Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American Study Group

Subfascial Endoscopic Perforator Vein Surgery

Chronic venous insufficiency is a tremendous health care problem in western societies. Venous disease can affect any combination of the superficial, deep, and perforator venous systems of the lower extremities. Generally the superficial venous deficits are addressed through sclerotherapy, enovenous ablation, stab phlebectomy, and or stripping. Patients with advanced clinical sequelae (lipodermatosclerosis or ulceration) of CVI should also be evaluated for the presence of incompetent perforating veins. Open surgical approached to the calf perforating veins (ie. Linton procedure) were complicated by significant wound complications and have largely been replaced by the less invasive Subfascial Endoscopic Perforator Surgery (SEPS). The use of SEPS in patients with ulceration has been shown to be safe and to reduce the time that patients will have ulcers during follow-up. This chapter will review the pathophysiology, diagnosis, and treatment of incompetent perforating veins of the legs with particular attention to surgical issues.

A prospective study of the fate of venous leg perforators after varicose vein surgery

OBJECTIVE

To describe the fate of perforator veins after surgical treatment of varicose veins and factors that influence this.

METHODS

This prospective study of 104 patients assessed perforator veins by using duplex ultrasound scanning in 145 limbs before superficial vein surgery for varicose veins. Veins were marked preoperatively with ultrasound guidance and ligated with an open procedure; those missed were later treated with sclerotherapy. Duplex ultrasound scans and air plethysmography were used to confirm surgical success within 1 month and to monitor recurrence at 6 months, 1 year, and 3 years.

RESULTS

A total of 850 incompetent perforators were treated, but 5.7% were missed and required further ablation. After 3 years, 75.8% of the limbs had developed further incompetent perforators for a total of 380 incompetent perforators. The number of ultrasound-detectable competent perforators had also increased from 356 to 1047 in that time. The incompetent perforators arose by (1) new vessel formation at the site of previous ligation in 152 (40.4%), (2) changes in pre-existing perforator vessels at other sites in 225 (59.2%), and (3) vessels missed at treatment (< 1%). The diameter of the neovascular channels (3.0 +/- 1.0 mm) was greater than the other incompetent perforators (2.7 +/- 1.0 mm; P < .001). The anatomic distribution of the neovascular recurrences was also different, with 63% found in the paratibial region. The number of new incompetent perforators in a limb was associated with the clinical and physiologic severity of venous disease before surgery, but not to body mass index, gender, or age (P < .01).

CONCLUSION

This study shows that incompetent perforator recurrence after surgery is far more common than previously recognized and is primarily due to either neovascularization of previously ligated perforators or the development of incompetence in newly detected perforators in association with persistent venous disease rather than due to poor surgery.

Superficial vein surgery and SEPS for chronic venous insufficiency

Venous insufficiency in its severe forms leads to skin changes which, in turn may be treated by surgical therapy. Interventions are directed towards correction of the underlying abnormal venous physiology. This involves removal of varicose veins and ablation of incompetent axial veins and relevant perforating veins. In performing ablation of saphenous vein reflux, techniques include high ligation with stripping, radiofrequency ablation, endovenous laser therapy, and foam sclerotherapy. Incompetent perforator interruption can be accomplished surgically by subfascial endoscopic perforator surgery (SEPS) or controlled sclerotherapy using ultrasound. A variety of techniques have emerged to manage the varicose veins themselves. Surgical treatment of chronic venous insufficiency with high ligation in the groin and inversion stripping of the great saphenous vein to the knee combined with stab avulsion of varicose veins continues to be the standard in treatment of varicose veins. There are few comparisons of sclerotherapy of perforating veins with SEPS, but SEPS has become the most popular of surgical options.

Association of venous volume and diameter of incompetent perforator veins in the lower limb--implications for perforator vein surgery

PURPOSE

To define the association between venous volume as measured with air-plethysmography and the duplex ultrasound measured diameter of incompetent perforator of the lower limb.

PATIENTS AND METHODS

Thirty-six patients with chronic venous disease were investigated with air-plethysmography and duplex ultrasound. Venous volume and venous filling time was measured. Venous filling index was calculated. The findings were correlated with the diameter of the largest incompetent perforator vein of the lower limb.

RESULTS

Twenty-six patients with venous volume in the normal range (80-170 ml) had a median perforator diameter of 3.5 mm (IQR 3.2-4.3). Ten patients with venous volume above 170 ml had median perforator diameter of 5.5 mm (IQR 4.6-7.7). (p=0.001, Mann-Whitney). There was a correlation between the venous volume and diameter of the largest incompetent perforator vein. (Pearson correlation factor 0.69, p=0.01).

CONCLUSION

Limb volume correlates to the diameter of the largest incompetent perforator of the calf. Increase in venous limb volume could be partly responsible for an increase in the size of calf perforators thereby promoting incompetence.

The influence of superficial venous surgery and compression on incompetent calf perforators in chronic venous leg ulceration

OBJECTIVES

Previous studies have suggested that perforating vein incompetence is reduced by surgery to superficial veins. This study analysed the effect in a randomised clinical trial.

DESIGN

Retrospective analysis of duplex data.

METHODS

Patients in this study were part of the ESCHAR randomised controlled trial. All patients had chronic venous leg ulceration with superficial venous reflux. Patients were treated with compression bandaging alone or compression plus superficial venous surgery. Legs were assessed using colour venous duplex prior to treatment and at 3 and 12 months.

RESULTS

Of 500 patients recruited to the ESCHAR trial, 261 were included in this study. One hundred and forty six of 261 legs were treated with compression alone and 115/261 underwent compression and superficial venous surgery. In the compression group, more legs had incompetent perforators at 12 months (77/131) compared to baseline (61/146, p =0.010, Wilcoxon Signed Ranks test for paired data in 131 legs). Following surgery, significantly fewer legs had incompetent calf perforators (59/115 vs 44/104 at 12 months, p =0.001, Wilcoxon Signed Ranks test for paired data in 104 legs). In addition, significantly fewer legs in the compression and surgery group developed new perforator incompetence in comparison to the group treated with compression alone (12/104 vs 36/131, p =0.003, Chi-Squared test).

CONCLUSION

Surgical correction of superficial reflux may abolish incompetence in some calf perforators and offer protection against developing new perforator incompetence.

Leg Perforator Vein Incompetence: Functional Anatomy

PURPOSE

To retrospectively determine the anatomic patterns of reflux of incompetent perforator veins (IPVs) at the sites of their highest prevalence in relation to the anatomic distribution of valvular incompetence in the veins of the calf and thigh, with emphasis on the deep system, across the clinical spectrum of chronic venous disease (CVD).

