There are instances where EVLT has not entirely eliminated the varicose veins, this is usually apparent by the 6 week follow up visit, or EVLT is not applicable. This occurs when the saphenous veins is very tortuous, "twisty" and convoluted, and the catheter and laser fiber cannot negotiate these twists and turns. Also there may be such longstanding destruction of the valves further down the leg that blood under pressure remains and the enlarged veins persist. Lastly, there are cases where the greater saphenous vein is not refluxing but the reflux is occurring at a direct connection between the deep and superficial system called a perforator. Perforators are naturally occurring connections that direct blood from the superficial system to the deep system so that the muscular pump of the calf muscles can return the blood upward toward the heart. These perforators have valves, too. If these valves fail reflux occurs. This can result in localized or persistent varicose veins.

These veins can be removed with a procedure called Ambulatory Phlebectomy. This procedure is performed under a local anesthetic utilizing a small puncture wound about the size if a pencil lead through which a small hook is placed. The hook catches the vein and it is teased out through the tiny incision. The wound is then closed with a Steri-strip and the leg is wrapped. We prefer patients stay off there feet as much as possible for 24 hours following this procedure but can resume normal activities thereafter.