Comparative pilot study evaluating the treatment of leg veins with a long pulse ND:YAG laser and sclerotherapy

980 nm laser endo-perivenous treatment of lower limb reticular veins and telangiectasias. Technical notes

INTRODUCTION

For several years, the venous aesthetic problem has been tackled mainly with sclerotherapy techniques. In recent years, laser techniques have been added, both surface (transdermal) and endo-perivenous, performed with small optical fibers (100-200 μm) and low intensities in terms of LEED and Watt. The endo-perivenous technique has extended the possibilities of laser treatment also to the nourishing veins, to telangiectasias resistant to therapies with sclerosing agents and/or transdermal lasers and to vessels with larger diameters (1-3 mm) and depths >1.3 mm.

MATERIALS AND METHODS

We report a series of 20 patients affected by reticular veins and telangiectasias of the lower limbs (CEAP C1-2) treated with endo-perivenous technique. The most used setting was: 3 W (range: 2-4 W) with a mean fluence delivered of 11.25 J/cm (range: 6-18) in pulse mode with 980 nm laser, 200 μm fiber after a preventive skin cooling. Scheduled follow-up occurred 20 and 60 days after treatment.

RESULTS

Total technical success, understood as complete obliteration of all treated vessels, was achieved in 70% of cases (14/20) after just one treatment. The most observed early local complications were erythema, vesicles, and small cutaneous eschars that regressed in 3 weeks. At 60-day follow-up, just one complication was observed: a small area of hyperpigmentation (5%). In this case, chemical peel procedures was performed with good clinical results.

CONCLUSIONS

Endoperivenous laser treatment represents an effective and valid tool for the treatment of teleangectasias and reticular varicose veins.

Sclerotherapy in Aesthetic Medicine: Myths and Realities

BACKGROUND

Sclerotherapy is commonly performed for elimination of reticular and telangiectatic leg veins. There are several variations in practice, from the preparation to post-therapy directives.

OBJECTIVE

To critically examine the misconceptions of sclerotherapy for aesthetic indications.

MATERIALS AND METHODS

This review assesses evidence for and against each of the most common myths regarding sclerotherapy for aesthetic indications.

RESULTS

Sclerotherapy can be safely used to treat veins in areas other than the lower extremities, with the exception of the face. Laser therapy is not superior to sclerotherapy for the treatment of small telangiectatic veins on the lower extremities. The type of syringe used to produce foam sclerotherapy is an important procedural consideration. After sclerotherapy, graduated compression stocking usage is a vital part of the procedure. Detergent sclerotherapy agents are similar, but not equivalent. Touch-up treatments after sclerotherapy should not be performed for 2 months post-treatment. Foam sclerotherapy does not have a high risk for air emboli. It is not advisable to treat the leg veins in "sections." Finally, one cannot reliably treat the telangiectatic veins without treating the feeding reticular veins for a satisfactory result.

CONCLUSION

Many aspects of sclerotherapy have existing evidence to dictate best clinical practice.

Evaluation of the Efficacy and Safety Profile of Long-Pulsed 1064 Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) Laser in Hemangioma and Vascular Malformation in Darker Skin Types

Introduction

A prospective, interventional study was conducted to evaluate the efficacy and safety profile of long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in the treatment of vascular lesions in the darker skin patients of Fitzpatrick skin type IV and V.

Materials and method

The study was conducted at a tertiary care hospital. Institutional ethical committee permission was obtained before starting the study. Twenty-nine patients presenting with vascular lesions were enrolled in the study. The patients were called once a month for sessions for six months. Clinician Global Impression (CGI) scores were used for evaluation. We followed a “per protocol” analysis.

Results

Of the 29 patients we enrolled, three dropped out for various logistic reasons, and 26 patients completed their treatment. After six months of follow-up of the 26 patients who completed their treatment, 12 (46.15%) had shown complete healing (CGI = 4, 70%-100% improvement in lesions). The rest of the 14 (53.84%) patients showed good improvement (CG1 = 3, reduction of 50%-70% of lesions). No permanent side effects were noted.

Conclusion

Long-pulsed 1064 Nd:YAG laser proves to be an effective treatment for hemangioma and vascular malformation in darker skin patients with its major advantages of being a safe, well-tolerated, cost-effective procedure with minimal downtime and minimal side effects.

