An Expert Look at Treating
Leg Veins
July 2004
L aser therapy for varicose veins and other leg vessel conditions is a hot technology for dermatologists. But while the procedure is touted as a minimally invasive, highly successful and nearly pain-free alternative to conventional vessel surgery, is its press better than its performance?
To answer this question and to discuss specific methods for successfully treating leg veins, a panel of experts met during this year’s American Society for Laser Medicine and Surgery (ASLMS) meeting, offering their expertise on everything from treating veins intravascularly to treating telangiectatic matting.
Sclerotherapy’s Role
According to the panelists, sclerotherapy remains the gold standard for treating most leg veins, but lasers certainly have their place, as the panelists noted.
“If you critically look at the literature, at least in my opinion, it takes at least three laser treatments to do what one sclerotherapy treatment can do,” explained Dr. Mitchel P. Goldman, an Associate Volunteer Clinical Professor of Dermatology and Medicine at the University of California at San Diego and Medical Director of La Jolla SpaMD, who participated on the panel.
The biggest drawback of laser therapy for leg veins, Dr. Goldman said, is that doctors have to “spot-weld” blood vessels. But this allows the endothelial cells to migrate and re-establish the conduits that reopen the veins. “So, in my practice, the use of the external types of lasers is limited, and I only use them after I have finished treating with sclerotherapy and a few vessels remain. In addition, laser can be effective when patients just have the fine blushing telangiectasia that persist after sclerotherapy or have veins that are too small to be treated with sclerotherapy.”
For vessels on the face, Dr. Goldman primarily uses the long-pulsed 1064 nm lasers, to treat the lateral-orbital and infra-orbital rim vessels. He typically uses intense pulsed light to treat other types of facial vessels.
Panel member Dr. Arielle N. B. Kauvar, Clinical Associate Professor of Dermatology at New York University School of Medicine, in New York City, and founding director of New York Laser & Skin Care, said she performs “a lot of sclerotherapy and uses lasers for resistant vessels or very fine telangiectasia because sclerotherapy is a difficult method of treatment for someone covered with telangiectasia.”
Dr. Brian D. Zelickson, a dermatologist at the University of Minnesota and a panelist at the meeting, said he also frequently uses external lasers in patients who “have either failed regular sclerotherapy, have developed matting of the vessels, or they have vessels that are small enough that a needle can’t easily be inserted into them. In addition, external lasers are ideal for certain areas, such as around the ankles where these lasers work quite well.”
Dr. Zelickson has tried many types of lasers, and each has its virtues. “My laser of choice depends on the indication,” he said. For patients with very pale skin, a long-pulsed KTP or 532 nm works best, although “you have to be very careful because of the pigment absorption there,” he noted.
He has also used long-pulsed pulsed dye lasers, but he prefers the KTP device because the pulsed dye lasers can lead to purpura, which in turn can cause hyperpigmentation after treatment. His group has seen good results with longer pulsed Alexandrite lasers, as well as long-pulsed and high-powered Nd:YAG lasers. “Using a very small spot size you can get some of the smaller red vessels, but they also work quite well with some of the burgundy or bluish colored vessels,” he explained.
Treating Veins Intravascularly
When it comes to treating large, finger-sized varicose veins, Dr. Goldman said he prefers to use intravascular lasers as opposed to either external lasers or sclerotherapy. “Of course, we can use foam sclerotherapy agents, but there are a number of potential side effects, especially air embolisms, that can occur from injecting very large veins. I’ve found that the use of intravascular lasers for this purpose is very efficient.”
Getting to that point took a little ingenuity, Dr. Goldman said. “The laser companies started with an 810 nm diode laser just because that was a laser that they had, and that’s probably one of the least efficient and the least beneficial lasers that you can put inside of a vein.”
The 810 nm diode laser produced explosive holes in the vein, leaving patients with ecchymosis and pain for a few days. Dr. Goldman and colleague, Robert A. Weiss, Director of the Maryland Laser, Skin and Vein Institute in Hunt Valley, discovered that the best laser for intravascular work would be one with a 1320 nm wavelength. They approached a laser manufacturer with the specifics, and the company made a laser and developed a way to withdraw the fiber through the vein, allowing standardized treatment.
