Comment to: Laser assisted foam sclerotherapy (LAFOS): a new approach to the treatment of incompetent saphenous veins by Frullini A, Fortuna B. Phlébologie 2013;66:51-4.

Stefano Ricci

Abstract

For veins exceeding 1 cm of diameter, poorer outcome is expected as the occlusion rate of great or small saphenous veins (GSVs and SSVs, respectively). Reducing the diameter of the vein prior to sclerotherapy could improve the results, also requiring a limited volume of foam. A holmium:YAG (Ho:YAG) laser was employed to produce significant shrinkage on the vein media. This laser has been designed to avoid endothelium damaging while inducing coarctation of the vein wall by accumulating heat in the media (5 W, 500 mj, 350 µs max, 10 Hz max). The procedure under consideration – laser assisted foam sclerotherapy (LAFOS) – was applied in 50 patients (38 GSVs, mean diameter 9.17; 12 SSVs, mean diameter 7.91).
Veins were accessed by a 17 G short catheter with ultrasound (US) assistance. The laser fiber was placed 1-2 cm below the junction and manually retracted applying fluency from 150 to 400 mj without infiltration anesthesia. At the end of the laser phase, sclerosing foam (polidocanol: 3% GSV-5 mL mean; 2% SSV- 2 mL mean) was injected through the same catheter. One month of compression stockings was prescribed, with a 48-h-thigh eccentric compression by means of a pad. Patients were invited to walk daily for at least 1 h.
Vein shrinkage was constantly achieved and complete occlusion was always observed at 1 month. No patient referred extreme pain during laser procedure, while in 8 cases energy adjustment was required to avoid discomfort.

Comment by Stefano Ricci

Laser is an ever surprising technology. The ability to shrink the vein wall without damaging the endothelium is of particular interest, not only as a way to close veins (the Authors’ perspective), but also as a method for saphenous stem caliber restoration (a conservative perspective). As a matter of fact, what happens during this laser action is quite fuzzy, as no data or evidences are reported, the vein shrinkage possibly being due to the simple mechanical stimulation. In the past, the same effect has been studied through the action of radio frequency appliance (the Restore research) with inconsistent results. Finally, the costs of this combined technique should be analyzed to understand if laser+foam-tumescence is more convenient than laser+tumescence.

Reply by the Authors

The most frequent question on holmium laser vein shrinkage is whether this is a true coarctation or simply a vasospasm. In my perspective (and with the experience largely exceeding one hundred LAFOS), the answer is very simple: it is a true coarctation. Vasospasm is an all or nothing phenomenon: when it comes to positioning a needle, the vein disappears and LAFOS is not feasible as we need an open vein (even if shrinked). During LAFOS, the vein is commonly shrinked where laser has worked and, immediately below, it has the original diameter. Such a gap is not compatibile with a vasospasm, where a quite large segment of vein is affected. Obviously, the cost of the procedure will be of the outmost importance in the future of phlebology, but such an common procedure is capable to easily manage the saphenous trunk without the need of anesthesia. Moreover, as a laser procedure in some countries it will be reimbursed, with great convenience over simple sclerotherapy.

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