Endovenous laser ablation for saphenous vein insufficiency: immediate and short-term results of our first 60 procedures

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1 Diagn Interv Raiol 27; 13: Turkish Soiety of Raiology 27 INTERVENTIONAL RADIOLOGY ORIGINAL ARTICLE Enovenous laser alation for saphenous vein insuffiieny: immeiate an short-term results of our first 6 proeures Saim Yılmaz, Kağan Çeken, Ahmet Alparslan, Timur Sinel, Ersin Lülei PURPOSE To present the immeiate an short-term results of our first 6 enovenous laser (EVL) alation proeures. MATERIALS AND METHODS Between July 25 an Deemer 26, 6 EVL alations were performe in 36 symptomati patients (26 females, 1 males; mean age ± SD, 46 ± 14 years). The inompetent veins inlue the great saphenous vein (GSV) (n = 52), small saphenous vein (n = 6), an major ranhes of the GSV (n = 2). In all ases inompetent veins were punture uner ultrasoun (US) guiane an the laser fier was plae into these veins through a vasular sheath or with the help of a atheter. After tumesent anesthesia was aministere, the veins were alate with laser y elivering 5 1 joules/m energy to the vein wall. Following EVL alations, 29 patients also unerwent foam slerotherapy to treat the remaining variosities. After the EVL alation ± slerotherapy, patients were followe-up with Doppler US at 1 week, an then 3, 6, an 12 months post proeure. RESULTS In all patients EVL alation was tehnially suessful. Compliations were minor an inlue transient visual isturane ue to foam slerotherapy (n = 1), ruising/ehymoses (n = 24), postoperative pain (n = 16), an superfiial thromophleitis (n = 6). All patients returne to normal ativity within 2 ays. During the 7 ± 5 months (mean ± SD) of follow-up, reurrent reflux was seen in only one patient, in oth GSVs, whih was suessfully treate with foam slerotherapy. CONCLUSION EVL alation is a safe an effetive metho for the management of saphenous vein insuffiieny. Key wors: variose veins atheter alation laser oagulation enovenous laser alation From the Department of Raiology (S.Y. ysaim@akeniz.eu. tr), Akeniz University Shool of Meiine, Antalya, Turkey. Reeive 13 April 27; revision requeste 25 April 27; revision reeive 27 April 27; aepte 3 April 27. C hroni venous insuffiieny (CVI) affets approximately 2% 4% of people in the western worl (1). Its prevalene is higher among the elerly, females, an people living in evelope ountries (2). CVI ours ue to ysfuntion of the venous valves. In normal iniviuals, these valves prevent loo, whih is pumpe to the lungs, from returning into leg veins. When these valves eome inompetent ue to some geneti or environmental auses, the loo refluxes into the leg veins an inreases venous pressure. This venous hypertension results in graual ilatation an tortuosity of the inompetent vein, as well as its suermal venous ranhes, whih are then alle variose veins (1, 2). CVI an variose veins have a etrimental effet on patient quality of life; most patients have signifiant pain, ramping, urning sensations, an leg fatigue, whih inrease in the evening an after staning for long perios of time. In severe ases, leg eema, skin isoloration, an venous uleration may evelop. In rare ases, variose veins may thromose (superfiial thromophleitis) an ause pulmonary emolism, or may lee spontaneously, whih oul e angerous if the leg is not promptly elevate (3, 4). Despite these prolems, most patients i not unergo any treatment eause until reently the only therapeuti options were surgery, whih is invasive an has a high reurrene rate, an onservative measures, whih are iffiult for patients to omply with (2). This attitue, however, is expete to hange with the wiesprea use of new treatment methos, suh as enovenous laser (EVL) alation an ultrasoun (US) guie slerotherapy. The moern management of CVI inlues treatment of oth the ause (reflux) an result (variose veins). Naturally, reflux shoul e treate efore variosities eause if the ause is not eliminate variose veins will eventually reur (2). Elimination of reflux has een lassially aomplishe with surgery (2, 5); however, thermal alation methos, suh as EVL an raiofrequeny alation, are graually eoming the treatment of hoie (5). In this stuy, we present our single enter experiene with the first 6 EVL alations, along with the immeiate an short-term results. Materials an methos Between July 25 an Deemer 26, 36 patients with CVI were treate with EVL alation, with or without slerotherapy. These patients were not onseutive; rather, they onstitute roughly half of the patients to whom EVL alation was reommene y raiologists, ase on uplex Doppler finings. The remainer of the patients either refuse the proeure or i not ome to their appointments, mainly eause of their skeptiism aout EVL alation or its high ost. Patients with eep venous ostrution, preominant eep venous insuffiieny, an aute 156