MATERIALS AND METHODS

This study was granted institutional ethics committee approval; the need for patient consent was waived. Five hundred five limbs in 359 consecutive subjects who were suspected of having CVD but did not have arterial disease, prior venous thrombosis (<1 year), venous or orthopedic surgery, or vascular malformations were clinically stratified for CVD according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and underwent venous hemodynamic investigation with duplex ultrasonography. One hundred thirty limbs were CEAP clinical classes C(0-1), 262 limbs were classes C(2-3), and 113 limbs were classes C(4-6). IPV reflux patterns and anatomic distribution of deep venous reflux in the lower limb were determined across the clinical classes of CVD. Statistical analysis was performed with Spearman rank correlation, chi(2), and Mann-Whitney testing.

RESULTS

Valvular incompetence in limbs with IPVs increased with CEAP clinical class (P < .01) in femoral, popliteal, posterior tibial, peroneal, gastrocnemial, and soleal veins; reflux was distributed evenly across these veins. Of 554 IPVs found, 377 (68.0%) occurred at four sites: middle third of medial calf (n = 165 [29.8%]), lower third of medial calf (n = 85 [15.3%]), middle third of medial thigh (n = 73 [13.2%]), and middle third of posterior calf (n = 54 [9.7%]). IPVs with superficial and deep reflux in adjoining veins, as compared with IPVs with superficial reflux alone, increased as clinical class increased from C(2) to C(6) (P < .02) at all four sites of highest IPV prevalence; determined in detail, reflux patterns of IPVs were linked to CEAP clinical class (P < .05) but not anatomic site (P > .2). Most IPVs in C(1-3) limbs had superficial reflux alone. IPVs with superficial reflux outnumbered IPVs with superficial and deep reflux even in C(4-6) limbs, where deep venous incompetence was most prevalent. Axial venous reflux (proximal-to-distal) changes (P > .4) were small in superficial and deep veins across the spectrum of CEAP clinical classes C(2-6).

CONCLUSION

Patterns of perforator reflux were linked to clinical severity of CVD in the CEAP classification and displayed an even distribution anatomically. IPVs with deep and superficial reflux in adjoining veins increased with CEAP clinical class, in line with valvular incompetence in the deep veins of the calf and thigh.

Teaching subfascial perforator veins surgery: survey on a 2-day hands-on course

BACKGROUND

The present paper describes a training method with objective evaluation to enhance video-assisted surgical skills in subfascial endoscopic perforator veins surgery (SEPS). Training was scheduled during a 2-day intensive course.

METHODS

Hands-on exercises were performed (i) on a simulator to assess whether specific training exercises were helpful in attainment of skills; (ii) on a known animal model that uses the swine abdominal wall and which allows practice in endoscopic dissection and perforator veins (PV) using appropriate instrumentation in an environment that is a reasonable surrogate for the human calf; and (iii) assisting a senior surgeon performing SEPS. Thirty surgeons without experience in SEPS were trained to perform a sequence of standardized drills connected with the SEPS technique. The SEPS simulator consisted of an artificially constructed subfascial space of the leg in which false perforator veins had to be localized, and cut. The participants performed a sequence of drills three times in order to improve their dexterity. The same exercises were then performed on a swine model. The model consisted of the arteries and veins penetrating the rectus fascia and passing into the overlying cutaneous trunci muscle and hypodermis on either side of the midline between the arch of the ribs cranially and the umbilicus caudally. Trainees were required to achieve operative space in the animal subcutaneous fat, to reach and identify the "perforating" subcutaneous vessels, and to interrupt some of them with a 5-mm clamp coagulator ultrasonic scalpel. The time required to perform each dexterity drill was recorded in seconds. Finally, the day after, trainees were asked to drive the senior operator during clinical SEPS performed on eight patients, suggesting the following manoeuvres in order to: (i) enter the subfascial space of the leg; (ii) make operative space; (iii) identify the incompetent perforator vein(s); and (iv) coagulate and divide them with the ultrasonic scalpel. Each of these four steps scored 1 point.

RESULTS

All the trainees showed a steady improvement in skill acquisition on the SEPS simulator (P < 0.001), and on the animal model with the single-port technique (P < 0.001). These results reflect positively on the animal model using the dual-port technique, and on the scores achieved in the operating theatre during clinical SEPS.

CONCLUSIONS

The validity of the 2-day course was demonstrated by significant improvement in performance with increasing skill on the training models, and in clinical practice.

Improvement in Deep Vein Haemodynamics Following Surgery for Varicose Veins

OBJECTIVE

o analyse the effect of superficial and perforating veins surgery on deep vein incompetence.

METHODS

During a six-month period between 2000 and 2001 24 patients (32 limbs) with chronic venous insufficiency (CVI) were treated. They were selected because they had varicose veins and proximal deep vein incompetence with photoplethysmography (PPG) venous refilling time (VRT) <15 s with a below knee tourniquet, and a femoral or popliteal vein reflux time (RT) >1.5 s on duplex ultrasound. The group was divided according to aetiology into 21 legs with primary (Ep) and 11 with secondary CVI (Es). All patients underwent removal of varices with stripping of the saphenous veins, if appropriate. In 21 cases subfascial endoscopic perforating vein surgery (SEPS) was performed to ligate incompetent perforating veins.

RESULTS

The average VRT for the entire group increased from 9.8 s before to 15 s after operation (p<0.001, paired t test). In the Ep group the average VRT increased from 11 to 18 s (p<0.001, paired t test), in Es group from 7.5 to 10 s (p>0.001, paired t test). Duplex ultrasonography before surgery showed femoral vein incompetence in 28 and the popliteal incompetence in 26 cases. The average femoral vein RT was 1.9 s before and 1.4 s after surgery (p<0.001, paired t test). The femoral RT in the Ep group decreased from 1.9 to 1.3 s (p<0.001, paired t test) and in the Es group from 1.9 to 1.6 s (N.S.). In the popliteal vein, RT was 1.8 s before, and 1.3 s after surgery (p<0.001, paired t test). The RT in the Ep group shortened from 1.8 to 1.1 s (p<0.001 paired t test) and in the Es group from 1.9 to 1.5 s (N.S.).

CONCLUSION

Surgical treatment of varicose veins and of calf perforators results in reduced deep vein reflux. The improvement is most marked in cases of primary venous insufficiency.

