1. ENDOVENOUS LASER THERAPY (EVLT)

At the beginning of this century, there was a revolution in the treatment of venous disease that cause large varicose veins. In 2002, an interventional radiologist named Robert Min and his team treated the valve insufficiency in the “Saphena Magna” vein for the first time with the “endovenous laser therapy” (EVLT) method. This method is based on the principle of closing the leaking vein using laser energy inside the body, rather than removing it by surgically pulling it out. There is no leakage into the varicose veins from the vein closed with the laser; this closed vein is also absorbed by the body over time.

Endovenous Laser Therapy (EVLT) consists of a power source and a fiberoptic catheter that will transmit the energy from this power source into the vessel to be intervened under ultrasound guidance. Transmitting the laser beam at the appropriate wavelength for the tissue to be intervened, at the appropriate power and in the appropriate time. It is a modern treatment option based on the shrinkage and closure of the vessel by creating damage to the inner wall of the vessel with the heat generated.

HOW TO MAKE EVLT

With local anesthesia and sedation, If the vein we intervene is the great saphenous vein, that is, the great superficial vein on the inner face of our leg, our laser catheter is advanced from a region below the knee to the region where our superficial vein flows into the main deep vein in the groin region. From here, it is pulled back 1-2 cm, which is the safe zone, and placed. If the vein to be intervened is the small saphenous vein, that is, the small superficial vein on our calf, on the back of the leg, the same procedures will be repeated, but this time the catheter will be placed in the appropriate place in the back of the knee, accompanied by ultrasonography. Following these procedures, that is, after the laser catheter is placed in the appropriate place, cold serum containing appropriate doses of adrenaline, bicarbonate, and local anesthetic, which we call tumescent anesthesia, will be injected under the outer sheath of the vessel through the catheter. The purpose of this liquid application

1. Increasing the effect of the laser by shrinking the vein with cold serum and at the same time protecting the surrounding tissue from the effects of the high heat generated by the laser.
2. To limit possible bleeding with adrenaline 
3. With local anesthetics, it is to ensure that you spend the hours following the surgery more painless and comfortably.

CANDIDATES FOR EVLT?

EVLT, Laser vein treatment, can be applied to patients with a vessel diameter greater than 5.5 mm as a result of Doppler ultrasonography and with 3 or 4 degree venous insufficiency. Another point that should not be forgotten is that EVLT treatment is guaranteed up to 12 mm in diameter as classical information. Although we can successfully close vessels with higher diameters with additional measures and techniques, it should be kept in mind that the safe range is 12 mm and it should not be delayed too long.

WHO CANNOT BE TREATED WİTH EVLT

• Those who are pregnant,
• Those with advanced arterial disease,
• Bedridden patients,
• Patients with poor general condition,
• Patients with a life expectancy of less than 6 months,
• Patients with bleeding tendency

It is not preferred to be applied, but the main topic that needs attention is the patients with deep vein thrombosis. Patients with a history of deep vein thrombosis, advanced venous insufficiency or even open wounds should be approached very carefully.

WHAT ARE THE SIDE EFFECTS OF EVLT?

Although it is very rare compared to open surgery, which is the old method, there are minor side effects in EVLT, as in every interventional procedure.

• Feeling of withdrawal: After the procedure, some of the patients will have a feeling of pulling along the vein trace, which is burned with laser, and this will disappear within a few months when the leg and that area regain their elasticity.
• Neurological complaints: Some of our patients may have symptoms such as numbness, electrification shock, hypoesthesia, or hyperesthesia. Since the vascular nerve bundle in our arms and legs is adjacent to each other, minor damage to our sensory nerves due to the thermal injury of the laser may cause these complaints. It will disappear on its own within 3 to 6 months. Only patients with very advanced complaints can be supplemented with vitamin B.
• Phlebitis: Redness, tenderness, pain and temperature increase in the treated area can be seen in rare cases. It heals within a week with cold dressing, painkillers and antibiotics.
• Bruising: Although rarely, bruises may occur in the treatment area along the vein. As with any bruise, it heals spontaneously within 1-2 weeks.
• Deep vein thrombosis and pulmonary embolism: DVT and PE, a rare but feared complication after EVLT, can be life-threatening. Early mobilization anticoagulation and compression stockings are the best ways to protect themselves.
• Skin burns: Although it is a rare complication after EVLT, it is an annoying complication because it will not go away and will leave a scar. It can be easily avoided with a good tumescent anesthesia application and the use of high quality lasers.

WHEN CAN I RETURN TO MY NORMAL LIFE?

The pain and complication rate of EVLT itself is extremely low. The main cause of pain in patients who have surgery is the process of removing the vessels that are cosmetically disturbing to you through the small holes we call miniphlebectomy. Yes, these areas will be painful. And the complaints that bother you after the surgery will originate from these areas. However, you will have a very comfortable period after EVLT. Your hospital discharge will be with elastic bandages. The next morning, after removing your elastic bandage and showering, I will ask you to wear compression stockings for 20 days. Since early mobilization, absence of pain and bleeding are among the biggest advantages of this treatment, you can go to work even the next morning if you wish. We can operate on Friday evenings or Saturdays, for our patients who cannot take working leave, and then send them to their workplaces very comfortably on Monday. So you have no restrictions.