2 superfiial thromophleitis were not offere EVL alation. All the treate patients were symptomati; the most ommon symptom was visile variose veins, whih were present in at least one extremity in all patients. Other symptoms inlue pain, night ramps, restless leg, varieal leeing, an skin isoloration. Five patients ha previous treatments for variose veins (3 slerotherapy an 2 phleetomy), an the remainer ha no previous treatment. On uplex Doppler examination, all the patients were foun to have inompetent saphenous veins in one (n = 15) or oth lims (n = 21) (3 lims ha 2 inompetent veins eah). In these examinations signifiant reflux (>1 s uration) was seen in the great saphenous vein (GSV) (n = 52), small saphenous vein (SSV) (n = 6), or anterior lateral/posterior meial ranhes of the GSV (n = 2) (Fig. 1). In some patients, reflux was also present in the eep venous system at the level of the ommon femoral vein (n = 6) or popliteal vein (n = 2). Other emographi an linial etails of our patients are given in Tale. In all patients, the potential risks an enefits of EVL alation an slerotherapy were explaine, an informe onsent was otaine. Aitionally, throughout the stuy the priniples of the Helsinki Delaration were stritly followe. Before the proeure, a final Doppler US examination was performe an the ourse of eah inompetent vessel was marke on the skin. The leg was isinfete with etaine an alohol, an then was overe with sterile loths. The transuer (7.5 1 MHz linear) of the US mahine was similarly isinfete, an a suitale punture point was hosen along the ourse of the inompetent vein. GSV an its ranhes were punture either at the level of the knee or near the saphenofemoral juntion Demographi an linial ata of 36 patients in whom 6 enovenous laser alations were performe Age Sex Mean ± SD Meian Range Male Female Treate lim Right Left CEAP lassifiation Clinial C : no visile venous isease C1: telangietati or retiular veins C2: variose veins C3: eema C4: skin hanges without uleration C5: skin hanges with heale uleration C6: skin hanges with ative uleration Etiology Congenital Primary Seonary Anatomy Telangietasias or retiular veins Great saphenous vein aove the knee Great saphenous vein elow the knee Small saphenous vein Saphenous ranh veins Pathology Superfiial reflux Superfiial + eep reflux Deep reflux Ostrution Years 46 ± n 1 (28%) 26 (72%) n 27 (45%) 33 (55%) n 45 (75%) 15 (25%) 6 (1%) 12 (2%) 4 (67%) 6 (1%) 2 (3%) 52 (87%) 8 (13%) (SFJ), whereas the SSV was punture approximately 1 m proximal to the ankle. Base on our experiene with initial ases, we generally preferre to use a miropunture set (Cook, Bloomington, IN, USA) eause punturing with larger neeles an e prolemati in these low-pressure veins. The veins were punture with a 21-gauge neele uner US guiane as the patient was performing the Valsalva maneuver to isten the vein. The transuer was hel in the transverse position eause this enale a more preise punture into the enter of the vein. After the neele tip was seen in the vein, the transuer was plae in the longituinal position, whih improve the visualization of the neele tip an the posterior wall of the vein, as well as the guiewire exiting the neele an avaning in the vein lumen (Fig. 2). After the vein was suessfully punture, a.18-inh guiewire was inserte into the vein, whih was then exhange with a.35-inh stanar guiewire through the sheath of the miropunture set. This guiewire was then plae aross the SFJ an a 4 5F sheath or iagnosti atheter was avane over it. The guiewire was remove an the tip of the sheath/atheter was plae 2 3 m istal to the SFJ. At this stage, tumesent anesthesia was aministere. The anestheti solution inlue 5 ml saline, 5 ml 1% lioaine, 1 ml 8.4% soium iaronate, an 1 ml arenaline. This solution was injete just outsie the vein wall along its entire ourse, so that it provie loal anesthesia, ompresse the vein, an isolate it from the surrouning strutures (Fig. 3). After aministering the tumesent anesthesia, a 3 6-μm laser fier was inserte into the sheath/atheter, avane 1 2 m eyon, an fixe to the sheath/atheter via its valve or a Y onnetor. We mae sure that the tip of the laser fier was loate several m istal to the SFJ. The parameters of the laser mahine were then ajuste so that it elivere 1 joules per pulse. These parameters were power (W), pulse uration (s), an pulse interval (s). We generally preferre 1 12 W power, 1 s uration, an 1 s interval, so that the mahine woul eliver 1 12 joules per pulse at 1-s intervals. The mahine was then turne on an the fier-sheath/atheter assemly was slowly withrawn. Sine 5 1 joules/m la- Volume 13 Issue 3 Enovenous laser alation for saphenous vein insuffiieny 157