Perforator vein incompetence in chronic venous disease: A multivariate regression analysis model

OBJECTIVES

In the presence of superficial and deep vein insufficiency the effects, if any, of concurrent incompetent perforator veins (IPVs) on clinical status are masked. On the basis of multivariate regression analysis, this study examines the significance of perforator vein incompetence across the clinical classes of CEAP (C-class CEAP ) in relation to the superficial and deep systems, and assesses the role of factors implicated in the presence and number of IPVs in chronic venous disease (CVD).

METHODS

The study included 525 limbs in 360 patients, ages 17 to 96 years, referred for investigation of CVD. The protocol entailed history taking, physical examination, and duplex scanning (reflux > 0.5 s), with emphasis on IPVs. Exclusion criteria included peripheral vascular disease, unrelated edema, severe chronic obstructive pulmonary disease, and recent (< 1 year) deep vein thrombosis (DVT).

RESULTS

Limbs were stratified as C 0 , 84; C 1 , 25; C 2 , 231; C 3 , 66; C 4 , 48; C 5 , 23; and C 6 , 48. C-class CEAP was separately regressed with age ( P < .001), sex ( P < .25), contralateral CVD ( P < .2), CVD recurrence ( P = .022), previous DVT ( P < .001), superficial vein reflux ( P < .001); deep vein reflux ( P < .001), perforator vein reflux ( P < .001), and number of IPVs ( P < .001). In an optimized multivariate regression analysis of C class CEAP with all significant variables combined, age ( P < .001), previous DVT ( P = .017), superficial vein reflux ( P < .001), deep vein reflux ( P < .001), and number of IPVs ( P = .008) emerged as predictors of CVD severity (CEAP), based on the equation C class CEAP = -0.2807 + 0.028013 Age + 0.58530 Previous DVT + 0.3450 Superficial vein reflux + 0.17781 Deep Reflux + 0.14537 IPVs ( R 2 = 37.4%; P < .001). Perforator incompetence was predicted by superficial vein reflux ( P < .001) and deep vein reflux ( P = .044), age ( P = .019), CVD recurrence ( P = .038), and sex ( P = .018), as follows: Perforator incompetence = -0.2532 + 0.006457 Age + 0.41366 Superficial reflux + 0.06766 Deep reflux + 0.2450 CVD recurrence - 0.21310 Sex ( R 2 = 33.3%; P < .001). Number of IPVs per limb was best associated with superficial reflux ( P < .001) and deep reflux ( P = .023), linked as IPVs = - 0.11789 + 0.41323 Superficial reflux + 0.07646 Deep reflux ( R 2 = 26.1%; P < .001).

CONCLUSION

Perforator incompetence proved to be a significant factor for determination of CVD severity according to C-class CEAP , withstanding the conspicuous confounding effects of the superficial and deep venous systems. Perforator incompetence was significantly linked to aging, superficial or deep vein incompetence, recurrence of superficial disease, and sex, whereas the IPV number, regardless of location, depended on the presence of superficial or deep venous reflux.

Surgical options for the treatment of venous ulcers

Venous ulcers are a difficult problem for both patient and physician. Healing of venous ulcers with compression therapy and elevation, although usually successful, often takes months. Some venous ulcers do not heal with conservative therapy, or if they do, can often recur. Proper evaluation of the lower extremity venous system, usually with noninvasive imaging, is essential in planning any surgical intervention. In the appropriate patient, a number of surgical options are available to achieve ulcer healing and/or to prevent recurrence. These options include ablation of superficial reflux, perforator interruption, deep venous reconstruction, and endovenous procedures.

Minimally invasive vein surgery: its role in the treatment of venous stasis ulceration

Although traditional modalities used to treat venous disease and subsequent stasis ulceration have proved to be effective, they can have associated morbidities, such as postoperative pain, limited mobility, wound infection and dehiscence, as well as missed varicosities and/or incompetent perforator veins resulting in additional procedures. Recent advances have been made in minimally invasive vein surgery (MIVS) techniques that can decrease operative morbidity, number and size of incisions, recovery time, as well as operative time. These techniques are as durable as open procedures. The following procedures will be discussed: transilluminated powered phlebectomy, radiofrequency ablation of the greater saphenous vein closure, subfascial endoscopic perforator surgery, and percutaneous vein valve bioprosthesis. The advent of MIVS techniques allows the surgeon to manage venous pathophysiology associated with all 3 venous systems. MIVS is proving to be an important complement in the overall care of venous stasis ulceration.

Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial

BACKGROUND

Chronic venous leg ulceration can be managed by compression treatment, elevation of the leg, and exercise. The addition of ablative superficial venous surgery to this strategy has not been shown to affect ulcer healing, but does reduce ulcer recurrence. We aimed to assess healing and recurrence rates after treatment with compression with or without surgery in people with leg ulceration.

METHODS

We did venous duplex imaging of ulcerated or recently healed legs in 500 consecutive patients from three centres. We randomly allocated those with isolated superficial venous reflux and mixed superficial and deep reflux either compression treatment alone or in combination with superficial venous surgery. Compression consisted of multilayer compression bandaging every week until healing then class 2 below-knee stockings. Primary endpoints were 24-week healing rates and 12-month recurrence rates. Analysis was by intention to treat.

FINDINGS

40 patients were lost to follow-up and were censored. Overall 24-week healing rates were similar in the compression and surgery and compression alone groups (65% vs 65%, hazard 0.84 [95% CI 0.77 to 1.24]; p=0.85) but 12-month ulcer recurrence rates were significantly reduced in the compression and surgery group (12% vs 28%, hazard -2.76 [95% CI -1.78 to -4.27]; p<0.0001). Adverse events were minimal and about equal in each group.

INTERPRETATION

Surgical correction of superficial venous reflux reduces 12-month ulcer recurrence. Most patients with chronic venous ulceration will benefit from the addition of simple venous surgery.

Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery

INTRODUCTION

In the United States more than 6 million persons have chronic venous insufficiency and more than 500,000 have venous ulcers. Patients in whom conservative therapies fail may improve after surgical treatment of superficial and perforating venous disease, but the degree of this benefit is uncertain.

PURPOSE

We performed a systematic review of health outcomes in patients with severe chronic venous insufficiency treated with surgical management that incorporated subfascial endoscopic perforator surgery (SEPS), to quantify the overall rates of surgical outcomes.

METHODS

Published studies in English reporting venous ulcer healing and recurrence outcomes after SEPS were obtained from a MEDLINE search. Data regarding patient characteristics and surgical outcomes were abstracted from each study, and the outcomes were combined by using a random effects model.