Adjuvant radiofrequency thermocoagulation improves the outcome of liquid sclerotherapy in the treatment of spider veins of the leg: A pilot study

OBJECTIVE

This study evaluated the effect of low-energy radiofrequency thermocoagulation added to standard liquid sclerotherapy on clinical outcomes of patients with venous insufficiency.

PATIENTS AND METHOD

We included 111 patients with spider veins CEAP/C1 stage. The patients were randomized into sclerotherapy (Group 1) and sclerotherapy + sclerotherapy immediately followed by low energy percutaneous RF thermocoagulation (Group 2) groups and followed up with same protocols prospectively.

RESULTS

The study groups did not differ in terms of the mean age, body mass index, the number of spider veins and pre-interventional venous clinical severity scores (VCSS). Patients' self-assessed satisfaction ratings of cosmetic outcomes were found to be higher compared to the baseline (p = 0.001). While both techniques caused a significant decline in VCSS at postprocedural third month, it was observed that the type of applied intervention did not affect the VCSS (p = 0.43 and p = 0.93, respectively). There was a significant difference in hyperpigmentation and trapped blood between the two groups after the procedure (p = 0.009 and p = 0.02, respectively), there was no statistically significant difference in terms of skin necrosis (p = 0.52). A significant difference in the self-assessed cosmetic outcomes was observed in patients treated with sclerotherapy followed by low energy percutaneous RF thermocoagulation compared with patients whom sclerotherapy performed alone (p = 0.001).

DISCUSSION

This study suggests that radiofrequency thermocoagulation added to the sclerotherapy provides better cosmetic outcomes with less treatment sessions and no additional complication rates.

Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019

Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.

Endovenous and perivenous 808-nm laser treatment of lower limb collateral, reticular and telangiectasiac veins

BACKGROUND

Visible leg veins are not only a mere aesthetic problem, but may also be manifestation of altered microcirculation and superficial venous incompetency. Sclerotherapy is the first-line treatment for leg veins < 4 mm, but it often needs multiple sessions and sometimes fails. The main limitations of transcutaneous laser treatment are the diameter and the depth of the veins: the greater, the harder photothermolysis is, so that higher powers may lead to aesthetic complications.

MATERIALS AND METHODS

We report our experience in the treatment of small collateral (< 4 mm), reticular and telangiectasiac veins with endovenous and perivenous 808-nm laser.

RESULTS

Overall, 325 treatments were performed on 113 patients. The endovenous and perivenous treatment proved to be a safe, quick, well-tolerated and effective procedure. It ensured an optimal closure of the target veins right from the first treatment in most patients. Sometimes, a second treatment of the same vein was needed.

CONCLUSIONS

The endovenous and perivenous 808-nm laser photothermal sclerosis ensures a quick coagulation-fibrosis of the veins of the lower limbs, thus allowing rapid healing and good aesthetic results (stable in 95% of patients after an average follow-up of 18 months). It may be an effective alternative to sclerotherapy.

A Novel Approach for the Treatment of Spider Veins

Background

Spider veins on the lower limbs are very common and have been reported to be present in 41% of women over 50. Sclerotherapy as a traditional treatment for spider veins has a low cost, though it may have adverse sequelae. Lasers have shown fewer but still substantial complications as well. Its lower efficacy relative to sclerotherapy has limited laser application for the treatment of spider veins.

Objectives

To present a new alternative in management of spider veins which involves a low voltage current delivered via an insulated micro needle with beveled tip.

Methods

Thirty female patients were treated with the “Given Needle.” The technique utilizes a micro needle with an insulated shaft with an exposed beveled tip, which is inserted into a hand piece connected to a mono-polar electrical generator. The needle is introduced through the skin into or on the spider vein. The current is then applied with obliteration of the vein.

Results

Twenty patients (66%) had more than a 70% resolution. The most common complication was skin erythema, which developed in 15 patients, followed by bruising in 13 patients. Both of these complications resolved in 2-3 weeks.

Conclusions

A novel approach for the treatment of spider veins has been described. The development of an insulated micro needle with an exposed beveled tip utilizing low current has minimized adjacent tissue damage and improved efficacy. The low cost, low level of complications, and comparable results offer a valuable alternative to sclerotherapy and laser treatment.

