The Final Word in Non-Surgical Varicose Vein Treatment: EVLA (Endovenous Laser Ablation)

Varicose veins are one of the most common vascular diseases in the population. Studies conducted to determine their prevalence show that approximately 25-30% of the adult population has varicose findings at some stage, while 5-15% have advanced and significant varicose disease.

A large proportion of patients who present with swelling in the legs, a feeling of heaviness, night cramps and itching ask, “Do I have to undergo major, painful surgery?” At the point we have reached today, the answer is: No.

The gold standard of modern varicose vein treatment is no longer classic open surgery but endovenous thermal ablation methods, and foremost among them is EVLA (Endovenous Laser Ablation – entering the vein from within and sealing it with laser) .

In this article I will address what EVLA is, how it is performed, its success rates in the scientific literature and the questions patients most often ask, in language that is both easy to understand and medically accurate.

Why Do Varicose Veins Develop and Why Should They Be Treated?

The veins of the leg contain valves that open in one direction only, so that blood flows solely towards the heart. They open as the heart draws blood upwards and close when this suction effect decreases, so that gravity cannot pull the used blood back down. Just as our skin wrinkles and hardens, these valves too may sometimes wrinkle, thicken and lose their ability to close completely. In this condition, which we call ‘valve insufficiency’, blood flows back to where it came from (venous reflux). Blood pools in the legs, the veins widen, and tortuous, swollen varicose veins appear beneath the skin. If left untreated, darkening of the skin colour (stasis dermatitis), eczema, recurrent superficial vein clots and, at the most advanced stage, wounds on the leg that heal with great difficulty or do not heal at all may develop over time. Varicose disease is therefore not merely a cosmetic problem but a progressive circulatory disease.

What Is EVLA and How Does It Work?

EVLA is the procedure in which a thin laser catheter (fibre) is placed under ultrasound (Doppler) guidance inside the great or small saphenous vein that is the source of the reflux, and the vein wall is destroyed and sealed in a controlled manner using heat energy. In these laser catheters, which work with specially selected wavelengths, the heat generated is directed towards the target tissue rather than the surrounding tissues, which forms the basis of the high success rate and low level of pain.

The basic steps of the procedure are as follows:

1. Doppler ultrasound mapping: Kaçağın olduğu damar bölümleri, çapı ve reflü süresini (>0.5 seconds is considered abnormal) is determined.
2. Access to the vein: From below the knee or at calf level, under ultrasound guidance, we insert a needle into the diseased vein and advance the laser fibre through the access obtained with this needle into the vein, reaching as far as the point where the problem begins.
3. Local anaesthesia: Around the vein, under ultrasound guidance, we inject cold, sterile, diluted local anaesthetic fluid. The aim is both to prevent damage to the surrounding tissues, to increase the effectiveness of the vein ablation, and to increase the patient’s comfort.
4. Ablation: We activate the laser fibre that has been advanced to the target and withdraw it slowly and in a controlled manner as far as the point where the disease ends. The diseased vein shrinks in a controlled way and closes (fibrotic occlusion).
5. Compression: After the procedure we recommend a compression bandage or stocking on the leg for a short period.

The procedure usually takes 45-90 minutes and, if you are comfortable in the operating theatre environment, it does not require general anaesthesia. Whichever form of anaesthesia we use, it does not require hospital admission.

Why Has It Come So Far Ahead of Surgery?

High-quality large studies comparing classic varicose vein surgery with EVLA (e.g. Rasmussen et al., British Journal of Surgery, 2011) and the subsequent meta-analyses (large data analyses) (van den Bos et al., Journal of Vascular Surgery, 2009) have shown that endovenous thermal ablation methods have a long-term success rate similar to that of surgery, while offering the following advantages:

• No incision, no stitches: There is only a single needle entry point, and it leaves no cosmetic scar.
• Local anaesthesia is sufficient: The risks of general anaesthesia (nausea, being placed on a ventilator, the burden of anaesthesia on the heart, and so on) are eliminated; it can be applied safely even in patients of advanced age or with additional illnesses.
• Less pain: In studies, pain assessment scores (VAS) during the first week after the procedure were found to be significantly lower than in the surgery group.
• Same-day discharge: The patient can walk home 30-60 minutes after the procedure.
• Rapid return to work and daily life: For office workers, a return to daily life is possible on average within 1-2 days, and within 3-5 days for occupational groups that require standing.
• Low rate of complications (unexpected adverse events): Side effects such as superficial vein clotting and temporary loss of sensation occur less frequently than with surgery; the risk of deep vein thrombosis (clotting in a large deep vein) is below 1% and can be detected early with routine post-procedure ultrasound checks.