RESULTS

Our search identified 20 studies, 1 randomized trial and 19 case series, involving 1140 treated limbs. CEAP classification was secondary cause (E(S)) in 36%, deep venous involvement (A(D))in 56%, and obstructive (P(O)) in 12%. Overall, after surgical treatment including SEPS, with or without concomitant superficial venous ablation, ulcers in 88% of limbs healed. Ulcers recurred in 13%, at mean time of 21 months. Risk factors for nonhealing and recurrence included postoperative incompetent perforator veins, pathophysiologic obstruction, secondary cause, and ulcer diameter greater than 2 cm. Complications and their overall rates after surgical treatment including SEPS were wound infection (6%), hematoma (9%), neuralgia (7%), and deep venous thrombosis (1%).

CONCLUSION

Our results suggest that surgical management of venous ulcer including SEPS, with or without saphenous ablation, leads to an 88% chance of ulcer healing and a 13% chance of ulcer recurrence over the short term. Randomized controlled trials are needed to discern the contributions of compression therapy, superficial venous surgery, and SEPS in the treatment of venous ulcer disease.

Treatment of superficial and perforator venous incompetence without deep venous insufficiency: is routine perforator ligation necessary?

PURPOSE

We investigated whether routine ligation of incompetent perforator veins is necessary in treatment of symptomatic chronic venous insufficiency (CVI) due to combined superficial and perforator vein incompetence, without deep venous insufficiency.

METHODS

This was a retrospective review of prospectively collected data. Twenty-four limbs with both superficial and perforator venous incompetence but no deep venous insufficiency were identified at venous duplex scanning. Air plethysmography (APG) was performed preoperatively, to obtain venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) of the affected limb. Saphenous vein stripping from the groin to knee and powered transilluminated phlebectomy for varicosity ablation were performed in all patients. Postoperatively, all patients underwent duplex scanning and APG to determine the status of the perforator veins and hemodynamic improvement from surgery.

RESULTS

Average patient age was 55.8 years; 62% of patients were women. CVI was class 3 in 4 limbs, class 4 in 12 limbs, and class 5 and class 6 in 4 limbs each. Postoperative duplex scans demonstrated that 71% of previously incompetent perforator vessels were now competent or absent. Significant improvement in all APG values was documented after superficial surgery. VFI improved from 6.0 +/- 2.9 preoperatively to 2.2 +/- 1.3 after surgery (P <.001); EF improved from 56.3 +/- 18 to 62 +/- 21 (P =.02); and RVF improved from 40.1 +/- 19 to 28.3 +/- 18 (P =.009). Mean preoperative symptom score (5.3 +/- 1.9) was significantly improved at mean follow-up of 18.3 months (1.4 +/- 1.2; P <.001).

CONCLUSION

Patients with superficial and perforator vein incompetence and a normal deep venous system experienced significant improvement in APG-measured hemodynamic parameters and clinical symptom score after superficial ablative surgery alone. This suggests that ligation of the perforator veins can be reserved for patients with persistent incompetent perforator vessels, with abnormal hemodynamic parameters or continued symptoms after superficial ablative surgery.

Venae perforantes: a clinical review

BACKGROUND

Although many articles on perforating veins have been published, much knowledge about these veins is lacking.

OBJECTIVE

In this review relevant facts about the clinical importance of perforating veins in venous disease are described.

METHODS

A literature search on English, French and German articles has been performed using literature databases like Medline, Embase and Cochrane.

RESULTS

Selection criteria are described.

CONCLUSION

A few conclusions are drawn: incompetent perforating veins can be of haemodynamic importance, especially in venous ulceration and (recurrent) varicose veins. The current definition of incompetent perforating veins is reflux more than 0,5 seconds (detected by Duplex ultra-sonography). Good anatomical and clinical classifications are published and should be integrated in the CEAP classification. Based on the clinical classification treatment options are described for the different types of incompetent perforating veins. Two different treatment modalities for incompetent perforating veins are surgery (SEPS) and sclerotherapy. SEPS seems to be of benefit in patients with venous ulceration and advanced CVI. Sclero-therapy (especially ultra sound guided sclerotherapy) is promising and worth further evaluation.

Great saphenous vein stripping with liberal use of subfascial endoscopic perforator vein surgery (SEPS)

This study is based on a unique registry of 632 patients who underwent great saphenous vein (GSV) stripping and liberal use of subfascial endoscopic perforator vein surgery (SEPS) for minimal to severe lower limb venous insufficiency. Clinical examinations and color-coded duplex scanning were performed on a randomly selected, manageable sample of 170 limbs to assess the affect of early SEPS on junctional (saphenofemoral [SFJ] and/or saphenopopliteal [SPJ]) and perforator vein (PV) insufficiencies and superficial varicosities at a median of 6.5 years. PV incompetence was present in 68 legs (40%), as the sole transfascial insufficiency in 28 limbs and combined with SFJ or SPJ incompetence in 40 limbs. Junction incompetence alone characterized an additional 38 limbs, bringing the total transfascial insufficiency prevalence to 62%. Superficial varicosities affected 46% of limbs. Overall CEAP clinical class was unimproved beyond preoperative values. PV incompetence was associated with higher CEAP and clinical venous severity scores than were junctional insufficiencies alone. We concluded that PV incompetence alone or combined with junctional insufficiency is associated with increased symptoms and disease progression. The prevalence of SFJ, SPJ, and PV incompetence (62%) and recurrent varicosities (46%) suggests that early use of SEPS does not prevent disease progression and offers no benefit over GSV stripping in the absence of deep vein insufficiency or threatened ulceration.

Subfascial endoscopic perforator surgery: a review

Approximately 1-2% of the UK population suffers from venous ulcers. Incompetent perforator leg veins are thought to be a major contributory factor. Subfascial endoscopic perforator surgery treats incompetent perforators in a minimally invasive fashion with significant improvement in wound healing and reduction in ulcer recurrence rates.

Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis

OBJECTIVE

This study was undertaken to determine the results of subfascial endoscopic perforator vein surgery (SEPS) combined with ablation of superficial venous reflux.

METHODS

Clinical data were retrospectively analyzed for 74 consecutive limbs (65 patients) in which this combination treatment was performed at a university medical center. Preoperatively, 58 lower extremities had an open venous ulcer (CEAP clinical class 6 [C(6)]) and 16 had healed ulceration (C(5)). Preoperative and postoperative ulcer care remained constant. Main outcomes measured included perioperative complications, ulcer healing, and ulcer recurrence. Clinical severity and disability scores were tabulated before and after surgery. Mean patient follow-up was 44 months.