Level of Evidence

4 Therapeutic

[Therapeutic indications for percutaneous laser in patients with vascular malformations and tumors]

Lasers are increasingly used to treat vascular abnormalities. Indeed, this technique is non-invasive and allows a specific treatment. The aim of this review is to present some biophysical principles of the lasers, to describe the different sorts of lasers available for treatment in vascular medicine indications. Three principal lasers exist in vascular medicine: the pulsed-dye laser, for the treatment of superficial pink lesions, the NdYAG-KTP laser for purple and bigger lesions, and the NdYAG long pulse laser for even deeper and bigger vascular lesions. In vascular malformations, port wine stains can also be treated by pulsed-dye laser, KTP or NdYAG when they are old and thick. Telangiectasias are good indications for the three sorts of lasers, depending on their depth, color and size. Microcystic lymphatic malformations can be improved by laser treatment. Arterio-venous malformations constitute a contraindication of laser treatment. In vascular tumors, involuted infantile hemangiomas constitute an excellent indication of pulsed-dye laser treatment. Controlled studies are necessary to evaluate and to compare the efficacy of each laser, in order to determine their optimal indications and optimal parameters for each machine.

Treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. Nd:YAG laser: a prospective, comparative, randomized, open-label trial

BACKGROUND

Telangiectasias of the lower extremities are very common. There are no blinded, randomized, controlled clinical trials comparing laser modalities with the gold standard sclerotherapy, while the few available studies encompass small patients cohorts.

OBJECTIVE

This prospective, randomized, open-label trial compares the efficacy of sclerotherapy with polidocanol vs. long-pulsed neodymium-doped yttrium aluminium garnet (Nd:YAG) laser in the treatment of leg telangiectasias.

PATIENTS AND METHODS

Fifty-six female patients with primary leg telangiectasias and reticular veins (C1A or SEpAS1PN) were included in the study. One leg was randomly assigned to get treatment with the multiple synchronized long-pulsed Nd:YAG laser, while the other received foam sclerotherapy with polidocanol 0.5%. The patients were treated in two sessions at intervals of 6 weeks. The patients were evaluated by the handling physician after 6 weeks and 6 months. Two investigators assessed blindly at the end of the study the photographs for clearing of the vessels using a six-point scale from 1 (no change) to 6 (100% cleared). Patients reported about pain sensation and outcome satisfaction.

RESULTS

According to the handling dermatologist, at the last follow-up, there was an improvement of 30-40% with a median of 3 (IQR 2) and a good improvement of 50-70% with a median of 4 (IQR 2) after laser treatment and sclerotherapy respectively. In contrast, according to the blinded investigators, there was a median of 5 (IQR 1) with a very good improvement of >70% after both therapies. Improvement was achieved more quickly by sclerotherapy, although at the last follow-up visit there was no difference in clearance between the two groups as assessed by the blinded experts (P-value 0.84). The degree of patient's satisfaction was very good and similar with both therapeutic approaches. There was a significant difference (P-value 0.003) regarding pain perception between the types of therapy. Laser was felt more painful than sclerotherapy.

CONCLUSION

Telangiectasias of the lower extremities can be successfully treated with either synchronized long-pulsed Nd:YAG laser or sclerotherapy. The 1064-nm long-pulsed Nd:YAG laser is associated with more pain and is suitable especially in case of needle phobia, allergy to sclerosants and in presence of small veins with telangiectatic matting, while sclerotherapy can also treat the feeder veins.

Optimal and safe treatment of spider leg veins measuring less than 1.5 mm on skin type IV patients, using repeated low-fluence Nd:YAG laser pulses after polidocanol injection