3 a Figure 1. a. A 4-year-ol woman with symptoms of venous insuffiieny. Photograph of the left leg (a) showing typial variosities loate in the meial alf suggestive of great saphenous vein (GSV) insuffiieny. Duplex Doppler US () shows reflux in the GSV near the saphenofemoral juntion with istal manual ompression. First efletion is reate y the prograe flow upon istal manual ompression an the seon efletion is reate y the retrograe flow (reflux) upon release of the ompression. Duplex Doppler US () shows reflux with the Valsalva maneuver. Note that the flow is typially uniiretional (retrograe only) an is reate y the Valsalva maneuver, whih inreases pressure in the entral veins. The appearane of reflux on olor Doppler US () with the Valsalva maneuver. Color an power Doppler US may failitate the ientifiation of refluxing segments; however, they are not routinely use sine they are known to unerestimate the egree of reflux in patients with venous insuffiieny. a Figure 2. a. Typial stages of venous punture in a patient with great saphenous vein (GSV) insuffiieny. The GSV is punture with a gauge neele uner US guiane (a) while the patient is performing the Valsalva maneuver. US image () showing the transuer hel in the transverse position an the neele is introue towars the enter of the vein (arrow). After the vein is suessfully punture, the transuer is put into the longituinal position (). In this position, the exat loations of the neele tip (arrows, ) an the guiewire, in relation to the vessel walls, are visualize more aurately. Before the miropunture sheath is avane, it is etter to onfirm the intravasular loation of the guiewire on the longituinal US view (arrows, ). Otherwise, the sheath may perforate the vessel, leaing to extensive venous spasm an perivasular hematoma, in whih ase it may e extremely iffiult to repunture the saphenous vein sine it eomes virtually invisile on US. 158 Septemer 27 Diagnosti an Interventional Raiology Yılmaz et al.

4 a Figure 3. a. After the great saphenous vein (GSV) is punture suessfully, the sheath/atheter is plae aross the saphenofemoral juntion (SFJ) over a.35 guiewire. The sheath/atheter (arrows) is withrawn so that its tip is loate several entimeters istal to the SFJ (a). In this loation, the eep venous system an superfiial epigastri vein are protete from heat amage. Tumesent anesthesia is then aministere uner US guiane with the transuer in the longituinal position (). The neele (yellow arrowheas) is avane into the vein wall an the tumesent solution (T) is injete only aroun the vessel. The tumesent anesthesia ompresses the vein an apposes its walls (re arrows) onto the sheath (white arrows); as a result, there is little loo in the vein an the vein walls are very lose to the laser eam. The tumesent solution (T) also isolates the saphenous vein from the surrouning soft tissues (arrows, ). Therefore, the patient experienes no pain an the soft tissues are protete from heat amage. During laser alation, the laser energy is asore y the loo an steam ules are proue (). These ules (yellow arrow) an e seen on US an are elieve to e the key fator leaing to intimal amage. Re arrows point to the saphenous vein, whih is surroune y the tumesent solution (T). ser energy is reommene uring EVL alation (5), the fier was withrawn at suh a rate that the mahine proue 5 1 pulses/m. We use lower energy levels for small size veins an higher energy levels for larger veins. After eah vein was alate all along, the fier an the sheath/atheter were remove, an the punture hole was overe with sterile tape. An elasti anage was then wrappe aroun the leg an patients were immeiately requeste to walk for 2 3 min. After EVL alation, patients were given a non-steroial anti-inflammatory rug for 1 2 weeks, epening upon the severity of their omplaints. They wore elasti anages for 1 week an lass II (3 4 mmhg) stokings for at least 1 month. They were also avise to walk at least 1 h per ay, ut to avoi intense exerise, high temperatures, an staning for a long perio of time. In 29 patients (4 legs), after the inompetent saphenous vein was