WHAT IS THE SUCCESS OF EVLT TREATMENT?

EVLT treatment is the most applied and most successful treatment method in the world for the last 15 years. Success rates between 94% and 98.5% are reported in the results published from different centers. With increasing experience and developing technology, success rates are increasing gradually.

WHAT ARE THE ADVANTAGES OF EVLT TREATMENT?

In addition to its many advantages, the prominent advantages of EVLT treatment are:

• No need for general anesthesia
• No pain
• No bleeding
• No bruising
• No scars
• The procedure is around 30-90 minutes depending on the number of veins to be intervened associated miniphlebectomy
• There is almost no risk of infection.

I NEED THIS VESSEL

Since there is an average of 100,00-150,000 km of vessels in our body, closing a diseased vessel will not do you any harm. The circulation will be diverted to new pathways outside the closed vessel, and even if there is a temporary edema, this will resolve itself within a few weeks. One of the most frequently asked questions in this topic is that this vein should be saved for a future coronary bypass surgery, which is why we do not use sick veins for this purpose, so you don't need this vein.

CAN EVLT BE APPLIED IN THE SAME SESSION FOR BOTH 2 LEGS?

Since the patients remained immobile after classical, that is, open surgeries, and the risk of deep vein thrombosis and pulmonary embolism increased, it was not preferred to perform open surgeries on both legs. However, since early mobilization is possible with the EVLT method, both legs can be operated easily and there will be no problems.

HOW TO PREPARE FOR EVLT

There is no significant preparation before EVLT. As with any patient entering the operating room, an anesthetic examination and a small blood test panel are required. Apart from this, the most important point to be considered is hunger and thirst for 8 hours, as in every patient, before entering the operating room. For male patients, it is also necessary to shave from the navel region down.

WHAT IS THE RECURRENCE RATE AFTER EVLT?

After EVLT treatment, which has a success rate of over 94% and 98,5%, recurrence is almost non-existent with the developing technology and our increasing experience. Recurrence is actually very rare in venous diseases. However, due to your genetic predisposition, our blood vessels that are healthy today are more likely to get sick over time.

DO SPECIAL INSURANCES PROTECT EVLT TREATMENT?

Since EVLT treatment is classified as inpatient treatment in the guidelines, YES is fully covered by private insurances.

WHEN I SHOULD CALL MY DOCTOR AFTER EVLT?

Although EVLT is a very successful treatment method with a very low complication rate, although there is a rare risk of deep vein thrombosis, when there is an unexpected redness, increase in temperature, tenderness or sudden swelling in the leg, an exaggerated pain, a feeling of tension or when you have shortness of breath, you should contact your doctor immediately.

WHAT SHOULD I DO WHEN I COME HOME AFTER TREATMENT

Like the EVLT treatment itself, the post-operative period will be very comfortable and enjoyable. You can continue your normal life without any restrictions. I recommend antibiotics and anti-inflammatory for 3 days. Apart from this, you will use compression stockings for 20 days.

HOW MANY DAYS DO I HAVE TO STAY IN HOSPITAL AFTER EVLT

Unlike classical, open surgery, EVLT treatment is an outpatient treatment. There is no hospitalization. The total time you will spend in the hospital will be around 5-6 hours, after this operation we performed with local anesthesia and sedation, you will be at home within 2-3 hours after the operation.

2. CLASSICAL TREATMENT OR OPEN SURGERY

Venous insufficiency, can be treated surgically for about 100 years. Surgical operation is performed in the form of ligation or ligation (ligation stripping). In classical open surgery, a plastic or steel wire called a stripper is placed into the vein at the ankle level. With a 3-5 cm incision made in the inguinal fold, the end point of the vein is found and separated from the main vein, the stripper pushed from the wrist is tied on the wire. Then, the vein attached to the wire is pulled from the wrist and removed. In the meantime, severe bleeding and bruising occur as the side branches are broken to bleed. In addition, because the nerve, which runs parallel to the vein, is mostly damaged, neurological complaints, namely; Complaints such as numbness and electric shock occur. Surgical operation also requires general anesthesia, causes blood clots and nerve damage in the veins up to 5%, delays returning to normal life, recurrence of varicose veins in approximately half of the patients after surgery, requiring hospitalization, long times to return to work and normal life, and unfortunately deaths. Therefore, it is no longer preferred not only by patients but also by doctors.
Adhesives used in the treatment of veins, namely glue, are actually new for the treatment of varicose veins, but have been used in many branches of medicine for years. adhesive or
The active substance we call super glue consists of the development of cyanoacrylate.

3. ADHESIVE APPLICATION

Adhesive application, as in laser treatment, is based on the principle of advancing a needle placed in a suitable position below the knee and a thin hollow catheter through this needle that will allow the injection of adhesive. As with other interventional treatments, ultrasound guided cannulation and appropriate groin positioning.

