Optimal and safe treatment of spider leg veins measuring

Lasers Med Sci (2013) 28:925–933
DOI 10.1007/s10103-012-1180-6
ORIGINAL ARTICLE
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
Javier Moreno-Moraga & Esteban Hernández &
Josefina Royo & Justo Alcolea & M. Jose Isarría &
Mihail Lucian Pascu & Adriana Smarandache &
Mario Trelles
Received: 4 June 2012 / Accepted: 25 July 2012 / Published online: 11 August 2012
# Springer-Verlag London Ltd 2012
Abstract 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
J. Moreno-Moraga : J. Royo : M. J. Isarría
Instituto Médico Laser,
Madrid, Spain
E. Hernández : J. Alcolea : M. Trelles (*)
Instituto Médico Vilafortuny, Fundacion Antoni de Gimbernat,
Cambrils, Spain
e-mail: [email protected]
M. L. Pascu : A. Smarandache
National Institute for Laser, Plasma and Radiation Physics,
Bucharest, Romania
few and transient complications were observed. POL foam
injection followed by laser pulses is safe and efficient for
vein treatment in dark-skinned patients.
Keywords Vein treatment . Laser . Polidocanol injection .
Leg veins . Spider veins
Introduction
Despite the numerous procedures proposed in recent years
for the treatment of spider veins—sclerotherapy [1, 2], laser
[3–5], dual laser [6], laser and polidocanol (POL) [7–9]—
the treatment of small vessels is technically challenging in
all patients but specially so in those patients with dark skin
phototypes and fine vessels, where it becomes more
difficult.
Sclerosis of very fine vessels using liquid chemicals or
foam is less efficient, due to the blood flow rate and the low
quantity of sclerosing agent used [10]. The venous blood
flow ranges from 0.1–1 mm/s in capillaries to approximately
22 mm/s a velocity that, when extrapolated to larger vessel
diameters, continues to be slow. This, together with the low
concentration of sclerosant used, does not give it time for
the detergent effect to take action on the endothelium cells
which makes it necessary to carry out various treatment
sessions.
Laser treatment requires high energy delivered in short
pulses, thus increasing the risk of burns and reactive hypoor hyper-pigmentation, especially in patients with dark skins
[11, 12]. If the optical conditions of the circulating fluids are
improved then, hypothetically, it should be possible to avoid
using such high fluences that increase the risk of burns. Due
926
to the behavior of POL in the absorption of the 1,064-nm
wavelength of the Nd:YAG laser and the scattering produced by the superficial pressure in the form of microfoam, optical absorption of blood and sclerosant mixed
together will noticeably improve [13].
The thermal relaxation time of the skin is shorter than
that of the veins [14]; therefore, applying the laser energy
moving the hand-piece over the vein, using 8 Hz repeated
pulses of low fluence, epidermis would be preserved and
thermal effect should accumulate in dermis. Because heat
focuses on vessels due to hemoglobin chromophore acting
as principal target, laser light in presence of POL foam,
which modifies scattering, might easily and effectively damage the vascular endothelium producing vein closure.
Based on this reasoning, a prospective comparative study
was set up to evaluate the efficacy and safety of a combined
POL and laser treatment for leg veins on dark skin patients.
Three similar groups of patients were prepared for treatment
of 1.5 mm veins: One group received combined POL and
laser treatment comparing results to those achieved by a
group treated only with POL and another group treated only
with laser.
Materials and methods
This prospective comparative study was designed for treatment of three groups of 30 each in which patients were
randomly assigned. Age of patients in all three groups
ranged from 19 to 46 years (mean, 32.9 years). The total
90 patients only had cosmetic complaints; all were female
with skin phototype IV and 1.5 mm varicules (Table 1).
Ages of patients assigned to the three groups were similar,
and no significant differences were found to exist after
statistical analysis using the ANOVA test (p00.778).
Appointments for the first evaluation were scheduled for
Mondays, Wednesdays, and Thursdays, which served to
randomly assign the patients. All patients explored on Mondays were assigned to group A; all who were seen on
Wednesday to group B, and all who were evaluated on
Thursdays were allocated to group C.