Treatment of micro-veins of less than 1.5 mm with laser and with chemical sclerosis is technically challenging because of their difficulty to remedy. Laser treatment is even more difficult when dark phototypes are involved.Three groups of 30 patients each, skin type IV, and vessels measuring less than 1.5 mm in diameter, were enrolled for two treatment sessions 8 weeks apart: group A, polidocanol (POL) micro-foam injection; group B, Nd:YAG laser alone; and group C, laser after POL injection. Repeated 8-Hz low-fluence pulses, moving the hand piece over a 3-cm vein segment with an average of five laser passes maximum and with a total time irradiation of 1 s were used. Sixteen weeks after the second treatment, statistically, degree of clearance after examining photographs and patients satisfaction index, plotted on a visual analogue scale and comparing results of all three groups, results were significantly better for group C (p<0.0001). No significant differences in complications were noticed between the three groups. Efficacy of combining POL and laser proved safe and satisfactory in 96 % of patients using low-fluence laser pulses with a total cumulative energy in the 3 cm venous segment, lower than that of conventional treatment. Very few and transient complications were observed. POL foam injection followed by laser pulses is safe and efficient for vein treatment in dark-skinned patients.

Sclerotherapy of telangiectasias: a painless two-step technique

BACKGROUND

Sclerotherapy of telangiectasias and reticular leg veins can be unpleasant and painful for some patients.

OBJECTIVE

To determine pain level with two different sclerotherapy techniques in a prospective randomized trial.

METHODS

Patients with symmetrical telangiectasias and reticular veins on both legs (C(1A) or (S)E(P)A(S)P(N1) were randomized to the standard (successive injections of chromated glycerin mixed with one-third lidocaine-epinephrine 1%) or two-step technique (first treating only reticular veins with a single injection at the base of each cluster of telangiectasias and then successively injecting all remaining telangiectasias a few minutes later. Pain was assessed using a 100-point visual analogue scale (0 = no pain, 100 = maximum pain).

RESULTS

Data from 53 consecutive patients could be evaluated. The two-step technique was significantly less painful (28.2) than the standard technique (40.6, p < .001).

CONCLUSION

The two-step technique with chromated glycerin mixed with one-third lidocaine-epinephrine 1% significantly reduces sclerotherapy pain. This may be a useful technique for patients who are particularly sensitive or afraid of sclerotherapy.

Neodymium:YAG laser treatment of lower leg telangiectasia: a new minimally invasive approach

The aim of this study was to validate the safety and effectiveness of a new therapeutic procedure for the treatment of lower leg telangiectasia without clinical vein insufficiency. A group of 20 healthy women aged between 24 and 47 years (mean±sem 37.05 ± 1.47) with lower leg telangiectasia without clinical vein insufficiency, previously investigated by echo colour Doppler sonography, were recruited and were treated with neodymium:YAG laser (mean±sem 2.5 ± 0.11 sessions). Good or excellent results were obtained in 16 patients and the improvements were statistically significant (p < 0.01). Out of the 20 patients, 16 were satisfied with the procedure. We strongly support laser treatment of lower leg telangiectasia since it allows injection of chemicals to be avoided, and changes the stromal microarchitecture rearranging the fibroblast network into a more resistant pattern reducing the likelihood of relapse.

Current concepts: laser treatment of adult vascular lesions

Patients frequently seek treatment of cutaneous vascular lesions for both medical and cosmetic reasons. Advances in the use of lasers and light sources enable physicians to effectively treat vascular lesions that were previously untreatable. Given the plethora of devices available, selecting the appropriate laser system and treatment parameters can be confusing for the laser surgeon. This article reviews current concepts in the treatment of adult vascular conditions. It highlights the different types of lasers and the most common vascular lesions amenable to therapy. Also, the article offers several pearls regarding selection of the laser and of the treatment parameters.

Comparison of the 532-nm KTP and 1064-nm Nd:YAG lasers for the treatment of cherry angiomas

BACKGROUND

Laser therapy is the treatment of choice for cherry angiomas since it is more effective and has better cosmetic results. There is no comparative study about the treatment efficacies with KTP and Nd:YAG lasers for cherry angiomas.

OBJECTIVE

To compare the efficacy and side effects of 532-nm KTP and 1064-nm Nd:YAG lasers for the treatment of cherry angiomas.

METHODS

Two comparable lesions of the same patient were chosen. One of them was treated with the KTP laser while the other was treated with the Nd:YAG laser. Sessions were repeated every 4 weeks until complete clearance was achieved. Side effects were evaluated using a severity scale (0 to 4).

