64 JUNE 2007 SKIN & AGING

VENOUS INSUFFICIENCY

Venous disease still presents a form i d a-ble challenge to diagnose and tre a t .Venous insufficiency, which is caused byvalvular incompetence in the deep orsuperficial venous system, is the mostcommon form of venous disease.2Ve n o u sdisease affects 40% to 55% of the popula-t i o n ,with common symptoms of leg pain,swe l l i n g , and skin changes.3 The mostcommon form of lower extremity ve n o u sdisease is superficial venous insufficiency.

The two major divisions of the superfi-cial venous system are the greater or g r e ats aphenous ve i n (GSV) and lesser or s m a l ls aphenous ve i n ( L S V ) . (See Figure 1.)F rom an anatomical standpoint, the dis-tinction between the two divisions is sim-ple to make. The GSV distri bution isalong the medial aspect of the leg fro mthe groin to the ankle, while the LSV dis-t ri bution is along the middle of the pos-t e rior calf, f rom the popliteal fossa to thel ower posterior calf.

VENUS INSUFFICIENCY CAUSES

Venous insufficiency is the result ofincompetence or reflux in either or

both of these truncal veins. Greater than90% of the time, the GSV is the cause ofvenous insufficiency.Venous insufficien-cy occurs when a high-pressure leakagedevelops between the deep and superfi-cial systems or within the superficial sys-tem itself, followed by sequential failureof the venous valves in superficial veins.

This allows venous blood to escape fromits normal flow path and to flow in a ret-rograde direction down into an alreadycongested leg. Over time, incompetenttruncal veins acquire the typical dilatedand tortuous appearance of varicosities.

ASSOCIATED SKIN CHANGES

Furthermore, insufficiency can lead tochronic morbidity in the form of ulcer-ative, edematous, and pigmentary skinchanges in the lower extremities. Onesuch example of a skin change, which isa direct consequence of venous insuffi-ciency, is stasis dermatitis. (See Figure 2on the next page.)

Stasis derm at i t i s has an estimated preva-lence of 6% to 7% in adults over the age of5 0 . In the United States, this is thought to

Clinical manifestations of lower extremity venous disease encom-passes a wide spectrum of manifestations, f rom an asymptomaticcluster of spider veins along the medial ankles, to bu l ging va ri c o s e

veins extending across the anterior thigh, to stasis derm a t i t i s , leg edemaand chronic ulceration of the lower medial calf.

P h l e b o l og y, the science of treatment of venous disease, has roots dating tothe ancient Greeks in 400 B. C, at which time venous disease was viewed asp ro blematic and unsightly.1 P ro c e d u res involving the use of instru m e n t a t i o nto traumatize veins we re described by Hippocrates in the fourth century B. C. ,and pro c e d u res such as ru d i m e n t a ry vein stripping we re routinely practiced.1

GIRISH MUNAVALLI, M.D., M.H.S., AND ROBERT A. WEISS, M.D.

LOWER EXTREMITY VENOUS DISEASE

AND ADVANCES IN TECHNIQUES FOR

ENDOVENOUS ABLATION

Figure 1: Distributions of the Greater (Great) and Lesser (Small) Saphenous VeinsCourtesy Robert Weiss, M.D.

Saphenofemoraljunction

Superficial iliancircumflex vein

Anterior lateraltributary

Femoral vein

Deep femoral vein

Anterior tributary vein

Superficial inferiorepigastric vein

Posterior medicaltributary

Greater saphenousvein

Dorsal venous arch

Posteromedialsuperficial thigh

vein

Vein of Giacomini

Saphenopoplitealjunction

Lesser saphenousveinPosterior arch vein

Dorsal venous arch

Posterolateral tributary vein

Anterolateral superficialthigh vein

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JUNE 2007 SKIN & AGING 65

be between 6 and 7 million people.4 A sm e n t i o n e d , a b n o rmal function of theo n e - way venous valvular system in thedeep and superficial venous systems of thelegs results in backflow of blood from thedeep venous system and perforating ve i n sto the superficial venous system, w i t ha c c o m p a nying venous hy p e rt e n s i o n .