Number and density of varicosities in the three groups of
patients were scored as follows:
1. Low: less than 10 % leg’s surface with varicosities
2. Medium: between 10 and 30 % leg’s surface with
varicosities
3. High: more than 30 % leg’s surface varicosities
The density and multiple veins present in the treated
limbs were similar in the three groups as reflected in
Table 2.
The ANOVA test (p00.697) showed that no significant
differences were found between the three groups (Table 2).
Lasers Med Sci (2013) 28:925–933
No patient had been exposed to UV-B less than 8 weeks
before treatment, nor had they taken oral contraceptives for
at least 12 weeks. The exclusion criteria were: less than
18 years of age, pregnancy, breastfeeding, scarring or infection at the treatment site, use of iron supplements or anticoagulants, history of photosensitivity, or scarring. None of
the patients had previously received laser or POL treatment
for varicules.
All patients were treated according RTC consort guidelines. Group A was treated only with POL; group B was
treated only with laser, and group C received combined
treatment of both POL and laser with the POL injection first
followed by laser treatment.
All patients gave their written informed consent for treatment and clinical photographs and underwent Doppler ultrasound (Soniline 050, Siemens, Issaqua, Japan) to rule out
deep system reflux at the saphenous junctions and in
the perforating veins. The study was reviewed and approved by the Ethics Committee of the Fundación
Antoni de Gimbernat.
Micro-foam was prepared following the Tessari technique [15, 16] using a POL concentration of 0.3 %, obtained
by diluting the commercial presentation of Aetoxysclerol®
tamponné/lauromacrogol 400 by Kreussler Pharma, Germany, with 0.5 % saline solution. Two milliliters of the
sclersonat was placed in the syringe with 8 ml of CO2 to
prepare the micro-foam, using a filter for micro-particles
with the three-stage stopcock to ensure stable and sterile
micro-foam. The Tegernsee consensus advises to use liquid
form of the sclerosant to avoid the presence of nitrogenous
into the mixture; therefore, we used only CO2. POL in liquid
form does not produce a scattering reaction when in contact
with laser light, therefore and for this reason, we used POL
in foam form as according to what we have previously
reported; it produces an active light scattering which would
increase the time of interaction between the laser beam and
POL, leading to prolonged reactions of vein walls [17]. The
laser used was the 1,064-nm-long pulse Nd:YAG (Synchron
HP Laser Deka, Florence, Italy), with 2-mm spot, 150 J/cm²
fluence, programmed for emission in a train of 8 Hz pulses,
with a total pulse duration of 35 ms and a delay of 15 ms
(Fig. 1). Treatment was applied on a 3-cm vein segment
with a maximum of five laser passes, as this length can be
controlled with precision of 1 s used per pass.
The Laser handpiece was connected by an adapter to
an air-cooling system, in the #5 flux position of the
various offered by the manufacturer (Cryo 6, Zimmer
ElektroMedizin, Neu-Ulm, Germany). Program #5 corresponds to 6,000 l/s flux at −20 °C. The cooling hose
nozzle adapted to the handpiece focuses directly where
the laser handpiece tip is pointed in order to ensure
stacking of continuous cold air directly on the treatment
area.
Lasers Med Sci (2013) 28:925–933
927
Table 1 Patient characteristics in the various groups
Group A: POL
Group B: laser
Group C: POL+laser
Patient
Age
Sex
Photo-type
Patient
Age
Sex
Photo-type
Patient
Age
Sex
Photo-type
1
2
3
4
5
27
25
28
39
46
F
F
F
F
F
IV
IV
IV
IV
IV
1
2
3
4
5
20
36
42
32
36
F
F
F
F
F
IV
IV
IV
IV
IV
1
2
3
4
5
23
38
46
41
32
F
F
F
F
F
IV
IV
IV
IV
IV
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
33
35
37
42
40
39
34
36
29
22
27
20
36
24
41
36
32
33
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
36
28
22
36
41
44
43
20
21
36
24
38
35
21
40
23
35
33
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
25
37
20
29
31
35
28
41
37
33
28
36
42
28
19
42
39
35
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
24
25
26
27
28
29
30
28
40
39
25
32
22
20
F
F
F
F
F
F
F
IV
IV
IV
IV
IV
IV
IV
24
25
26
27
28
29
30
39
22
23
26
36
28
24
F
F
F
F
F
F
F
IV
IV
IV
IV
IV
IV
IV
24
25
26
27
28
29
30
37
43
20
23
24
32
44
F
F
F
F
F
F
F
IV
IV
IV
IV
IV
IV
IV
The energy used per 3 cm of the treated vein was estimated on the basis that the area of the 2 mm spot corresponds to (πr²) 3.14 mm², 0.0314 cm², and the energy of
each laser pulse was of 150 J/cm², which when multiplied
by 0.0314/100 gave 4.71 J. Because eight pulses were given
in 1 s, 37.68 J/s were given in five passes of 5 s which
corresponded to a total of 188.4 J total energy delivered on
in the 3 cm of vein length.
