LASER : VARICOSITES DES MEMBRES INFERIEURS
Mise à jour SFLM - FEVRIER 2011
GENERALITES
Lasers Surg Med 1987;7(3):219-23
Study of three laser systems for treatment of superficial varicosities of the
lower extremity
Apfelberg DB, Smith T, Maser MR, Lash H, White DN
Three separate laser modalities were investigated in the treatment of
superficial varicosities/telangiectasias of the lower extremities. Sixteen
patients were treated and followed for 12 m onths. The superpulse CO2, the pulsed
focally specific CO2, and the Nd:YAG laser transmitted through a diffusing
sapphire tip were able to produce cosmetically satisfactory permanent
obliteration of vessels after a 12-month follow-up interval. These results were
a significant improvement over six-month results indicating a long fading time
for laser treatment of leg veins.
Zentralbl Chir 1993;118(7):383-9
Use of laser in vascular surgery
Berlien HP, Philipp C, Engel-Murke F, Fuchs B
The use of lasers in the field of vascular surgery concerns 3 completely
different principles of application. The main field is the therapy of
hemangiomas and congenital vascular diseases (CVD). The experience of the
therapy of congenital diseases can be also used in the treatment of varicosis,
especially in the treatment of the perforating veins. In contrast to the
angioplasty, where the therapeutic aim is recanalisation of an arterial vessel,
in the venous system it is the occlusion of a vessel. The thermal procedures
using argon- or Nd:YAG lasers with hot tips, saphire tips or with the bare fiber
are no longer relevant. Only photoablation using pulsed lasers is able to remove
calcified material. The excimer laser is currently the best known system for
angioplasty. New developments, for example solid state lasers like the holmium
laser, have as yet to show their advantages. A main emphasis of research should
be the improvement of catheter systems since present applications are limited by
those currently available catheter systems. Tissue fusion is still an
experimental procedure. There is a lot of basic research to be done to establish
this procedure in the clinical routine.
J Dermatol Surg Oncol 1993 Jan;19(1):74-80
Cool laser optics treatment of large telangiectasia of the lower extremities
Chess C, Chess Q
BACKGROUND. Lower extremity telangiectases have been traditionally treated using
sclerotherapy. However, because of significant side effects from sclerotherapy,
laser treatments have been investigated. Results from laser treatments have been
generally unsatisfactory. OBJECTIVE. This study was based on the premise that
simultaneous cooling and lasing would permit more effective treatment. METHODS.
Thirty lower extremity telangiectases on 13 patients were treated by a technique
of simultaneous cooling and lasing. Argon (488/514 nm) and argon dye (577 nm,
585 nm) laser light were delivered through a new cooling device to
telangiectatic vessels of approximately 1-mm diameter on the thigh and leg.
Pulsed and continuous beam treatments were utilized at high levels of
irradiance. RESULTS. Sixty-seven percent of treated sites were improved; half of
these were completely or nearly completely cleared. There were no complications.
In only 2 of 30 (7%) treated sites were there persistent pigmentary changes.
CONCLUSION. These results compare favorably with other methods for treatment of
lower extremity telangiectases. Successful treatment of large lower extremity
telangiectases by simultaneous cooling and lasing with minimal side effects
suggests a reduction of thermal injury to nonvascular tissue while allowing
destruction of ectatic vasculature.
Lasers Surg Med 1997;20(3):346-53
Optimal parameters for laser treatment of leg telangiectasia
Kienle A, Hibst R
BACKGROUND AND OBJECTIVE: The optimal parameters for treatment of leg
telangiectasia with a pulsed laser are investigated. STUDY DESIGN/MATERIALS AND
METHODS: The Monte Carlo method is used to calculate the light penetration and
absorption in the epidermis, dermis, and the ectatic blood vessel. Calculations
are made for different diameters and depths of the vessel in the dermis. In
addition, the oxygen saturation of the blood vessel, the laser beam diameter,
and the laser irradiation profile is varied. RESULTS: It is found that for
vessels with diameters between 0.3 mm and 0.5 mm wavelengths about 600 nm are
optimal to achieve selective photothermolysis for the considered damage model.
