EVLT Type Procedures Worth It for Varicose Veins?

I am a 45 yr old female and have had varicose veins since age 28. I have been unable to wear shorts or skirts or a bathing suit in public for the last 10 years due to how thick and visible my varicose veins are. I've always worn compression hose. Due to aching, my primary dr. referred me to a vascular surgeon. Ultrasound was "normal" he said. He said continue the stockings nothing else. He said EVLT or like procedures are a waste of money. How can that be??

Doctor Answers 10

Reasons to undergo EVLT procedures

EVLT is specifically indicated for the endovenous ablation of the greater saphenous vein in cases of venous reflux.  If your ultrasound is normal, chances are you would not benefit from EVLT. 

Los Angeles Plastic Surgeon
4.8 out of 5 stars 90 reviews

Treating veins using EVLT

it is definitely worth it to have your veins treated. I have many people like you who had them for years with a significant impact on their quality of life

Varicose Veiins with normal ultrasound

Thanks for posting your case. Varicose veins are most commonly seen in the presence of reflux. The ultrasound did not show this in your case. Keep in mind the ultrasound has some limitations. First, the ultrasound technician may have missed the reflux. Second, you may have been dehydrated which can effect the ability to detect reflux. It never hurts to have a second opinion. Finally, the varicose veins may not be coming from the greater saphenous or small saphenous veins (the two most common problem veins). You may be seeing reflux occurring from a branch not looked at during the ultrasound. Even if there isn't reflux you can pursue an ambulatory phlebectomy to remove the varicose veins. Be well, Dr. M

Jared Mallalieu, DO
Annapolis General Surgeon
5.0 out of 5 stars 4 reviews

Get second opinion.

Varicose veins are almost always due to leaking(refluxing) valves of the saphenous system.  However, they can also be due to refluxing valves of other veins such as the small saphenous vein, anterior accessory saphenous veins, pelvic or pudental veins, etc. The bottom line is that, if you do have varicose veins, then there has to be a cause and it is probably a refluxing valve somewhere.  The physician  needs to identify it with a complete venous reflux ultrasound.  You should see a vein specialist who has experience in treating these problems.  

John Landi, MD
Naples General Surgeon
5.0 out of 5 stars 5 reviews

Leg Varicose Vein Procedures, EVLT, Effectiveness

I disagree with the vascular surgeon who saw you and would recommend that you get a 2nd opinion (and a repeat ultrasound as well) by another vascular surgeon, but one that specializes in vein treatments.  Based on the description you give, I think it is very likely that you have venous reflux disease and would benefit from treatment.  The only way to know if you would truly benefit from an EVLT is by getting a good quality venous reflux ultrasound of the legs.  Even if you are not a candidate for EVLT, there are plenty of other varicose vein treatments that you potentially could benefit from.  In my experience, about 70% of patients with varicose veins are candidates for the EVLT procedure.

In terms of the EVLT procedure itself, it is very effective (over 95% effectiveness rate) and is the most common procedure used for treatment of varicose veins in the United States.

EVLT and Venefit Procedures Treat Venous Reflux Disease and Not Varicose Veins - Buffalo, NY

EVLT and VNUS Closure are FDA approved to treat venous reflux disease and not necessarily varicose veins. The VNUS Closure procedure is now called the Venefit Procedure. Often, with EVLT and VNUS Closure procedures the burden of visible varicose veins are reduced. Varicose veins may need additional treatments such as microphlebectomy and sclerotherapy. Read the EVLT book provided on the link below. 

Endovenous treatment for reflux associated with varicose veins

since you have pain, varicose veins and have worn compression hose without improvement I would recommend a repeat duplex exam done elsewhere.  The odds are you have venous reflux of the superficial saphenous system.  I personally recommend and perform VNUS endovenous (RF) radiofrequency ablation of the affected saphenous veins since I feel it is safer and less traumatic than EVLT (laser).  RF uses temperatures of 85 or 120 degrees celcius and EVLT (laser) uses temperatures of 700 degrees celcius and depends on the surgeons ability to 'pull back the catheter' at a given rate.  RF does not require the treatment to depend upon 'rate of pull back'.  I personally have had RF on one leg and it is the best thing I have ever done for myself.  Reasearch has also shown that RF is 97% successful in multicenter trials and post operative bruising and pain is much less than EVLT. Hope this is helpful.  You can find a local surgeon at www . VNUS . com

Louise Ferland, MD
Richmond Plastic Surgeon
4.2 out of 5 stars 11 reviews

Symptomatic varicose veins can be treated in many ways

If some time has passed since your last evaluation, I would consider getting another duplex ultrasound evaluating the deep and superficial venous systems for venous reflux. Occasionally, reflux is not apparent or difficult to see on certain days. It sounds like you have symptomatic venous disease. If reflux is NOT found again then  superficial foam sclerotherapy or microphlebectomy can also be good options for localized disease and pain relief.

Kevin M. Johnson, MD, FACS
Spokane General Surgeon
4.1 out of 5 stars 14 reviews

Varicose veins treatment

EVLT and simmilar procedures work very well, I have seen very good results.

Those veins that EVLT cannot reach or get, can be treated by surgical excision through very small incisions along the course of the vein.

Samir Shureih, MD
Baltimore Plastic Surgeon
5.0 out of 5 stars 6 reviews

Venous obstruction can give aching painful legs that may need more than just EVLT

You probably have problems that are deeper than just varicose veins.   There are different types of deep venous obstruction and deep venous obstruction is not treated by EVLT. 