Data to be published soon show a near perfect success rate at treating saphenous veins of up to 1 cm with the 1320 nm laser, Dr. Goldman said. “There have been no holes produced in the veins, and patients have minimal, if any, ecchymosis and no post-operative pain. So I think that the primary role of lasers, at least in my practice, is intravascular.”
Combining Treatments Using Sclerotherapy and External Lasers
Of course, leg vein therapy doesn’t have to be all or nothing. Some doctors report using a combination of external lasers and sclerotherapy with near-uniform success. One reason for the synergy may be that the initial dose of laser energy creates a lesion in the vessel that allows the sclerotherapy injection to linger longer in the leg. That boosts its effectiveness while preventing the formation of clots.
Dr. Goldman, who has published research on the combination treatment, considers the approach “very excellent” in theory. However, he cautioned, when treating with a laser followed by sclerotherapy, or the other way around, the result can be hard to control. In his own research, he said, he’s found that the joint therapy often led to excessive hyperpigmentation and even epidermal necrosis.
In that study, Dr. Goldman explained that his group was using a 0.25% polidocanol solution (considered “very weak”) for sclerotherapy along with a modestly effective 585 nm pulsed dye laser with 7 J/cm2, a 5-mm spot size, and a 0.5 ms pulse duration. “Either one alone had very minimal effects on the vessel, but when used together they had massive effects.”
In other words, he said, “you have to be extremely cautious because of the additive effect. The laser will disrupt the endothelium, and then when you follow it with sclerotherapy the sclerosing solution will react more significantly against normal endothelium.”
Different Lasers, Different Side Effects
External lasers cause different side effects depending on the quality of their light.
For example, with pulsed dye lasers, said Dr. Goldman, they may eliminate the blood vessels but leave hypopigmentation. “If patients have any tan on their legs or if they want to get tan later, you’re often left with hypopigmented circles” where the laser was used, he said. The procedure also carries a high risk of staining or browning from the iron in hemoglobin — or hyperpigmentation, which can last 6 months or more, he said.
Panelist Dr. Weiss said shorter wavelength green lasers typically provide “less complete healing of the vessel because [the energy is] so strongly absorbed by hemoglobin that the front 25% of the vessel is heated up so you’ll see immediate urticaria reaction. You’ll see methemoglobin formation and darkening of the vessel.
“As we get into the longer wavelengths that are absorbed more significantly by water as well, and not as well by hemoglobin — such as the 1064 nm and Nd:YAG — that’s a big advantage.”
But a blast from a 1064 laser takes at least 2 seconds or so for the heat to dissipate, Dr. Weiss said. “So if one does pulse stacking, with 1064 nm, you’re at high risk for developing a heat-inducing necrosis of the surrounding tissue. That’s one of the most worrisome side effects.”
In addition, Nd:YAG lasers, for example, are known to trigger prolonged spasms in the veins that complicate subsequent treatment with sclerotherapy injection. However, these spasms are temporary, and they don’t completely occlude vessels, experts said.
Because of the tissue heating caused by 1064 nm lasers, said Dr. Kauvar, “double pulsing is just absolutely contraindicated when you’re using these extremely high fluences.
“What’s best to do if you’re just starting out with a 1064 laser is not even apply the pulses contiguously but leave a pulse width of space between each pulse,” she added. “You might want to set your laser, depending on the laser you have, to a low rep rate so you don’t accidentally fire away in the same area.”
Although 1064 nm lasers do come with cooling systems, some doctors prefer alternatives. For example, Dr. Goldman prefers continuous cold air cooling or dynamic cooling to external methods like copper plates or even ice cubes; however, no method is fail-safe. And an inadequately cooled long-pulsed laser in the hands of all but the most expert physician is a recipe for poor outcomes, he said.
A counterpoint to diligent cooling should also be observed. Overzealous cooling can weaken a laser’s effectiveness, the experts said. “The lower the skin temperature, the lower the target vessel temperature will be as well,” Dr. Weiss noted.
Do Topical Anesthetics Curb the Pain?