Success Rates in the Scientific Literature

The effectiveness of EVLA is assessed on the basis of the rate at which the diseased vein can be closed (occlusion). Studies with long-term follow-up and the European Society for Vascular Surgery (ESVS) 2022 Guidelines on Chronic Venous Disease (Kakkos et al., European Journal of Vascular and Endovascular Surgery) recommend heat-energy methods of closing varicose veins (EVLA and radiofrequency ablation) as first-line treatment in varicose vein disease. In summary, the general trend in the literature is as follows:

• Vein closure (occlusion) rate at 1 year: %93-98
• Rate of permanent closure at 3-5 years of follow-up: %90-96
• Significant improvement in clinical symptoms (pain, swelling, quality-of-life scores)
• Recurrence rate: approximately %3-5 per year (mostly occurring in segments where insufficient energy was applied and which could not be completely sealed)

These rates are related to correct patient selection, the application of sufficient energy density and procedures performed in experienced centres; for this reason, having the procedure carried out under ultrasound guidance by a physician experienced in vascular surgery directly affects the outcome.

Summer or Winter? Does the Season Matter?

One of the questions patients ask most often is “Can I have varicose vein treatment in the summer, can I go out in the sun?” Unlike classic surgery, EVLA has no seasonal restriction. Since there is no open wound or wide surgical incision, the concerns specific to the summer months regarding infection and wound healing do not apply here. The only practical recommendation is that for the first few days after the procedure the entry point should not be exposed to direct sunlight or to prolonged hot water (thermal springs, sauna, long baths); apart from this, it can be performed safely in any month of the year.

Who Is a Candidate and Who Is Not?

Before EVLA, a detailed assessment is always carried out with colour Doppler ultrasonography . Where the problem begins, where it ends and the diameters of the diseased veins are determined, and thus the fibre to be used and the amount of heat energy to be delivered are established.

• Those with cramps, oedema or itching due to varicose veins
• Those who have or have not previously undergone surgery
• All patients who are troubled cosmetically and who have underlying venous reflux

are suitable candidates for EVLA unless there are unusual circumstances.

In contrast, in patients with recent clotting of a main deep vein, severe arterial disease of the limb, or an uncontrolled clotting disorder, alternative methods (radiofrequency ablation, foam sclerotherapy or venous closure with cyanoacrylate) may be considered.

In Summary

• Discharge on foot is possible on the same day, usually within 30-60 minutes of the procedure
• Daily use of a compression stocking is recommended for 1-2 weeks
• Daily activities can be resumed immediately, apart from heavy exercise and prolonged standing
• A return to work is possible within 1-2 days in office-type jobs and within 3-5 days in physically demanding jobs
• One week after the procedure, closure of the vein is confirmed with a follow-up Doppler ultrasound

Frequently Asked Questions

Is EVLA a painful procedure? During the procedure there is only the sensation of the local anaesthetic needle; after local anaesthesia the procedure itself is painless. The mild tightness and tenderness that may be seen after the procedure subside within a few days.

Is general anaesthesia required? No. EVLA is performed under local anaesthesia and does not require hospital admission.

How many sessions does it take? A single leg is usually completed in one session. If there are extensive varicose veins in both legs, the physician may plan treatment in the same session or in separate sessions.

Does it recur? In the vascular surgery literature, long-term recurrence rates are low; however, if risk factors that predispose to venous insufficiency, such as excess weight and prolonged standing, persist, the formation of new varicose veins (in a different vein) is possible. Regular follow-up is therefore recommended.

Conclusion

EVLA has become the first-line option in modern varicose vein treatment as a method supported by the scientific literature that requires no incision, is performed under local anaesthesia, involves a low level of pain, allows same-day discharge and a rapid return to work and daily life. When applied with correct diagnosis, detailed Doppler ultrasound assessment and an experienced vascular surgery team, lasting and reliable results are obtained both cosmetically and functionally.

If you have varicose veins, swelling or a feeling of heaviness in your legs, we look forward to seeing you for a detailed examination and Doppler ultrasound assessment.

References

1. Kakkos SK, Gohel M, Baekgaard N, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease. Eur J Vasc Endovasc Surg. 2022.
2. Rasmussen LH, Lawaetz M, Bjoern L, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011.
3. van den Bos R, Arends L, Kockaert M, et al. Endovenous therapies of lower extremity varicosities: a meta-analysis. J Vasc Surg. 2009.
4. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011.
5. National Institute for Health and Care Excellence (NICE). Varicose veins: diagnosis and management. NICE guideline NG168.