alate, slerotherapy was performe for variosities. Sine almost all patients ha large (>4 5 mm) variose veins, foam slerotherapy was preferre rather than the liqui form. We prepare foam aoring to the Tessari metho (6); two 5 1 ml sterile injetors were attahe via a 3-way stopok. One injetor ontaine one volume (1 2 ml) polioanol an the other, 4 volumes (4 8 ml) air. The slerosant an air were then mixe (15 3 times) until thik foam was otaine. The foam was immeiately injete into the variosities at 1 3 sites uner US guiane. The injetion was stoppe when the target variosities were fille an the ehogeni foam passe into the eep veins (Fig. 4). The leg was wrappe with elasti anages just as it was one after EVL alation, an the patient was immeiately aske to walk for 2 3 minutes. Early in our experiene, we performe slerotherapy 1 2 weeks after EVL alation (n = 15). Later, we generally i it uring the same session, shortly after EVL alation (n = 25). This was more aeptale to the patients sine they ha to wear elasti anages only one. Patients were followe-up with Doppler US at 1 week, an then 3, 6, an 12 months post proeure. The 1-week follow-up was performe to hek for thromus formation at the SFJ or saphenopopliteal juntion (SPJ), an the susequent follow-ups were to evaluate the effetiveness of the proeure(s). In our stuy, tehnial suess was efine as suessful atheterization an omplete alation of the inompetent saphenous veins. Compliations were efine as minor when they require only minor therapy an overnight oservation, or major when they require major therapy, prolonge hospitalization, or an unplanne inrease in the level of are. At follow-up, suess was efine as the persistent olusion an graual narrowing/isappearane of the treate vessel. Results In all proeures, EVL alation was tehnially suessful. In our very first ase, it took aout one hour to suessfully punture the GSV at the knee. In this patient, we trie to enter the vein with a stanar 18-gauge neele after loal anesthesia, whih resulte in multiple faile attempts, venospasm, an rupture. In susequent ases, we punture the veins with a miropunture set, without loal anesthesia, an Volume 13 Issue 3 Enovenous laser alation for saphenous vein insuffiieny 159

5 a Figure 4. a. After enovenous laser alation (EVL) alation, the remaining variose veins are generally treate with slerotherapy (liqui or foam) or phleetomy to erease the reurrene rate an inrease patient satisfation. Foam is usually preferre to liqui in the slerotherapy of variose veins, an is prepare aoring to the Tessari metho (6). One volume of polioanol an 4 volumes of air are aspirate into the injetors, an the 2 injetors are attahe via a 3-way stopok (a). The slerosant an air are mixe y pushing the pistons of the injetors 15 3 times, sequentially, until a thik foam is reate (). This foam shoul e injete immeiately sine it liquefies approximately 9 s after its preparation (). US image showing the foam (arrows, ). It an e irete into the target veins y elevating an rotating the leg. Sine it avanes in the vein like an air olumn, an pushes the loo rather than mixing with it, it reates suffiient intimal amage for most variosities, even from a single injetion site. were generally ale to enter the veins on the first attempt. After the EVL alation ± slerotherapy, no major ompliations ourre. Minor ompliations, however, were quite ommon an inlue transient visual isturane ue to foam slerotherapy (n = 1), ruising/ehymoses (n = 24), postoperative pain that require analgesis (n = 16), an superfiial thromophleitis (n = 6), all of whih isappeare within one month. Skin urn an paresthesia i not our. All patients returne to normal ativity within 2 ays. After the proeures, symptoms of venous insuffiieny erease (n = 1) or isappeare (n = 25) in all ut one patient. In this partiular patient the persistene of symptoms was attriute to oexistent severe gonarthrosis. At one-week Doppler US follow-up, none of the patients ha eep venous thromosis or extension of thromus into the eep venous system. During the 7 ± 5 months (mean ± SD; range, 1 17 months) of follow-up, reurrene was not seen, exept in a patient who unerwent EVL alation for ilateral GSV insuffiieny. In this patient, reanalization was seen in oth GSVs on Doppler US 8 months post proeure, an oth vessels were suessfully treate with foam slerotherapy. In the remaining 35 patients, follow-up Doppler US showe graual narrowing or isappearane of the treate vessels (Fig. 5). Disussion For more than a entury, the lassi treatment for saphenous vein insuffiieny