RESULTS

The number of sessions was significantly higher with the KTP than with the Nd:YAG laser (p = 0.002). Erythema, edema, pain and scar formation were higher in the Nd:YAG laser group (erythema: p = 0.001; edema: p < 0.001; pain: p < 0.001; scar: p < 0.001). The hyperpigmentation rate was statistically higher with the KTP laser (p = 0.01).

CONCLUSION

Both KTP and Nd:YAG lasers were found to be effective methods. The Nd:YAG laser offered fewer treatment sessions, but a higher risk of scar formation. The KTP laser seems more advantageous, but in dark-skinned patients the Nd:YAG laser may be preferable.

Nd:YAG laser combined with IPL treatment improves clinical results in non‐ablative photorejuvenation

BACKGROUND

Intense pulsed light (IPL) sources have been reported in non-ablative photorejuvenation, but the excellent histological findings do not always coincide with the clinical results and patient satisfaction index (SI).

METHODS

Ten female patients (two forehead, four periocular and four perioral), ages ranging from 28 to 46 years, skin types II-IV, wrinkle types I-III, participated in the study. The IPL system was applied with the yellow (570 nm) cut-off filter, 30 J/cm(2), single pulse, followed by the Nd:YAG at 120 J/cm(2), double pulse (7 ms per shot with 20 ms between pulses) on the wrinkled areas only. Three sessions were given at monthly intervals, and an assessment was made 1 and 6 months after the third session. Biopsies were taken from four consenting patients as a cross-section before the first treatment and then 1 and 6 months after the third session. For clinical control and contrast of tissue results, a group of 10 patients (two forehead, four periocular and four perioral; ages ranging from 27 to 47 years, skin types II-IV, wrinkle types I-III) was treated only with IPL, using the same parameters and sessions. Histologies were taken from four consenting patients.

RESULTS

The histology showed thickening of the epidermis with good dermal collagen organization in both groups. However, the combined treatment showed more dramatic changes in histological tissue condition, and ectatic blood vessels were seen in the deeper dermis. The patient SI values, related to the results, were lower when IPL was used alone. All patients completed the study. In the combined treatment group, overall SIs of 8 (80%) and 8 (80%) were obtained at the control points of 1 and 6 months, respectively, after session 3, compared with SIs of 6 (60%) and 4 (40%) scored by patients in the IPL group at the same points. Discomfort and side effects were minimal in both groups.

CONCLUSIONS

The addition of the Nd:YAG laser to the IPL regimen in non-ablative skin rejuvenation gave very good histological results, which were echoed by stronger patient satisfaction than in the control group treated only with IPL. Visible improvement in the skin condition of both groups was achieved, but was better in the combined treatment group.

Laser therapy for leg veins

Visible veins on the leg are a common cosmetic concern affecting approximately 80% of women in the United States (Engel A, Johnson MI, Haynes SG. Health effects of sunlight exposure in the United States: results from the first national health and nutrition examination survey, 1971-1974. Arch Dermatol 1988;124:72-9). Without a quick and noninvasive treatment available, leg veins present a therapeutic challenge. This challenge has been tackled by the design of lasers with longer pulse durations, and the use of lasers with longer wavelengths and cooling devices. Recent studies show the efficacy of laser treatment beginning to approach that of sclerotherapy, the gold standard. This review outlines the principles guiding laser treatment, the current available options, and a clinically oriented approach to treating leg veins.

Laser therapy of spider leg veins

BACKGROUND

Spider leg veins are a common aesthetic problem in females. The standard treatment is sclerotherapy but lasers have been used for decades to solve this problem as well.

AIM

To review recent advances in laser physics and its tissue interactions with skin vessels. The different laser types used to treat spider leg veins are discussed, including their advantages, limitations and possible adverse effects.

METHOD

The international literature on laser therapy for spider leg veins has been reviewed with particular emphasis on the last decade.

RESULTS

Recent developments in laser technology allow a more selective and well-tolerated therapy. Efficacy has also improved. Most studies report a greater than 75% improvement in spider leg veins as a realistic goal for laser therapy. Clinic response depends upon wavelength, fluence, pulse width and pulse duration, cooling and the diameter and colour of spider leg veins.

CONCLUSIONS

Sclerotherapy remains the gold standard treatment for spider leg veins. Nevertheless, laser therapy has become increasingly efficacious and convenient. Laser selectivity has been improved by technological progress. The ideal laser, however, has yet to be invented.