It is also shown that an elliptical laser beam area has advantages compared to a
circular beam area for treatment of leg telangiectasia. CONCLUSIONS: We
recommend the treatment of leg telangiectasia with dye laser wavelengths longer
than the normally used 577 nm and 585 nm.
Dermatol Surg 1999 Apr;25(4):328-35; discussion 335-6
The role of lasers and light sources in the treatment of leg veins
Dover JS, SadickNS, Goldman MP
Telangiectasia of the legs occurs in 29% to 41% of women in the United States.
The variation in size, flow, depth, and type preclude the possibility of a
single effective treatment modality. When a systematic approach is used where
feeder vessels are first surgically removed and sclerotherapy proceeds from
largest to smallest vessels, 80-90% of vessels respond to a single sclerotherapy
treatment. Because of the relatively modest results demonstrated with lasers and
light sources and the high rate of success and the relatively low cost of
ambulatory phlebectomy, compression sclerotherapy and superficial sclerotherapy,
we generally recommend using lasers and light sources only for vessels that
remain after this treatment approach. Lasers and light sources should be
considered prior to sclerotherapy in patients who are fearful of needles, who do
not tolerate sclerotherapy, who fail to respond to sclerotherapy, or who are
prone to telangiectatic matting. Carefully monitored, controlled studies are
essential to better define the role of the available laser and light sources in
the treatment of leg veins.
Lasers Surg Med 2000; 26(2):158-63
New approaches to the treatment of vascular lesions
Dover JS, Arndt KA
BACKGROUND AND OBJECTIVE: The pulsed dye laser was developed based on the concept of selective photothermolysis. By using a wavelength of light well absorbed by the target and pulse duration short enough to spatially confine thermal injury, specific vascular injury could be produced. STUDY DESIGN/MATERIALS AND METHODS: Although the pulsed dye laser revolutionized the treatment of port wine stains (PWS) and a variety of other vascular lesions, the ideal thermal relaxation time for the vessels in PWS is actually 1-10 ms, not 450 micros of the original pulsed dye laser machines. These original theoretical calculations recently have been proven correct in a study that used both an animal vessel model and in human PWS. RESULTS: Longer wavelengths of light, within the visible spectrum, penetrate more deeply into the skin and are more suitable for deeper vessels, whereas longer pulse durations are required for larger caliber vessels. CONCLUSION: A variety of lasers recently have been developed for the treatment of vascular lesions which incorporate these concepts into their design, including pulsed dye lasers at 1.5 ms, a filtered flash-lamp pulsed light source with pulse durations of 1-20 ms, several 532-nm pulsed lasers with pulse durations of 1 ms to as high as 100 ms, long pulsed alexandrite lasers at 755 nm with pulse durations up to 20 ms, pulsed diode lasers in the 800 to 900 nm range, and long pulsed 1064 Nd:YAG sources.
Les lasers vasculaires sont exploités depuis les années 80; ils présentent une alternative intéressante à la greffe cutanée pour le traitement des angiomes plans y compris sur les membres inférieurs. Depuis quelques années ils sont appliqués au traitement des télangiectasies des membres inférieurs sont plus ou moins associés à la sclérothérapie classique. Ce traitement reste un complément de la sclérose qui reste indispensable, de même que la prise en charge phlébologique classique. Son efficacité intéresse surtout les vaisseaux inaccessibles à l’aiguille de 0,3 mm soit 300 µm de diamètre. Ces vaisseaux constituaient auparavant les foyers de récidive ultérieure. Le KTP 532 nm est particulièrement adapté aux vaisseaux rouges alors que d’autres longueurs d’onde comme le Diode 810 nm voire le Nd:YAG 1064 nm sont plus adaptées aux vaisseaux bleus. Le laser se caractérise en comparaison aux autres méthodes par son caractère sélectif.
