the venous wall followed by obliteration, nor, consequently,criteria for administration thereof The search for an optimal method and mode of intravascular intervention is based on study-ing the mechanisms of the damaging action of laser energy on the venous wall. The article contains a literature review of the studies dedicated to investigating the mechanisms of action of endovasal methods of treatment for varicose disease.

[Comparative characteristics of laser-mediated and radiofrequency-powered thermal obliteration in varicose disease].

The article deals with a comparative analysis of the two most commonly used methods techniques of thermal ablation used for elimination of truncal varicosis in varicose disease, i. e., endovasal laser-mediated and radiofrequency-powered obliteration, underlining differences in the mechanisms of physical impact of the two competitive methods, clinical peculiarities of their application, as well as economic aspects of these interventions under the conditions of the present-day Russia.

A prospective double-blind randomized controlled trial of radiofrequency versus laser treatment of the great saphenous vein in patients with varicose veins.

BACKGROUND: Endovenous ablation of varicose veins using radiofrequency ablation (RFA) and endovenous laser therapy (EVLT) has reported advantages over traditional open surgical treatment. There is little evidence comparing the efficacy and patient-reported outcomes between the 2 endovenous solutions. This study compares the RFA and EVLT strategies in a prospective double-blind clinical trial. METHODS: Consecutive patients with primary unilateral great saphenous vein (GSV) reflux undergoing endovenous treatment were randomized to RFA (VNUS ClosureFAST) or EVLT (810-nm diode laser). The primary outcome measure was GSV occlusion at 3 months after treatment. Secondary outcome measures were occlusion at 7 days, postoperative pain, analgesic requirement, and bruising, assessed at day 7 after surgery. Quality of life (QoL) was assessed preoperatively and 3 months after surgery using the Aberdeen Varicose Vein Questionnaire (AVVQ) and EQ-5D. RESULTS: A total of 159 patients were randomized to RFA (79 patients) or EVLT (80 patients). Groups were well matched for demographics, disease extent, severity, and preoperative QoL. Duplex scanning confirmed 100% vein occlusion at 1 week in both groups. At 3 months, occlusion was 97% for RFA and 96% for EVLT; P = 0.67. Median (interquartile range) percentage above-knee bruise area was greater after EVLT 3.85% (6.1) than after RFA 0.6% (2); P = 0.0001. Postoperative pain assessed at each of the first 7 postoperative days was less after RFA (P = 0.001). Changes in the AVVQ (P = 0.12) and EQ-5D (P = 0.66) at 3 months were similar in both groups. CONCLUSIONS: RFA and EVLT offer comparable venous occlusion rates at 3 months after treatment of primary GSV varices; with neither modality proving superior. RFA is associated with less periprocedural pain, analgesic requirement, and bruising. REGISTRATION NUMBER: ISRCTN63135694 (http://www.controlled-trials.com).

Changing to endovenous treatment for varicose veins: how much more evidence is needed?

Surgical ligation and stripping of varicose veins has been the accepted treatment for almost a century but within the last decade this has been challenged by endovenous thermal and chemical ablation methods. Surgery is not without significant complications including paraesthesia and has reflux recurrence rates of up to 54% at five years, even though it has been shown to provide significant health-related quality of life benefits cost-effectively. Ultrasound-guided foam sclerotherapy, endovenous laser ablation and radiofrequency ablation are all consistently proving to be at least as beneficial as surgery, without the same complications and with less post-procedure morbidity and more rapid recovery. This article presents a review of the latest published evidence and comparative analysis of vein surgery and it's alternatives. Endovenous treatment under local anaesthesia in a clinic room or office-based setting is now being recognized internationally as an acceptable standard for dedicated venous practice in a cost-effective environment. Although more long-term comparative trials of these innovative methods compared with surgery are desirable, many centres are now conducting trials testing the latest endovenous device technologies with each other to support the development of contemporary pathways of care. Patients are entitled to a range of treatment strategies, particularly when complex and recurrent venous disease has such unacceptably high surgical complication and recurrence rates compared to endovenous alternatives. There is questionable logic in procrastinating until there is more convincing evidence. Now is the time for vascular surgeons to enhance their ultrasound skills and future-proof their venous practice for the benefits of patients and institutions.