The adhesive injection is completed with the catheter, which is withdrawn within a few seconds after placement in the area, and it is aimed to instantly stick the vessel walls together with the external pressure.

WHAT ARE THE ADVANTAGES

• No anesthesia required
• No need for tumescent anesthesia as it does not produce high heat as in laser and radiofrequency
• Fast
• You can return to your daily life immediately after the application.
• Minor complaints such as bruising, numbness, electric shock, withdrawal and mild restlessness that can be seen after laser and radiofrequency apply the adhesive are not seen afterwards.

WHAT ARE THE DISADVANTAGES

• There is no such widespread use and experience as laser and radiofrequency worldwide.
• FDA-approved material is very expensive.
• There is a risk of embolization, especially from the groin area, if it is not performed by appropriately experienced hands.
• There are problems with homogenization, that is, equal distribution in the vein and closure of the vein along the length, following the Glue applications.
• Due to the foreign substance reaction, the rates of superficial phlebitis and cellulite are quite high.
• Especially in weak individuals, the adhesive substance in the closed vein will be hard and rarely crunchy.

4. MINIFLEBECTOMY

Local anesthesia is applied around the bulging varicose veins, then the varicose veins are taken out with tiny punctures of 1 mm . Small incisions are not sutured, these incisions heal without leaving any scars. It is a time-consuming and careful process. However, when applied carefully, it provides cosmetic improvement in a short time. Instead of miniphlebectomy, classical pack excision (removal of varicose veins by making large incisions and suturing the incisions), which is still practiced by some physicians, should be avoided because it gives bad cosmetic results. Although miniphlebectomy is usually performed in the same session following EVLT, it can rarely be applied to non-saphenous veins alone or for cosmetic purposes under local anesthesia in practice conditions. It can also be applied to the chest wall, hand, forehead and around the eyes. Its superiority over liquid or foam therapy is complete recovery within a few weeks. Because the recovery after sclerotherapy, which is applied to vessels large enough to perform miniphlebectomy, will take a few months. If there is hemosiderin pigmentation, that is, a brown spotting on the trace, it may take more than 1 year to heal.

5. SCLEROTHERAPY

Sclerotherapy is a treatment method that aims to ensure that the cells on the inner surface of the vein that come into contact with the blood are destroyed and closed with drugs by entering into the veins with special, thin needles. Damaged cells will die over time, the vessel will be closed, and will be metabolized by the body. Although there are 3 drugs used worldwide for this purpose, there is only one licensed drug in our country. The drug, which has various concentrations, is selected according to the diameter of the vein, can be used as a liquid or foam depending on the situation and preference. Both methods have their own advantages and disadvantages.
The purpose of foam treatment is to obtain a thick foam by mixing 1 cc of drug with 4.6 cc of air. The resulting foam has many advantages. The most important advantage is that the total drug dose to be given to the patient is reduced, since the volume is increased by 4.6 times. İncrease in volume allows a larger space to be covered with less drug dose. In addition, the foam will stay in the vessel longer than the liquid, penetrate the cells more and will be more effective. Since mixed with air and given to the vascular system, which is a closed system, the complication rates seen with foam sclerotherapy are slightly higher. Although sclerotherapy application varies according to your pain threshold, it is not a very painful procedure. In the sessions, it is possible to infect medicine around 2mg/kg. Although some publications recommend bandages and compression stockings, the effectiveness of external compression, that is, compression, during the treatment period has not been proven.
Since the dose of medication is limited, your legs and veins will determine the number of sessions. Sclerotherapy, which is generally a successful treatment, brings with it certain complications and side effects, as with any drug administration and every interventional method.

• Bruises: Needle entry bruises are bruises that are as large as a pinhead. They usually disappear on their own within 1-2 weeks.
• Palpable hardness: As a result of deliberate damage to the vessel wall, the smooth surface, which is the first rule of fluidity, will deteriorate and clots will form in the vessel. This is part of the treatment. The clots will be absorbed by the body in a few months and the vessels will disappear completely.
• Discoloration: These are brown color changes that we call hemosiderin pigmentation. If they occur, it will take 6 months to fade away.
• Matting: Occurrence of new capillaries.  They disappear spontaneously between 3 and 6 months, even if left untreated, but my preference is to treat them as well.
• Allergy: One of the most important side effects of the drug is allergic reactions of various degrees. Allergic reaction, which is one of the side effects that can be seen in all drugs, can even be life-threatening.
• Migraine attacks: It is possible to trigger migraine attacks, especially following foam treatment. If you do not have migraine, such a thing is out of the question.
• Ulcerations or Necrosis: The permeability of the vessel wall, the rupture of the vessel that cannot withstand the pressure, the accidental administration of the drug under the skin. Or, it is a rare complication that may occur as a result of especially red spider veins being an artery rather than a vein. If occurs unfortunately, a permanent scar will remain in the form of a cigarette burn.
• Deep vein thrombosis: Although rare , it is a feared complication. Although rare, the drug can escape into the deep main system through the connection paths between the superficial and deep systems, that we call the perforating veins. Thrombus formed here can cause complaints like pain, swelling and even life-threatening emboli.