The procedure involved disinfection of the area of 30×
30 cm with hydrogen peroxide, followed by the POL microfoam injection using a 2-ml Omnifix syringe and a 30 G
needle. No anesthesia of any sort was used. Immediate
disappearance of the vein outline occurred after the POL
injection. Two to three minutes later, a light pink color
appeared which allowed following the route of the injected
vessel. Laser treatment carried out on 30×30-cm squares
was after the POL injection and only when vessel turned
pinkish in color. Various laser passes were made with a
maximum of five respecting a precise 1 s per 3-cm segment,
thus obtaining a progressive increase in temperature. Due to
heat accumulation in the dermis, temperature increased progressively and patient experienced discomfort; therefore all
patients were asked to report any unpleasant reaction, pain,
or burning sensation during treatment. In case of these
symptoms or intense redness, laser operation was stopped.
Treatment was considered complete once varicules faded.
The procedure was repeated after 8 weeks. All patients were
recommended to wear a 35mmHg compressive stocking
(Mediven®Struva® 35, mediGmbH &Co KG, Bayreuth,
Germany) for a week after both treatments.
Patients evaluated their satisfaction with the results
16 weeks after the second treatment, using a questionnaire
928
Lasers Med Sci (2013) 28:925–933
Table 2 Vein number and density in each group
Patient no.
Group 1
Score
Group 2
Score
Group 3
Score
1
2
3
4
5
6
7
8
9
10
11
12
13
2
1
2
1
3
1
2
1
3
1
2
3
3
1
3
1
2
2
2
2
3
3
3
1
1
1
3
2
1
1
1
3
3
3
1
1
2
2
1
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Average
1
1
1
1
2
2
2
2
1
3
3
3
2
1
1
3
1
1,83
1
2
2
3
1
1
1
2
3
3
3
1
1
1
1
1
3
1,83
3
3
1
1
2
2
2
2
1
3
1
1
2
2
1
3
1
1,83
with a visual analogue scale (VAS) index. A VAS was
implemented as a psychometric scale in questionnaires answered by patients. In this way, it was possible to measure
and assess subjective characteristics or attitudes as perceived by each patient. When responding to a VAS item,
patients indicated their level of agreement by designating a
position along a continuous line between two end-points.
Scores were: very good, >90 % improvement; good,
70 %–89 % improvement; fair, 50 %–59 % improvement;
and poor, <50 %. Questionnaires filled out permitted correlation in percentages of patient’s subjective impression regarding blanching effects in veins or their disappearance.
Percentages were >90 %, very good results; 70 to 89 %,
good results; 50 to 59 %, fair results, and<50 %, poor
results. To determine patient’s satisfaction with the treatment, very good and good results were summed up.
The blind evaluators, unfamiliar with the study and the
patients, used the same scale to score improvement observed. Arithmetically, the average of the results given by
the evaluators was used for statistical calculations. In group
A, the same procedure but only injecting POL foam was
carried out, selecting areas of 30×30 cm for vein treatment.
Compressive tape was applied on every patient injected, and
compressive stockings were recommended for 1 week. In
group B, no POL injection was applied but only laser
treatment with the same method and parameters as in group
C. All groups were re-treated 8 weeks after the first treatment, and also, all groups used compressive stocking for
1 week following both treatments.
