Laser endo-veineux: État de l'art et expérience personnelle (Partie II)

Endovenous laser or EVLT ¡s a recent technique for endovascular sclerosis of venous axis by thermal effect. Since the first publications of Dr C Bone (1997) and Min RJ (1999) with 810 nm, the technique has been refined for both parameters (wavelength, transmission time, energy delivered, distribution linear and radial light), as well as hardware and instructions. The thermal effect is based on three steps responding in part to precise physical laws: Heavy check mark Conversion of light into heat (absorption and diffusion), Heavy check mark Heat transfer to the tissues (blood, wall and perivenous) of a primary volume after firing to a secondary volume, thermally affected (thermodynamics tissue and cell), Heavy check mark Change thermochemical (iso-damage curves and histology). The histological works have the following findings: endoluminal thrombus, intimai injury (edema, disruption, endothelial detachment, injury of ligands), intimo-medial section, coagulation necrosis, medial lesions (alteration and shrinkage of collagen, edema, vacuolization, nuclear lesions), adventitial lesions (holes of the fiber in contact with the wall, parietal disruption by thermomechanical effect), peri-adventitial haemorrhages, lymphoceles. The LEV enables real "endo-phlebectomy and intimectomies" to a depth of 100 to 900 microns. The indications are now many published: the great saphenous and small saphenous vein, the saphenous branches, perforators, ulcers, surgical recurrence (CHIVA included),venous malformations. The main side effects described (in order of frequency): indurations, hematomas and bruises paraesthesia and dysaesthesia (especially with leg vein endosclerosis), superficial and deep venous thrombosis, recanalization, hyperpigmentation, lymphoceles, burns, secondary infections (cellulitis), arteriovenous fistulas, stroke. An ultrasound classification was developed to better assess the impact of different laser parameters The wavelengths used: 810 nm has been supplanted by the 980 nm and 940 nm, better adapted to the absorption by hemoglobin and water. These have been studies of longer follow-up to say 3 to 6 years basically. LEV compared to surgery: the practice of LEV associated with phlebectomy allows better results without additional complications. These can be replaced by endovenous treatment, the period of sick leave and hospitalization is reduced in some studies, as well as postoperative pain and recurrence rate. Local anesthesia and locoregional are more common with the LEV. Meta-analysis (12 320 members followed to 3 years) call for the LEV with a success rate of 94% for LEV, 84% for RF, 78% for stripping and 77% for the foam. The recurrence rate is lower in the absence of ligation. LEV and sclerosis: the LEV is working occlusion above the GVS sclerosis. Ultrasound-guided sclerotherapy after procedure improves the rate of secondary occlusion in the long term, it remains competitive with the LEV for the small saphenous vein. LEV compared to radiofrequency : recanalization rates in favor of LEV. The comparative scales of pain and period with induration are in favor of the RF. Conclusion: LEV appears to be the technique of choice for the treatment of great saphenous vein, it is discussed with ultrasound-guided sclerotherapy for the small saphenous vein. Its efficiency published meta-analysis, probably due to the fact that the absence of ligation of the saphenofemoral junction saves angiogenesis described with conventional ligation. It fits perfectly in the context of an outpatient procedure with regard to vector-saving reduction of sick leave, prescription of analgesics and the number of sessions of sclerotherapy. We find its global leadership and the many publications and as evidenced by the recent recommendations (2011) of the American Venous Forum. Methodological rigor and relevant analysis of the quality of life should finally convince our health authorities