has een surgial ligation an stripping (L&S) (2). This proeure is assoiate with an exellent early outome sine the inompetent vessel is totally remove. In the long term, however, 2% 4% of the ases present with reurrent reflux within 5 years, mainly eause of the neovasularization that ours in the saphenous ompartment (7, 8). In aition, L&S has a numer of isavantages that make it unesirale to patients, suh as general anesthesia, risk of eep venous thromosis, paresthesia, hospitalization, prolonge return to aily ativities, an postoperative sarring (2, 3). EVL alation was introue as an alternative to L&S y Navarro et al. in 22 (9) an has rapily eome the treatment of hoie for treating saphenous vein insuffiieny. This proeure is ase on the thermal alation of the inompetent vein with laser energy via a fier plae in the vein lumen. This laser energy leas to intimal amage, whih results in permanent olusion with susequent firosis of the vein (5, 1). EVL alation is proven to e very suessful an urale in the treatment of saphenous vein insuffiieny. In a numer of large ase series, the tehnial suess rate was lose to 1%, an the long-term suess rate (up to 5 years) range from 9% to 1% (11 13). Likewise, in our stuy the tehnial suess of EVL alation was 1% an the short-term suess rate was 97%. These figures are learly superior to those of L&S, although they have not yet een onfirme with prospetive ranomize stuies (2, 1). From the tehnial point of view, venous punture an tumesent anesthesia are the most ruial omponents of EVL alation. Venous punture is important eause if it is not suessfully performe in initial attempts, venos- 16 Septemer 27 Diagnosti an Interventional Raiology Yılmaz et al.

6 a Figure 5. a. The follow-up of the patient in Fig. 1a. Color Doppler US (a) at one week post proeure emonstrates the olusion of the great saphenous vein (GSV) istal to the superfiial epigastri vein (arrow). There is no thromus at or near the saphenofemoral juntion. Transverse US image at one month (), shows that the GSV is still olue an its iameter is reue, with an inrease in luminal ehogeniity. Longituinal US image at 3 months (), shows that the GSV looks remarkaly shrunken (arrows). At 9 months after enovenous laser alation an 3 sessions of slerotherapy, variose veins almost isappear, an the patient eomes asymptomati (). pasm or rupture an frequently evelop an the proeure may have to e aanone. Suessful punture of the saphenous vein may e very hallenging for several reasons: first, the saphenous veins are rather moile in the fat tissue, partiularly in oese patients; seon, in the staning position, loo pressure in superfiial veins is aroun 1 mm Hg, an therefore the veins are very istene. In the supine position, however, this loo pressure rops to virtually mm Hg, making these veins very thin an easily ompressile (13, 14). Thus, if punture of the saphenous veins are attempte in the usual manner, it is likely to fail. There are, however, a numer of maneuvers that may failitate the punture. First, loo pressure in the saphenous vein may e inrease y putting the patient in the reverse Tranelenurg position or getting the patient to perform the Valsalva maneuver. Seon, use of a miropunture set with a small gauge neele an guiewire may erease trauma to the vein an thus lower the risk of venospasm. In our patients, we i not use the reverse Tranelenurg eause out patient tale i not tilt; instea, we routinely punture the veins with a miropunture set while the patient was performing the Valsalva maneuver an i not experiene any punture failures. Tumesent anesthesia is another important stage of EVL alation. It is useful in 3 ways: first, it provies loal anesthesia, making EVL alation a virtually painless proeure; seon, it isolates the saphenous veins from the surrouning soft tissues an prevents heat amage to the skin an aompanying nerves [these first 2 points inrease patient omfort an erease the risk of ompliations, suh as skin urn an paresthesia (13)]; thir, tumesent anesthesia ompresses the vein an rains the loo from insie the lumen, thus ereasing thromus formation an inreasing intimal amage y ringing the vein wall into lose ontat with the laser fier. This last point may iretly affet the longterm suess of EVL alation, as uring the proeure the laser energy is ompletely asore y all the loo within <1 mm of the fier, whih results in extremely high intraluminal temperatures (7 13 C). These high temperatures proue steam ules, whih inue oth intraluminal thromosis an intimal amage (15). For a urale saphenous