The treated area of was photographed at a constant 18 cm
distance under the same light and environmental conditions,
using a digital camera (Canon EOS 400D, Tokina ATX Pro
100 f 2.8 with a Macro lens, Sea&Sea Flash Macro DRF 14;
Canon, Tokyo, Japan). Photographs were taken before the
first treatment session and at 16 weeks after the second
treatment. Photographs were used for objective evaluation
which was done by two independent physicians familiar
with vein sclerosis and laser treatment. For the statistical
analysis of the SI expressed by patients, a contingency table
was used. Results recorded in the VAS scale and evaluation
of outcome, as presented before and after photographs, were
analyzed using a Chi-square test (χ2). The reference used
for significance of results was p<0.05.
Contingency tables and Chi-square test were also used to
evaluate complications observed in the three groups such a
burns, hyperpigmentation, and/or matting.
Results
Fig. 1 Immediately after treatment with laser. Notice erythema of
various intensities and edema with elevation where veins were more
evident
On examining ages of the patients enrolled in the three
groups, no significant differences were noticed (p00.778).
In group A, veins faded as soon as POL foam entered the
Lasers Med Sci (2013) 28:925–933
vessel. In group B, after laser irradiation, erythema
reaction was observed following the vein silhouette.
Erythema was not homogenous indicating more or less
reaction to laser pulses and energy absorption (Fig. 1).
Reactive erythema was followed by edema with skin
elevation in some parts of the vein route. In group C
(POL+laser), treatment was well-tolerated, and erythema
and edema were also seen after laser pulses. In this
group, after laser treatment, veins which were larger in
diameter, skin darkened immediately, showing perivenous erythema (Fig. 2). No procedures, in any group,
had to be interrupted because of discomfort, burning
sensation, or pain (Table 3).
In the case of group C, limit of the vein path was observed diffused and slightly red. It was assumed that the
vein wall altered due to heat turned visible and damage
made the route outline irregular. However, these alterations
were observed in all groups but more intense in group C, in
which POL and Nd:YAG laser pulses were used. All these
side effects had completely disappeared at 8 weeks after the
first treatment.
Improvement at 16 weeks after the second treatment,
according to patients, and percentages assigned were as
follows for the three groups:
Group A POL injection: two (6.66 %) patients, very good;
seven (23.33 %) patients, good; and 21 (70 %)
patients, fair. SI deduced by summing up the
very good and good results was 30 % (Fig. 3).
Group B Laser treatment: three (10 %) patients, very good;
four (13.33 %) patients, good; and 23 (76.66 %)
patients, fair. SI was 23.33 % (Fig. 4).
Group C POL and laser: 25 (83.33 %) patients, very good;
four (13.33 %) patients, good; and one (3.33 %)
patient, fair, which corresponded to a patient who
developed matting. SI was 96.66 % (Fig. 5).
Fig. 2 Immediately after treatment with POL+laser. Erythema following vein path and minor ecchymosis
929
Table 3 Complications: burns, hyperpigmentation, and matting
Burns
Treatment
POL
Laser
POL+Laser
Yes
2
3
2
No
30
27
28
Total
30
30
30
No significant differences between groups, χ2 , p00.227
Hyperpigmentation
Treatment
POL
Laser
POL+Laser
Yes
2
0
0
No
28
30
30
Total
30
30
30
No significant differences between groups, χ2 , p00.129
Matting
Treatment
POL
Laser
POL+Laser
Yes
0
0
1
No
30
30
29
Total
30
30
30
No significant differences between groups, χ2 , p00.364
Results of the objective assessment through control of
photographs at 16 weeks correlated very well with the
subjective impression expressed by patients (Table 4). Analysis of the whole set of before and after by the two physicians revealed that comparing groups A, B, and C,
improvement was very good in eight, five, and 28, respectively. Good were in seven, six, and one, and fair in 15, 19,
and one (Fig. 6).
Comparing results achieved in the three groups, according to VAS questionnaires for the SI, statistical analysis gave
significantly better results for group C in which the combination of POL and laser treatment was used (Table 4).
Likewise, comparing results of photographs for the three
groups, statistics were significantly better for group C,
p< 0.0001 (Table 2).