Laser procedures can be painful, so what about offering patients topical anesthetics to prevent discomfort? That depends, said Dr. Zelickson. Generally, for small vessels that require KTP or visible light lasers, anesthesia isn’t necessary. “However, if we’re using some of the infrared lasers to treat the larger vessels, one of the big differences between that and sclerotherapy is the pain — it can be extremely painful.”
But Dr. Zelickson and other experts said they’ve seen little value in currently available products that can obscure target vessels by constricting them.
Dr. Kauvar has studied an experimental product, S-Caine, from Johnson & Johnson, that she said could be an effective option for leg laser surgery.
Dr. Goldman, however, injected a note of caution to his fellow dermatologists who are tempted to use anesthesia too liberally in leg vein procedures. “Although I’m nice to my patients and I like them, I think the problem of masking pain is that it will give you a false sense of security and you won’t realize how much perivascular damage you’re causing with a laser,” he said. “So I tend to be very opposed to using topical anesthetic agents when treating patients with the laser. Because if it is so painful that they can’t tolerate it, undoubtedly something bad is happening. And just like we wouldn’t give morphine to a patient with an acute abdomen, I don’t think we should be giving anesthetics when we’re doing laser procedures on the leg veins.”
Treating Telangiectatic Matting
This common, but thorny, problem for dermatologists can occur on its own or after a round of sclerotherapy. What causes the condition isn’t clear. It’s believed to be partly a problem of blood vessel growth and partly a problem of excessive dilation of existing veins, perhaps spurred by inflammation.
Dr. Zelickson said his group has had success treating more routine matting with high-powered long-pulsed KTP lasers and intense pulsed light. “With both of these technologies we employ cooling, and both have worked quite effectively.”
However, he explained, “we must use caution if the patient has some melanin on the skin.” Dr. Zelickson’s group has also used long-pulsed pulsed dye lasers, taking multiple passes at the veins, and seen good results. “But, again, you have to be careful of epidermal injury,” he noted.
Dr. Weiss cited unpublished data from his group, which has found that with bright red spider veins — which account for about 80% of patients — a regimen of glycerin injections directly into the area can resolve the discoloration.
Dr. Goldman suggested that treating matting with lasers is riskier, yet no more effective, than merely leaving it alone. “At least in my experience over 20 years or so, telangiectatic matting in 99% of [cases] goes away with time.”
Well-Rounded Advice
Although the panelists explained that they primarily chose sclerotherapy as a first-choice treatment for most leg veins, external lasers do play a role in all of their practices. In addition, intravascular use of lasers appears quite effective for larger varicose veins.
Effective cooling remains an issue with higher powered lasers, and topical anesthesia was often not employed because the general consensus was that it wasn’t effective and that an anesthetic could mask tissue damage caused by too high temperatures.
L aser therapy for varicose veins and other leg vessel conditions is a hot technology for dermatologists. But while the procedure is touted as a minimally invasive, highly successful and nearly pain-free alternative to conventional vessel surgery, is its press better than its performance?
To answer this question and to discuss specific methods for successfully treating leg veins, a panel of experts met during this year’s American Society for Laser Medicine and Surgery (ASLMS) meeting, offering their expertise on everything from treating veins intravascularly to treating telangiectatic matting.
Sclerotherapy’s Role
According to the panelists, sclerotherapy remains the gold standard for treating most leg veins, but lasers certainly have their place, as the panelists noted.
“If you critically look at the literature, at least in my opinion, it takes at least three laser treatments to do what one sclerotherapy treatment can do,” explained Dr. Mitchel P. Goldman, an Associate Volunteer Clinical Professor of Dermatology and Medicine at the University of California at San Diego and Medical Director of La Jolla SpaMD, who participated on the panel.
The biggest drawback of laser therapy for leg veins, Dr. Goldman said, is that doctors have to “spot-weld” blood vessels. But this allows the endothelial cells to migrate and re-establish the conduits that reopen the veins. “So, in my practice, the use of the external types of lasers is limited, and I only use them after I have finished treating with sclerotherapy and a few vessels remain. In addition, laser can be effective when patients just have the fine blushing telangiectasia that persist after sclerotherapy or have veins that are too small to be treated with sclerotherapy.”