RESULTS

Greater saphenous vein (GSV) stripping and varicose vein excision accompanied SEPS in 57 limbs (77%), and SEPS was performed alone or with varicose vein excision in 17 limbs that had previously undergone GSV stripping. Postoperative complications occurred in 12 limbs (16%), all with C(6) disease (P =.04). Ulcer healing occurred in 91% (53 of 58) of limbs with C(6) disease at a mean of 2.9 months (range, 13 days-17 months). Multivariate analysis demonstrated that ulcer healing was negatively affected by previous limb trauma (P =.011). Ulceration recurred in 4 limbs (6%) at 7, 20, 21, and 30 months, respectively. This was associated with a history of limb trauma (P =.027) and preoperative ultrasound evidence of GSV reflux combined with deep venous obstruction (P(R,O); P =.043). Clinical severity and disability scores improved significantly after surgery (both, P <.0001).

CONCLUSIONS

Most venous ulcers treated with SEPS with ablation of superficial venous reflux heal rapidly and remain healed during medium-term follow-up. Ulcer healing is adversely affected by a history of severe limb trauma, and ulcer recurrence is similarly affected by a history of limb trauma in addition to superficial venous reflux combined with deep venous obstructive disease. Overall, there was marked improvement of postoperative clinical severity and disability scores compared with those obtained before surgery.

Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein ligation

Existing data in the literature lack answers to several questions about the optimal treatment of patients with advanced CVI, especially venous ulcers. There is no level I evidence to support the superiority of surgical over medical treatment and the extent of surgical intervention. Specifically, knowledge about the efficacy and applicability of SEPS is incomplete, and prospective, randomized studies are needed. In the light of present-day knowledge, all patients should undergo a trial of medical management before resorting to surgery. Patients who benefit from surgical treatment and the addition of SEPS, if indicated, are patients with ulcers resulting from PVI of the superficial and perforating veins, with or without DVI. Based on available data, these patients can be assured an 80% to 90% chance of long-term freedom from ulcer recurrence. Despite subjective symptomatic and objective clinical score improvement, the role of surgery and SEPS is controversial in patients with PT because only 50% of patients can be predicted to have long-term freedom from ulcer recurrence. Patients with ulcer recurrence after SEPS should undergo duplex scanning to exclude recurrent or persistent perforators. If these are found to be incompetent, repeat SEPS is warranted. If there is no perforator incompetence, patients should be considered for deep venous reconstruction.

Hook phlebectomy versus transilluminated powered phlebectomy for varicose vein surgery: early results

OBJECTIVES

to compare Transilluminated Powered Phlebectomy (TIPP) (TriVex System) with Muller's hook phlebectomy.

MATERIALS AND METHODS

between January and April 2001, 40 patients (group 1) undergoing TIPP were non-randomly compared to 40 patients undergoing Muller's hook phlebectomy (group 2) in the course of conventional vein stripping and perforator ligation. All patients had at least C2 CEAP disease.

RESULTS

hospital stay averaged 2 days (range 1-3 days; median 2 days) and was similar for the two groups. TIPP took significantly longer (56+/-12 vs 45+/-10 min, p<0.001) but was associated with significantly fewer incisions (6 [2-8] vs 8 [4-21], p<0.001). The mean pain score (out of 10) at 2 and 7 days and 6 weeks was 5, 2 and zero after TIPP and 4, 2 and zero after hook phlebectomy. The incidence of postoperative haematoma formation was significantly higher after TIPP (45 vs 25%, p=0.06), especially in the calf region (25 vs 2.5%,p =0.003).

CONCLUSION

TIPP was slower (although speed increased with practice) associated with more haematoma (although this reduced with practice) and fewer incisions. In other respects (pain, cosmetic satisfaction, other complications, residual varices) it was not significantly different from hook phlebectomy. Greater clinical experience with the technique and randomized studies are required to determine whether TIPP is a valuable addition to our armamentarium.

[Surgical therapy of venous leg ulcers]

Surgical treatment of venous leg ulcers is a domain of dermatology. Special knowledge of differential diagnosis considerations and various treatment options are necessary to develop complex, sometimes interdisciplinary treatment plans together with angiologists,vascular surgeons and interventional radiologists. Besides surgical treatment options aiming towards normalization of venous hemodynamics, local options such as shave or total ulcer excision are well established. Additionally, new surgical techniques such as subfascial endoscopic perforator surgery (SEPS) or implantation of iliac stents now have their place in the surgical treatment of venous ulcer disease.

Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial

OBJECTIVES

to compare minimally invasive surgical haemodynamic correction of reflux (CHIVA) with compression in the treatment of venous ulceration.

DESIGN

prospective randomised study.

MATERIALS AND METHODS

from a cohort of 80 patients with 87 venous leg ulcers, 47 were randomised to either surgery or compression.

RESULTS

at a mean follow-up of 3 years, healing was 100% (31 days) in the surgical and 96% (63 days), in the compression group (p<0.02). The recurrence rate was 9% in the surgical and 38% in the compression group (p<0.05). In the surgical group, all plethysmographic parameters except ejection fraction, had improved significantly at 6 months in the surgical group, and at 3 years residual volume fraction remained in the normal range. Finally, quality of life significantly improved in the operated group.

CONCLUSIONS

this study supports the effectiveness of surgical therapy for leg ulceration secondary to superficial venous reflux.

Optimal therapy for advanced chronic venous insufficiency

INTRODUCTION

While definitive therapy awaits level I evidence, controversy persists regarding the optimal operation for treatment of advanced chronic venous insufficiency (CVI). We propose a pragmatic approach to the correction or amelioration of venous hypertension resulting from hydrodynamic and hydrostatic venous reflux. We evaluated a strategy of balloon dissection, subfascial endoscopic perforating vein surgery (SEPS) with routine posterior deep compartment fasciotomy, including ligation and stripping of the superficial system, for use when reflux is documented at duplex ultrasound (US) scanning.

METHODS

This is a cooperative, multicenter, retrospective review of 832 patients stratified by CEAP classification. The series consisted of 300 patients with C4 CVI, 119 patients with C5 CVI, and 413 patients with C6 CVI. A subset of 92 patients with C4 disease were prospectively randomized, and ambulatory venous pressure (AVP) was determined preoperatively and postoperatively. All patients underwent duplex US scanning to document reflux in the deep, superficial, and perforating venous systems. Efficacy, safety, and durability were evaluated over follow-up of 1 to 9 years (mean, 31/2 years). Uniformity was attempted by adoption of the senior author's protocol and technique through on-site preceptorship in each surgeon's operative theater.

