Treatment of varicose veins – endovenous laser (EVLA/EVLT)

Four methods, one pathway

Which method suits you depends on the ultrasound scan. We go through the choice with you at the preliminary examination. For symptomatic varicose veins where the scan shows a leaking main vein in the leg, the European vascular surgery guideline (ESVS 2022) recommends heat-based closure from inside the vein (laser or radiofrequency) as the first choice over classic surgery (stripping) and foam treatment. Side branches and thread veins are treated with other methods, and the choice is made together with you. Possible complications with all methods include pain and bruising along the treated vein, skin discolouration, temporary nerve irritation with numbness, superficial thrombophlebitis, infection and, rarely, deep vein thrombosis. Your individual risk depends on your anatomy, your general health and the extent of the procedure, and no method can guarantee a particular cosmetic result.

• Laser treatment (EVLA/EVLT), a form of endovenous thermal ablation. For symptomatic varicose veins with a leaking main vein, this method is recommended over classic surgery and foam treatment. This does not apply to side branches, reticular veins or thread veins, and the choice of method depends on anatomy, symptoms, goals, other illness, previous treatment and your preference. The anaesthetic fluid is injected along the whole vein through several small pricks, and the laser fibre itself is inserted through a single small puncture. No hospital stay. How quickly you can return to work varies.
• Classic surgery (stripping), when laser is not technically possible or the vein has an unfavourable course. Well documented and durable.
• Microphlebectomy, visible side branches are removed through 1-2 mm punctures without stitches. Whether and when side branches are treated is agreed with you.
• Foam sclerotherapy, medical foam closes smaller veins and remaining branches after laser treatment.

The important preliminary examination

A thorough preliminary examination is essential before treatment. Its purpose is to clarify which treatment options are relevant for you, so that you and the doctor can choose the course together.

We perform a simple venous scan (duplex ultrasound), where pressure from the probe can be felt and where the experience varies from person to person. The scan aims to:

• Precisely identify where in the vein the problem (venous insufficiency) lies.
• Assess the size and shape of the varicose veins.

Laser treatment (EVLA): how it works

Laser treatment for varicose veins is one of the methods we use. For symptomatic varicose veins with a leaking main vein, this method is recommended over classic surgery and foam treatment. It does not apply to side branches, reticular veins or thread veins, and the choice of method depends on anatomy, symptoms, goals, other illness, previous treatment and your own preference.

1. Local anaesthesia: The entire procedure is performed under local anaesthesia. The anaesthetic fluid is placed along the whole vein through several small pricks, so the area is numb by the time the laser treatment itself begins. How much discomfort the pricks cause varies from person to person.
2. Minimal intervention: Through a single small puncture of a few millimetres, a thin laser fibre is inserted into the diseased vein.
3. Thermal energy: The laser uses thermal energy (heat) to close the diseased veins and varicose veins from within. Blood flow is then automatically redirected to the healthy veins.

Advantages of laser treatment

• Gentle: Only local anaesthesia and a minimal puncture.
• Pain: Discomfort after the procedure varies from person to person. If you need pain relief, we agree with you what suits you and your other medication. Never change prescribed medication without agreeing it with your doctor.
• Recovery: How quickly you can return to work varies with the method, the extent of treatment and the type of work. Whether and for how long you need a compression stocking is decided individually, and any follow-up scan is arranged individually. You will not drive yourself home after the procedure; that is the clinic's safety instruction.
• Durability: Closure rates in studies are high but vary with method, vein anatomy and length of follow-up. Recurrence and new varicose veins can occur, and some patients need additional treatment.

Other treatment options (microsurgery)

In cases where the shape or location of the varicose veins does not allow full laser treatment, a modified form of surgery may be necessary.

• Microsurgery: Large superficial varicose veins are removed through very small incisions of a few millimetres. The incisions are small and scars are usually discreet, but scar healing varies from person to person. Whether it is combined with laser treatment of the main vein, and in what order, is decided together with you based on the scan findings and your goals.

How are varicose veins removed?