For vessels on the face, Dr. Goldman primarily uses the long-pulsed 1064 nm lasers, to treat the lateral-orbital and infra-orbital rim vessels. He typically uses intense pulsed light to treat other types of facial vessels.
Panel member Dr. Arielle N. B. Kauvar, Clinical Associate Professor of Dermatology at New York University School of Medicine, in New York City, and founding director of New York Laser & Skin Care, said she performs “a lot of sclerotherapy and uses lasers for resistant vessels or very fine telangiectasia because sclerotherapy is a difficult method of treatment for someone covered with telangiectasia.”
Dr. Brian D. Zelickson, a dermatologist at the University of Minnesota and a panelist at the meeting, said he also frequently uses external lasers in patients who “have either failed regular sclerotherapy, have developed matting of the vessels, or they have vessels that are small enough that a needle can’t easily be inserted into them. In addition, external lasers are ideal for certain areas, such as around the ankles where these lasers work quite well.”
Dr. Zelickson has tried many types of lasers, and each has its virtues. “My laser of choice depends on the indication,” he said. For patients with very pale skin, a long-pulsed KTP or 532 nm works best, although “you have to be very careful because of the pigment absorption there,” he noted.
He has also used long-pulsed pulsed dye lasers, but he prefers the KTP device because the pulsed dye lasers can lead to purpura, which in turn can cause hyperpigmentation after treatment. His group has seen good results with longer pulsed Alexandrite lasers, as well as long-pulsed and high-powered Nd:YAG lasers. “Using a very small spot size you can get some of the smaller red vessels, but they also work quite well with some of the burgundy or bluish colored vessels,” he explained.
Treating Veins Intravascularly
When it comes to treating large, finger-sized varicose veins, Dr. Goldman said he prefers to use intravascular lasers as opposed to either external lasers or sclerotherapy. “Of course, we can use foam sclerotherapy agents, but there are a number of potential side effects, especially air embolisms, that can occur from injecting very large veins. I’ve found that the use of intravascular lasers for this purpose is very efficient.”
Getting to that point took a little ingenuity, Dr. Goldman said. “The laser companies started with an 810 nm diode laser just because that was a laser that they had, and that’s probably one of the least efficient and the least beneficial lasers that you can put inside of a vein.”
The 810 nm diode laser produced explosive holes in the vein, leaving patients with ecchymosis and pain for a few days. Dr. Goldman and colleague, Robert A. Weiss, Director of the Maryland Laser, Skin and Vein Institute in Hunt Valley, discovered that the best laser for intravascular work would be one with a 1320 nm wavelength. They approached a laser manufacturer with the specifics, and the company made a laser and developed a way to withdraw the fiber through the vein, allowing standardized treatment.
Data to be published soon show a near perfect success rate at treating saphenous veins of up to 1 cm with the 1320 nm laser, Dr. Goldman said. “There have been no holes produced in the veins, and patients have minimal, if any, ecchymosis and no post-operative pain. So I think that the primary role of lasers, at least in my practice, is intravascular.”
Combining Treatments Using Sclerotherapy and External Lasers
Of course, leg vein therapy doesn’t have to be all or nothing. Some doctors report using a combination of external lasers and sclerotherapy with near-uniform success. One reason for the synergy may be that the initial dose of laser energy creates a lesion in the vessel that allows the sclerotherapy injection to linger longer in the leg. That boosts its effectiveness while preventing the formation of clots.
Dr. Goldman, who has published research on the combination treatment, considers the approach “very excellent” in theory. However, he cautioned, when treating with a laser followed by sclerotherapy, or the other way around, the result can be hard to control. In his own research, he said, he’s found that the joint therapy often led to excessive hyperpigmentation and even epidermal necrosis.
In that study, Dr. Goldman explained that his group was using a 0.25% polidocanol solution (considered “very weak”) for sclerotherapy along with a modestly effective 585 nm pulsed dye laser with 7 J/cm2, a 5-mm spot size, and a 0.5 ms pulse duration. “Either one alone had very minimal effects on the vessel, but when used together they had massive effects.”