Laser therapy of vascular lesions

Since the first construction of a laser by Maiman in 1960 and the first clinical application of a laser in the therapy of skin lesions by Leon Goldman, laser therapy has become an important therapeutic modality in dermatology. Various lasers can be used for the treatment of different vascular and non-vascular lesions. According to our results, vascular lesions constitute the most important indication for laser therapy in dermatology.

Optimal parameters for the treatment of leg veins using Nd:YAG lasers at 1064 nm

BACKGROUND

The treatment of large vessels such as leg veins is successfully performed in clinical practice using pulsed Nd:YAG lasers. However, it is still unclear how laser parameters such as wavelength, fluence and pulse duration influence vessel destruction in leg veins.

OBJECTIVES

To elucidate the governing parameters in selective photothermolysis of large vessels.

METHODS

A recently developed mathematical model for photothermolysis has been adapted for the treatment of leg veins. The model was used to analyse the effectiveness of the selective photothermolysis process in laser treatment of leg veins by Nd:YAG at 1064 nm. The efficiency of laser-induced vessel heating was defined as a ratio between the absorbed and delivered energy.

RESULTS

The efficiency improved with increasing vessel diameter, in agreement with clinical findings in various studies. The pulse duration made a minor contribution for laser fluences of 100-400 J cm(-2), whereas the efficiency was better for a small spot. The use of moderate fluences of 100-200 J cm(-2) reduced excess dermis heating and pain.

CONCLUSIONS

We provide reference parameters for optimal treatment of leg veins using Nd:YAG lasers at 1064 nm. Our model predicts a maximal efficiency of a range of fluences (100-200 J cm(-2)) and pulse durations (10-100 ms).

Laser treatment of leg veins

The development of lasers using deeper-penetrating, near-infrared wavelengths with millisecond pulse durations and skin-cooling methods has produced safer and more predictable results for the treatment of leg veins less than 1 mm in diameter and depth. Recent prospective studies of the near-infrared lasers show comparable efficacy and side effect profiles to those observed with sclerotherapy. Treatment of reticular and varicose veins is effective with these wavelengths but is limited by patient discomfort when compared with sclerotherapy. Visible light lasers (such as the pulsed dye and KTP) and intense pulsed-light sources are reproducibly effective only for superficial, nonarborizing pink-to-red telangiectasia, in the absence of points of proximal reflux. Because most lower-extremity vascular ectasias comprise a heterogeneous group of vessel sizes and depths, many patients achieve the best results using a combination of techniques. This article reviews the fundamentals of laser tissue interactions for the treatment of leg veins and details the recent clinical experience with the newer near-infrared devices.

Cosmetic aspects of pregnancy

There are a vast number of changes to the female body that occur during pregnancy, to which any pregnant woman will attest. The changes, although considered, for the most part, physiological and not pathological, are quite distressing to many women. This chapter serves to review those changes and comment on their physiological origins. Most of these changes can be definitively or inferentially linked to the dramatic hormonal changes that take place to support a pregnancy. Comments are also made about treatment as they pertain to pregnant women. In addition, a brief discussion about performing cosmetic procedures during pregnancy is included.

A Side-by-Side Prospective Study of Intense Pulsed Light and Nd:YAG Laser Treatment for Vascular Lesions

Recently, lasers and light systems are used more for the treatment of vascular lesions due to their noninvasiveness, ease of use, and short recovery time. This side-by-side prospective study compares results, satisfaction, and complications after intense pulsed light (IPL) and Nd:Yag laser treatment of small vascular lesions. Twenty-five patients with telangiectases, leg veins, or cherry angiomas underwent treatment of the same category of lesion in the same area. One year after completing treatment, patients were asked to report their satisfaction level after comparing digital photos before and after treatment; 72% felt they had good to excellent results after Nd:Yag treatment, while only 48% felt the same after IPL. The most common side effect after Nd:Yag was hyperpigmentation. Satisfaction level was significantly higher after Nd:Yag than after IPL. Patients with telangiectases, cherry angiomas, or leg veins <1 mm were more satisfied after IPL, while those with leg veins >1 mm were more satisfied after Nd:Yag. Overall, satisfaction with treatment of vascular lesions was greater with Nd:Yag although this method was more painful.

