2 The procedure

2.1 Indications

2.1.1 Varicose veins are a sign of underlying venous insufficiency and affect 20–30% of adults. Long saphenous vein insufficiency is the most common form of venous insufficiency in people presenting with symptoms.

2.1.2 People with venous insufficiency may have symptoms of fatigue, heaviness, aching, throbbing, itching and cramps in the legs. Chronic venous insufficiency can lead to skin discolouration, inflammatory dermatitis, cutaneous infarction and ulceration in some patients.

2.1.3 Endovenous laser treatment is a minimally invasive alternative to surgical stripping of the long saphenous vein, which is an important part of the most common operation for varicose veins.

2.2 Outline of the procedure

2.2.1 Under ultrasound guidance and local anaesthesia, a catheter is placed into the long saphenous vein. A laser fibre is passed through it and positioned below the saphenofemoral junction. An anaesthetic agent is then injected, and the fibre is slowly withdrawn while energy from a diode laser (810 nm or 940 nm wavelength) is applied in short pulses. This is repeated along the entire length of the vein until the long saphenous vein is closed from the saphenofemoral junction to the point of access.

2.3 Efficacy

2.3.1 The evidence for efficacy was based on five case series. In these studies, the mean follow up ranged from 1 to 17 months. Saphenous vein closure rates were between 90% and 100%. One study reported a closure rate of 93.4% in patients followed up for 2 years (113/121 veins), and in 40 patients who were followed up for 3 years, no new recurrences were reported. For more details, refer to the Sources of evidence section.

2.3.2 Opinion varied among the Specialist Advisors as to the efficacy of the procedure. One Advisor stated that short-term results were favourable but that long-term results were still unknown. A second Advisor commented that durability of the procedure had been established, at least in the medium term, while a third Advisor felt that efficacy had not yet been established.

2.4 Safety

2.4.1 The most common complications reported in the studies were pain and bruising. In a case series report of 423 patients, 90% (381) of patients reported feeling tightness along the limb and 24% (102) of patients experienced bruising; this resolved within 1 month after treatment. Phlebitis was also reported in between 5% (21/423) and 12% (10/85) of patients. For more details, refer to the Sources of evidence section.

2.4.2 The Specialist Advisors listed the potential complications as sensory loss, skin burns and perforation of deep veins. One Advisor stated that endovenous laser treatment had fewer complications than standard surgical treatment, whereas another Advisor believed that the complication rate was unknown.

2.5 Other comments

2.5.1 It was noted that although the procedure may be effective in occluding the vein, few studies have reported on patient-orientated outcomes, such as improvement in symptoms.