Causes of loss of valvular functioni n c l u d e : genetic pre d i s p o s i t i o n , h o rm o n-al influences from pre g n a n c y, t r a u m a , a n dan age-related decrease in va l ve compe-t e n c y. Other eve n t s , such as deep ve n o u st h rombosis or prior vein surgery, c a ns eve rely damage the lowe r - e x t re m i t yvenous system function and cause va l v u-lar incompetence.

The mechanism by which ve n o u shy p e rtension causes skin inflammat i o nand stasis derm at i t i s has been exten-s ively studied. It is thought thati n c reased venous hy d rostatic pre s s u re istransmitted to the dermal micro c i rc u-l a t i o n , leading to increased perm e a b i l-ity of dermal capillari e s .This incre a s e dp e rmeability enables plasma macro-m o l e c u l e s , such as fibri n og e n , to leakout of the va s c u l a t u re into the peri c a p-i l l a ry tissue; t h e n , p o l y m e rization of

f i b ri n ogen to fibrin results in the for-mation of a fibrin cuff around derm a lc a p i l l a ri e s , f u rther congesting flow.4

Stasis derm atitis fre q u e n t ly occurs alongwith a b a ck g round of skin ch a n ges typicalfor venous insufficiency patients. C h a n g e sinclude edema, va ri c o s i t i e s , hy p e rp i g m e n-t a t i o n , a t rophic patches (atrophie bl a n c h e ) ,and diffuse re d - b rown discoloration re p re-senting deep dermal deposits of hemo-s i d e rin (from degr a d e d , e x t r avasated ery-t h ro c y t e s ) . O f t e n , these chronic changesp e rsist despite stasis dermatitis activ i t y.5

COMPLICATIONS THAT CAN OCCUR

The dreaded complication of skin ulcer -at i o n often occurs with chronic stasis der-matitis and accompanying edema. It isthought that 60% to 70% of lower legu l c e rs can be attri buted to venous disease.Aside from skin changes, patients alsoe x p e rience other nagging symptoms suchas lower leg thro b b i n g , swe l l i n g , i t c h i n g ,aching pain and restless leg tendencies.

PREVENTING SKIN CHANGES

To prevent chronic skin changes fromvenous reflux as well as avoid the dailyoccurrence of pain, definitive treatmentfor venous hy p e rtension should besought as soon as possible.

Surgical Correction H i s t o ri c a l l y, methods for surgical cor-

rection have included vein stri p p i n g ,ligation and div i s i o n , e c h o s c l e ro t h e r a py,and va l ve re p l a c e m e n t . Vein stri p p i n ghas a fa i l u re rate as high as 60%6 , 7 , 8 a n dre q u i res general or spinal anesthesia.R e c ove ry times can often take 2 to 3we e k s . Similar to vein stri p p i n g , t h ere p o rted incidence rate for GSV re f l u xf o l l owing high ligation alone is signifi-cant with up to 71% re c u rre n c e.6 , 7

Postulated reasons for this includeu n d e r - re c ognized anomalous anatomicvascular patterns in the saphenous sys-tems and neo-va s c u l a ri z a t i o n .

Endovenous Laser TreatmentIn 2002, the FDA approved endove-

nous laser treatment as a m i n i m a l ly inva -s ive method of ablating incompetentsaphenous ve i n s .This in-office pro c e d u reuses local anesthesia, thus eliminating theneed for general or spinal anesthesia, a n dthe inherent risks associated with them.

The use of endovenous procedures toeliminate saphenous and pri m a rybranch reflux has been growing expo-

VENOUS DISEASE

AFFECTS 40% TO 55% OF

THE POPULATION, WITH

COMMON SYMPTOMS OF

LEG PAIN, SWELLING, AND

SKIN CHANGES.3

Figure 2: Arrow points to early

evidence of stasis dermatitis in a

45-year-old male patient. Photo courtesy of G. Munavalli, M.D.