Laser treatment of leg veins: Physical mechanisms and theoretical considerations

BACKGROUND AND OBJECTIVES

A discussion of laser treatment of leg veins is based on a review of the literature, theoretical analysis, and the clinical experiences of the authors. Theoretical computations are discussed within the context of clinical observations.

STUDY DESIGN/MATERIALS AND METHODS

A Monte Carlo model is used to examine volumetric heat production, fluence rate, and temperature profiles in blood vessels at 1,064 and 532 nm wavelengths with various beam diameters, vessel diameters, and pulse durations.

RESULTS

Clinical observations, Monte Carlo results, and a review of the literature suggest that longer wavelengths and longer pulses durations favor vessel contraction over intraluminal thrombosis. Monte Carlo simulations show that longer wavelengths are more likely to uniformly heat the vessel compared to highly absorbing wavelengths. Methemoglobin production causes deeply penetrating wavelengths to generate more volumetric heat for the same input radiant exposure.

CONCLUSIONS

Clinical observations and models support the role of long wavelengths and long pulses in optimal clearance of most leg telangiectasias.

Long pulse Nd:YAG laser for treatment of leg veins in 40 patients with assessments at 6 and 12 months

BACKGROUND AND OBJECTIVES

This study assessed subjectively and objectively the efficacy of a long-pulsed Nd:YAG laser system in clearing dermal leg veins, successful treatment of which remains problematic.

STUDY DESIGN/PATIENTS AND METHODS

Forty female patients (24-58 years old, skin types II-IV) with leg veins were treated with synchronized micropulses from a long-pulsed 1,064 nm Nd:YAG laser, 6 mm diameter spot size, 130 and 140 J/cm2. One to three treatments were given at 6-week intervals, with post-treatment assessments at 6 and 12 months. Patients assessed improvement subjectively with a satisfaction index (SI). Objective assessment was based on the clinical photography, and in addition on computer-generated data from a Canny operator-based edge-detection program.

RESULTS

The overall patient satisfaction rates and objective assessments at the 6 and 12 month assessments were 42.5 and 57.5%, and 75 and 82.5%, respectively.

CONCLUSIONS

The long-pulsed Nd:YAG laser offered efficient treatment of leg veins. Side effects were minimal and transient. The edge-detection program may help patients appreciate better the actual results of the treatment.

Comparison and sequential study of long pulsed Nd:YAG 1,064 nm laser and sclerotherapy in leg telangiectasias treatment

BACKGROUND AND OBJECTIVES

Millisecond pulsed 1,064 nm Nd:YAG lasers have been developed for the treatment of leg telangiectasias. To date there have been very few side by side comparison studies of laser versus the gold standard sclerotherapy in treating small leg veins. This study aims to compare a long pulsed Nd:YAG laser with contact cooling to sclerotherapy for treating small diameter leg telangiectasias by evaluating objective and subjective clinical effects.

STUDY DESIGN/PATIENTS AND METHODS

Fourteen patients were selected with leg telangiectasias ranging from 0.5 to 2 mm at four comparable sites. One site was treated with long pulsed Nd:YAG alone, the second received sclerotherapy alone, the third laser then sclerotherapy, and the last one sclerotherapy then laser. The patients were followed up at 3 months after the last treatment. Photographs were taken pre-operatively and at 3 months after the last session. They were used for objective and comparative analysis. Statistical analysis was performed using Friedman's test controlling for subject.

RESULTS

Improvement was tabulated from the photographic assessment on an improvement scale from 0 (no change) to 4 (greater than 75% clearing). There were clinical improvements in the laser group than sclerotherapy without statistical significance. Side effects were minimal and included hyperpigmentation.

CONCLUSIONS

This pilot study demonstrates that the Smartepil LS long pulse Nd:YAG 1,064 nm laser can yield results similar to sclerotherapy in the treatment of small leg telangiectasias. Combination of both methods could increase response to treatment.

Microthrombectomy reduces postsclerotherapy pigmentation: multicenter randomized trial

OBJECTIVE

Postsclerotherapy pigmentation occurs in nearly 30% of patients. Hemosiderin, from degradation of the venous thrombus, is the possible cause. The hypothesis that early removal of the thrombus may eliminate or decrease the incidence of pigmentation has not been proved or documented. The objective of this study was to investigate the effects of early microthrombectomy on incidence of postsclerotherapy pigmentation.

