The information provided here comes from

The Mapperley park Clinic (lasers and light) www.mapperleypark.co.uk

and Mr Bruce Braithwaite (surgical procedures) www.braithwaite.webden.co.uk

A good source of further information can be found at www.wikipedia.co.uk.

 

Vascular lesions are defined here as malformations of the arterial or venous systems causing visible lesions that may be congenital or acquired.

 

Vascular lesions may be single blood vessels (thread and varicose veins), collections of blood vessels (spider naevi and port-wine stains) or blood-rich structures (angiomas and haemangiomas).

 

Vascular lesions may be treated in a number of ways, largely breaking down as:

• Lasers and Intense Pulsed Light - the use of an external light source to damage or disrupt the target without surgical intervention.
• Surgical Avulsion - of varicose veins.
• EndoVenous Ablation - removal of varicose veins using laser or radio-energy.
• Sclerotherapy - the injection of sclerosing substances designed to damage vessel walls causing collapse and disappearance of the vessel.
• Varicofoam - Foam Sclerosants that are used on larger vessels.

 

What are Lasers and Intense Pulsed Light?

Lasers and Intense Pulsed Light (IPL) sources are simply machines that deliver energy in the form of pulses of light. This light is absorbed by certain structures, such as blood vessels and converted to heat, causing damage.

 

Vascular lasers and light - how do they work?

Lasers and IPL are able to selectively target vascular structures because one of the properties of haemoglobin (the oxygen carrying property that gives blood its red colour), is that it absorbs light. This absorption is variable, so that some wavelengths (colours) of light are absorbed more strongly than others - red light for example is not absorbed very well at all, and is in fact mostly reflected, which is why blood appears to be red. Lasers can take advantage of this property to deliver light that can pass through skin and then be absorbed by vascular structures, which may be deep within dermal tissue.

 

When light is absorbed by haemoglobin, the energy is transferred, usually as heat and this heat can be used to damage or destroy the target structure while sparing the surrounding tissue. This process is known as selective photothermolysis and allows different laser/light sources to create different tissue effects.

 

We will look at some of these effects in a little detail but first, it is worth looking at the key features of light which enable lasers to target vascular structures so accurately and then to damage them in very specific ways.

 

Wavelength

Lasers are defined as ‘monochromatic' sources - that is, the wavelength of light produced is of a single wavelength (or a very narrow band). The wavelength of the energy produced by a laser is the signature of its source; for example, a 532nm wavelength means Frequency Doubled Nd:YAG (sometimes known as a KTP) laser .

IPL systems produce energy of a broad band rather than a single wavelength but both types of energy can be targeted at vascular structures quite effectively and, depending on the parameters delivered, cause a wide range of physical effects.

 

Pulse Duration and tissue damage

Both lasers and IPL deliver their energy as a 'pulse' of light - that is the energy is delivered across a defined pulse, the time-scale of which is very important in defining what type of damage is delivered.

 

Vascular lasers generally deliver 3 types of pulse (IPLs are restricted to long pulse delivery only):

 

Continuous Wave - energy is delivered as a long, continuous pulse (CW)

Long Pulse - each pulse is thousandths of a second long (Millisecond or ms)

Short-pulse - each pulse is millionths of a second long (microsecond)

 

CW pulses tend to be used only where large doses of energy are required to be absorbed slowly be large targets - some varicose vein treating lasers use a CW mode but it is more usual to measure the dose of light delivered as a number of pulses of fixed length.

 

Millisecond Pulses also deliver their energy relatively slowly so that this energy is gradually transferred as heat causing haemoglobin proteins to heat up in direct proportion to the amount of energy that is delivered; that is, the more energy, the more heat builds up in the target and the more damage that is done.

 

Microsecond Pulses deliver energy faster than haemoglobin molecules can absorb that energy as heat and some energy is transferred as a shock-wave that passes through the molecule very quickly and causes it to break into small pieces (while it is being heated).

 

These two mechanisms cause very different tissue effects.

 

In millisecond techniques, the amount of heat absorbed can be carefully calibrated to the size and type of vessel so that haemoglobin proteins are heated up and that heat is then allowed to radiate outwards to damage blood-vessel walls, causing them to collapse. In this way, it is possible to carefully seal up individual blood vessels. In both thread-vein and some varicose vein treatments, this long-pulse method is used to deliver virtually invisible blood vessel closure.

 

In microsecond techniques, the energy is delivered up to 1,000 times faster and this extra punch causes protein molecules, blood cells and even whole blood vessels to literally explode under the assault of rapid heating/mechanical shock. This is a very effective way of destroying a blood vessel but, the downside is that tissue debris is created that can take weeks and even months for the body to clear up.