Figure 3: Clinical improvement 6 weeks after treatment of the LSV with

endovenous ablation. Photo courtesy of G. Munavalli, M.D.

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66 JUNE 2007 SKIN & AGING

nentially over the last few years. In starkcontrast to the very invasive nature ofstripping and ligation, the concept ofobtaining percutaneous access to a veinunder local anesthesia and using a formof directed laser energy from the insideto shrink and seal the targeted veinallows for quick patient recovery. (SeeFigure 3, previous page.)

Although initially developed by der-matologic surgeons, the endovenous abla -tion has been embraced by many otherspecialties including radiology, vascularsurgery and anesthesiology.

It began with the use of a specially andelegantly designed bipolar radiofre q u e n c y(RF) catheter for gentle heating and wa squickly applied to bare laser fibers fire dwithin the targeted va ricose or re f l u x i n gsaphenous ve i n .9 With worldwide clinicale x p e rience of more than 60,000 pro c e-d u res since 1999,ra d i o f requency shri n k ageof ve i n s has been a va l u a ble addition tot reating large va ricose veins resulting fro msaphenous re f l u x .

To d ay there are nu m e rous systemsava i l a ble that utilize va rious infrare dwavelengths as well as radiofrequency toaccomplish endoluminal heating ands h rinkage of saphenous tru n k s .

ENDOVENOUS LASER TREATMENT

The following discussion will focuson two classes of laser endovenous treat-ment: lasers targeting hemoglobin (810nm, 940 nm and 980 nm) within blood

inside the ve i n , and lasers targetingwater in the vein wall (1320 nm).

Utilization of Tumescent AnesthesiaAs a prelude to this discussion,it is impor-

tant to emphasize the role of tumescentanesthesia in reducing side effects follow i n ge n d ovenous laser abl a t i o n . D e rm a t o l ogi cs u r g e o n s , e x p e rienced with large-vo l u m e,l ow-concentration tumescent anesthesia forliposuction and other surgical pro c e d u re s ,we re the first to apply tumescent infiltrationto endovenous techniques.

Tumescent anesthesia or the place-ment of large volumes of dilute anes-thesia in a peri - vascular position, u n d e rthe direction of duplex guidance, s e rve ss e ve ral purp o s e s :

■ It protects peri-vascular tissues fromthe thermal effects of intravascularenergy by serving as a heat sink.

■ It decreases the diameter of thetreated vein to allow for betterabsorption of energy by the targetchromophore and thus secondarilyreduce intravascular blood for non-specific coagulation.

■ It provides more effective and saferanesthesia for patients.

Using tumescent anesthesia, the GSVcould be sealed with endovenous tech-niques as a totally painless procedurewith little downtime and immediat eambulation of the patient.

F rom the authors ’ e x p e rience withtumescent anesthesia (utilized in eve rye n d ovenous ablation surgical case), t h etechnique is vital to pre vent the fo rm a -tion of deep vein thro m b o s i s ( DV T ) .The incidence of DVT as measured byduplex ultrasound follow-up at 3 to14 days is 0% (personal commu n i c a-t i o n , R . We i s s , M . D. ) . It is our firmbelief that the use of tumescent anes-thesia in non-sedated, c o n s c i o u spatients followed by immediate ambu-lation at the conclusion of the pro c e-d u re is the reason for lack of seri o u sa d ve rse sequelae such as DV T.

TARGETING HEMOGLOBIN

E n d ovenous laser treatment allow sd e l ive ry of laser energy directly into theblood vessel lumen in order to pro d u c eendothelial and vein wall damage withsubsequent fibro s i s . The va rious lasersava i l a ble for endovenous are summa-rized in Table 1.