Excimer Laser Coronary Angioplasty (ELCA): Fundamentals, Mechanism of Action, and Clinical Applications.

Laser coronary angioplasty was developed to modify atherosclerotic plaque and help with the acute and longer-term limitations of balloon angioplasty, namely, intimal dissection and restenosis, respectively. Excimer laser debulks and modifies the tissue with its photochemical, photothermal, and photokinetic properties without causing significant injury. With important refinements and advancements, laser has gained a renewed place in treating complex and resistant coronary lesions after a disappointing start. When used in line with the instructions, laser is an important tool that allows the completion of difficult and complicated cases. It is a useful tool in the catheterization laboratory to treat lesions that are uncrossable or undilatable. Laser is also helpful in cases where a stent was deployed but remains under-expanded, with accumulating evidence of its efficacy in such cases. In addition, laser is increasingly used for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) to facilitate modification of the proximal CTO cap to allow penetration with a wire and completion of the procedure. Laser has been used in certain circumstances by experienced operators with simultaneous contrast rather than saline injection, to increase its effect and allow the successful completion of complex PCIs. This article outlines the scientific background, experimental data, practical procedural techniques, and clinical applications of excimer laser coronary angioplasty in the treatment of coronary artery disease.

Laser angioplasty of peripheral arteries: basic principles, current clinical studies, and future directions.

Percutaneous transluminal angioplasty (PTA) is a routine procedure for the treatment of peripheral arterial disease. However, its main limitation is late restenosis occurring at a 1-year rate of 6%-60%. Restenosis arises from injury to the arterial wall including overstretching, compression and rupture of the atherosclerotic plaque during balloon inflation. It is hypothesized that better long-term angioplasty results are observed if atherosclerotic plaques are removed rather than compressed and fractured. Laser angioplasty is one method to remove atherosclerotic plaques. We discuss the principles of lasers, physical properties of laser light, history of laser angioplasty and effects of laser radiation on tissues. Large clinical studies using laser angioplasty are critically assessed. In comparison to conventional PTA, there are some advantages of laser angioplasty: easier passage through chronic and calcified occlusions and according to some studies, better short- and medium-term results regarding limb salvage and management of in-stent restenoses.

Endovenous ablation.

Varicose vein surgery is among the most commonly performed surgical interventions. The standard treatment 'high ligation and stripping' has in many countries been replaced by endovenous techniques. However, there are many different techniques available. All have a different way of action and sometimes need different skills. The purpose of this review article is to give an update in those different endovenous ablation techniques. We describe the indications, technique, mechanisms of action, and results. We conclude that all different techniques can be used safely and are effective. Even on long term there seems to be no difference in outcome, even compared to high ligation and stripping.

Randomized clinical trial comparing endovenous laser ablation of the great Saphenous vein with and without ligation of the sapheno-femoral junction: 2-year results.

OBJECTIVE: To evaluate whether ligation of the sapheno-femoral junction (SFJ) improves the 2-year results of endovenous laser ablation (EVA). METHODS: Forty-three symptomatic patients with bilateral varicose veins were studied in which one limb was randomly assigned to receive EVA without SFJ ligation, and the other limb received EVA with SFJ ligation. Recurrence of varicose veins and abolition of great saphenous vein (GSV) reflux on duplex ultrasound imaging, and venous clinical severity score (VCSS) were investigated at 6, 12, and 24 months after treatment. RESULTS: Two-year life table analysis showed freedom from groin varicose vein recurrence in 83% of 43 limbs (95% CI; 67-95%) in the EVA without ligation group and in 87% of 43 limbs (95%; CI 73-97) of limbs in the EVA with ligation group (P=0.47). Thirty-eight (88%) treated GSV segments were ablated completely in the EVA without ligation group and 42 (98%) in the EVA with ligation group (N.S.). Groin recurrence was due to an incompetent SFJ/GSV (9%) and to incompetent tributaries (7%) in the EVA without ligation group and due to neovascularisation (12%) in the EVA with ligation group. The VCSS improved significantly and was comparable in both groups. CONCLUSION: The addition of SFJ ligation to EVA makes no difference to the short-term outcome of varicose veins treatment. Establishing whether SFJ ligation results in a poorer long-term outcome because of neovascularisation needs to be studied in larger populations with longer follow-up.

