Identifying The Problem

The vasculature of the lower extremity is comprised of a complex, intertwined network of superficial and deep venous plexuses. The superficial veins, as suggested by their name, lie directly underneath the skin surface. The deep veins, in contrast, traverse the muscle of the leg. The individual flow patterns of these two networks intertwine to such a great degree that superficial spider veins may be the direct result of increased hydrostatic pressure in the deep reticular veins.

In contrast to the treatment of facial veins, the varying sizes, depths, flow patterns, and vessel thickness of leg veins make the treatment of leg veins more challenging. Presently,

PATIENT SELECTION: WHEN AND HOW TO CHOOSE LASER/IPL VERSUS SCLEROTHERAPY

Laser therapy is most efficacious for treating telangiecta-sia/venulectasia or reticular veins less than 3 mm in diameter.3,4 As mentioned earlier, lasers have become indicated in patients with areas of neovascularization with telangiectatic matting or angiogenic flushing, with sclero-resistant/ noncannulizable vessels, and who are needle-phobic. Relative contraindications to the use of laser surgery include tanned skin, pregnancy, the use of iron supplements or anti-coagulation, history of photosensitivity disorder, or hypertrophic and keloidal scarring (see Table 16.1).

BOX 16.1 Indications for Laser Therapy Treatment of Leg Veins

• Refractory noncannulable vessels

• Telangiectatic matting

• Angiogenic flushing

• Sclero-resistance

• Needle-phobic patients

• Vessels smaller than the diameter of a 30-gauge needle are present

BOX 16.2 Fundamental Properties of a Laser for Leg Veins

• Must have a wavelength proportionately better absorbed by hemoglobin than the surrounding tissue.

• Penetration should reach the full depth of the target vessel.

• Sufficient energy must be delivered to damage the vessel without damaging the overlying skin.

• Energy must be delivered over an exposure time long enough to slowly coagulate the vessel without damaging surrounding tissue.

TABLE 16.1 Comparison of the 1064 nm Nd:YAG, 810 nm Diode, and 755 nm Alexandrite Lasers for Leg Veins 0.33 mm in Diameter

Laser

Patients achieving 75% clearance at 3 months

1064 nm Nd:YAG

88%

810 nm diode

29%

755 nm Alexandrite

33%

TABLE 16.2 Vessel Thermal Relaxation Time

Vein diameter Time (seconds)

TABLE 16.2 Vessel Thermal Relaxation Time

Vein diameter Time (seconds)

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