 

Microsecond lasers in vascular treatments - in particular Dye Lasers - are usually restricted to situations where it is necessary to destroy large volumes of vascular materials and where the short term cosmetic effect is relatively unimportant. In practice, this limits such treatments to dense, superficial lesions such as port-wine stains and larger haemangiomas.

 

Microsecond pulsed Dye Lasers are not normally used for treatment of facial thread veins for while effective, the short-term cosmetic consequences are undesirable.

 

Conclusion on Lasers and IPLs

Different horses suit different courses. There is no single laser or IPL that can treat the entire range of vascular conditions.

 

The problem is that operators who have only one system may use that system rather than a more appropriate technology that they do not have. It is known as the nail syndrome

 

If all you have is a hammer, everything looks like a nail.

 

Make sure that your chosen practitioner has the range of technologies available to treat your condition appropriately and the expertise to use it.

 

 

 

 

What are Varicose Veins?

Veins are the blood vessels that return blood to the heart after the oxygen and nutrients have been delivered to tissue.

 

There are two main systems of veins in our legs. The deep veins that drain most of the blood and superficial veins which are close to the skin. There are two main veins in the superficial system: The Great saphenous vein which runs from our ankles to our groins on the inner side of our legs and the small saphenous system which runs from the ankle to the back of the knee on the outside of our legs.

 

If one thinks of the deep veins as the main motorways for blood to flow in, then the long and short saphenous veins are the A roads while the smaller superficial veins are the B roads and country lanes.

 

When we stand up, you can imagine that all the blood in veins would run down to our feet because of gravity. This does not happen because the veins in our legs have special non-return valves that allow blood to go towards the heart but not back to our feet. The veins are therefore one-way roads.

Varicose veins occur when the superficial veins near the skin become diseased so that they get bigger (dilate) and the valves break (incompetent). This means the veins become two-way roads so that they fill up instead when someone stands (reflux). If someone has varicose veins, when they stand up the veins become more visible or lumpy like bunches of grapes. The veins no longer work properly.

Are varicose veins common?

Yes, Varicose veins often run in families and nearly 4 in every 10 people in the country have varicose veins of some kind.

 

What problems do varicose veins cause?

For most people the only problem is that the veins do not look nice so some people do not wear shorts or skirts.

 

For some their legs ache after standing for long times. This can happen to people without varicose veins. In those with varicose veins, the refluxing blood fills veins in the calves. This blood stretches the muscles in the legs and makes them ache.

 

Some people find that their ankles swell at the end of the day. When they wake after lying in bed the swelling has gone. Swelling can be uncomfortable and is caused by fluid leaking out of the veins.

 

When varicose veins are more severe, the skin around the ankle can turn brown and can flake and itch. This condition is know as venous eczema or lipodermatosclerosis. If this occurs then there is a risk that an ulcer (sore) can develop around the ankle.

 

 

What should I do if I have varicose veins?

If you are concerned about your legs then you should first discuss the problem with your GP( family practitioner). They may refer you to a hospital doctor for a further opinion. Although any General Surgeon should be able to give sound advice, many would recommend that you should see a specialist vascular surgeon.

 

Why do varicose veins come back (recurrent varicose veins)?

There are several reasons for recurrent varicose veins:

1.    Inadequate surgery.

2.    Neovascularisation.

3.    Normal veins become varicose.

 

 

 

What are avulsions?

Avulsions is the name of the technique for removing lumpy varicose veins that cannot be treated by endovenous ablation or traditional surgery alone.

 

Avulsions can be performed under general and local anaesthesia.

 

In some patients, the veins are caused by a broken valve in the middle of the thigh or from within the pelvis. These veins can be treated by avulsions.

 

Avulsions are normally done as part of another procedure such as traditional surgery or EVA but can be the only part of an operation. The codes used for insurers are L8750 +L8751.

 

How is an avulsion done?

A small hole about 1mm  in diameter is made in the skin and the vein underneath is removed with a special hook until the vein snaps. Another hole is then made further along the vein and more is removed.

 

The whole varicose vein is therefore removed through several small nicks in the skin. They do not need to be stitched.

 

This part of the operation is not very painful and appears to be as uncomfortable as it would be if you fell into a thorn bush!

 

The created are so small that, after a few weeks, it is almost impossible to see where the vein has been treated. This therefore gives a good cosmetic result.

 

Are there any risks to avulsion surgery?