A new method for hemorrhoid surgery: experimental model of diode laser application in monkeys.

OBJECTIVE: Detailed here is an experimental model in monkeys of a new approach to treat hemorrhoids using a diode laser. BACKGROUND DATA: Hemorrhoids are a common source of pain and suffering. Endovascular laser therapy for variceal veins is a method that potentially could be used in the treatment of hemorrhoids. There is currently no such method described in the literature. MATERIALS AND METHODS: Hemorrhoids were induced in monkeys by ligation of the inferior hemorrhoidal vein, similar to their cause in humans. After the piles were identified, laser fibers were introduced into them, and they were irradiated with laser energy (810 nm at 1-2 W in 1-sec pulses of 1-2 J each, for a total fluency of 4-10 J). RESULTS: The piles were completely reduced, and histological examination performed 10 d post-surgery showed reduction of the dilated vessels and complete healing. The laser energy was not delivered directly into the veins, but instead to the surrounding submucosal interstitial tissue, effectively reducing the hemorrhoids. CONCLUSION: The diode laser energy delivered into the hemorrhoids led to their complete resolution. Further clinical trials using this protocol must be carried out to determine its applicability to human hemorrhoids.

Recanalization of infrainguinal vessels: silverhawk, laser, and the remote superficial femoral artery endarterectomy.

There are multiple endovascular options to achieve percutaneous revascularization of chronic superficial femoral artery (SFA) stenoses and occlusions. Most rely on forceful displacement of plaque via balloon angioplasty, either as a stand-alone therapy or supplemented by cold thermal injury (cryoplasty), microtome assistance (cutting balloon angioplasty), nitinol stent deployment, or expanded polytetrafluoroethylene-lined nitinol stent deployment. Excellent technical success rates are routinely described in the literature. The essential problem associated with these techniques is the predictable compromise of the initial result by neointimal hyperplasia leading to poor long-term results. An alternative to forceful displacement techniques is use of directional atherectomy or excimer laser to debulk the atheromatous lesion, with the addition of low-pressure angioplasty or stent deployment as needed. Currently, directional atherectomy is performed using the Silverhawk Plaque Excision System (FoxHollow, Redwood City, CA), while laser atherectomy is frequently performed with the CLIRpath Excimer Laser (Spectranetics Corp., Colorado Springs, CO). While both techniques can be utilized for de novo atherosclerotic lesions, even eccentric lesions or ostial lesions, proponents of these devices have also shown good short-term results in the treatment of restenoses. Remote SFA endarterectomy with the Aspire stent (Vascular Architects, San Jose, CA) is a hybrid surgical and endovascular technique that is useful for debulking plaque from the SFA with adjunctive stenting of the distal SFA. We present a review of various alternative techniques to forceful balloon dilation used in the recanalization of the SFA with potential pitfalls and complications, along with a review of literature associated with each of these techniques.

[Surgical treatment for varicose vein].

OBJECTIVE: To explore the techniques and outcomes of the surgical treatment for varicose vein. METHODS: Totally 2 200 patients with varicose vein received surgical treatment in our hospital from July 2000 to January 2006. The latest techniques for endovenous occlusion were used for most cases, among which 1 802 cases were treated with endovenous laser treatment (EVLT) combined with transilluminated powered phlebectomy (TIPP), 82 cases with radiofrequency endovenous occlusion (RFO) combined with TIPP, and 218 cases with limited invaginated vein stripping and foam sclerotherapy. The remaining 98 cases were treated with laser, radiofrequency or ligation for saphenous vein trunk, and with resection, electric coagulation, and transfixation for vein clusters as additional methods. Perforators were also cut and ligated as well. RESULTS: Satisfied surgical results were obtained in all cases. The average operative time was 40 minutes (range 20-78 minutes). CONCLUSIONS: Limited invaginated vein stripping, EVLT, and RFO can be used to treat saphenous vein reflux. Surgical resection, transfixation, electric coagulation, and sclerotherapy are reasonable options for vein cluster or tributaries. Transection and ligation of the perforators are important. TIPP is ideal for the treatment of vein clusters.