Semin Cutan Med Surg 2000 Dec;19(4):245-52
The role of lasers in the treatment of leg veins
Kauvar AN
New developments in laser technology have enabled improved therapy of small and
large leg telangiectasia. While sclerotherapy remains the gold standard of
treatment, laser therapy should be considered a first line approach for
isolated, superficial, fine-caliber, nonarborizing telangiectasia and
postsclerotherapy telangiectatic matting. Laser therapy is an excellent option
for patients who are fearful of needles or have demonstrated a poor response to
sclerotherapy injections. Recent studies have demonstrated good clearance of leg
telangiectasia and reticular veins using a variety of laser systems with deeper
penetrating, near-infrared wavelengths and higher fluences in conjunction with
various epidermal cooling methods. As with sclerotherapy, optimal results are
achieved with lasers when larger feeding vessels are treated first using
appropriate modalities.
Dermatol Surg 2001 Jan;27(1):31-3
Clinical characteristics of 500 consecutive patients presenting for laser
removal of lower extremity spider veins
Bernstein EF
BACKGROUND: Laser treatment for removal of lower extremity spider veins is
emerging as a modality of choice in patients with small spider veins, those who
have previously undergone sclerotherapy or vein stripping, and those refusing
sclerotherapy. OBJECTIVE: To determine clinical characteristics of patients
presenting for laser treatment of leg veins. METHODS: The clinical
characteristics of 500 patients presenting for laser treatment of spider veins
were evaluated to investigate characteristics leading to their development, and
to characterize the type of patients presenting for laser treatment. RESULTS:
Patients presenting for treatment range widely in age and have had spider veins
for an average of 14 years. Both pregnancy and previous sclerotherapy were
factors that contributed to the development or exacerbation of spider veins.
CONCLUSION: As laser treatment of spider veins improves, this modality will play
an increasing role in the management of lower extremity telangiectasias.
Dermatol Clin 2001 Jul;19(3):467-73
Treatment of leg veins with lasers and intense pulsed light. Preliminary
considerations and a review of present technology
Goldman MP
Each laser system has different wavelengths, spot sizes, cooling mechanisms, and
pulse durations. This article examines the advantages and disadvantages of
different lasers with the proposition that, in the end, the best laser is the
one that the practitioner can use best.
Phlébologie 2001, 54 (4), 405-11
Theorical and technical bases of vascular laser treatment
Anastasie B, Célerier A, Blanchemaison Ph
Cet article détaille les différentes étapes entre l’irradiation par une lumière laser et la dénaturation tissulaire conduisant à la photo-coagulation du vaisseau cible. D’autres mécanismes peuvent être impliqués comme la photo-thermolyse ou la photo-thrombose.
Le commencement est une inversion de population dans la chambre d’activation du laser jusqu’à la dénaturation tissulaire aboutissant à la sclérose du vaisseau. La conversion de la lumière en chaleur implique l’absorption de la lumière par un chromophore comme l’hémoglobine. La manipulation de cet outil exige des connaissances concernant la diffusion optique tissulaire, objet de ce travail.
This article details the different stages between laser irradiation and tissular alteration leading to photocoagulation of target vessel. Other mechanisms can be involved as photothermolysis and photothrombosis. The beginning is the inversion of an atomic population in the activation chamber of the laser until the target tissue alteration leading to sclerosis of the vessel. The conversion of light into heat involves absorption by a chromophore as haemoglobin.The manipulation of this tool requires knowledges interesting the field of optic tissular diffusion, subject of this work.
J Cosmet Dermatol. 2003 Apr;2(2):73-81
The treatment of leg telangiectasia
Neumann HA, Kockaert MA
Leg telangiectasia is more difficult to treat than facial telangiectasia.
Investigations may be needed to elucidate the origin of the telangiectasia. In
cases of venous insufficiency, investigation of venous haemodynamics is
desirable. Treatment is primarily by sclerotherapy, including foam
sclerotherapy. Light and laser treatments are also effective, especially for
telangiectasia up to 1 mm in diameter. New developments incorporate longer pulse
durations, such as frequency-doubled neodynium YAG and diode lasers as well as
intense pulsed light. After all treatment methods, compression for 48 h using
pads, bandages or hosiery is recommended. As with all cosmetic procedures,
patients need to be tutored comprehensively about anticipated results and
possible complications or side-effects.