The presumed t a r get for lasers w i t h8 1 0 - n m , 9 4 0 - n m , and 980-nm wa ve -l e n g t hs is i n t ra vascular red blood cella b s o rption of laser energy with dissipa-tion of heat and thrombotic vein oc c l u-sion with some intramural heat damage.

Steam bu b bles occurring as blood isboiled within the lumen have been show nto occur as the pri m a ry mechanism forh e m oglobin targeting laser endove n o u socclusion effects.10

D i rect thermal effects on the vein wa l lwithout the presence of blood pro b a bly donot occur.1 1 The extent of thermal injuryto tissue depends strongly on the amountand duration of heat the tissue is exposedt o, which for these lasers depends on mu l-tiple fa c t o rs including blood in the lumen,

TABLE 1. Currently Available Endovenous Lasers

Wavelength Brand NameTarget

Chromophore

Mechanism of

Action

810 nm*

EVEVLT —

endovenous laser

treatment

Hemoglobin

Heating blood,

transmitting to

vein wall

940 nm

ELT —

endovenous laser

treatment

Hemoglobin

Heating blood,

transmitting to

vein wall

980 nmELVeS — Endo

Laser Vein SystemHemoglobin

Heating blood,

transmitting to

vein wall

1320 nm

CTEV — Cool

Touch

Endovenous

WaterHeating of water

in vein wall

*Other 810-nm devices are presently being sold byVascular Solutions called Vari-Lase 810 nm andby MedArt called ILVO Intra-lumenal Laser Vein Occlusion using MedArt 426.

…TUMESCENT ANESTHESIA

IN NON-SEDAT E D ,

CONSCIOUS PAT I E N T S

FOLLOWED BY IMMEDIAT E

A M B U L ATION AT THE

CONCLUSION OF THE

PROCEDURE IS THE REASON

FOR LACK OF SERIOUS

ADVERSE SEQUELAE

SUCH AS DVT.

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JUNE 2007 SKIN & AGING 67

rate of pullback and amount of tumescentanesthesia placed around the ve i n .1 2

Initial re p o rts have shown this tech-nique with an 810-nm diode laser to havegood short - t e rm efficacy in the tre a t-ment of the incompetent GSV, with 96%or higher occlusion at 9 months with aless than 1% incidence of transientp a re s t h e s i a .1 3 , 1 4 M o re re c e n t l y, 2 - ye a rf o l l ow-up of 499 limbs has been com-pleted with a re c u rrence rate of lessthan 7% at 2-year follow - u p. H oweve r,90% of these patients experi e n c e dd e grees of post-operative ecchy m o s i sand va rying degrees of discomfort .1 5

Skin bu rns have been observed by ourcenter and recently have been re p o rt e dusing the 810-nm wave l e n g t h .1 6 DV Textending into the femoral vein re c e n t-ly has also been re p o rted with endove-nous laser tre a t m e n t .1 7

P O S T- T R E ATMENT EFFECTS

Patients treated with an 810-nmdiode laser have shown an increase inp o s t - t reatment purpura and tender-n e s s . Most patients do not re t u rn tocomplete functional normality for 2 to7 days as opposed to the 1 day “ d ow n -t i m e ” with RF closure of the GSV.Recent studies suggest that pulsed810-nm diode laser tre a t m e n t , with itsi n c reased risk for perforation of thevein as opposed to continuous tre a t-ment (which does not have interm i t-tent vein perforations), m ay be re s p o n-s i ble for the increased symptoms with810-nm laser vs. RF tre a t m e n t .1 8

When using a wavelength stro n g l yabsorbed by hemog l o b i n , such as 810 nm,t h e re is a significant amount of intralumi-nal blood heating with transmission of heatto the surrounding tissue through longheating times. Te m p e r a t u res in animalmodels have been re p o rted as high as1 2 0 0 ° C.1 8When we have tried e x - v i vo ve i nt reatment without bl o o d , the 810-nmwavelength simply chars a gro ove alongthe inside of the ve i n .