MATERIAL AND METHODS

This multicenter, randomized, controlled study involved 101 patients with varicose veins (100 women, 1 man; mean age, 46 years [range, 25-68 years]). Patients were divided into two groups, with veins 1 mm or less in diameter (group 1, n = 50) or veins 3 mm or less in diameter (group 2, n = 51). Group 1 was treated with Sotradecol (STD) 0.25%, and group 2 with STD 0.50%. In each patient, an area of varicosities was selected and divided into halves. One half was randomized to microthrombectomy and the other half served as control. Microthrombectomy was performed 1 to 3 weeks after treatment in the randomized half. Standard photographs were obtained before and 16 weeks after treatment, and were evaluated by three independent reviewers who were blinded to treatment assignments. Each reviewer received an identical set of pretreatment and posttreatment 10 x 15-cm color photographs of the study area, and completed a scoring sheet. Average of the scores was used to evaluate primary (pigmentation) and secondary (overall clinical improvement) end points. The paired t test and chi-square test were used for statistical analysis.

RESULTS

In group 1, microthrombectomized areas had statistically significant less pigmentation (P =.0047) and better overall clinical improvement scores (P =.0002) compared with the control side. In group 2 there was no significant difference between the two areas, but patients reported significant relief of pain and inflammation associated with postsclerotherapy thrombophlebitis.

CONCLUSION

In veins 1 mm or smaller, microthrombectomy reduced pigmentation and improved overall clinical results. In veins 3 mm or smaller, statistical significance was not achieved, but thrombectomy resulted in faster resolution of the postsclerotherapy pain and inflammation. On the basis of these results, microthrombectomy after sclerotherapy is recommended.

Using a "non uniform pulse sequence" can improve selective coagulation with a Nd:YAG laser (1.06 microm) thanks to Met-hemoglobin absorption: a clinical study on blue leg veins

BACKGROUND AND OBJECTIVES

Evaluation of the efficacy, on 1-2 mm blue leg telangiectasia, of a 1,064 nm Nd:YAG laser emitting in a non uniform pulse sequence calculated to consider Met-Hb formation during laser irradiation of a blood vessel.

MATERIALS AND METHODS

A 1,064 nm Nd:YAG laser (Quantel Medical, Athos, France) was used in a non uniform pulse sequence mode, fluences: 300-360 J/cm(2) spot: 2 mm, + 5 degrees C contact cooling. The clinical evaluation was performed on 11 female patients, average age: 43 (25-57) years, phototype I-VI. All subjects were previously examined with Doppler ultrasound. A treatment site (6 x 4 cm) was selected on each patient. The topography of the vessels network was reported on a tracing plastic frame before each session and 6 weeks after the last one. These frames were digitized and the number of vessels was determined using the Digitized Tracing Frames Technique. Side effects were noted before and after every treatment, and 6 weeks after the last one. This study lasted for 10 months.

RESULTS AND DISCUSSIONS

Patients tolerated the procedure without anesthesia. Moderate pain, transient erythema and edema, one hyperpigmentation and one matting were noted. There was no hypopigmentation. 55% (P < 0.002) vessels clearance after one session, 86% after two sessions (P < 0.001), and 98% (P < 0.001) after three sessions were obtained. On two patients, the treatment was completed after two sessions with a full clearance. Data reported in this study were obtained thanks to a computerized calculation of vessels clearance. They are similar or superior to those reported in the literature about 1,064 nm Nd:YAG lasers and leg telangiectasia.

CONCLUSIONS

Since, it was developed to consider the modification of blood absorption and the methemoglobin formation which leads to an increase of the 1.06 microm wavelength absorption, the non uniform pulse mode emphasizes the efficacy of this 1,064 nm Nd:YAG laser concerning the treatment of blue leg veins telangiectasia between 1 and 2 mm. This mode gives the possibility to deliver high energy while preserving the surrounding tissue and leads to a rapid vessel clearance with reduced pain and few side effects when compared to previously published clinical studies using a 1.06 microm laser.