RESULTS

This technique interrupted 3 to 14 (mean, 7) incompetent perforating veins per patient. Of the 832 patients undergoing SEPS, 460 (55%) underwent saphenous vein ligation and stripping at the same operation. In 92% ulcers healed or were significantly improved within 4 to 14 weeks. In 64 (8%) patients, ulcers failed to heal or there was no benefit from the operation. Thirty-two patients (4%) experienced recurrent ulceration or skin deterioration at 6 months-2 years (mean, 15 mo). Repeat SEPS was successful in 25 of these 96 patients, and deep valve repair was successful in 4 patients. In the 92 randomized patients with C4 disease, 41 refused postoperative AVP, leaving 51 compliant patients. The SEPS group (n = 25) had significantly reduced AVP (P <.01) compared with the control group (n = 26). Complications in 825 patients were less than 3% and consisted mostly of transient neurologic disorders (eg, paradysthesia), but deep venous thrombosis occurred in 2 patients, with pulmonary embolus in 1. No operative deaths occurred. Follow-up for 1 to 9 years (mean, 31/2 years) demonstrated durability.

CONCLUSION

The efficacy, safety, and durability of this operative protocol proved beneficial in our clinical experience with 832 patients during 9 years of follow-up. The SEPS subset of randomized patients with C4 disease experienced significant decrease in AVP, objectively supporting the effectiveness of reflux surgery in advanced CVI. Until definitive level I evidence is available, this operative technique is advocated as optimal therapy for CVI.

Does severe venous insufficiency have a different etiology in the morbidly obese? Is it venous?

OBJECTIVE

Chronic venous insufficiency (CVI) is the most common cause of leg ulcers. Patients with morbid obesity are remarkable for particularly recalcitrant ulcers. Because obesity is not specifically incorporated in CEAP or other venous scoring systems, we sought to characterize this group of patients more completely.

METHODS

Patients with severe CVI (CEAP clinical class, 4, 5, and 6), and class III obesity (body mass index [BMI], >40) were reviewed. Findings from clinical and duplex ultrasound scan (DU) examinations were compared with the CEAP classification, its adjunctive venous clinical severity score, and sensory thresholds.

RESULTS

A review of clinic records identified 20 ambulatory patients with a mean age of 62 years, a mean BMI of 52, and a mean weight of 164 kg (361 lbs); all but one had bilateral symptoms. No evidence of venous insufficiency was detected with DU in 24 of the 39 limbs. Although some valvular incompetence was detected with DU in 15 of 39 limbs, these abnormalities were widely dispersed between 28 sites; eight limbs had findings at only one site. Ulceration (mean area, 29 cm(2)) was present in 25 limbs and necessitated 7 months for healing; 13 (52%) recurred at least once during a mean observation period of 36 months. The mean sensory threshold of 5.21 exceeded current risk thresholds used in diabetic screening programs. The distribution of CEAP clinical class was C4 (n = 14), C5 (n = 14), and C6 (n = 11). Increasing CEAP class correlated with an increased mean BMI of 47, 52, and 56, respectively (P <.01). CEAP also correlated with a rising mean venous clinical severity score of 10, 11, and 15, respectively (P <.05).

CONCLUSION

Patients with class III obesity had severe limb symptoms, typical of CVI, but approximately two thirds of the limbs had no anatomic evidence of venous disease. The association of increasing limb symptoms with increasing obesity suggested that the obesity itself contributes to the morbidity.

Subfascial endoscopic perforator surgery with tumescent local anesthesia

BACKGROUND

Subfascial endoscopic perforator surgery (SEPS) has become an established procedure.

OBJECTIVE

To evaluate SEPS with tumescent local anesthesia (TLA) using an single-port device originally designed for that purpose.

METHODS

Patients selected for SEPS received subcutaneous infiltration of TLA into the medial aspect of the calf 20 minutes before surgery. Bipolar coagulation and dissection were used to treat incompetent perforators.

RESULTS

Fifty-one patients with 67 legs of CEAP stages C3-C6 underwent SEPS with TLA. In 40 patients or 53 legs (79.1%) TLA alone allowed successful completion of the SEPS procedure. Five patients with 7 legs (10.4%) required additional intravenous analgesics during surgery. In 4 patients or 4 legs (6.0%) with marked dermatoliposclerosis, pain control with TLA was so inadequate that SEPS had to be stopped.

CONCLUSION

SEPS with TLA is feasible in patients with CEAP stage C3-C6. However, patients with pronounced dermatoliposclerosis are likely to need more invasive analgesic measures.

Ten years experience with subfascial endoscopic perforator vein surgery

We report here results from our 10-year experience of performing subfascial endoscopic perforator vein surgery (SEPS). Between 1989 and 1999 we performed 254 SEPS in 224 patients. SEPS results were evaluated 1 month after surgery and every 6 months during observation. In the year 2000, all patients who underwent the procedure were called in for a final follow-up examination. Analysis covered all documented data of 130 patients and 146 limbs (58% and 57.5%, respectively, of those that underwent surgery). The study group comprised 51 men and 79 women, between 26 and 72 years of age. The chronic venous insufficient clinical condition of patients prior to surgery was as follows: class 3, 3.1%; class 4, 40%; class 5, 29.2%; class 6, 27.7%. Post-thrombotic syndrome was diagnosed in 85 patients (65.3%). The observation period ranged from 6 months to 10 years (4 years and 8 months on average). Long-term SEPS results demonstrated the efficacy and safety of this surgical technique. SEPS is a new treatment method, especially for patients with ulcerations. Unfortunately, it dose not completely solve the problem of treating chronic venous insufficiency.

Recurrence of chronic venous ulcers on the basis of clinical, etiologic, anatomic, and pathophysiologic criteria and air plethysmography

INTRODUCTION

Leg ulcers associated with chronic venous insufficiency (CVI) frequently recur after healing. The risk of recurrence has not been well defined for patients in different anatomic and hemodynamic groups. We reviewed the risk of ulcer recurrence on the basis of clinical, etiologic, anatomic, and pathophysiologic criteria and hemodynamic characteristics of the affected limb as assessed with air plethysmography (APG).

METHODS

Ninety-nine limbs with class 6 CVI were assessed clinically and with standing duplex ultrasound scanning and APG for the definition of clinical, etiologic, anatomic, and pathophysiologic criteria. Leg ulcers were treated with high-pressure compression protocols. Surgical correction of venous abnormalities was offered to patients with appropriate conditions. After ulcer healing, the limbs were placed in compressive garments and followed at 6-month intervals for ulcer recurrence.

