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THE SIGNIFICANCE OF
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PERFORATOR REFLUXINCVI
e incidence of perforator incompetence increases as the
clinical severity of CVI worsens. e majority of limbs in
CEAP clinical classes 5 and 6 have been reported to contain perforators with incompetence on duplex imaging. For
this reason, some clinicians believe that incompetent perforators should be corrected whenever they are diagnosed.
Unfortunately it is di cult to clearly determine the hemodynamic signi cance of incompetent perforators because
they are usually seen in limbs that also display super cial
and/or deep system incompetence. ere clearly are cases
where incompetent perforators are seen in a limb previously
treated with saphenous stripping with persistent symptoms
of CVI. In these patients, perforator interruption is necessary. But it is unclear whether perforators should routinely
undergo ligation in severe CVI at the time of saphenous
ablation.
CONVENTIONAL SURGICAL
LIGATION OFIPVS
When the surgeon believes that IPVs are associated with
clinical symptoms, elimination of perforator re ux can be
performed using a variety of techniques. Open surgical ligation, mini-incision ligation, subfascial endoscopic ligation,
and percutaneous ablation can all be considered. Until the
last decade, only open surgical perforator ligation was performed, usually using the Linton procedure. As originally
described by Linton, the procedure involves a medial lower
limb incision placed over the site of the clinically signi cant
IPVs. Dissection proceeds down to the level of the fascia,
where the perforators are located and ligated with suture
ligatures (Figure52.4). e use of skin aps was advocated
to help reduce the potential for skin breakdown at the incision site postoperatively.
ough the Linton procedure was e ective at eliminating perforator re ux, it has been associated with a high
incidence of complications, mostly occurring at the incision site in the area of hyperpigmented, scarred skin typical
Figure52.4 Linton procedure.
of advanced CVI. In a report of thirty-seven limbs treated
with the Linton procedure, Stuart etal. reported that calf
wound complications occurred in seven patients (19%), and
25
the average hospital time was 9 d.
Recurrent ulceration
was reported in 7–22% of treated limbs at varying lengths
of follow-up a er the Linton procedure.
For these reasons, alternate methods were developed
to ligate IPVs while eliminating the need for surgical incisions in the area of diseased skin expected to be at risk for
compromised wound healing. e most widely performed
alternative to the Linton procedure employs endoscopy to
facilitate subfascial perforator ligation (SEPS) through a
small remote incision just below the knee. See Chapter53
for a full description of this technique. e primary bene ts
of this technique have been reported to include more rapid
recovery and fewer perioperative complications with equivalent hemodynamic results in comparison to the Linton
procedure. In a prospective comparison of the Linton
procedure to SEPS, Pierik et al. randomized thirty-nine
26
patients to open or endoscopic perforator ligation.
1997
In the open group, 53% of patients developed postoperative
wound infection compared to 0% in the SEPS group (p <
0.001). Ulcer healing rates and recurrence rates were similar
in the two groups.
Other alternate options have been reported for treatment of re uxing perforators. Perforator ligation has
been reported using a mini-incisional technique minimizing wound complications. Results have been reasonably
good, but experience is limited. Initial reports of the use of
endoluminal techniques have suggested that percutaneous
ablation of perforator veins is feasible. Larger prospective
studies are needed to determine the e cacy of these less
invasive methods.
A more fundamental question concerns the indications
for perforator ligation. is remains controversial with
proponents arguing that perforators are frequently present in severe CVI and should be ligated whenever present.
Skeptics argue that perforators are usually present in combination with super cial and/or deep venous incompetence
and the relative contribution of the incompetent perforator to venous insu ciency is less important. Iafrati et al.
reported on the treatment of y-one limbs with perforator
27
re ux and leg ulcers using SEPS.
Venous disability scores
improved signi cantly a er the procedure, and 74% of limb
ulcers healed within 6 months. e recurrent ulceration
rate was low at 13%. Excellent results were obtained, but
thirty- ve of the y-one limbs were treated concomitantly
with saphenous or varicose vein removal. Of note, SEPS
performed without saphenous surgery was associated with
delayed ulcer healing.