Fig. 3 Before and after treatment with laser only. Few veins have
disappeared and veins will need further laser treatment sessions
930
Lasers Med Sci (2013) 28:925–933
Table 4 Comparison of results according to patient satisfaction (SI)
and objective assessment
Fig. 4 Before and after one treatment session with POL. Results
indicate that, although there is improvement and a few veins were no
longer present, extra sessions of injections will be necessary
In general, most authors state that sclerotherapy is more
efficient than laser therapy to treat leg varicosities. However, when evaluating our results which were about the same,
the frequency of sclerotherapy treatment should be taken
into consideration as it was not carried out with a standard
frequency. This could explain the reason why results were
not so good
Complications were observed in three patients of
group B and three of group C, who presented mild
burns. All these five patients healed without scarring
but developed a transitory hyperpigmentation. Hyperpigmentation was also noticed in two patients from group
A. One patient form group C developed discreet matting
in one of the segments of treatment. No hypopigmentation was noticed. Comparison of complications observed
such as burns, hyperpigmentation, and matting, showed
no significant differences between the three groups
(Table 3).
Fig. 5 Before and after a single treatment session with POL+laser.
There is an evident improvement
Patient satisfaction (SI) according to treatment
Patient satisfaction
Treatment
POL
Laser
Very good
2
3
Good
7
4
Fair
21
23
Total
30
30
Objective assessment according to treatment
Objective assessment
Treatment
POL
Laser
Very good
8
5
Good
Fair
Total
7
15
30
6
19
30
POL+Laser
25
4
1
30
POL+Laser
28
1
1
30
χ2 , p<0.001
Statistically significant differences in favor of group C (POL+Laser) in
both SI and objective assessment
Discussion
At the time of low-fluence laser pulses, energy is gradually
deposited on the treated area building up heat with thermal
effect propagation preferentially concentrating in vessel due
to hemoglobin chromophore absorption. Total laser fluence
per length of vessel treated and time between pulses leads to
progressive heat propagation from the vein interior to its
wall. External cooling provided by the cold air prevented
skin surface damage. A constant cold air flow directed to the
skin surface drastically evacuates heat by convection preventing skin surface damage [18]. Also, constant air cooling
alleviates pain perception by nociceptive nerves located
superficially in the skin, making treatment bearable [19].
A progressive and relatively rapid increase in temperature
Fig. 6 Before and after treatment of vein with POL+laser. Notable
resolution with a single session of treatment
Lasers Med Sci (2013) 28:925–933
with heat transfer is produced from the maximum point of
laser energy absorption. The heat increase will produce pain
and burning sensation, as reported by patients, which serves
as a sign of alarm and an indication to move laser pulses to a
neighboring venous segment, preventing epidermal damage
and blistering. During the process of laser energy absorption, hemoglobin chromophore saturates and heat affects
thermal sensitive proteins of the vessel intima, producing
damage and wall contraction
Since the vein is in thermal equilibrium with the surrounding tissue and is more sensitive due to absorption of
laser wavelength energy, it is more prone to thermal damage
with repetitive pulses. Thus, once subdermal layer is significantly heated and temperature in the vessel increases, only
a few additional low-fluence pulses given in constant motion are needed to raise temperature and damage the vein,
impairing its biological function [14]. The effective low
fluences used for vein closure may be explained by the
phenomenon of collagen contraction, which depends on
the temperature and time ratio, e.g., smaller vessels cool
more quickly, an observation that implies a requirement
for longer exposure to laser radiation [12].
Efficiency of vessel damage process qualifiedly depends
on light propagation (wavelength and time) and the fluence
per pulse. Absorption coefficient per volume of hemoglobin
has to be rapidly saturated to give heat a chance to travel and
to dissipate. Repeated low-fluence pulses encounter blood
stream; it is hemodynamics, as a transporter and “coolant”
of laser energy. The basic typical condition is to deliver a
package of energy per pulse in a single pulse to obtain a
rapid and effective damage in the intima via absorption,
saturation, and propagation. Within this process, blood dehydration and coagulation occurs together with vein closure.
In short, the mechanism of vein closure depends on wavelength and rapid thermal saturation of the chromophore for
blood coagulation and light/heat propagation to damage the
vessel intima wall. However, in our study, we propose a
different approach.