In other words, he said, “you have to be extremely cautious because of the additive effect. The laser will disrupt the endothelium, and then when you follow it with sclerotherapy the sclerosing solution will react more significantly against normal endothelium.”
Different Lasers, Different Side Effects
External lasers cause different side effects depending on the quality of their light.
For example, with pulsed dye lasers, said Dr. Goldman, they may eliminate the blood vessels but leave hypopigmentation. “If patients have any tan on their legs or if they want to get tan later, you’re often left with hypopigmented circles” where the laser was used, he said. The procedure also carries a high risk of staining or browning from the iron in hemoglobin — or hyperpigmentation, which can last 6 months or more, he said.
Panelist Dr. Weiss said shorter wavelength green lasers typically provide “less complete healing of the vessel because [the energy is] so strongly absorbed by hemoglobin that the front 25% of the vessel is heated up so you’ll see immediate urticaria reaction. You’ll see methemoglobin formation and darkening of the vessel.
“As we get into the longer wavelengths that are absorbed more significantly by water as well, and not as well by hemoglobin — such as the 1064 nm and Nd:YAG — that’s a big advantage.”
But a blast from a 1064 laser takes at least 2 seconds or so for the heat to dissipate, Dr. Weiss said. “So if one does pulse stacking, with 1064 nm, you’re at high risk for developing a heat-inducing necrosis of the surrounding tissue. That’s one of the most worrisome side effects.”
In addition, Nd:YAG lasers, for example, are known to trigger prolonged spasms in the veins that complicate subsequent treatment with sclerotherapy injection. However, these spasms are temporary, and they don’t completely occlude vessels, experts said.
Because of the tissue heating caused by 1064 nm lasers, said Dr. Kauvar, “double pulsing is just absolutely contraindicated when you’re using these extremely high fluences.
“What’s best to do if you’re just starting out with a 1064 laser is not even apply the pulses contiguously but leave a pulse width of space between each pulse,” she added. “You might want to set your laser, depending on the laser you have, to a low rep rate so you don’t accidentally fire away in the same area.”
Although 1064 nm lasers do come with cooling systems, some doctors prefer alternatives. For example, Dr. Goldman prefers continuous cold air cooling or dynamic cooling to external methods like copper plates or even ice cubes; however, no method is fail-safe. And an inadequately cooled long-pulsed laser in the hands of all but the most expert physician is a recipe for poor outcomes, he said.
A counterpoint to diligent cooling should also be observed. Overzealous cooling can weaken a laser’s effectiveness, the experts said. “The lower the skin temperature, the lower the target vessel temperature will be as well,” Dr. Weiss noted.
Do Topical Anesthetics Curb the Pain?
Laser procedures can be painful, so what about offering patients topical anesthetics to prevent discomfort? That depends, said Dr. Zelickson. Generally, for small vessels that require KTP or visible light lasers, anesthesia isn’t necessary. “However, if we’re using some of the infrared lasers to treat the larger vessels, one of the big differences between that and sclerotherapy is the pain — it can be extremely painful.”
But Dr. Zelickson and other experts said they’ve seen little value in currently available products that can obscure target vessels by constricting them.
Dr. Kauvar has studied an experimental product, S-Caine, from Johnson & Johnson, that she said could be an effective option for leg laser surgery.
Dr. Goldman, however, injected a note of caution to his fellow dermatologists who are tempted to use anesthesia too liberally in leg vein procedures. “Although I’m nice to my patients and I like them, I think the problem of masking pain is that it will give you a false sense of security and you won’t realize how much perivascular damage you’re causing with a laser,” he said. “So I tend to be very opposed to using topical anesthetic agents when treating patients with the laser. Because if it is so painful that they can’t tolerate it, undoubtedly something bad is happening. And just like we wouldn’t give morphine to a patient with an acute abdomen, I don’t think we should be giving anesthetics when we’re doing laser procedures on the leg veins.”
Treating Telangiectatic Matting
This common, but thorny, problem for dermatologists can occur on its own or after a round of sclerotherapy. What causes the condition isn’t clear. It’s believed to be partly a problem of blood vessel growth and partly a problem of excessive dilation of existing veins, perhaps spurred by inflammation.