RESULTS

The mean patient age was 54.3 years, and 46% of the patients were female. Corrective venous surgery was performed in 37 limbs. The mean follow-up time for all 99 limbs was 28 months. The ulcer recurrence rate with life table was 37% +/- 6% at 3 years and 48% +/- 10% at 5 years. The patients who underwent venous surgery had a significantly lower recurrence rate (27% +/- 9% at 48 months) than did those patients who had not undergone surgery (67% +/- 8% at 48 months; P =.005). The patients with deep venous insufficiency (DVI; n = 51) had significantly higher recurrence rates (66% +/- 8% at 48 months) than did the patients without DVI (n = 48; 29% +/- 9% at 48 months; P =.006). This difference was significant even after accounting for the effects of surgery (P =.03). The hazard ratio of ulcer recurrence increases by 14% for every unit increase in the venous filling index (VFI; P =.001). This remains significant even after accounting for the effects of surgery (P =.001). The combination of DVI and a VFI of more than 4 mL/s yields a risk of ulcer recurrence of 43% +/- 9% at 1 year and 60% +/- 10% at 2 years.

CONCLUSION

Leg ulcers associated with CVI have a high rate of recurrence. Ulcer recurrence is significantly increased in patients with DVI and in patients who do not have venous abnormalities corrected surgically. The VFI obtained from APG is useful in the prediction of increased risk for recurrence, particularly in association with anatomic data.

Advances in venous surgery: SEPS and phlebectomy for chronic venous insufficiency

Chronic venous insufficiency (CVI) and its complications of chronic pain, intractable ulceration, and infection are important conditions to treat by modern surgical techniques. As early as the 1930s, perforating veins with outward flow were implicated in the pathogenesis of this condition. Recognition that such outward flow promotes leukocyte adhesion and activation as the principal microcirculatory cause for the cutaneous changes has explained the importance of perforating vein interruption? Because of disability of CVI, surgeons and patients reluctantly tolerated the open Linton perforator interruption operation with its morbid knee-to-ankle incisions. It was tolerated because it worked. Modifications to reduce the morbidity of the procedure eliminated two of the three incisions used in the explorations of the 1930s. Other modifications such as DePalma's modification of the incisions further reduced wound complications. However, the most significant surgical alteration was to utilize the endoscopic techniques introduced in Europe by Fischer and Hauer. Very quickly it was obvious that the endoscopic technique minimized postoperative complications. Application of endoscopic perforator interruption to varicose vein surgery validated the safety of the procedure but did not contribute to knowledge about treating CVI.

Subfascial endoscopic perforator vein surgery in patients with post-thrombotic venous insufficiency--is it justified?

Previous results following subfascial endoscopic perforator vein surgery were reported to be worse in post-thrombotic syndrome than in limbs with primary valvular incompetence. This report comprises a larger patient cohort with longer follow-up. The goal of this study was to determine if subfascial endoscopic perforator vein surgery is justified in patients with post-thrombotic venous insufficiency. The clinical data of 91 consecutive patients who underwent subfascial endoscopic perforator vein surgery with or without superficial reflux ablation over a 7-year period from May 1993 to June 2000 were retrospectively analyzed. Fifty-four females and 37 males (median age, 53 years; range, 20-77) underwent 103 subfascial endoscopic perforator vein surgery procedures. Forty-two limbs were classified as C6 (active ulcer), 34 as C5 (healed ulcer), and 24 as C4 (lipodermatosclerosis). Thirty procedures were performed in post-thrombotic limbs. Concomitant superficial reflux ablation was performed in 74 limbs (72%); saphenous vein stripping had been previously performed in 29 (28%). Deep venous incompetence was present in 89% of limbs; 13% had venous outflow obstruction on plethysmography. Cumulative ulcer healing in post-thrombotic limbs was not significantly different from limbs with primary valvular incompetence; 30-, 60-, and 90-day healing rates were 44%, 72%, and 72% vs 39%, 70%, and 87%, respectively (p = 0.35). On univariate analysis, the presence of ulcer greater than 2 cm in diameter was associated with delayed ulcer healing (p = 0.02). Cumulative ulcer recurrence in all limbs was 4%, 20%, and 27% at 1, 3, and 5 years, respectively. Ulcer recurrence in post-thrombotic limbs was higher than in limbs with primary valvular incompetence at 1, 3, and 5 years; 16%, 47%, and 56% vs 0%, 8%, and 15%, respectively (p = 0.001). Recurrent ulcers were small, superficial, and easier to heal. Clinical improvement was significant even in post-thrombotic limbs; median clinical score decreased from 9.5 to 3 (p = 0.001), and median outcome score was +2 (mean 1.9; range, -1 to 3). Median clinical score in patients with primary valvular incompetence improved from 6 to 1.5 (p = 0.0001). Subfascial endoscopic perforator vein surgery with superficial reflux ablation promoted ulcer healing, improved clinical outcome, and resulted in a low long-term ulcer recurrence rate in limbs with primary valvular incompetence. Despite good clinical outcome in post-thrombotic limbs, ulcer recurrence was high. These results imply that the role of subfascial endoscopic perforator vein surgery with superficial reflux ablation in patients with post-thrombotic limbs continues to be controversial.

Senescence and the healing rates of venous ulcers

OBJECTIVE

Premature cellular senescence has been linked to venous hypertension and may contribute to delayed healing of venous ulcers. We hypothesized that the percentage of senescent cells in in vitro populations of fibroblasts isolated from venous ulcers is directly related to the clinical time-to-healing.

METHODS

Biopsy specimens were obtained from ulcer margins and unaffected dermal tissue of the ipsilateral thigh of seven patients with active venous ulcers. Using explant culture techniques, we obtained populations of wound fibroblasts and normal fibroblasts. The percentage of senescence in these cell populations was determined with X-Gal (5-bromo-4-chloro-3-indolyl beta-D-galactoside), which was used as a stain for B-galactosidase, a biomarker for senescent dermal fibroblasts. The X-Gal stain is a peroxidase stain for B-galactosidase. All patients in the study were treated with compression dressings. On a weekly basis, digital images were taken until ulcers healed. Planimetric healing rates were calculated from these images, and an overall time-to-healing was recorded. All cytologic investigations were performed on first passage cells.

RESULTS

The average starting ulcer size was 4.2 cm2. Five of the data points represented healed ulcers. The two remaining patients withdrew from the study to pursue other therapies after having been treated with compression dressings for a long time. Linear regression analysis of healed ulcers identified a relationship between percent of senescence and time-to-healing, which was statistically significant (R2 = 0.81, P =.037). High percentages of senescent cells also had a correlation with slowed planimetric healing, which was not statistically significant.