olusion, there must e maximal intimal amage an minimal thromosis, eause a thromose vein without intimal amage will eventually reanalize. Thromosis is favore when there is too muh loo in the vein an relatively less laser energy is given to the vein wall; intimal amage is favore when there is little loo in the lumen an suffiient laser energy is elivere; thus, more heat is transferre to the intima y steam ules. Tumesent anesthesia reates maximal intimal amage y attahing the vein walls to the laser fier, an ereases thromosis y ompressing the vein an emptying its loo ontent; therefore, it improves the longterm outome of EVL alation (5, 13, 16, 17). For ieal tumesent anesthesia aministration, the tumesent neele shoul touh the outer surfae of the vein without perforating it. In this position, the injete loal anestheti goes just aroun the saphenous vein an the surrouning soft tissues Volume 13 Issue 3 Enovenous laser alation for saphenous vein insuffiieny 161

7 are pushe away (Fig. 3, ). If the tumesent solution is given at a istane from the vein, these tissues are not pushe away, ut are attahe to the vein wall an thus may e expose to some egree of heat amage (13). In our patients, we stritly followe these rules uring the use of tumesent anesthesia, an think that it has ontriute to the low ompliation an reurrene rates in our series. Both venous punture an tumesent anesthesia require extensive US skills an experiene, an this is the reason why EVL alation shoul e performe y interventional raiologists (IRs) who are traine on ultrasoun an experiene in perutaneous tehniques. For instane, in ases suh as a tortuous saphenous vein, it is very important to have ha the neessary training/experiene to manage plaing the tip of the atheter in the proper position. Likewise, it is important to see the tip of the laser fier at the SFJ or SPJ with US, eause if the fier tip is in or near to the eep veins it may lea to eep vein thromosis (DVT). Some operators inexperiene with US-guie proeures usually perform surgial ut own for aessing the GSV, perform tumesent anesthesia without US guiane, or use spinal or general anesthesia, all of whih an erease the tehnial suess an inrease ompliation rates. Aessing the vein with single/multiple ut-owns instea of the perutaneous tehnique transforms EVL alation into a more invasive, semisurgial proeure. Tumesent anesthesia performe without US guiane will not effetively ompress an isolate the saphenous veins from the surrouning tissues, whih may inrease ompliations an negatively affet long-term outome (5, 13, 17). Use of general/regional anesthesia will inrease the risk of DVT eause the patient will not e ale to stan an walk immeiately (11, 13) post proeure. In our patients, we always performe EVL alation with loal anesthesia, without premeiation, an mae the patients walk immeiately post proeure. We elieve that this is the primary reason why there was no DVT in our series, espite the simultaneous use of foam slerotherapy in some patients. Before the avent of EVL alation, raiologists were mainly intereste in the iagnosis an follow-up of patients with venous insuffiieny. After the introution of EVL alation, some raiologists (mainly IRs) were also involve in treatment. It is known that EVL alation is performe y a variety of speialties, inluing interventional raiology, vasular surgery, general surgery, ermatology, et. (2, 5, 15) In our opinion, however, IRs shoul e atively involve in EVL alation an other phleologi proeures for the following reasons: 1) IRs are the only interventionalists who are offiially traine in US an US-guie interventions, an EVL alation is a typial US-guie perutaneous intervention. 2) US is extremely important for the iagnosis an post treatment follow-up of venous insuffiieny; it etets the inompetent vein(s), loalizes the point(s) of reflux, shows variosities, an exlues venous or arterial ostrution, proviing virtually all the neessary information for the treatment. After EVL alation, US provies an ojetive evaluation of suess, an emonstrates ompliations an reurrene (if any) (14); thus, IRs have alreay een oing a great eal of the work in the iagnosis an followup of venous insuffiieny, an it is only natural that they are also intereste in its treatment. 3) EVL alation was first introue y an IR (Min) an 2 other physiians (9) (there were no vasular surgeons in this group). IRs have also proue a onsierale numer of sientifi puliations on EVL alation (5, 11, 13, 17 23). It is evient, therefore, that IRs have also een very ative from the researh point of view. 4) EVL an slerotherapy proeures are far safer than other perutaneous proeures, an thus surgial ak-up is not neessary. 