Dr. Zelickson said his group has had success treating more routine matting with high-powered long-pulsed KTP lasers and intense pulsed light. “With both of these technologies we employ cooling, and both have worked quite effectively.”
However, he explained, “we must use caution if the patient has some melanin on the skin.” Dr. Zelickson’s group has also used long-pulsed pulsed dye lasers, taking multiple passes at the veins, and seen good results. “But, again, you have to be careful of epidermal injury,” he noted.
Dr. Weiss cited unpublished data from his group, which has found that with bright red spider veins — which account for about 80% of patients — a regimen of glycerin injections directly into the area can resolve the discoloration.
Dr. Goldman suggested that treating matting with lasers is riskier, yet no more effective, than merely leaving it alone. “At least in my experience over 20 years or so, telangiectatic matting in 99% of [cases] goes away with time.”
Well-Rounded Advice
Although the panelists explained that they primarily chose sclerotherapy as a first-choice treatment for most leg veins, external lasers do play a role in all of their practices. In addition, intravascular use of lasers appears quite effective for larger varicose veins.
Effective cooling remains an issue with higher powered lasers, and topical anesthesia was often not employed because the general consensus was that it wasn’t effective and that an anesthetic could mask tissue damage caused by too high temperatures.
L aser therapy for varicose veins and other leg vessel conditions is a hot technology for dermatologists. But while the procedure is touted as a minimally invasive, highly successful and nearly pain-free alternative to conventional vessel surgery, is its press better than its performance?
To answer this question and to discuss specific methods for successfully treating leg veins, a panel of experts met during this year’s American Society for Laser Medicine and Surgery (ASLMS) meeting, offering their expertise on everything from treating veins intravascularly to treating telangiectatic matting.
Sclerotherapy’s Role
According to the panelists, sclerotherapy remains the gold standard for treating most leg veins, but lasers certainly have their place, as the panelists noted.
“If you critically look at the literature, at least in my opinion, it takes at least three laser treatments to do what one sclerotherapy treatment can do,” explained Dr. Mitchel P. Goldman, an Associate Volunteer Clinical Professor of Dermatology and Medicine at the University of California at San Diego and Medical Director of La Jolla SpaMD, who participated on the panel.
The biggest drawback of laser therapy for leg veins, Dr. Goldman said, is that doctors have to “spot-weld” blood vessels. But this allows the endothelial cells to migrate and re-establish the conduits that reopen the veins. “So, in my practice, the use of the external types of lasers is limited, and I only use them after I have finished treating with sclerotherapy and a few vessels remain. In addition, laser can be effective when patients just have the fine blushing telangiectasia that persist after sclerotherapy or have veins that are too small to be treated with sclerotherapy.”
For vessels on the face, Dr. Goldman primarily uses the long-pulsed 1064 nm lasers, to treat the lateral-orbital and infra-orbital rim vessels. He typically uses intense pulsed light to treat other types of facial vessels.
Panel member Dr. Arielle N. B. Kauvar, Clinical Associate Professor of Dermatology at New York University School of Medicine, in New York City, and founding director of New York Laser & Skin Care, said she performs “a lot of sclerotherapy and uses lasers for resistant vessels or very fine telangiectasia because sclerotherapy is a difficult method of treatment for someone covered with telangiectasia.”
Dr. Brian D. Zelickson, a dermatologist at the University of Minnesota and a panelist at the meeting, said he also frequently uses external lasers in patients who “have either failed regular sclerotherapy, have developed matting of the vessels, or they have vessels that are small enough that a needle can’t easily be inserted into them. In addition, external lasers are ideal for certain areas, such as around the ankles where these lasers work quite well.”
Dr. Zelickson has tried many types of lasers, and each has its virtues. “My laser of choice depends on the indication,” he said. For patients with very pale skin, a long-pulsed KTP or 532 nm works best, although “you have to be very careful because of the pigment absorption there,” he noted.
