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Regarding “Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: Thrombolytic occlusion after endoluminal thermal damage by laser-generated steam bubbles”

2003; Elsevier BV; Volume: 37; Issue: 1 Linguagem: Inglês

10.1067/mva.2003.33

1097-6809

Ronald G. Bush,

Venous Thromboembolism Diagnosis and Management

I am writing in regards to the published article by Proebstle et al in the Journal (J Vasc Surg 2002;35:729-36). To date, over 350 procedures have been done using the 940-nm diode laser in our clinics using a modification of techniques previously described.1Navarro L Min R Bone C. Endovenous laser: a minimally invasive method of treatment of varicose veins: preliminary observations using an 810-nm diode laser.Dermatol Surg. 2001; 27: 117-122Crossref PubMed Scopus (410) Google Scholar, 2Bush RG Hammond KA. Tumescent technique for long saphenous stripping.J Am Coll Surg. 1999; 189: 626-628Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar A total of 280 patients have been treated with follow-up of 18 months. Results at 18 months show that of 350 limbs treated for saphenous insufficiency, 14 had partial recanalization, for a complete closure of 96%. Of these with partial recanalization, two common factors are present. Either persistent retrograde flow persists through a large incompetent branch or perforator (Dodd's, Hunter's) or the saphenous vein is greater than 15 mm in diameter, signifying significant retrograde flow. Histologic analysis was performed on 20 treated vein segments. With 1-second duration at 12 joules, perforations of the vein do not occur, but there is complete destruction of the endothelium and subendothelium. This occurs when about 120 to 140 pulses are delivered throughout the course of the saphenous vein. The saphenofemoral junction remains open in all patients treated to date. Treatment starts 1 to 2 cm distal to the junction. The fact that microscopic examination reveals no endothelium and that the saphenofemoral junction remains open lends credence to the steam bubble theory proposed by Proebstle et al. However, in this author's experience, 15 joules at 1-second duration is not the optimal parameter to be used. With 1.2-second to 1.3-second durations, microperforation of the vein occurs with a resealing phenomenon. With this duration of pulsing, the lumen is reduced by half, resulting in less thrombus formation with less chance of recanalization. This phenomenon was verified by partial retrograde invagination stripping in four patients. The intense heat created seals the vein as the microperforations occur resulting in a reduced luminal area. Using longer pulsing durations, the saphenous vein becomes undetectable by ultrasound within 2 to 3 months in the majority of patients. Our clinics experience is in accord with the experience of Proebstle et al in that the EVLT procedure is safe and easily performed as an ambulatory procedure. To date, there have been no complications associated with this NO LABELCompetition of interest: Dr Bush has received a fee for speaking on the effects and therapeutic benefits of the 940-nm laser by Dornier but has not received any fees in the past year. NO LABELCompetition of interest: Dr Bush has received a fee for speaking on the effects and therapeutic benefits of the 940-nm laser by Dornier but has not received any fees in the past year.