Significantly better results were achieved in group C,
which can be explained on the one hand because possibly:
1. The laser improves its efficacy by light scattering
2. The laser is absorbed by POL components
3. The laser is more efficient because it previously damages the endothelium
And on the other hand, because:
1. POL improved sclerosant chances due to an active
interaction with laser light
2. POL would be more efficient due to the endothelial
damage produced by laser
The laser irradiation in the presence of POL foam develops a non-linear absorption of light due to scattering and
931
modified light propagation. For most of authors, these optical changes should improve the results of the laser beam
[17, 20, 21]. Absorption of energy coefficient is activated by
POL foam, helping efficacy towards vessel closure.
We have not yet fully clarified the mechanisms of interaction between veins tissue and POL under the influence of
laser radiation. Ethanol, one of the components of POL, has
an absorption peak of 250 nm [21], but it is possible that a
non-linear absorption effect takes place in tissue, such as
absorption of 4 photons at 1,064 nm (which corresponds to a
transition at 265 nm), which will be responsible for further
effects. Hypothetically, at λ 01.064 nm, the absorption
would be produced by the ethyl alcohol contained in POL,
and thus, could modify the sclerosant properties.
The main chromophore is hemoglobin and especially
methemoglobin and melanin [22–24]. This would contribute
to an effective vein sclerosis in exposed areas, but it still
remains unclear which are the exact mechanisms which lead
to this effect.
Modifications of POL molecular structure may be produced by the Nd:YAG laser radiation once this drug is
introduced in the vein lumen. The effect of laser light
enhances when POL is injected as foam, since then, light
scattering becomes more important, although absorption of
the laser beam becomes larger. This situation will lead to a
larger number of modified POL molecules in foam form,
which facilitate photons/heat contact with the vein wall,
acting as irritant, damaging the intima.
Delivering laser pulses in motion prevents energy from
being concentrated at a single point.
Dynamic movement of laser hand piece over a treatment
area produces an increased thermal profile and tissue absorption for effective results with low morbidity. This treatment approach has been proved clinically successful and
safe when applied for laser epilation [25].
Within the learning curve for treatment, the handpiece
has to be moved at a constant speed following the vein.
Accurate control of hand motion is coordinated with laser
pulse delivery frequency and should be comfortable and
homogenously maintained during treatment. This is compulsory; otherwise, the safety of treatment is lost because
skin burns due to repeated pulses delivered on the same
point.
The energy delivered on 3 cm vein length using eight
pulses per second results in a low cumulative fluence per
unit of vein when compared with that applied during conventional Nd:YAG laser treatment [14, 16, 22, 26]. In our
treatment, pulses are administered over a relatively long
period, thus enabling laser energy to gradually increase in
the vein segment. The five passes of laser pulses means a
total of 188.4 J for the 3 cm of vessel segment, while other
authors used fluences of 350 J/ cm² with a 3 mm spot, or
500 J/ cm² with a 2 mm spot [14, 22, 23]. In case of 350 J/
932
cm², energy per pulse (350 × 0.07/100) corresponds to
24.72 J for a 3 cm vein. Therefore, if ten pulses are given,
the total energy administered is 247.2 J. In case of 500 J/ cm²
(15.7 J per pulse), on 3 cm vein length, 15 pulses given with a
2 mm spot size means a total energy of 235.5 J. Even though
in our case the 8 Hz pulse rate used with several passes, the
total energy is still lower, a parameter which represents safety
for the epidermis maintaining its viability.
The lower total energy applied to the vein in the dynamic
mode can explain the low efficacy of treatment noticed in
group B, treated only with laser.
Patients in group A were treated only with two sessions
of POL injections, 8 weeks apart, which are less than those
used by other authors [2, 16, 27]. In principal, we can say
that patients who received treatment only with laser or only
with POL received subtherapeutic dosages, compared with
dose given by other authors and therefore results in both
cases are less satisfactory. The difference is clearly noticeable being better when laser is applied after POL injection.
The combined method is safe and of high efficacy for
treating dark skin patients. Low-energy laser pulses used
prevent pigmentary reactions and, in combination with
POL, obtain effective vein closure.