He has also used long-pulsed pulsed dye lasers, but he prefers the KTP device because the pulsed dye lasers can lead to purpura, which in turn can cause hyperpigmentation after treatment. His group has seen good results with longer pulsed Alexandrite lasers, as well as long-pulsed and high-powered Nd:YAG lasers. “Using a very small spot size you can get some of the smaller red vessels, but they also work quite well with some of the burgundy or bluish colored vessels,” he explained.
Treating Veins Intravascularly
When it comes to treating large, finger-sized varicose veins, Dr. Goldman said he prefers to use intravascular lasers as opposed to either external lasers or sclerotherapy. “Of course, we can use foam sclerotherapy agents, but there are a number of potential side effects, especially air embolisms, that can occur from injecting very large veins. I’ve found that the use of intravascular lasers for this purpose is very efficient.”
Getting to that point took a little ingenuity, Dr. Goldman said. “The laser companies started with an 810 nm diode laser just because that was a laser that they had, and that’s probably one of the least efficient and the least beneficial lasers that you can put inside of a vein.”
The 810 nm diode laser produced explosive holes in the vein, leaving patients with ecchymosis and pain for a few days. Dr. Goldman and colleague, Robert A. Weiss, Director of the Maryland Laser, Skin and Vein Institute in Hunt Valley, discovered that the best laser for intravascular work would be one with a 1320 nm wavelength. They approached a laser manufacturer with the specifics, and the company made a laser and developed a way to withdraw the fiber through the vein, allowing standardized treatment.
Data to be published soon show a near perfect success rate at treating saphenous veins of up to 1 cm with the 1320 nm laser, Dr. Goldman said. “There have been no holes produced in the veins, and patients have minimal, if any, ecchymosis and no post-operative pain. So I think that the primary role of lasers, at least in my practice, is intravascular.”
Combining Treatments Using Sclerotherapy and External Lasers
Of course, leg vein therapy doesn’t have to be all or nothing. Some doctors report using a combination of external lasers and sclerotherapy with near-uniform success. One reason for the synergy may be that the initial dose of laser energy creates a lesion in the vessel that allows the sclerotherapy injection to linger longer in the leg. That boosts its effectiveness while preventing the formation of clots.
Dr. Goldman, who has published research on the combination treatment, considers the approach “very excellent” in theory. However, he cautioned, when treating with a laser followed by sclerotherapy, or the other way around, the result can be hard to control. In his own research, he said, he’s found that the joint therapy often led to excessive hyperpigmentation and even epidermal necrosis.
In that study, Dr. Goldman explained that his group was using a 0.25% polidocanol solution (considered “very weak”) for sclerotherapy along with a modestly effective 585 nm pulsed dye laser with 7 J/cm2, a 5-mm spot size, and a 0.5 ms pulse duration. “Either one alone had very minimal effects on the vessel, but when used together they had massive effects.”
In other words, he said, “you have to be extremely cautious because of the additive effect. The laser will disrupt the endothelium, and then when you follow it with sclerotherapy the sclerosing solution will react more significantly against normal endothelium.”
Different Lasers, Different Side Effects
External lasers cause different side effects depending on the quality of their light.
For example, with pulsed dye lasers, said Dr. Goldman, they may eliminate the blood vessels but leave hypopigmentation. “If patients have any tan on their legs or if they want to get tan later, you’re often left with hypopigmented circles” where the laser was used, he said. The procedure also carries a high risk of staining or browning from the iron in hemoglobin — or hyperpigmentation, which can last 6 months or more, he said.
Panelist Dr. Weiss said shorter wavelength green lasers typically provide “less complete healing of the vessel because [the energy is] so strongly absorbed by hemoglobin that the front 25% of the vessel is heated up so you’ll see immediate urticaria reaction. You’ll see methemoglobin formation and darkening of the vessel.
“As we get into the longer wavelengths that are absorbed more significantly by water as well, and not as well by hemoglobin — such as the 1064 nm and Nd:YAG — that’s a big advantage.”
But a blast from a 1064 laser takes at least 2 seconds or so for the heat to dissipate, Dr. Weiss said. “So if one does pulse stacking, with 1064 nm, you’re at high risk for developing a heat-inducing necrosis of the surrounding tissue. That’s one of the most worrisome side effects.”
