1. Endovenous Laser Therapy for Lower Limb Varicose Veins: intermediate outcomes of 800 limbs. Khalid AL-Ghamdi, MD Vascular Fellow, King Saud University Vascular Fellow, King Saud University King Khalid University Hospital. Riyadh, Saudi Arabia

2. Endovenous Laser Therapy for Lower Limb Varicose Veins. Therapeutic Options for truncal varicose veins Open procedures: High ligation :High ligation : Barrier techniques. Barrier techniques. Stripping :Stripping : Invagination. Cryostripping. Electrical stripping. Endoscopic stripping.

3. Endovenous Laser Therapy for Lower Limb Varicose Veins. Therapeutic Options for truncal varicose veins Endovenous procedures: Endothermal obliteration:Endothermal obliteration: - Radiofrequency ablation (RFA) - Radiofrequency ablation (RFA) VNUS Closure plus & fast. Celon RFITT - Laser Therapy (ELT) 810 – 1470 nm Bare fiber Cylindrical diffuser Radial fiber

4. Endovenous Laser Therapy for Lower Limb Varicose Veins. Therapeutic Options for truncal varicose veins Endovenous procedures: Chemical obliteration: Ultra-sound Guided Foam Sclerotherapy.Ultra-sound Guided Foam Sclerotherapy.

5. Endovenous Laser Therapy for Lower Limb Varicose Veins. First Publication of Endovenous Laser Endovenous Laser : a new minimally invasive method of treatment for varicose veins – preliminary observation using an 810 nm diode laser. Endovenous Laser : a new minimally invasive method of treatment for varicose veins – preliminary observation using an 810 nm diode laser. Navarro L et al Dermato Surg 2001:27(2):117-22. Vein treatment Center & Beth Israel Medical Center.NY,USA.

6. Endovenous Laser Therapy for Lower Limb Varicose Veins. Interventions for varicose veins Millennium Research Group – Market Growth in Varicose Veins Procedures (USA)

7. Endovenous Laser Therapy for Lower Limb Varicose Veins. How EVLT Work VEIN WALL CATHETER FIBER BLOOD LASER BEAM HEATING INTERACTION GEOMETRY irreversible localized venous tissue damage

8. Endovenous Laser Therapy for Lower Limb Varicose Veins. Tissue Ablation 10 C – 45 C: Conformation change of proteins 50 C: Reduction of enzyme activity 60 C: Denaturation 100 C: Water vaporizes Thermal damage

9. Endovenous Laser Therapy for Lower Limb Varicose Veins. Endolaser Available Wave Lengths: 810 nm - Dropped.810 nm - Dropped. 940 nm.940 nm. 980 nm.980 nm. New 1320.New 1320. New 1470 - The best so far.New 1470 - The best so far.

10. Endovenous Laser Therapy for Lower Limb Varicose Veins. EndolaserAdvantages: Efficient : more than 95%.Efficient : more than 95%. Adapt energy according size of the vein.Adapt energy according size of the vein. Adapt energy according depth of the vein.Adapt energy according depth of the vein. Less painful & less ecchymosis with 1470nm.Less painful & less ecchymosis with 1470nm.

11. Endovenous Laser Therapy for Lower Limb Varicose Veins. Objectives Early & Intermediate Early & Intermediate Outcomes of EVLT in patients with varicose veins.

12. Endovenous Laser Therapy for Lower Limb Varicose Veins. Methods Study Design Prospective Non – Randomized Clinical Trial Setting Vascular Surgery Division - KKUH Period March 1,2006 – february 28, 2013

13. Endovenous Laser Therapy for Lower Limb Varicose Veins. Methods Inclusion Criteria Patients with incompetent GSV & SSV Intervention EVLT using 980-nm and 1470-nm laser tumescent local anaesthetics tumescent local anaesthetics Follow - up Venous Duplex at 1week and 6months

14. Endovenous Laser Therapy for Lower Limb Varicose Veins. Results Demographics: Demographics: Patients625 Limbs867 Mean Age35 Female72% CEAP85% C2 General Anesthesia was used in 0.6%

15. Endovenous Laser Therapy for Lower Limb Varicose Veins. Results Intervention : Average voltage used 14.6W ( range 10 to 15W).Average voltage used 14.6W ( range 10 to 15W).

16. Endovenous Laser Therapy for Lower Limb Varicose Veins. Results Concomitant avulsion phlebectomy 75.1% of limbs

17. Endovenous Laser Therapy for Lower Limb Varicose Veins. ResultsComplications: Significant bruising - 19%.Significant bruising - 19%. Superficial thrombophlebitis – 0.5%.Superficial thrombophlebitis – 0.5%. No edema, excessive pain, haematoma or cellulitis.No edema, excessive pain, haematoma or cellulitis. Thrombus protruding into the lumen of common femoral vein was seen in 11 limbs (1.3%)Thrombus protruding into the lumen of common femoral vein was seen in 11 limbs (1.3%) Disappeared after 3 months. Disappeared after 3 months.

18. Endovenous Laser Therapy for Lower Limb Varicose Veins. Results

19. Results PreoperativePreoperative 2 days PO 2 weeks PO

20. Endovenous Laser Therapy for Lower Limb Varicose Veins. 82 Currently 82 articles have been published on RF obliteration and EVLT for treating varicose veins - English (68) - French (14) 19 ------------ compared RF versus EVLT but no RCT. 7 ------------ compared RF versus HL + Stripping +/Stab Avulsion including 4 RCT 1 ------------ compared RF, EVL, L+stripping Discussion

21. Endovenous Laser Therapy for Lower Limb Varicose Veins. Between Jan 1994 – Feb 2007 92% in the last 5 years 72 study arms, 81% prospective 7 RCTs 12320 limbs 2804 (23%) stripped 2126 (17%) UGFS 4876 (40%) EVLA 2514 (20%) RFA

22. Endovenous Laser Therapy for Lower Limb Varicose Veins. Meta-analysis

23. Meta-analysis Anatomical Success Rate

24. Endovenous Laser Therapy for Lower Limb Varicose Veins. Early technical success EVLT-Duplex findings<6months. Early technical success EVLT-Duplex findings<6months. KKUH 2013 86798.3% Occlusion at 6 months

25. Endovenous Laser Therapy for Lower Limb Varicose Veins. Conclusion standardizing an effective method EVLT treatment is coming closer to the goal of standardizing an effective method for the treatment of varicose veins Further controlled studies are required to compare optimized EVLT treatment protocols with not only other endothermal modes of treatment but also with conventional open surgery

26. Endovenous Laser Therapy for Lower Limb Varicose Veins. Conclusion Early and intermediate results of EVLT are excellent.Early and intermediate results of EVLT are excellent. Greater doses of energy delivered are associated with better results.Greater doses of energy delivered are associated with better results. Long term follow - up is required to confirm the durability of EVLT.Long term follow - up is required to confirm the durability of EVLT.

27. Endovenous Laser Therapy for Lower Limb Varicose Veins. King Khalid University Hospital