Endovenous laser therapy for major saphenous reflux has been in use for approximately five years in USA and Europe and two years in Australia. Results reported for more than 1000 patients show a low risk of complications and excellent short to medium-term results. This technique is used to block off either main saphenous veins by passing up a laser probe introduced through a puncture needle under local anaesthetic with ultrasound guidance. Both legs can be treated at the one session. However, at least one further session will be required to treat the visible varicose veins by ultrasound-guided sclerotherapy.

What should you do before EVLT?
Do not apply moisturiser to your legs on the day of treatment. Wear slacks or loose trousers and sandals or loose shoes to hospital to allow for the thickness of the stockings.

What happens during EVLT?
You will be asked to present 30 minutes before the procedure for a subcutaneous injection of the anticoagulant drug heparin. Just before the procedure, a sonographer performs a full scan of the leg similar to the initial screening scan to familiarise us with the veins. The procedure is performed with you lying on a treatment couch that is tilted at stages through the treatment. The vein is punctured through an anaesthetized site at about the knee for great saphenous reflux and the ankle for small saphenous reflux. A wire is passed up the vein, a 45cm long fine tube is passed over the wire, and the laser probe is introduced through the tube. Local anaesthetic is infiltrated around the vein at several levels using extremely fine needles directed by ultrasound. The laser tip is precisely positioned just below the end of the saphenous vein using ultrasound guidance. The probe is activated and slowly withdrawn destroying the full length of the vein. The procedure involves minimal discomfort. A bandage is applied after treatment.

What are the possible complications from EVLT?
Adverse reactions for EVLT do not differ much from those for UGS. Complications can occur even with perfect technique.

• Deep vein thrombosis. Clots extending into the deep veins can occur but this serious complication is very uncommon if the protocol of compression and regular daily walking is followed. DVT has not been encountered in our experience with EVLT to date. It is important to stop oral contraceptives or HRT prior to EVLT as they increase the risk of DVT.
• Pigmentation along the treated vein consists of haemosiderin, a form of iron from the blood. Most disappears within 12 months but there is permanent staining in about 5% and this is of cosmetic significance. Persistent pigmentation may respond to laser treatment.
• Nerve damage. The adjacent sensory nerves can suffer heat damage causing numbness but this is usually mild and rarely lasts for more than a few weeks.

What should you do after EVLT?
You will be asked to go for a five minute walk immediately after treatment. It is recommended that you arrange for someone to drive you home. Walk or keep the leg elevated as much as possible for the first 24 hours and walk 30 minutes each day. Maintain normal daytime activities and avoid standing still for long periods. Avoid strenuous physical activity such as aerobics for three to four weeks after treatment since this increases the risk of blood flow returning into the treated veins. You are required to avoid any flights of 2-4 hours duration for 2 weeks and any flights of greater than 4 hours duration for 6 weeks after treatment. If travel is unavoidable, then the flight should be covered by subcutaneous heparin for anticoagulation given before departure and after arrival.

The bandage or stocking is worn continuously for three days. Stockings are then worn through the day, removing them at night and replacing them in the morning after the shower. It is routine practice to perform a check ultrasound scan at three days after treatment to ensure that the treated vein is occluded and to exclude the very small risk of DVT. Residual veins will require further UGS at a subsequent appointment.

What can you expect following EVLT?
The following features are expected and do not need to be reported:

• Bruising down the length of the treated vein is almost invariable and shows that the vein has been destroyed to the point where it has disintegrated in parts.
• Mild to moderate pain invariably occurs commencing a day or two after treatment. Aching in the leg persists for up to two weeks and shows that the procedure is working. Pain is usually improved by walking or by Panadol. Soreness behind the knee can result from rubbing by the bandage or stocking.
• Discolouration is usual early on and is not a cause for concern. Red, raised areas can develop over tributaries but these usually disappear within two to three weeks.
• Tender lumps due to clot in the treated vein is common and persists for the first few weeks. This is an early sign that treatment has been successful. Lumps may need to be pricked and squeezed to let out “trapped blood”.
• Phlebitis or Inflammation of the treated veins can occur. It is treated by further compression and regular walking.