MINIMIZING COMPLICATIONS

Minimizing direct contact with the ve i nwall for hemoglobin-dependent methodsminimizes the charring of the vein wa l land pro b a bly lowe rs the post-operativepain leve l s . Ideally for a hemog l o b i n -absorbed wavelength to wo r k , it would bebest to have a well-defined layer of hemo-

globin between the fiber and the ve i nwa l l . In re a l i t y, h oweve r, va ricose veins arenot straight segments, but rather saccularand irre g u l a r, so that pockets of hemog l o-bin are frequently encountere d , leading tos h a rp rises in temperature and vein perfo-rations when using hemog l o b i n - a b s o r b i n gwavelengths such as 810 nm.

A further concern occurs when usingtumescent anesthesia with a hemog l o-bin-targeting wave l e n g t h . It can some-times be ve ry difficult to gauge the cor-rect amount of solution needed toc o m p ress the vein and still leave someintraluminal blood (necessary for themechanism of action). If too mu c htumescence is used, and hemoglobin is

e l i m i n a t e d , t h e re can be charring of theinner wall of the vein without heatingof the vein wa l l , with resulting pain andfa i l u re of vein occlusion.

TARGETING WATER

In an attempt to circumvent problemsassociated with hemoglobin-absorbingwavelengths, 1320 nm was investigatedfor endovenous ablation beginning in2002. Clinical trials were performedresulting in FDA clearance in September2004 for treatment of the greater saphe-nous vein, and in August of 2005 suffi-cient data for approval for obliteration ofreflux in the lesser saphenous vein wascleared by the FDA.

Figure 4: 1320-nm wavelength is selective for water as the chromophore. This

allows for targeting heating and transmural thermal injury to the vein. Courtesy of Robert Weiss, M.D.

Figure 5: Comparison between greater saphenous vein treatment with 810 nm vs.

1320 nm after 48 hours post-treatment. Photos courtesy of Robert Weiss, M.D.

Post 810 nm at 48 hours Post 1320 nm at 48 hours

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68 JUNE 2007 SKIN & AGING

Some laser models with the 1320-nmwavelength use a special conducting laserfiber coupled to an automatic device pre -set to pull back at 1 mm/sec. Tissue wat e ris the target and the presence or absence ofred blood cells within the vessels is not re l-evant to effectiveness of the pro c e d u re.This 1.32 micron wa ve l e n g t h is uniqueamong endovenous ablation lasers in thatthis wavelength is absorbed only by wa t e rand not by hemog l o b i n . (See Figure 4.)This makes it significantly different inmechanism of action compared to theother (hemoglobin targeting) wave l e n g t h sused for endovenous laser tre a t m e n t s .

ADVANTAGES OF 132O NM OVER 810 NM

The authors ’ e x p e rience reflects areduction in pain and bru i s i n g of 80%when switching from 810-nm endove-nous to 1320-nm endove n o u s . No sig-nificant pain and interference witha m bu l a t i o n , such as observed with 810n m , has been observe d . H aving tre a t e dm o re than 200 greater saphenous ve i n swith 1320 nm, our incidence of mildpain is 5% and our success rate of ve i na blation is 95% at 2 ye a rs . Goldman eta l1 9 h ave re p o rted a similar experi e n c e,concluding that at 6 months follow -u p, a 5-W, 1320-nm intravascular laserwith 1 mm/s automatic pullback,d e l ive red through a diffusion-tip fiber,is safe and effective in treating anincompetent great saphenous vein upto 1.2 cm in diameter.

It is postulated that there is reducedpain with 1320 nm versus hemoglobintargeting wavelengths probably due toless vein perforations, less thrombus for-mation and more uniform heating by1320 nm targeting water in the veinwall. Although rarely patients experi-ence mild pain after 1320 nm, this isprobably related to heat dissipated intosurrounding tissue, not vein perfora-tions, as the incidence of bruising isextremely low. Cumulative experiencein the literature indicates that 1320-nmwater targeting versus 810-nm, 940-nmor 980-nm hemoglobin targetingendovenous occlusion is more gentle,leading to far less bruising and post-operative pain. (See Figure 5.)