Progressive increase in temperature in vessel with each
laser pass leads to better light transmission [28–31] helping
treatment efficacy. Moreover, during 1,064-nm Nd:YAG laser
pulses, a significant transformation of red blood cells is induced. Cells become rounder at the time that the methemoglobin fraction increases [12, 16, 28, 29, 32–34]. During
treatment, laser wavelength absorption will exponentially
and safely increased due to the higher absorption coefficient
of methemoglobin formed due to pulse repetition. Positive
increase in methemoglobin improving laser absorption has
also been reported to occur after POL injection used for
sclerosis of esophagus veins [27, 35]. This implies a synergistic mechanism of action enhancing efficacy of results under
safe margins, as clinically noticed in dark skinned patients.
Conclusions
Treatment of leg veins with the 1,064 nm Nd:YAG longpulsed laser, moving the hand piece at the time of repeated
low-fluence pulses over the vessel after POL foam injection,
is safe and has proven a high efficacy for treatment of small
leg veins in patients who are phototype IV.
References
1. Cavezzi A, Frullini A, Ricci S, Tessari L (2002) Treatment of
varicose veins by foam sclerotherapy: two clinical series. Phlebology 17:13–18
Lasers Med Sci (2013) 28:925–933
2. Frullini A (2000) New technique in producing sclerosing foam in a
disposable syringe. Dermatol Surg 26:705–706
3. Sadick N, Prieto V, Shea C, Nicholson J, McCaffrey T (2001)
Clinical and pathophysiologic correlates of 1064-nm Nd:YAG
laser treatment of reticular veins and venulectasias. Arch Dermatol
137:613–617
4. Sadick N (2001) Long-term results with a multiple synchronizedpulse 1064 nm Nd:YAG laser for the treatment of leg venulectasias
and reticular veins. Dermatol Surg 27:365–369
5. Sadick N (2003) Laser treatment with a 1064-nm laser for lower
extremity class I-III veins employing variable spots and pulse
width parameters. Dermatol Surg 29:916–919
6. Trelles M, Weiss R, Moreno-Moraga J, Carmen Romero C, Vélez
M, Alvarez X (2010) Treatment of leg veins with combined pulsed
dye and Nd:YAG lasers: 60 patients assessed at 6 months. Lasers
Surg Med 42:609–614
7. Moreno J, Royo J, Cornejo P, González-Ureña A, Orea JM,
Jiménez J (2004) Utilización de una inyección previa de
polidocanol en forma de microespuma para la extirpación
indolora de varices mediante láser. Bol Oficial Prop. Indust.,
Madrid, ES 2 247 898: 383-397
8. López Dominguez H, Royo de la Torre J, Cornejo Navarro P, Sanz
Alonso I, Moreno Moraga J (2004) Intensificación de la absorción
del láser químicamente inducida en el tratamiento de las varices.
Abstr Surginews VII J Int 20:6–7
9. Isarría MJ, Moreno J. Photodynamic therapy for varices (2007)
IMCAS Abstracts Congress Book, Paris, January 2007, 223
10. Wollmann JC (2004) The history of sclerosing foams. Dermatol
Surg 30:694–703
11. Altshuler GB, Anderson RR, Manstein D, Zenzie HH, Smirnov
MZ (2001) Extended theory of selective photothermolysis. Lasers
Surg Med 29:416–432
12. Suthamjariya K, Farinelli WA, Koh W, Anderson RR (2004)
Mechanisms of microvascular response to laser pulses. J Invest
Dermatol 122(2):518–525
13. Trelles M, Smarandache A, Moreno-Moraga J, PAScu ML (2010)
Studies of the optical properties of the commercial grade Aetoxisclerol. The Annual Conference of the faculty of Physics, Bucharest,
Romania
14. Ross EV, Domankevitz Y (2005) Laser treatment of leg veins:
physical mechanisms and theoretical considerations. Lasers Surg
Med 36(2):105–116
15. Tessari L (2001) Extemporary sclerosing foam according to personal method: experimental clinical data and catheter usage. Int
Angiol Suppl 1:54
16. Tessari L, Cavezzi A, Frullini A (2001) Preliminary experience
with a new sclerosing foam in the treatment of varicose veins.