LONG ANSWER:  EVLT works for veins that are bad in certain superficial Saphenous Veins.  An ultrasound ordered by a board certified vascular surgeon would be able to determine this.   As your vascular surgeon's ultrasound examination was "normal" your vascular surgeon knows that although the superficial veins are aching and painful, they won't just get better with EVLT or other simple procedures.  Your vascular surgeon also knows from this initial ultrasound that your deep veins are not completely blocked either. 

Venous Obstruction:  There are two types of venous obstruction.  Venous obstruction can either be completely blocked or not completely blocked.  The physician terminology is Occlusive or NON-occlusive venous obstruction.  As your ultrasound was "normal" you don't have occlusive venous disease.  Non-occlusive venous occlusion is generally painful. 


Deep venous occlusion:  A duplex ultrasound can generally tell if your deep veins are occluded (completely blocked).  Think of it like a helicopter sent up to see why traffic is being held up for miles.  If a bridge collapses it is obvious and the helicopter can report back to the newscaster (in this case your vascular surgeon) a certain bridge is out and this needs to be rebuilt or bypass road needs to be built.

Deep venous NON-occlusive obstruction:  Even if there is not a "bridge out" traffic can still get backed up for miles.  Only one single lane out due to a minor fender-bender can do this.  On the other hand it might be just increase in traffic around one or two corners in front of and behind a mountain at a certain times of day.  It can also be combination of both.  Endovenous stenting works because it is like adding the few lanes here and there to keep traffic from being backed up for miles. 

Q:  How does my vascular surgeon tell if I have the NON-occlusive type of venous obstruction and if so what to do about it? 

A:  Although NON-occlusive venous obstruction is common the testing is very extensive so the first test is to gauge your pain.  Your vascular surgeon needs to know your pain is chronic and won't just get better on its own (like clearing up a fender bender in the above example).   If pain your pain is bad enough to go back and sit in the waiting room all day again that is the first test to suspect significant non-occlusive venous obstruction. 

Treatment for NON-occlusive venous obstruction involves Conservative Management (which you are doing with the compression stockings and leg elevation) and surgical treatment such as endovenous angioplasty and stent placement for Quality of Life issues.  The evidence based medicine recommendation by the American Venous Forum Handbook of Venous Disorders 3rd edition is Class 1A . This is the highest recommendation given by this group.

Traffic Analogy:  Unless you had multiple helicopters in the air all the time it is difficult to tell where to expand the road, you won't look into it unless people are complaining.

Orthostatic Pain:  This means pain in your legs when you are standing up but not when you are lying down.

Visual Analogue Scale (VAS):  This scale ranges from 0 no pain, to 10 the worst possible pain.  For orthostatic pain we are interested in the last four weeks.   Rate your pain in the right leg and the left leg.  Usually endovenous stenting is considered when the pain is 5 or more, although some patients will qualify with less pain.

Quality of Life:  What we mean are certain patient surveys that have been validated (that means checked out and that they are valid).  Copies of these surveys are available for your physician at the end of the American Venous Forum Handbook of Venous Disorders 3rd edition (these are not available in the online edition).

Venous angioplasty and stenting of patients with orthostatic pain is reserved for those that want relief of their symptoms which are pain and swelling.  EVLT may be indicated at the same time as the angioplasty and stent placement due to the changes in the "traffic flow" brought out by the stent placement.  The veins bulging out of the skin can also be removed at the same time.

Unfortunately, the testing involved at this time to decide whom to treat is so involved that very few centers around the country are actually offering this type of very involved testing to treat NON-occlusive venous obstruction. 

Peter Neglen, MD, PhD has been charged with coming up with a dedicated venous stent.  He and Dr. Seshadri Raju, MD (president-elect of the American Venous Forum) are recognized world-wide as the foremost experts in this type of problem and their office is Flowood, Mississippi (a suburb of Jackson).  An evaluation there will require additional ultrasound testing as well as testing involving needles in your arms legs and feet and even a dye test of your veins.  If you qualify for a procedure you should plan to stay for at least a week.  An endovenous stent is a stainless steel device (much like a spring) that is permanently implanted and guided by IntraVascular UltraSound IVUS.  Generally more than one stent is required to be placed at the same time.  These stents have been followed for more than 10 years and this long-term data for relief of pain and swelling from Dr's Raju and Neglen is excellent. 

This particular problem although common is generally not mentioned precisely because no single good test exists for it.  All of the extensive testing and follow-up that is tough on both the patient and the vascular surgeon/ vascular lab to swallow. 

How would you feel if you had all kinds of tests and needles, then found out you actually were NOT a candidate for an endovenous stent?

Wearing stockings and waiting another few years to see if the testing for the endovenous angioplasty and stenting for non-occlusive iliac venous obstruction gets simpler is certainly a very prudent option.  Even office and outpatient clinics such as ours are beginning to develop the infrastructure to offer the testing required.  Until there is patient demand most vascular labs simply cannot justify the cost.

If your VAS score is 5 or more go BACK to your local vascular surgeons office and ask for your Quality of Life survey (be ready to tell the office staff where to find it in the book referenced above).  Then ask your local vascular surgeon when extensive testing based on Dr. Neglen's vascular lab may be available.  Remember that endovenous stent placement is based upon Quality of Life and is being pushed by the patient demand not by the medical device industry. 

However, if you just can't take it any more in 2010, and can afford to take off at least a week and travel to Flowood/Jackson, Mississippi an endovenous stent might just put that SPRING back in your step.

John W. Hovorka, MD
Austin General Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.