By Larry Storer

Traditional laser technology uses light energy to target the lining of the blood vessels and the blood within the blood vessels. The heat generated causes a coagulation of the blood, which destroys the vein and is then absorbed by the body.

VNUS came along with radiofrequency (RF) heating and its Closure system. Under ultrasound guidance, a RF catheter is inserted into the abnormal vein and treated with radio-energy, resulting in closure of the involved vein with much less bruising than the laser and offering a fast return to normal activities.

But the newer 1320 nanometer (nm) and the 1470nm wavelength lasers target the water in the vein wall instead of the hemoglobin, which results in a more comfortable procedure for patients without post-operative bruising or swelling. These newer lasers have been getting high marks from both the physicians who use them and the patients who are treated with them.

CoolTouch’s 15-watt CTEV 1320nm Nd:YAG laser and biolitec’s 1470nm ELVeS PL 15-watt laser have been on the market for approximately a year. Total Vein Systems (TVS) introduced a totally new 12-watt ThermaLite 1470nm laser this year.

Because they target the water in the vein walls, these newer lasers can operate at lower energy densities, resulting in fewer thermal side effects and a higher success rate. The ThermaLite 1470nm laser’s water absorption rate, for example, is approximately 40 times more than the 980nm lasers.

Physician Reaction
Michael F. Bardwil, MD, FACS, and owner of Texas Vein and Cosmetic Specialists in Houston, has successfully completed vein surgeries using traditional lasers, the VNUS Closure, and more recently, the biolitec 1470 ELVeS PL and the ThermaLite 1470. For the last year he has done about 400 surgeries using the two 1470nm wavelength units.

“I’ve done both laser and VNUS Closure,” he said. “I started with the laser and was disappointed with how much bruising it caused, so I incorporated the VNUS Closure in my practice to reduce the bruising. But I was more disappointed with the fact there was so much more recanalization with the VNUS Closure device than there was with the laser.

“So, I went back to the laser, and have continued with the laser since, but I hate having to tell people that for about two weeks they are going to be a little sore and may bruise a little more. I explain that I will do their surgery either way, but most people want the better results that we would get with the laser, even with the limited soreness, as opposed to what we would get with the VNUS Closure.”

But Dr. Bardwil said that with the 1470 he can tell them there will be virtually no pain, no complications and they can resume all normal activities when they walk out the door.

“I will never forget the first two people I treated using the 1470,” he said. “I asked them how much pain they had on a scale of 1 to 10 with 1 being no pain and 10 being the most painful, and both of them said, ‘Maybe a 1.’

“That was really strikingly different with what I saw with the 940 laser I had been using. That prompted the realization that I needed to be doing all these procedures with the 1470.

“And I feel real comfortable telling people now that they can go back to work the next day if they want to,” he said. “I still advise them to wait a couple of weeks before doing anything really vigorous, but they can resume doing normal activity immediately with the 1470, which is something they could not do with the 940. And with the approximate 400 surgeries we have done with the 1470, we have had no significant complications.”

Dr. Bardwil has been using the biolitec 1470 ELVeS PL for the past year, but when his agreement with biolitec expired in September, he purchased a ThermaLite 1470 and uses it exclusively. For a period before switching, he used both the biolitec and ThermaLite 1470 lasers, and said he got similar results.

He said that the original advantage to the VNUS was that there was less bruising. The advantage to the laser has always been better results, noting that it is a simpler, more straightforward procedure than the VNUS.

“But the ThermaLite 1470 has it all,” he said. “You get the superior laser results of better than a 95 percent success rate with closing the vein; and you either have the same or less bruising that you got with the VNUS Closure device.”

Dr. Bardwil said the question he had while using the biolitec unit was whether it was the wavelength of the laser or the covered fibers that produced the results he was getting. He found that the reusable bare tip fibers from TVS achieved the same results he had always gotten using the covered fiber from biolitec.

“So the significance of that is economics,” he said. “With an out of pocket per procedure cost of $75 with the ThermaLite vs $225 with the biolitec; and you’re getting the same advantage of the 1470 wavelength with the more economical reusable fiber that you are getting with the 1470 using the more expensive non-reusable fiber, it becomes a matter of simple math. I come out way ahead financially.

“It’s critical that we do something about the economics,” he explained. “I’ve been doing these procedures for awhile now and I’ve watched the reimbursement from them go down, down, down. We’ve got to find some way to cut the cost of the procedure so that we still make it profitable to do these.”

David Centenni, co-owner of TVS (www.totalvein.com), said performance plus price has increased demand for the 1470nm wavelength lasers.

“Many physicians are requesting the higher wavelength laser systems for their practices,” Centanni said. “The low cost of the ThermaLite 1470 allows them an economical option. In addition, the ThermaLite 1470 has a universal SMA 905 connector that is compatible with many laser fibers from 380 to 1,000 micron cores. This flexibility allows the physician more cost saving options including reusable fibers.”

Dr. Tom Clark, a vascular surgeon with RGV Vein, Laser & Aesthetic Clinic in Harlingen and Brownsville, Texas, agreed that economics are important, but that it was only a part of the equation.
“Most of us guys who do this work are looking for the laser that is economical,” Dr. Clark said. “But we also want one that always does the work that it is supposed to do and, most importantly, leaves the patient with minimal or no pain or discomfort.”