CONCLUSIONS

This study demonstrates a clinical correlation between quantitative in vitro senescence and time-to-healing. A percentage of senescence that is greater than 15% in populations of cells isolated from venous ulcers may identify a "difficult to heal" ulcer. There is no good clinical indicator for determining the likelihood of ulcer healing, but these results indicate that senescence percentage may have potential in this regard.

Subfascial Endoscopic Perforator Surgery is More Cost-Effective Than Compression Bandaging for Healing Venous Ulcers

Objective:

To determine whether subfascial endoscopic perforator surgery (SEPS) is more cost-effective than compression bandaging for healing venous ulcers.

Design:

Cost analyses based on theoretical patients supposing the two methods are equally effective in healing venous ulcers.

Setting:

District hospital.

Patients:

A theoretical population of 200 patients with unilateral leg ulceration due to incompetent perforating veins.

Intervention:

The cost of SEPS was calculated based on outpatient visits, investigations and surgery including complications, with varying failure and re-ulceration rates. The cost of compression bandaging was estimated from published data and compared with that of SEPS.

Results:

The average cost per patient undergoing SEPS was £723. In 100 patients with an operative failure rate of 2% and a 10% re-ulceration rate, the cost increased to £818/patient in the first year (£16/ulcer-free week). A re-ulceration rate of 35% increased the cost to £23/ulcer-free week. However, the cost of compression bandage was £33/ulcer-free week using the same model, with healing rates of 50–70% at 20–40 weeks and a recurrence rate of 18–30% at 30–40 weeks.

Conclusion:

In a theoretical model SEPS was more cost-effective in healing venous ulcers due to incompetent perforators compared with compression bandaging.

Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: long-term follow-up

PURPOSE

Subfascial division of incompetent perforating veins seems to be a successful treatment for patients with venous leg ulceration (CEAP 6). For postoperative wound complications, endoscopic techniques are more common than open subfascial division of incompetent perforating veins (Linton procedure). We investigated the long-term results of ulcer healing and recurrence rates and compared them with preoperative and postoperative duplex findings.

METHODS

Patients with venous ulceration on the medial side of the lower leg were randomly allocated to endoscopic exploration or open exploration by means of the modified Linton approach. Ulcer healing and recurrence rates were documented.

RESULTS

Thirty-nine patients were randomly allocated to exploration, 19 patients to open subfascial division of incompetent perforating veins (Linton group), and 20 patients to subfascial endoscopic division of incompetent perforating veins (SEPS group). During the follow-up period, four patients in the SEPS group died, all of causes other than the venous leg ulcer. Because of a squamous cell carcinoma that had developed in the venous ulcer, one patient in the SEPS group underwent a below-knee amputation. In a mean follow-up period of 50.6 months, the venous ulceration of all 18 patients in the Linton group who were available for follow-up initially healed. The recurrence rate in this group was 22% (4 patients). In the SEPS group, the mean follow-up period for 19 patients was 46.1 months, with the ulceration healing in 17 patients and a recurrence rate of 12% (2 patients). The presence of deep venous incompetence (DVI) did not influence the recurrence rates (P =.044, Fisher exact test), but it significantly influenced the development of new incompetent perforating veins (3 of 10 without DVI; 7 of 10 with DVI; P =.011, binomial test).

CONCLUSION

The long-term follow-up results of the endoscopic division of perforating veins are comparable with those of the open division of perforating veins (modified Linton procedure).

In situ hemodynamics of perforating veins in chronic venous insufficiency

PURPOSE

The prevalence of incompetent perforators increases linearly with the clinical severity of chronic venous insufficiency (CVI) and the presence of deep vein incompetence. Putative transmission of deep vein pressure to skin may cause dermal hypoxia and ulceration. Despite extensive prospective interest in the contribution of perforators toward CVI, their hemodynamic role remains controversial. The aim of this prospective study was to determine the in situ hemodynamic performance of incompetent perforating veins across the clinical spectrum of CVI, by means of duplex ultrasonography.

METHODS

A total of 265 perforating veins of 90 legs that had clinical signs and symptoms consistent with CVI in 67 patients referred consecutively to the blood flow laboratory were studied. The clinical distribution of the examined limbs was CEAP(0), 10 limbs; CEAP(1-2), 39 limbs; CEAP(3-4), 21 limbs; and CEAP(5-6), 20 limbs. With the use of gated-Doppler ultrasonography on real-time B-mode imaging, the flow velocity waveforms were obtained from the lumen of perforators on release of manual distal leg compression in the sitting position and analyzed for peak and mean velocities, time to peak velocity, volume flow, venous volume displaced outward, and flow pulsatility. The diameter and duration of outward flow (abnormal reflux > 0.5 seconds) were also measured.

RESULTS

Incompetent perforators had bigger diameters, higher peak and mean velocities and volume flow, longer time to peak velocity, and bigger venous volume displaced outward (VV(outward)) than competent perforators (all, P <.0001). The diameter of incompetent perforators did not change significantly with CEAP class (all, P >.1). Incompetent thigh and lower-third calf perforators had a significantly bigger diameter than perforators in the upper and middle calf combined (both, P <.05), in incompetent perforators: reflux duration was unaffected by CEAP class or site (P >.3); peak velocity was higher in those in CEAP(3-4) than those in CEAP(1-2) (P =.024); mean velocity in those in CEAP(3-6) during the first second of reflux was twice that of those in CEAP(1-2) (P <.0001); both higher volume flow and VV(outward) were found in the thigh perforators than those in the upper and middle calf thirds (P <.03); CEAP(3-6) volume flow and VV(outward), both in the first second, were twice that in those in CEAP(1-2) (P <.002); flow pulsatility in those in CEAP(5-6) was lower than in those in CEAP(1-2) (P =.014); in deep vein incompetence, higher peak velocity, volume flow, VV(outward), and diameter occurred than in its absence (P <.01). CEAP designation correlated significantly with mean velocity and flow pulsatility, both in the first second (r = 0.3, P <.01). The flow direction pattern in perforator incompetence was uniform across the CVI spectrum: inward on distal manual limb compression, and outward on its release; competent perforators had a smaller percentage of outward flow on limb compression (P <.01).

CONCLUSION

In addition to an increase in diameter, perforator incompetence is characterized by significantly higher mean and peak flow velocities, volume flow, and venous volume displaced outward, and a lower flow pulsatility. Differences in early reflux enable a better hemodynamic stratification of incompetent perforators in CVI classes. In the presence of deep reflux, incompetent perforators sustain further hemodynamic impairment. In situ hemodynamics enable quantification of the function of perforators and can be used in the identification of the clinically relevant perforators and the impact of surgery.