Yes. Apart from the risk of bleeding from the small hole made, some people can develop tender lumps under the skin. These settle with time and are very similar to a blood blister.

 

Some patients (less than 1 in 100) can develop a wound infection.

 

Some small nerves that give feeling to the skin can be damaged so the skin may feel numb to touch.

 

Spider veins can develop at the site of an avulsion and may require scelerotherapy.

 

Are there any alternatives to avulsions?

Apart from conventional avulsions, the veins can be treated with varicofoam.

 

 

 

What is Endovenous Ablation (EVA)?

Endovenous Ablation is the name for a new technique to remove varicose veins by heat sealing. There are 2 methods Radiofrequency and Laser. The VNUS Closure System is the most commonly used while an alternative is the Olympus CELON RFiTT system.There are many Laser systems available.

 

How does EVA work?

A fine tube (catheter) is passed through the skin near the knee and then threaded up the diseased Great (GSV)or Short saphenous vein (SSV). The catheter is attached to a power unit that heats up the end of the catheter. The heat seals the walls of the vein so that no blood can flow through it. The operation can be done under local and general anaesthetic (asleep) depending on your preference.

 

How is EVA different to traditional surgery?

If you have varicose veins then one of the causes is normally an incompetent Great or Small saphenous vein. Research has shown that it is important to remove this vein to treat varicose veins and reduce the chance of them coming back soon. Traditional surgery, frequently requires a cut in the groin or behind the knee to disconnect the vein and then it is removed by a stripping device. This can cause dramatic bruising. EVA  avoids the need for a cut and there is minimal bruising. This means people who have EVA can usually return to normal activity sooner  (often the same or next day) than those who have traditional treatment.

 

Is EVA  better than standard surgery?

It is now thought that EVA is superior than traditional surgery for the treatment of patients with Great and small saphenous varicose veins. Scientific studies have shown that the degree of pain after EVA is much less than traditional surgery. In addition, people who have EVA return to normal activity much more quickly.

 

Is everyone with varicose veins able to have EVA?

No. Some people have large, winding veins that are not suitable. Your Veincare specialist will be happy to discuss whether your veins are suitable for EVA.  Our research suggests that about 70% of people with varicose veins can be treated with EVA.

 

Is EVA all I need for my veins?

EVA will remove the major superficial veins, including the GSV , SSV and anterior thigh veins. It is, however, usually necessary to have the bulging veins around the calf, thigh and foot removed through small cuts called avulsions.

 

What is the catch?

EVA uses special catheters that cost several hundred pounds each. During the operation, an ultrasound machine has to be used and a technician is sometimes required to control it.

 

Will my insurance company pay for EVA?

EVA has been approved by the Government agency NICE. Most Insurance companies will now pay if the code used is L8540 or L8541.  Some insurance companies are not able to pay for the full cost of treatment so a supplementary fee may apply.

 

Why do some surgeons not offer EVA?

There may be many reasons. Some surgeons may not have been trained to use the technique or their hospital may not have approved it for use because of cost.

 

 

 

What is Sclerotherapy

Sclerotherapy is a technique for the removal of spider veins. One of two sclerosant compounds is usually used. The first is called Aethoxysclerol (Polidocanolum 600 and Ethanolum, Resinag AG). The second type is called Fibrovein (Sodium Tetradecyl Sulphate, STD pharmaceuticals). Both contain an irritant chemical that, when injected into the vein, cause inflammation to the lining of the vein. The walls of the vein then stick together and the blood stops flowing through them. After the injections, you may be asked to wear a pair of surgical stockings to help squash the vein. You will need to wear them for about 5 days, night and day.

 

What happens when I have sclerotherapy?

Sclerotherapy is done as an outpatient procedure. You will be asked to lie on a couch, using a tiny needle that is almost painless a small amounts of the sclerosant is injected into the vein (see the video to the right of this text)

 

If your spider veins look a little like a bush then he can usually treat the whole area with only one or two injections. Sometimes more injections are required.

 

After the injections, there may be a little bleeding from the 'pin-prick'. Plasters like 'Band-Aids' are used to cover the injection site. These can be removed later the same day.

 

What happens after sclerotherapy?

There will be a reaction in the area treated. The skin often turns pink and the spider veins can look much worse than before treatment. This is NORMAL. With time, the redness settles and becomes brown in colour as your body removes the treated vein.

 

The whole process can take several weeks so it is probably best to plan treatments when you do not want to expose your legs. Most patients have their sclerotherapy done in the Autumn or Winter. This gives time for the treatment to work, ready for the summer.

