Vascular lesions are enlarged abnormal blood vessels. They can be congenital or acquired and include port wine stain, facial and leg telangiectases, spider angioma, pyogenic and venus lake, hemangioma lesions and vascular malformations.

Vascular laser treatment overview

These lesions can be treated easily and effectively by targeting the chromaphore hemoglobin by lasers based on the principle of selective thermolysis. Only targeted vessels are destroyed, without adversely affecting the surrounding tissues. Advanced laser technology now allows safe treatment of infants as young as a few weeks old.

Laser choice is determined by vessel depth and diameter, laser wavelength, thermal relaxation time and to a limited extent spot size. Pulsed lasers are safer as hemaglobins have thermal relaxation time that prevents heat from spreading too rapidly. However, all pulsed lasers cause purpura. Continuous wave (CW) laser do not cause purpura. CW lasers are effective in small lesions. PDL is more effective in macular and childhood lesions and in regions with thin skins.

Patient specific fluences are important to avoid adverse side effects.

Port wine stain laser removal

PDL is the preferred treatment and has proved effective and safe with low incidence of side effects. However, full clearance is never attained in most cases. Some lesions remained resistant

Recently, PDL has been suitably modified to incorporate longer wavelength and pulse widths, higher fluences and dynamic cooling devices. Modified PDLs have yielded better results. Modified PDLs are also effective in resistant port wine stains, though at the cost of higher incidence of side effects.

Facial and leg telangiectases

Laser treatment of facial telangiectases has given good results. Virtually any laser that targets hemaglobin can clear facial telangiectases. Treatment is usually at purpuric pulse durations. Treatment at longer pulse sub-purpuric levels showed less purpura but unpredictable improvements. However, incorporating pulse stacking and multiple passes in PDL produced outstanding results.

More recently, IPL at 520 to 1200nm has given equally good results, though at these settings there can be significant melanin absorption. Extreme care is needed in treating dark skins.

In leg telangiectases, laser therapy is gradually replacing traditional sclerotherapy. Lasers using visible light may be effective in treating superficial leg telangiectases. Longer wavelengths may be more effective in deeper lesions.

Spider angioma laser removal

Spider angioma consists of a central feeder arteriole with superficial branches giving it a spider-like appearance. Laser treatment aims at closing the hole of the feeder and subsequent treatment of the superficial branches. PDL is effective, though there may be some localized bruising. A repeat treatment may be required.

Pyogenic granuloma and venous lake treatment

Pyogenic granulomas have varying thickness making laser treatment difficult. Treatment may be easier if the hypertrophic papular aspect of the lesion is removed before treatment or if treatment is early and diascopy is used to arrest arteriole flow. PDL is the preferred treatment. Multiple pulses may be needed. Venous lakes require deep penetrating lasers like, PDL or Nd: YAG. Superficial lesions may be successfully treated by PDL and diascopy.

Thicker and more nodal lesions need longer wavelength Nd: YAG or alexandrite lasers with contact cooling and adjustable pulse durations. Anesthesia may be needed, as the operation is painful. Two or three treatments may be needed.

Hemangioma laser removal

Not all hemangiomas are considered for laser treatment, as they tend to regress. The main aim of treatment is arresting further growth and is preferred in complicated cases. PDL at low fluences are successful in treating ulcerations. Treatment of deep or combined superficial and deep hemangiomas is avoided when the lesion is proliferating.

Laser treatment cannot clear the bulk of hemangiomas due to limited penetration of current laser technology.

Vascular malformation laser removal

Capillary malformations show three types of vascular patterns and laser treatments depend on the pattern revealed by video microscopy. PDL is the best treatment available. In children, the risk of hypopigmentation or scarring is low. However, it is far from ideal since 4 to 12 treatments are needed and even then total clearance is not achieved. It seems deeper penetrating lasers than what are now available may be needed to get better results.

Venous formations are congenital and acquired and can be completely removed in most cases by laser treatment. The more severe ones need laser treatment and subsequent surgical excision.

Arterial malformations are mostly arterlovenous malformations, a fast flowing anomaly, occurring in children. Laser treatment is doubtful as shown by low success rates, perhaps, due to the fast flowing nature of these malformations.

Lymphatic formations appear at birth or before 2 years of age. Laser treatment is restricted to reducing symptoms in superficial lesions, and minimizing spontaneous bleeding in combined lesions. Mixed lymphatic venous formations may benefit from combined CO2 and PDL/ Nd:YAG laser treatment.

Varicose vein laser treatment

Laser treatment of most varicose vein cases is very unpredictable as they involve vessels with varying sizes located at different depths. PDL and KTP lasers are effective in treating small sized lesions at low depths. Larger and deeper vessels need lasers with longer milliseconds range pulse widths that are currently not available.

Conclusions

Laser treatments of vascular lesions have made excellent progress but are still far from satisfactory. Resistant port wine stain lesions remain untreatable. Laser treatments combined with photodynamic therapy has given encouraging results and holds promise for the future.