Endovenous laser treatment

Endovenous laser treatment (ELT), also called endovenous laser ablation (EVLA), is a minimally invasive ultrasound-guided technique used for treating varicose veins under tumescent local anesthesia, in which the vein wall is sealed using laser-generated heat. It belongs to the group of endovenous thermal ablation (EVTA) techniques, alongside radiofrequency ablation (RFA), and is considered by several international professional societies, including the Society for Vascular Surgery (SVS) and the European Society for Vascular Surgery (ESVS), as a first-line, less invasive alternative to traditional high ligation and vein stripping.^[1][2] It is commonly performed by a phlebologist, interventional radiologist or vascular surgeon.

Surgical incisions, as used in traditional vein stripping procedures, are not required in endovenous laser treatment. Under ultrasound guidance, a catheter is introduced percutaneously into the affected vein and advanced to the target segment. A thin laser fiber, typically 2-3 mm in diameter, is then inserted through the catheter and positioned within the vein. In modern laser systems, the laser light is transmitted via the fiber to the catheter tip, where it is delivered either as a ring-shaped or, in some devices, as a radial beam, either continuously or in pulses. Both water molecules and the red blood pigment hemoglobin absorb the laser energy, converting it into heat.^[3] The vein wall is heated to approximately 70 °C, causing controlled damage and contraction.^[4] The treated vein closes as a result of this thermal injury, preventing pathological venous reflux. Over the following months, the vein hardens, gradually shrinks, and is either absorbed by the body or transformed into connective tissue.^[5]

Early laser fibers of the so-called “bare-tip” generation delivered energy forward only at the catheter tip, requiring a safety distance of 1-2 cm from the saphenofemoral junction to avoid damage to the femoral vein.^[6] Later, these were replaced by radial fibers, which emit laser energy evenly in a 360-degree ring around the catheter, either as a single or double ring. This includes systems such as the endo laser vein system, which use radial fibers to uniformly close the vein from the inside.^[7] Radial fibers are now standard in endovenous laser therapy, as they provide more uniform energy delivery, improved efficacy, and are associated with fewer side effects such as pain and bruising compared with older bare-tip fibers.^[8] These improvements were facilitated not only by the introduction of radial fibers but also by the development of higher-wavelength laser systems, which allow more efficient vein wall heating with less collateral tissue damage.^[9]

Endovenous thermal ablation, including endovenous laser treatment, is primarily used to treat varicose veins in the major saphenous veins of the legs. These procedures are considered a less invasive alternative to traditional surgical vein stripping, with outcomes that are comparable or, in some aspects, superior. Worldwide, minimally invasive endovenous techniques have largely replaced conventional vein stripping.^[10][11]

Complications of endovenous laser treatment can be categorized as minor or major. Minor complications, such as bruising, hematoma, phlebitis, temporary numbness, or localized vein induration, are uncommon with modern radial-fiber systems and optimized tumescent anesthesia. Earlier studies using first-generation bare-tip fibers reported higher rates of minor complications; however, these are no longer representative of current radial-fiber techniques.^[12][13] Major complications, including deep vein thrombosis (DVT), nerve injury, skin burns, or pulmonary embolism, are rare (<1%).^[14][15] Serious ocular injury from reflected laser light is extremely rare and can be prevented by the use of appropriate protective eyewear.^[16]

Endovenous thermal ablation (EVTA), including endovenous laser treatment and radiofrequency ablation, is well-established as a safe and effective first-line treatment for saphenous vein reflux. Modern long-term studies and international guidelines have confirmed that these procedures provide outcomes comparable or superior to traditional high ligation and vein stripping, with a lower risk of complications.^{[17][18][19][20]}

Historically, early reports from individual practices (e.g., 2005–2008) summarized results of several hundred to a thousand treated limbs, showing initial vein closure rates around 98% and low rates of complications such as temporary paresthesia or deep vein thrombosis (<0.5%). While these studies provided the first evidence of effectiveness, more recent randomized trials and registry data have confirmed and extended these findings with longer follow-up and broader patient populations.

These minimally invasive techniques are typically performed under tumescent local anesthesia, avoiding general or regional anesthesia.^[21] Minimal blood loss allows treatment of patients on anticoagulants without interruption, and other medications can generally be continued.^[22] Access to the vein requires only a very small puncture (usually ≤1 mm), which minimizes scarring and reduces the risk of bleeding or wound infection. The treated vein remains in the body and is gradually resorbed over several months, leading to less postoperative pain, fewer bruises, and lower rates of nerve injury compared with open surgery.^[23][24] Treatment times are short, and patients usually experience rapid recovery and minimal time off work.^[25][26]

Current international guidelines support the preferential use of endovenous thermal procedures as first-line therapy for refluxing saphenous veins. For example, the European Society for Vascular Surgery (ESVS, 2022)^[27] recommends EVTA over open surgery when technically feasible, and similar recommendations are provided by the Society for Vascular Surgery (SVS, USA)^[28] and NICE (UK)^[29].

Patients are usually fitted with Class 3 (30-40mmHg) graduated compression stockings and/or bandages for a limited period, typically 1-2 weeks. Duplex ultrasound is used during follow-up to assess the success of the procedure, detect any endothermal heat-induced thrombosis (EHIT) or deep vein thrombosis (DVT), and determine whether additional treatments, such as sclerotherapy, are needed.

• Interventional radiology

Wikimedia Commons has media related to Endovenous laser treatment.

• American College of Phlebology
• Vascular Web - Varicose Veins