Like Dr. Bardwil, he said he thinks that the ThermaLite 1470 is the best laser he has seen because it does the job with no complications.

“Initially, Centenni sent us a demonstration unit of the ThermaLite 1470 and we used it on 11 or 12 patients over a period of three days and we got excellent results. Then we followed up on all of them within a week, and that’s a pretty good test of a laser.

“All of the treatments were successful — you’ve got to have that with any laser — but what really impressed me the most was that not one of these patients had any post-operative pain or discomfort.”
Dr. Clark said that most of the traditional laser treatments do leave a fair amount of discomfort afterwards because of the reaction that is created by the laser energy with the blood in the vein walls.
“So I’m very impressed that this laser not only does the job, but it does it with almost no discomfort.”

He has now bought a ThermaLite 1470 because he said patients have gotten to where they expect to be back to full duty immediately.

“This is a good laser,” Dr. Clark said. “It’s the best one I’ve seen.”

Bruce Hoyle, MD and owner of the Advanced Vein Center in Anaheim Hills, Calif., has used the ThermaLite 1470 in about 30 procedures since buying it a month ago, and one of the first things he said he noticed was that it uses about a third of the energy of the Dornier 940nm that he was using before he got the new laser from TVS.

“All lasers use light energy to selectively heat an object resulting in its destruction, while preserving the surrounding tissue,” Dr. Hoyle said. “The Dornier and Diomed lasers target the hemoglobin in a vein wall; but when you get up there in the 1300nm and 1400nm wavelength range, the target is water and these new lasers work better in the sense of doing the job with the lowest amount of expended energy That’s probably one explanation for the less post-op discomfort.”

He said he wanted to do a study on it, but it is already obvious that the patients are happy with it.
“My patient response is that there has been less pain, and my nurses are telling me that the patients are definitely having less post-op discomfort or other complications, and certainly it seems like we are seeing less bruising with the 1470 laser.”

CoolTouch CTEV 1320 nm
The CoolTouch 15-watt CTEV (cooltouch.com/ctev.aspx) provides an ideal treatment for endovenous ablation of varicose veins. The 1320nm wavelength also targets water in the vessel wall, not hemoglobin, which means a much more comfortable procedure for patients without post-op bruising or swelling.

The laser has an absorption length of 300-500 microns (0.3-0.5mm) in tissue. The chromophore for this laser is water as collagen is primarily water, resulting in a shorter absorption length than diode lasers. Specific absorption of energy only in the vein wall results in a more controlled depth of vein coagulation than any other wavelength.

“If comparing the side effect profile of a diode laser to a 1320nm laser, the side effect of a 1320nm laser are occurring less frequently and are observed for shorter durations,” Thomas M. Proebstle, MD, PhD, wrote in an article in Endovascular Today in July. “In general, the 1320nm laser behaves more like a RF Closure than like a typical diode laser.

CoolTouch stated in  Vein Therapy News  in August that the CoolTouch 1320nm has an exclusive JouleTracker automated pullback system with variable speeds for efficacy, even energy delivery and a faster procedure time. The pull-back device controls the rate of fiber movement along the vein wall providing consistent exposure and minimizing treatment time.

Because of its versatility, the 1320 can be used for more endovenous procedures resulting in a greater return on investment. With a range of fiber sizes, a physician can treat a variety of vein diameters, from the great and small saphenous veins to future applications including incompetent accessory veins.

Like the ThermaLite 1470, the 1320 offers reusable fibers that can be used for up to five treatments with sterilization. Spokesmen say that in addition, CoolTouch offers exclusive, sterile disposable fibers featuring a specially designed tip that simplifies the procedure, minimizes the use of accessories and allows doctors to treat a range of patient conditions.

Biolitec’s ELVeS PL 1470nm
Biolitec’s 1470nm Endo Laser Vein System (ELVeS PL) laser for use in vein surgery has been on the market for approximately a year, and the biolitec website (www.biolitec-us.com) states the device is specifically indicated for the treatment of reflux of the saphenous veins associated with varicose veins and varicosities.

“The diode laser is the energy source for the ELVeS PL endoluminal laser therapy system, which is used in a non-contact mode that is especially suited to out-patient treatment in the office environment,” states online information.

“Using a laser tuned to 1470nm wavelength delivered through an optical fiber lets doctors quickly achieve photodestruction and collapse of vein walls, treating the entire length to ensure complete closure of the vein. This provides a fast (45 minute) procedure with rapid patient recovery to normal activities.”

Biolitec explains why the 1470nm laser does the job with minimal discomfort. Many medical laser systems for vein ablation use a 980nm wavelength, which is absorbed by water to ablate tissue by creating vapor bubbles in nearby fluids. “The 1470nm wavelength has 40 times greater absorption by water and more specifically targets soft tissue in the vein wall, resulting in a more satisfying patient experience.”

Biolitec reports that the pain reported by patients treated with the 1470nm laser was significantly lower than that reported by those treated with the 980nm laser. “During follow-up exams substantially less ecchymosis was observed after ablation with the 1470nm laser than with the 980nm laser and there was more paresthesia after ablation with the 980nm laser than was seen with the 1470nm.”