Dermatol Surg 27:58–60
17. Ratbun S, Norris A, Stoner S (2012) Efficacy and safety of
endovenous foam sclerotherapy: meta-analysis for treatment of
venous disorders. Phlebology 27(3):105–117. doi:10.1258/
phleb.2011.011111, Epub 2012 Feb 20
18. Romero F, Trelles OR, Trelles MA (2008) Modelado de la
piel en fototerapia y crioprotección de la epidermis. Láser en
Dermatología y Dermocosmética. Ed. Aula Médica, Madrid,
pp 559–579
19. Arthur C. Guyton, John E. Hall (2007) Text book of medical
physiology. Philadelphia, Elsevier, pp 632-57
20. Scheider JR (2012) Commentary to accompany ‘cost and effectiveness of laser with phlebectomies compared with foam sclerotherapy in superficial venous insufficiency. Early results of a
randomised controlled trial’. Eur J Vasc Endovasc Surg 43
(5):601, Epub 2012 Mar 15
21. Smarandache A, Trelles M, Pascu ML (2009) Measurement of the
modifications of Polidocanol absorption spectra after exposure to
NIR laser radiation. J Optoelectrons Adv Mater 12(9):1942–1945
Lasers Med Sci (2013) 28:925–933
22. Coles CM, Werner RS, Zelickson BD (2002) Comparative
pilot study evaluating the treatment of leg veins with a long
pulse Nd:YAG laser and sclerotherapy. Lasers Surg Med 30
(2):154–159
23. Omura NE, Dover JS, Arndt KA, Kauvar AN (2003) Treatment of
reticular leg veins with a 1064 nm log-pulsed Nd:YAG laser. J Am
Acad Dermatol 48(1):76–81
24. Trelles OR, Martín Vázquez M, Sola Vázquez A, Trelles MA
(2008) Evolución objetiva de resultados en fototerapia cutánea.
Láser en Dermatología y Dermocosmética. Ed. Aula Médica,
Madrid, pp 541–557
25. Royo J, Urdiales F, Moreno J, Al-Zarouni M, Cornejo P, Trelles
MA (2011) Six month follow-up multicenter prospective study of
368 patients phototypes III to V, on depilation efficacy using an
810 nm Diode laser at low fluence. Lasers Med Sci 26(2):247–255
26. Jaggi R, Goldman MP (2003) Prospective, comparative evaluation
of three laser systems used individually and in combination for
axillary hair removal. Dermatol Surg 31(12):1671–1677
27. Miyake RK, Miyake H, Duarte FH, Ribeiro RJR (2003) Microvarizes e telangiectasias. Angiologia e cirugía vascular:guia ilustrado. UNCISAL/ECMAL& LAVA, Maceió, p 36
28. Langston PG, Jarvis DA, Lewis G, Osborne GA, Russell WJ
(1993) The determination of absorption coefficients for measurement of carboxy-hemoglobin, oxy-hemoglobin, reduced
933
29.
30.
31.
32.
33.
34.
35.
hemoglobin and met-hemoglobin in sheep using the IL482 COoximeter. J Anal Toxicol 17(5):278–283
Mordon S, Rochon P, Dhelin G, Lesage JC (2005) Dynamics of
temperature dependent modifications of blood in the near-infrared.
Lasers Surg Med 37:301–307
Levy J, Elbahr C, Jouve E, Mordon S (2004) Comparison and
sequential study of long pulsed Nd:YAG 1,064 nm laser and
sclerotherapy in leg telangiectasias treatment. Lasers Surg Med
24(3):273–276
Randeberg LL, Daae Hagen A, Svaasand L (2002) Optical properties of human blood as a function of temperature. Proc Soc
Photo-Instrum Eng 4609:20–29
Black FB, Barton JK (2004) Chemical and structural changes in
blood undergoing laser photocoagulation. Photochem Photobiol
80:89–97
Black FB, Wade N, Barton JK (2005) Mechanistic comparison of
blood undergoing laser photocoagulation at 532 and 1,064 nm.
Lasers Surg Med 36:155–165
Mordon S, Brisot D, Fournier N (2003) 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. Lasers Surg Med 32(2):160–170
Van Dam J, Brugge WR (1999) Endoscopy of the upper gastrointestinal tract. N Engl J Med 341(23):1738–1748