SUMMARY

The latest techniques for endove n o u socclusion using radiofrequency abl a t i o n

c a t h e t e rs or endoluminal laser targetingwater are our pre f e rred methods to tre a ts a p h e n o u s - related va ricose ve i n s .Clinical experience with endove n o u stechniques in more than 1,000 patientss h ows a high degree of success withminimal side effects, most of which canbe prevented or minimized with use oftumescent anesthesia.

Tumescent anesthesia is critical to thesafety of endovenous techniques. Wi t h i nthe next 5 ye a rs , these minimally inva s ivee n d ovenous abl a t ive pro c e d u res invo l v-ing saphenous trunks should have virt u-ally replaced open surgical stri p p i n g s .M o re than 100,000 patients have beena l ready been treated wo r l d w i d e.■

D r. M u n a valli is ClinicalI n s t r u c t o r, D e p a rtment ofD e rm a t o l o gy Johns HopkinsU n i versity School of Medicine,B a l t i m o r e, M D, and Divisionof Derm a t o l o gy, U n i versity ofM a ryland School of Medicine,

B a l t i m o r e,M D.D r. Weiss is A s s o c i a t e

P r o f e s s o r, D e p a rt m e n tof Derm a t o l o gy, J o h n sHopkins University Sch o o lof Medicine, B a l t i m o r e,M D, and Director,M a ryland Laser, Skin and

Vein Institute, Hunt Va l l e y, M D.

R e f e re n c e s1 . Goldman MP. S cl e r o t h e ra py :Treatment ofVa ricose and Telangiectatic Leg Ve i n s. B a l t i m o re :M o s by, 1 9 9 1 .

