Stripping of the vein requires additional incisions at the knee or below the knee and is associated with a high incidence of minor surgical complications. Avulsion phlebectomy requires multiple 2- to 3-mm incisions along the course of the vein and can cause damage to adjacent nerves and lymphatic vessels.

Ablation of the vein by endovenous laser therapy (EVLT) is a newer procedure that is less invasive than surgery and has a lower complication rate. The procedure is well tolerated by patients and produces good cosmetic results. Excellent clinical results are observed at 2-4 years, but the long-term effectiveness of EVLT is not yet known. The varicose recurrence rate is less than 7% after 2 years, a rate comparable or superior to that reported for surgery, US-guided sclerotherapy, and radiofrequency ablation.

EVLT works by means of thermal destruction of the venous tissues. Laser energy (most commonly from an 810-nm diode laser) is delivered to the desired location inside the vein through a bare laser fiber that has been passed through a sheath to the desired location. When the laser is fired, it deposits thermal energy in the blood and venous tissues, causing irreversible localized venous tissue damage. The laser is repeatedly or continuously fired as the laser fiber is gradually withdrawn along the course of the vein until the entire vessel is treated. Although a hole may be created in the vessel wall where the laser beam makes contact with it, permanent ablation of the vein is caused by thermal injury to the entire circumference of the vessel.

Many laser sources are available for medical applications, and many lasers may be effective for endovenous ablation. The Diomed 810-nm laser is the system that has been used in most published studies to date, with a 940-nm diode laser also demonstrating good results in a smaller number of patients.

Follow up

Compression is vitally important after any venous procedure. Compression can reduce the (theoretic) risk of venous thromboembolism in the treated and untreated leg, and it is also highly effective in reducing postoperative bruising and tenderness.

Postoperative bruising can be significant after EVLT, but it is much less prominent when lidocaine with epinephrine is used as the local anesthetic. Bruising may be completely absent in patients who wear compression hose continuously during the first 3 days after treatment. Postoperative tenderness after day 3 has also been reported, and it may be related to the amount of intravascular coagulum in the closing vessel. Tenderness is usually not observed in patients who wear compression hose continuously during the first 3 days after EVLT.

Except when used by experts, wrapped bandages do not provide a safe or effective means of compression. Bandages may slip spontaneously, or the patient may remove them and reapply them incorrectly. The loss of gradient compression with the development of a tourniquet syndrome can increase the patient's risk for distal venous stasis and venous thrombosis. In the United States, gradient compression is most often applied by using surgical compression stockings. At least 30-40 mm Hg of compression is necessary for effective compression of the superficial veins.

Immediately after the procedure, a class II compression stocking (ie, one with a gradient of 30-40 mm Hg) is applied to the treated leg. Panty hose–style stockings, with compression applied to both legs, are preferred because the risk that the stocking will slip or roll is less. The stockings are worn for at least 1 week; they are kept in place continuously for the first 72 hours, but they may be removed for showering thereafter. Bedrest and heavy lifting are forbidden, but normal activity is otherwise encouraged.