Which laser and which fibre?

Venous specialists themselves are confused by announcements of new lasers and fibres so little wonder that patients and referring GPs would be.

EVLA varicose vein treatment is big business and many medical equipment manufacturers are eager to get a slice of the pie. EVLA was initially developed by a British company Diomed Ltd. To protect their business in the U.S. they protected the EVLA technique by a patent and a tradename EVLT® (such patenting of medical techniques as opposed to specific tools is common in the U.S. but, thankfully, not allowed in Europe).

Manufacturers like Angiodynamics tried to get around the patent by developing special tips for their fibres e.g. the Gold Tip Nevertouch® system.

Similarly, others, like Biolitec, tried to develop fibres that would avoid the need for the injections of local anaesthetic. They market the ELVES Radial™ but the hopes that it would allow EVLA painlessly without any local anaesthetic came to nothing. Another company Tobrix have developed yet another fancy tip the Tulip®.

Such developments are expensive and the marketing departments had to come up with good reasons why such devices are worth the added expense over the original simple bare laser fibre.

Clinical results

The clinical results of the original bare fibre laser are so good that there was little that could be improved. All 3 companies have concentrated their messages on providing patients with a gentler, less painful initial recovery. There is nothing else that could be improved! Having said that we used the simple bare fibre with the original Diomed laser for several years and very few patients complained of much discomfort.

Coincident with the development of the Radial and Gold Tip fibres both companies started using lasers with a different wavelength.

The original 810nm lasers, used by Diomed so successfully, target the blood in the vein lumen and heat the vein wall and destroy it by steam from vaporised blood.

The longer wavelength 1470nm lasers used by Angiodynamics and Biolitec target the water in the vein wall itself. A lower power can be used to achieve the same effect. This lower power is thought to lead to fewer perforations of the vein wall and less post-procedure pain and bruising.

Studies have shown some evidence, borne out by our own experience, that the 1470nm wavelength does indeed help reduce post-procedure discomfort. We now use this type of laser routinely in all our clinics. Many hospitals and cosmetic clinics still use the original 810nm lasers.

As all the studies have compared a simple bare fibre operating at high power (low wavelength) with a Radial or Gold Tip fibre operating at lower power (high wavelength) it is not possible to say whether it is the special fibre tip or the longer wavelength that is causing the reduced discomfort. The manufacturers of these devices obviously have a vested interest in making out that it is their special (and expensive) tip that is the crucial factor rather than the wavelength. We are not convinced. There is no published evidence that either Gold Tip or Radial fibres offer any advantage over bare fibres at the same wavelength. Our standard EVLA, therefore, uses bare fibres at 1470nm. This provides well-proven, comfortable, safe and effective treatment without unnecessary expenditure.

There is an interesting video from Tobrix, see below, demonstrating the effect in vitro of various laser fibres. You’d be hard pushed to tell the difference between the Gold Tip fibre of Angiodynamics and the simple bare fibre. The effect of the Radial and Tulip fibres do however appear rather smoother.