A description of the ‘smile sign’ and multi-pass technique for endovenous laser ablation of large diameter great saphenous veins

Abstract

Aims To report on great saphenous vein diameter distribution of patients undergoing endovenous laser ablation for lower limb varicose veins and the ablation technique for large diameter veins. Methods We collected retrospective data of 1929 (943 left leg and 986 right leg) clinically incompetent great saphenous vein diameters treated with endovenous laser ablation over five years and six months. The technical success of procedure, complications and occlusion rate at short-term follow-up are reported. Upon compression, larger diameter veins may constrict asymmetrically rather than concentrically around the laser fibre (the 'smile sign'), requiring multiple passes of the laser into each dilated segment to achieve complete ablation. Results Of 1929 great saphenous veins, 334 (17.31%) had a diameter equal to or over 15 mm, which has been recommended as the upper limit for endovenous laser ablation by some clinicians. All were successfully treated and occluded upon short-term follow-up. Conclusion We suggest that incompetent great saphenous veins that need treatment can always be treated with endovenous laser ablation, and open surgery should never be recommended on vein diameter alone.

Is Size Important? The French Experience

“…This might explain why the diameters of the refluxing GSVs were smaller than those reported in series of patients undergoing endovenous surgery. 3,4 This does make this population significantly different from others reported in the literature.…”

Safety and effectiveness of indirect radiofrequency ablation (closure FAST) of incompetent great saphenous veins with Type I aneurysms: Long-term results radiofrequency ablation for saphenous aneurysms

“…It has been shown by many groups that both EVLA and RF can be generally successful in ablating large great saphenous veins. [5][6][7][8][9] However, changes to the technique must be introduced in order to ensure high efficacy--for EVLA an increase in power density and/or repeated passage through a segment of incompletely collapsed vein (so called "smile sign"). 6,7 If not, like in standard RF procedure, closure rates drop to 70%.…”

“…[5][6][7][8][9] However, changes to the technique must be introduced in order to ensure high efficacy--for EVLA an increase in power density and/or repeated passage through a segment of incompletely collapsed vein (so called "smile sign"). 6,7 If not, like in standard RF procedure, closure rates drop to 70%. 5 Our practice to reach a decrease in output power to or below 12 W with repeated heat cycles, additional tumescence infiltration and external pressure eliminates the problem.…”

Choosing Wisely in France, for the Treatment of Saphenous Vein Insufficiency and Recurrences

“…Nowadays, with no exception, conventional surgery should not be offered for the treatment of saphenous veins or their recurrence, and endovenous thermal ablation should be considered even for treating large saphenous trunks (> 12 mm). Therefore, this CW should be amended and extended without exception [14,15,16,17,18,19]. 8.…”