Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3745_Библиотеки_им_академика_М_И_Перельмана

The pathophysiology behind venous ulcer is mainly reflux as opposed to obstruc­tion or occlusion. In a study on a consecutive series of 98 legs with an open venous ulcer, 85 per cent of the extremities had some form of superficial venous incompe­tence that might be treated with a simple operation on the superficial venous system. Axial reflux in the superficial (great saphenous vein) or the deep veins (femoral down to popliteal level) was present in 79 per cent of the legs [23]. Incompetent perforator veins and their role in chronic venous disease have been debated for years [24]. Incompetent perforator veins have been implicated as an important factor in the formation and recurrence of venous ulcers. This view is mainly based on clinical reports of excellent ulcer healing following the interruption of incompetent perforators. There is substantial evidence that subfascial endoscopic perforator surgery (SEPS) is effective in interrupting perforator veins, and it can be done without major wound complications that were often seen after the open sub­fascial Linton procedure [25–28]. Also, the ulcer healing rate after venous proce­dures that included SEPS has been satisfying [25, 26]. Patients undergoing surgery for incompetent perforator veins almost always have surgery simultaneously on the superficial venous system and therefore it is difficult to judge the actual contribu­tion of the incompetent perforator to the venous dysfunction. There is also evidence that reflux-eliminating surgery on one part of the venous system can abolish reflux in another part [29–31]. Operations on superficial veins have been shown to elimi­nate concomitant reflux in perforators [32]. Disregarding the incompetent perfora­tor veins in patients with superficial venous incompetence seems therefore to be appropriate. The low incidence of isolated perforator incompetence in patients with active venous ulcer does indicate that they are less important than previously thought [8]. The main indication (although not proven yet) for treating them is in patients with primary venous incompetence with recurrent ulceration despite optimal treatment of the superficial venous incompetence. The method of choice for treatment is then SEPS, mainly because of the low risk of wound complication. The use of sclerotherapy for the purpose of obliterating perforators is still under evalua­tion although the technique seems to be promising. [Q5: A, C]