In addition, Nd:YAG lasers, for example, are known to trigger prolonged spasms in the veins that complicate subsequent treatment with sclerotherapy injection. However, these spasms are temporary, and they don’t completely occlude vessels, experts said.
Because of the tissue heating caused by 1064 nm lasers, said Dr. Kauvar, “double pulsing is just absolutely contraindicated when you’re using these extremely high fluences.
“What’s best to do if you’re just starting out with a 1064 laser is not even apply the pulses contiguously but leave a pulse width of space between each pulse,” she added. “You might want to set your laser, depending on the laser you have, to a low rep rate so you don’t accidentally fire away in the same area.”
Although 1064 nm lasers do come with cooling systems, some doctors prefer alternatives. For example, Dr. Goldman prefers continuous cold air cooling or dynamic cooling to external methods like copper plates or even ice cubes; however, no method is fail-safe. And an inadequately cooled long-pulsed laser in the hands of all but the most expert physician is a recipe for poor outcomes, he said.
A counterpoint to diligent cooling should also be observed. Overzealous cooling can weaken a laser’s effectiveness, the experts said. “The lower the skin temperature, the lower the target vessel temperature will be as well,” Dr. Weiss noted.
Do Topical Anesthetics Curb the Pain?
Laser procedures can be painful, so what about offering patients topical anesthetics to prevent discomfort? That depends, said Dr. Zelickson. Generally, for small vessels that require KTP or visible light lasers, anesthesia isn’t necessary. “However, if we’re using some of the infrared lasers to treat the larger vessels, one of the big differences between that and sclerotherapy is the pain — it can be extremely painful.”
But Dr. Zelickson and other experts said they’ve seen little value in currently available products that can obscure target vessels by constricting them.
Dr. Kauvar has studied an experimental product, S-Caine, from Johnson & Johnson, that she said could be an effective option for leg laser surgery.
Dr. Goldman, however, injected a note of caution to his fellow dermatologists who are tempted to use anesthesia too liberally in leg vein procedures. “Although I’m nice to my patients and I like them, I think the problem of masking pain is that it will give you a false sense of security and you won’t realize how much perivascular damage you’re causing with a laser,” he said. “So I tend to be very opposed to using topical anesthetic agents when treating patients with the laser. Because if it is so painful that they can’t tolerate it, undoubtedly something bad is happening. And just like we wouldn’t give morphine to a patient with an acute abdomen, I don’t think we should be giving anesthetics when we’re doing laser procedures on the leg veins.”
Treating Telangiectatic Matting
This common, but thorny, problem for dermatologists can occur on its own or after a round of sclerotherapy. What causes the condition isn’t clear. It’s believed to be partly a problem of blood vessel growth and partly a problem of excessive dilation of existing veins, perhaps spurred by inflammation.
Dr. Zelickson said his group has had success treating more routine matting with high-powered long-pulsed KTP lasers and intense pulsed light. “With both of these technologies we employ cooling, and both have worked quite effectively.”
However, he explained, “we must use caution if the patient has some melanin on the skin.” Dr. Zelickson’s group has also used long-pulsed pulsed dye lasers, taking multiple passes at the veins, and seen good results. “But, again, you have to be careful of epidermal injury,” he noted.
Dr. Weiss cited unpublished data from his group, which has found that with bright red spider veins — which account for about 80% of patients — a regimen of glycerin injections directly into the area can resolve the discoloration.
Dr. Goldman suggested that treating matting with lasers is riskier, yet no more effective, than merely leaving it alone. “At least in my experience over 20 years or so, telangiectatic matting in 99% of [cases] goes away with time.”
Well-Rounded Advice
Although the panelists explained that they primarily chose sclerotherapy as a first-choice treatment for most leg veins, external lasers do play a role in all of their practices. In addition, intravascular use of lasers appears quite effective for larger varicose veins.
Effective cooling remains an issue with higher powered lasers, and topical anesthesia was often not employed because the general consensus was that it wasn’t effective and that an anesthetic could mask tissue damage caused by too high temperatures.
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October 2024
Volume 32
Issue 7
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