There is no single answer to how varicose veins are best removed. It depends on the size and location of the vein and on where the leak sits. In practice we most often combine laser treatment, microphlebectomy and foam sclerotherapy. Whether one or several are used, and in what order, is agreed with you based on the scan findings, your symptoms and your goals. Treatment of side branches is a shared decision between you and the doctor, not a fixed package:

• Endovenous laser ablation (EVLA/EVLT) closes the large, diseased main vein from within using heat from a laser fibre. For symptomatic varicose veins with a leaking main vein, this method is recommended over stripping and foam treatment. The choice between methods is made individually.
• Microphlebectomy removes the visible, bulging side branches through 1-2 mm punctures. The punctures heal without stitches, but how visible the scars become varies from person to person.
• Foam sclerotherapy (ultrasound-guided) is used for smaller varicose veins, side branches and residual veins after laser treatment. A small amount of foam is injected and closes the vein chemically.

Once the diseased main vein is closed, the pressure in the leg changes and some side branches become less prominent. The order of treatments is planned individually together with you, based on findings, symptoms and your goals.

How long does the treatment take?

The duration of the procedure on one leg depends on the method and the extent, and includes local anaesthesia and ultrasound guidance. You lie on a couch, awake and relaxed, while we work. When the laser has closed the vein, we assess individually whether a compression stocking should be applied, and you can go home after a short period of observation.

Whether both legs are treated on the same occasion or separately is planned together with you, based on findings, extent and your circumstances.

Before treatment: how to prepare

Good preparation makes it easier for us to work precisely and reduces the risk of infection and bruising.

• Skin: Take a thorough shower the same morning and avoid cream, oil and perfume on the leg on the day of treatment, so the skin is clean and dry when we disinfect it and apply a sterile dressing. This is the clinic's practical instruction.
• Blood thinners: There is no general rule that warfarin, apixaban, rivaroxaban, dabigatran, acetylsalicylic acid or other anticoagulant and antiplatelet medication must be paused. We assess this individually, based on the procedure and the reason for your treatment, and give you a specific instruction at the preliminary examination. Never start, stop or change prescribed medication without agreeing it with your treating doctor.
• Eating and drinking: You may eat and drink as normal. The procedure is performed under local anaesthesia, not fasting.
• Clothing: Bring loose trousers or a long skirt so the compression stocking can be put on without rubbing.
• Getting home: The clinic's safety instruction is that you do not drive yourself home after the procedure. Arrange to be collected, or take a taxi or public transport. When you can drive again is agreed with you.

Recovery after laser treatment

How quickly people return to work varies. The anaesthetic fluid is placed along the whole vein and eases discomfort in the hours after the procedure. If you need pain relief, we agree what suits you and your other medication. Do not change prescribed medication without agreeing it with your doctor.

• Right after the procedure: Move normally. When you can resume hard training, hot baths and sauna is stated in the instruction you take home. Whether and for how long you need a compression stocking is decided individually.
• After that: How quickly you can resume walking, cycling, running and strength training depends on the method, the extent and your symptoms, and is agreed with us.
• Check-up: Arranged individually. At a follow-up scan we assess the treated vein and any need for additional treatment of side branches.

Bruising and a tight sensation along the vein are common after the procedure. How pronounced they are, and how long they last, differs from person to person. Contact us if you have increasing pain, redness, fever or sudden swelling of the leg.

With or without a referral

The clinic holds a provider number and receives referred patients for services covered by the current agreement; whether a specific service is covered is clarified before the course of treatment. Without a referral you pay as a self-payer. The clinic confirms in writing what the price covers, and whether additional charges may apply, before you accept the course of treatment.

What does varicose vein treatment cost?

The clinic holds a provider number under the Danish public health insurance and receives referred patients for services covered by the current agreement; whether a specific service is covered is clarified before the course of treatment. For self-payers the prices are simple and include the full course (preliminary examination, procedure, compression stocking and follow-up scan):

Course	With GP referral	Self-payer , per leg
Endovenous laser ablation (EVLA/EVLT)	Under the rules in force	DKK 12,000
Classic surgical treatment	Under the rules in force	DKK 8,000

Talk to your own GP about whether a referral is relevant for you. Your GP assesses whether the conditions for a referral are met.

Sources

ESVS 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs, European Journal of Vascular and Endovascular Surgery, 2022 (recommendations 24, 28, 43 and 48).