2 . Weiss RA, Feied C. F. ,Weiss MA. Ve i nDiagnosis and Treatment:A ComprehensiveA p p r o a ch. N ew Yo r k : M c G r aw - H i l l , 2 0 0 1 .3 . Callam MJ. E p i d e m i o l ogy of va ri c o s eve i n s . Br J Surg. 1 9 9 4 ; 8 1 : 1 6 7 - 1 7 3 .4 . Engel A . J M H S. Health effects of sunlighte x p o s u re in the United States. Results fro mthe first National Health and Nutri t i o nExamination Survey, 1 9 7 1 - 1 9 7 4 . A r chD e rm a t o l . 1 9 8 8 ; 1 2 4 ( 1 ) : 7 2 - 7 9 .5. Dissemond J, Knab J, Lehnen M, et al.Successful treatment of stasis dermatitis with top-ical tacrolimus. Vasa. 2004 Nov; 33(4): 260-262.6 . S a r in S, S c u rr JH Coleridge Smith PhD.Assessment of str ipping of the long saphenousvein in the treatment of pri m a ry va ri c o s eve i n s . Br J Surg. 1 9 9 2 ; 7 9 : 8 8 9 - 8 3 .7 . D we rryhouse S, D avies B, H a rradine K,E a rn s h aw JJ. S t r ipping the long saphenousvein reduces the rate of reoperation for re c u r-rent va ricose ve i n s : f ive year results of a ran-domized tri a l .J Vasc Surg. 1 9 9 9 ; 2 9 : 5 8 9 - 5 9 2 .8. Jones L, Braithwaite BD, Selwyn D, Cooke S,Earnshaw JJ. Neo vascularization is the principlecause of varicose vein recurrence: results of a ran-domized trial of stripping the long saphenousvein. Eur J Vasc Endovasc Surg. 1996; 12:442-445.9 . Weiss RA, Weiss MA. C o n t rolled radiofre-quency endovenous occlusion using a uniquer a d i o f requency catheter under duplex guid-ance to eliminate saphenous va ricose ve i nre f l u x : a 2-year follow - u p. D e rmatol Surg.2002 Ja n ; 2 8 ( 1 ) : 3 8 - 4 2 .1 0 . P roebstle T M , Lehr HA, Kargl A ,Espinola-Klein C, Rother W, Bethge S, et al.E n d ovenous treatment of the greater saphe-nous vein with a 940-nm diode laser: t h ro m-botic occlusion after endoluminal therm a ldamage by laser-generated steam bu b bl e s . JVasc Surg. 2002 A p r; 3 5 ( 4 ) : 7 2 9 - 3 6 .1 1 . P roebstle T M , Sandhofer M, Kargl A , Gul D,Rother W, Knop J, et al.T h e rmal damage of theinner vein wall during endovenous laser tre a t m e n t :key role of energy absorption by intrava s c u l a rbl o o d . D e rmatol Surg. 2002 Ju l ; 2 8 ( 7 ) : 5 9 6 - 6 0 0 .1 2 . P roebstle T M , K rummenauer F, Gul D,Knop J. Nonocclusion and early reopening ofthe great saphenous vein after endove n o u slaser treatment is fluence dependent. D e rm a t o lS u r g. 2004 Feb;30(2 Pt 1):174-8.1 3 . Min RJ, Zimmet SE, Isaacs MN, Fo rre s t a lM D. E n d ovenous laser treatment of theincompetent greater saphenous ve i n . J Va s cI n t e rv Radiol. 2001 Oct;12(10):1167-71.1 4 . N ava rro L, Min RJ, Bone C. E n d ove n o u sl a s e r: a new minimally inva s ive method oft reatment for va ricose veins — pre l i m i n a ryo b s e rvations using an 810 nm diode laser.D e rmatol Surg. 2001 Fe b ; 2 7 ( 2 ) : 1 1 7 - 2 2 .1 5 . Min RJ, Khilnani N, Zimmet SE. E n d ove n o u slaser treatment of saphenous vein re f l u x : l o n g - t e rmre s u l t s . J Vasc Interv Radiol. 2003 A u g ; 1 4 ( 8 ) : 9 9 1 - 6 .1 6 . Sichlau MJ, Ryu RK. Cutaneous therm a li n j u ry after endovenous laser ablation of thegreat saphenous ve i n . J Vasc Interv Radiol.2004 A u g ; 1 5 ( 8 ) : 8 6 5 - 7 .1 7 . Mozes G, Kalra M, C a rmo M, S wenson L,G l oviczki P. Extension of saphenous thro m-bus into the femoral ve i n : a potential compli-cation of new endovenous ablation tech-n i q u e s . J Vasc Surg. 2005 Ja n ; 4 1 ( 1 ) : 1 3 0 - 5 .1 8 . Weiss RA. C o m p a rison of endove n o u sr a d i o f requency ve rsus 810 nm diode laserocclusion of large veins in an animal model.D e rmatol Surg. 2002 Ja n ; 2 8 ( 1 ) : 5 6 - 6 1 .1 9 . Goldman MP, M a u r icio M, Rao J.I n t r avascular 1320-nm laser closure of thegreat saphenous ve i n : A 6- to 12-month fol-l ow-up study. D e rmatol Surg. 0 4N ov ; 3 0 ( 1 1 ) : 1 3 8 0 - 5 .

CLINICAL EXPERIENCE WITH

ENDOVENOUS TECHNIQUES

IN MORE THAN 1,000

PATIENTS SHOWS

A HIGH DEGREE OF

SUCCESS WITH MINIMAL

SIDE EFFECTS…

DISCLOSURES: Dr.Weiss is a con -sultant, scientific advisor and has otherfinancial interests in Cool Touch.

Dr. Munavallli is a member of thespeakers’ bureau for Cool Touch.

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7140-0124 Rev. A

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