 

 

 

Do I need to restrict my activities after sclerotherapy?

No. After the treatment, you can walk out of the clinic and return to normal activities. Only if you have been asked to wear stockings will you need to abstain from some things. This will be discussed with you.

 

Are there any problems with sclerotherapy?

Rarely some people can have an allergic reaction to the injection.

 

Immediately after the injections, the skin becomes red and looks worse than before the injection. This redness settles down over a few days but the final result is not always complete for several months.

 

Your skin may become blistered at the site of an injection but this will heal.

 

The skin can get a brown discolouration where the injection has been but this is often not as obvious as the veins that have been injected

 

The veins can come back.

 

Very tiny red veins that look like matting can develop at the site of injections. This happens rarely and cannot be predicted. The matting can be treated by laser.

 

The treatment may not work completely. If this is the case, you may be suitable for laser treatment.

 

Will I need more than one treatment?

Sometimes it is necessary to have more than one treatment if you have a large number of veins and therefore you cannot have a large does of the injections.

 

Does sclerotherapy hurt?

Sclerotherapy uses very fine needles so the injections do no hurt too much. When the chemical is injected you may feel a tingling sensation and warmth in the area that has been treated.

 

 

 

What are Varicofoam Injections?

Foam Sclerotherapy is a new technique for treating veins and the Government agency NICE has issued information for people who are considering treatment.

 

Varicofoam is a form of sclerotherapy used to remove varicose veins. It is commonly called Ultrasound Guided Foam Sclerotherapy or UGFS. The latest name is endovenous chemical ablation (EVCA)

 

How does it work?

Using a special ultrasound machine (Duplex Scanner), the vascular surgeon will identify the veins in the leg that have blood flowing in the wrong direction.  With the use of local anaesthesia, A small needle is put into the affected vein and  a small amount of a chemical called a sclerosant (Fibrovein) is injected. Before the injection, the chemical is mixed with air or carbon dioxide to form Varicofoam.

 

When the Varicofoam is inside the vein, it pushes the blood out of the way so that the sclerosant can treat the lining of the vein. Once treated, the vein is squashed using a combination of bandages and elasticated stockings.

 

How is Varicofoam different to standard surgery?

Firstly the procedure can be performed under local anaesthetic so those people treated with the technique can get up and walk immediately without the side effects or worries of a general anaesthetic.

 

There are no cuts or stitches so the risks of infection and bruising are much less than standard surgery.

 

As there is no general anaesthetic, the procedure is much cheaper than traditional surgery.

 

Is Varicofoam all I need for my veins?

Varicofoam will remove the major superficial veins, including the Great and small saphenous veins as well as anterior thigh veins. It is, however, usually necessary to have any fine veins injected with another technique known as sclerotherapy.

 

What are the advantages of Varicofoam?

Apart from the lack of any cuts in the groin or on the leg, there is minimal bruising of the leg and people can return to normal activities straight after treatment?

 

What is the catch?

Those who are treated with varicofoam need to wear bandages and a stocking for 5 days and then a stocking for 2 weeks. This means it is difficult to have a shower or bath for the first week. Wrapping the bandaged leg in cling film or in a bin liner can allow showering without wetting the leg and bandages.

 

 

 

What does all this information mean in practice?

There is no single treatment, laser or light system that can deal with all types of vascular lesions.

 

A complete armoury of aesthetic vascular systems would include

 

• Surgical techniques for the avulsion of varicose veins      surgeon delivered.
• Endo-venous laser/RF for large varicosities                               surgeon delivered
• Foam sclerosant - for larger varicosities                                    surgeon delivered
• Microsclerotherapy - for fine veins
• a short wavelength device , such as an IPL or a KTP laser to target shallow structures effectively
• a long wavelength diode or Nd:YAG laser to target deeper structures.
• A short-pulse (µs) device such as a pulsed dye laser to deliver explosive energy to break up dense vascular lesions such as port-wine stains.

 

Given there is no one-size fits-all solution to vascular problems, a person seeking cosmetic vascular work should be careful about where they seek treatment from for there is clearly a significant investment required in both equipment and expertise to deliver effective treatments (with endo-vascular work requiring the expertise of an experienced vascular surgeon).

 

While it is possible for effective treatments to be carried out by a non specialist with an IPL machine, the range of treatments available is limited and may be over-stated.  More importantly, the equipment may be available but not the expertise to use it properly.

 

Always seek out a clinic registered with the Care Quality Commission.

 

 

 

 

 

 

 

 

 

 

 

Back to News