5) Clinial aspets of venous insuffiieny are, of ourse, important, ut they are relatively easy to learn. Moreover, linial examination an never ompete with a goo uplex Doppler US examination in the iagnosis an treatment planning of venous insuffiieny. 6) Patient referral is a prolem as in every fiel of interventional raiology; however, venous insuffiieny is a highly prevalent isorer, patients are intereste in new noninvasive treatments, an eause of the geneti aspet of the isease, most patients have relatives suffering from saphenous vein insuffiieny. As a result, patients are generally referre y other patients who have een satisfie with EVL alation. In onlusion, EVL alation is a safe an effetive metho for the management of saphenous vein insuffiieny. Due to a numer of reasons, IRs must e atively involve, not only in the iagnosis an follow-up, ut also in the treatment of this isorer. Referenes 1. Beee-Dimmer JL, Pfeifer JR, Engle JS, Shottenfel D. The epiemiology of hroni venous insuffiieny an variose veins. Ann Epiemiol 25; 15: Teruya TH, Ballar JL. New approahes for the treatment of variose veins. Surg Clin North Am 24; 84: Laas P, Camal M. Profuse leeing in patients with hroni venous insuffiieny. Int Angiol 27; 26: Marhiori A, Mosena L, Pranoni P. Superfiial vein thromosis: risk fators, iagnosis, an treatment. Semin Throm Hemost 26; 32: Min RJ, Khilnani NM. Enovenous laser alation of variose veins. J Cariovas Surg 25; 46: Tessari L, Cavezzi A, Frullini A. Preliminary experiene with a new slerosing foam in the treatment of variose veins. Dermatol Surg 21; 27: Fisher R, Line N, Duff C, Jeanneret C, Chanler JG, Seeer P. Late reurrent saphenofemoral juntion reflux after ligation an stripping of the greater saphenous vein. J Vas Surg 21; 34: Van Rij AM, Jones GT, Hill GB, Jiang P. Neovasularization an reurrent variose veins: more histologi an ultrasoun eviene. J Vas Surg 24; 4: Navarro L, Min RJ, Bone C. Enovenous laser: a new minimally invasive metho of treatment for variose veins: preliminary oservations using an 81 nm ioe laser. Dermatol Surg 21; 27: Bergan JJ, Kumins NH, Owens EL, Sparks SR. Surgial an enovasular treatment of lower extremity venous insuffiieny. J Vas Interv Raiol 22; 13: Min RJ, Khilnani N, Zimmet SE. Enovenous laser treatment of saphenous vein reflux: long-term results. J Vas Interv Raiol 23; 14: Agus GB, Manini S, Magi G; IEWG. The first 1 ases of Italian Enovenous-laser Working Group (IEWG): rationale, an long-term outomes for the perio. Int Angiol 26; 25: Septemer 27 Diagnosti an Interventional Raiology Yılmaz et al.

8 13. Min RJ, Khilnani NM. Enovenous laser treatment of saphenous vein reflux. Teh Vas Interv Raiol 23; 6: Min RJ, Khilnani NM, Golia P. Duplex ultrasoun evaluation of lower extremity venous insuffiieny. J Vas Interv Raiol 23; 14: Proestle TM, Lehr HA, Kargl A, Espinola- Klein C, Rother W, Bethge S, Knop J. Enovenous treatment of the greater saphenous vein with a 94-nm ioe laser; thromoti olusion after enoluminal thermal amage y laser-generate steam ules. J Vas Surg 22; 35: Proestle TM, Moehler T, Heremann S. Reue reanalization rates of the great saphenous vein after enovenous laser treatment with inrease energy osing: efinition of a threshol for the enovenous fluene equivalent. J Vas Surg 26; 44: Timperman PE, Sihlau M, Ryu RK. Greater energy elivery improves treatment suess of enovenous laser treatment of inompetent saphenous veins. J Vas Interv Raiol 24; 15: Min RJ, Zimmet SE, Isaas MN, Forrestal MD. Enovenous laser treatment of the inompetent greater saphenous vein. J Vas Interv Raiol 21; 12: Kim HS, Paxton BE. Enovenous laser alation of the great saphenous vein with a 98-nm ioe laser in ontinuous moe: early treatment failures an suessful repeat treatments. J Vas Interv Raiol 26; 17: Timperman PE. Prospetive evaluation of higher energy great saphenous vein enovenous laser treatment. J Vas Interv Raiol 25; 16: Timperman PE, Sihlau M, Ryu RK. Greater energy elivery improves treatment suess of enovenous laser treatment of inompetent saphenous veins. J Vas Interv Raiol 24; 15: Sihlau MJ, Ryu RK. Cutaneous thermal injury after enovenous laser alation of the great saphenous vein. J Vas Interv Raiol 24; 15: Timperman PE. Arteriovenous fistula after enovenous laser treatment of the short saphenous vein. J Vas Interv Raiol 24; 15: Volume 13 Issue 3 Enovenous laser alation for saphenous vein insuffiieny 163