Ross V, Domankevitz Y
Laser leg vein treatment: a brief overview
J Cosmet Laser Ther. 2003 Dec; 5(3-4): 192-7
Laser treatment of leg veins has been associated with a number of disadvantages,
but the introduction of new devices has increased the role of lasers in the
treatment of leg veins. This paper reviews the role of laser devices applied
from the surface in the treatment of reticular and spider veins. Success is
determined by the proper selection of wavelength, fluence, pulse duration, spot
size, and number and frequency of treatments.
J Cosmet Laser Ther. 2004 Nov;6(3):152-5
A prototype vessel compressor helps efficient laser treatment of small leg
veins
Trelles MA, Calderhead RG
The eradication of small leg veins with lasers continue to present problems.
Visible light lasers (488 nm approximately 595 nm) are well absorbed in
haemoglobin but melanin is also a target, necessitating aggressive skin cooling
to prevent damage to the epidermis and adding to the expense of these laser
systems. A new generation of much less expensive semiconductor-based lasers
operating in the near infrared offers a different approach, with protein as the
main target rather than pigment. For visible light lasers, compression of the
target vessels is a contraindication, since the target pigment is removed. For
near IR diode lasers, however, compression of the vessels is a benefit, as the
cooling effect of the blood flow is removed and the highly proteinous vessel
walls are coapted which encourages efficient coagulative vessel closure. The
prototype of a simple vessel compressor is presented, which first compresses
vessels and coapts the walls, and then presents the coapted vessels as a target
for a laser of an appropriate wavelength.
Lasers Surg Med. 2005 Feb;36(2):105-16
Laser treatment of leg veins: Physical mechanisms and theoretical
considerations
Ross EV, Domankevitz Y
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.
Dermatol Surg. 2005 Apr;31(4):388-90
Laser-doppler examination shows high flow in some common telangiectasias of the
lower limb
Bihari I, Muranyi A, Bihari P
BACKGROUND: The accepted pathophysiology of telangiectasias is reflux from
superficial or deep veins. There are physical signs and scientific findings that
do not fit this theory but support the possibility of arteriovenous (AV) shunt
origin. OBJECTIVE: If there is a higher flow in spider veins than in the
surrounding skin, it means that AV shunts participate in the circulation of the
telangiectasia. On the other hand, slow flow indicates reflux as the etiologic
factor. METHOD: Telangiectasias and the surrounding skin of 22 legs of 19
patients were examined with laser-Doppler equipment. RESULTS: The probe over the
spider vein found a higher flow value (average 28.2 perfusion units [PU]) than
in the surrounding skin (15.6 PU) in 13 limbs, but it was significantly higher
only in 5 cases. In 9 limbs, the flow was slower. CONCLUSION: We interpret the
higher flow values as a consequence of open AV shunts. This means that AV shunt
pathophysiology was present in some of our cases.
Semin Cutan Med Surg. 2005 Dec;24(4):184-92
Laser treatment of leg veins
Kauvar AN, Khrom T
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.
Hautarzt. 2006 May 3; [Epub ahead of print]
Laser therapy for vascular lesions
Greve B, Raulin C
The use of lasers to treat vascular lesions began in the late 1960s with the
introduction of argon laser. More recently pulsed laser and intense pulsed light
techniques have further improved results and reduced side effects. Their
function is based on the principle of selective photothermolysis. Simultaneous
application of cooling methods (contact cooling, cold air, cryogen spray) has
become standard procedure for these types of therapy, whose most important
indications are port-wine stain, hemangioma, and telangiectasia. A persistent
difficulty is their limited penetration, resulting in limited or no effect on
deeper dermal layers. New approaches therefore include combinations with bipolar