Overview
Definition:
Endovenous Laser Ablation (EVLA) is a minimally invasive endothermal ablation technique used to treat symptomatic superficial venous insufficiency, primarily targeting the great saphenous vein (GSV) and small saphenous vein (SSV)
It involves the introduction of a laser fiber into the affected vein under ultrasound guidance, delivering thermal energy to ablate the vein intima, leading to venous occlusion and fibrosis
Peri-operative care encompasses the management of patients before, during, and immediately after the EVLA procedure to optimize outcomes and minimize complications.
Epidemiology:
Venous insufficiency affects a significant proportion of the adult population, with varicose veins being the most common manifestation, occurring in 10-30% of adults
EVLA has become a widely adopted treatment modality due to its efficacy, minimally invasive nature, and excellent patient tolerance
DNB and NEET SS candidates will encounter this topic frequently due to its prevalence in surgical practice.
Clinical Significance:
Effective peri-operative care is crucial for successful EVLA, influencing patient comfort, recovery speed, and the prevention of common complications such as bruising, phlebitis, and thrombophlebitis
Understanding these principles is essential for surgical residents to provide optimal patient management and achieve favorable long-term results in treating venous disease.
Indications Contraindications
Indications:
Symptomatic great saphenous vein (GSV) or small saphenous vein (SSV) reflux
Varicose veins causing pain, swelling, skin changes, or venous ulcers
Failure of conservative management
Patient preference for minimally invasive treatment
Presence of incompetent perforator veins requiring adjunctive treatment.
Contraindications:
Absolute contraindications include active deep vein thrombosis (DVT) or history of DVT, acute or chronic infection, severe peripheral arterial disease (PAD), inability to ambulate, pregnancy, and severe coagulopathy
Relative contraindications include significant comorbidities, untreated pelvic vein obstruction, and extensive superficial thrombophlebitis.
Preoperative Preparation
Patient Assessment:
Thorough medical history, including review of symptoms, prior venous procedures, and risk factors for VTE
Comprehensive physical examination to assess the extent of venous disease, including mapping of incompetent veins
Assessment of comorbidities and coagulation status.
Diagnostic Imaging:
Duplex ultrasound is essential for mapping venous anatomy, identifying reflux, and measuring vein diameter
This guides laser energy delivery and helps identify other incompetent tributaries or perforators.
Patient Education:
Detailed explanation of the procedure, expected outcomes, potential risks, and benefits
Instructions on pre-operative fasting, medication management (e.g., anticoagulants), and post-operative expectations regarding compression stockings and ambulation.
Medications:
Discontinuation of certain medications like aspirin or NSAIDs may be considered based on individual risk assessment for bleeding
Anticoagulation bridging may be required for patients on long-term anticoagulants, guided by specific protocols.
Consent:
Obtaining informed consent after a thorough discussion of the procedure, alternatives, risks, and benefits is paramount.
Procedure Technique
Anesthesia:
Local tumescent anesthesia is commonly used, infiltrated around the target vein under ultrasound guidance
Sedation may be administered for patient comfort
General anesthesia is rarely required.
Access And Cannulation:
Percutaneous puncture of the target vein, typically in the calf or ankle, using ultrasound guidance
A guidewire is advanced through the needle, and a sheath or catheter is inserted
The laser fiber is then passed through the sheath to the saphenofemoral junction (SFJ) or popliteal vein for GSV or SSV respectively.
Laser Energy Delivery:
The laser fiber is slowly withdrawn under real-time ultrasound visualization, delivering laser energy to ablate the vein wall
The wavelength, power, and energy density are adjusted based on vein diameter and the specific laser system used, following established protocols (e.g., 80-120 J/cm for 14-French catheter).
Adjunctive Treatments:
For larger veins or associated varicosities, ultrasound-guided foam sclerotherapy or phlebectomy may be performed concurrently or subsequently.
Postoperative Care
Immediate Care:
Application of firm compression stockings or bandages immediately after the procedure to minimize bruising and provide support
Patients are encouraged to ambulate within hours
Pain assessment and management with analgesics (e.g., paracetamol, NSAIDs if tolerated).
Medications:
Analgesics for pain relief
Anticoagulation (e.g., low molecular weight heparin or DOACs) may be prescribed for high-risk patients or those undergoing extensive procedures, although routine anticoagulation is debated and often guided by local protocols and patient factors.
Activity And Mobility:
Encourage regular walking and avoidance of prolonged sitting or standing
Patients can usually resume normal daily activities within 24-48 hours, with strenuous exercise avoided for 1-2 weeks.
Monitoring For Complications:
Educate patients on signs and symptoms of potential complications, such as persistent severe pain, swelling, redness, warmth, or shortness of breath
Advise them to seek immediate medical attention if these occur.
Follow Up:
Scheduled follow-up appointments are crucial
Typically, a follow-up duplex ultrasound is performed at 1-2 weeks post-procedure to assess venous occlusion and rule out DVT or recanalization
Subsequent follow-ups may be at 6 months and 1 year.
Complications And Management
Early Complications:
Bruising (ecchymosis) and hematoma: Common and usually resolve spontaneously
Pain and tenderness: Managed with analgesics and compression
Superficial phlebitis: Inflammation of a superficial vein, treated with compression, NSAIDs, and sometimes ambulation
rarely requires anticoagulation.
Late Complications:
Deep vein thrombosis (DVT): A rare but serious complication
Management involves anticoagulation
Persistent venous reflux: May require repeat treatment or alternative modalities
Skin burns or blistering: Usually due to excessive laser energy or inadequate tumescent anesthesia
Nerve injury: Rare, can cause paresthesia or numbness.
Prevention Strategies:
Adequate tumescent anesthesia, precise ultrasound guidance, appropriate laser energy settings, gradual withdrawal of the laser fiber, and immediate post-operative compression are key preventive measures
Careful patient selection and risk stratification are also important.
Key Points
Exam Focus:
Understand the indications, contraindications, and the role of duplex ultrasound in EVLA
DNB/NEET SS exams will test knowledge of peri-operative management steps, including compression, ambulation, and monitoring for DVT
Laser energy parameters and their impact on outcomes are also tested.
Clinical Pearls:
The success of EVLA is significantly influenced by meticulous pre-operative mapping and meticulous post-operative care
Always consider DVT as the most serious complication and have a low threshold for investigation
Educate patients thoroughly to ensure compliance with post-operative instructions.
Common Mistakes:
Inadequate tumescent anesthesia leading to pain and bruising
Incorrect energy settings causing incomplete ablation or thermal injury
Failure to adequately assess for DVT post-operatively
Insufficient patient education leading to poor compliance with compression and activity restrictions.