Tawes et al. reported a large retrospective multicenter
28
experience using SEPS in over 800 limbs with CVI.
e
majority of patients (532) were in CEAP clinical class 5
or 6. Concomitant GSV removal was performed in 55%
of cases. Reported results were excellent, with 92% of
448 • CHRONIC VENOUS INSUFFICIENCY
limb ulcers healing at 4–14 weeks a er SEPS. Recurrent
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ulceration occurred in only 4% at a mean follow-up of
15months. From this review, the authors concluded that
until de nitive level Ievidence is available, SEPS is advocated as optimal therapy for patients with CVI and incompetent perforatorveins.
Mendes etal. studied a common subset of patients with
IPVs, those with concomitant saphenous re ux and IPVs.
29
Twenty-four limbs were studied before and a er surgery
with duplex ultrasound and APG. In all limbs, saphenous
stripping was performed, with powered phlebectomy added
in patients with prominent varicosities. No SEPS or other
speci c treatment for the IPVs was performed. A er surgery,
71% of the limbs no longer contained IPVs. Hemodynamic
improvement on APG occurred in all limbs, with the VFI
improving from 6.0± 2.9 preoperatively to 2.2± 1.3 a er
surgery (p < 0.001). ey concluded that either the varicosity ablation performed an extrafascial perforator ligation by
removing the out ow tract for the IPVs, or the IPVs were of
relatively little hemodynamic importance in comparison to
saphenous re ux in this patientgroup.
It is not clear whether IPVs found in limbs coexisting
with deep venous re ux should be ligated, particularly in
the absence of corrective surgery for the deep venous system.
In the North American SEPS Registry report, there was an
increased incidence of leg ulcer recurrence in patients with
deep venous insu ciency a er SEPS. No prospective randomized studies have been performed to further evaluate
these important questions.
It is obvious that the treatment of limbs found to contain
IPVs remains controversial in many situations. Perhaps the
primary problem in this debate is the lack of a comprehensive de nition of perforator incompetence based on their
potential to cause venous hemodynamic dysfunction. Delis
and colleagues previously suggested that all perforators
demonstrating outward ow are not equal, proposing that
the volume of outward ow in 1 s a er compression release
(based on perforator size and velocity of re ux) may be used
30
to de ne classes of perforator re ux.
ey proposed that
the early hemodynamic function of the IPV determines its
clinical impact on the leg, rather than the duration of re ux.
e maximum diameter of IPVs may also be important in
determining the hemodynamic impact of IPVs. Further
research on diagnosis and management of IPVs is required
to allow optimal treatment ofIPVs.
C O N C L U S I O N
In patients with severe CVI, the primary goal is elimination
of abnormal venous re ux resulting in venous hypertension.
Rational treatment of this diverse group of patients requires
detailed anatomic and hemodynamic assessment with
duplex and plethysmography. Postprocedure reassessment
can reveal the results of therapy and direct further management. Standard surgical techniques for correction of super cial and perforator incompetence are being replaced by less
invasive methods that appear in early and mid-term studies
to have comparable symptomatic and hemodynamic results.
Long-term study will be required to evaluate the critical
areas of neovascularization and symptom recurrence a er
these alternative methods.
R E F E R E N C E S
1. Christopoulos D , Nicolaides AN , Szendro G . Venous
re ux: uantitation and correlation with the clinical severity of
chronic venous disease , Br J Surg. 1988 . 75 : 352 .
2. Criado E , Farber MA , Marston WA , Danniel PF , Burnham CB ,
K e a g y B A . e role of air plethysmography in the diagnosis of
chronic venous insu ciency , J Vasc Surg. 1998. 27 : 660–670 .
3 . O w e n s LV , Fa rb er M A , Yo u n g M L . e value of air plethysmogra-
phy in predicting clinical outcome a er surgical treatment of chronic
venous insu ciency , J Vasc Surg. 2000. 32 : 961–968 .
4. Marston WA , Carlin RE , Passman MA, etal. Healing rates and cost
e cacy of outpatient compression treatment for leg ulcers associated
with venous insu ciency , J Vasc Surg . 1999 . 30 : 491–498 .
5. Hammarsten J , Pedersen P , Cederlund CG , Campanello M. Long
saphenous vein saving surgery for varicose veins. A long-term
follow-up. Eur J Vasc Surg . 1990. 4 (4):361 – 364.
6. McMullin GM , Coleridge Smith PD , Scurr JH . Objective assessment of high ligation without stripping the long saphenous vein , Br
J Surg. 1991 . 78 : 1139–1142 .
7 . D e H a a n R J , L e g e ma t e D A , v a n G ur p J M , L e e u w e n b er g A .
uantitative measurements of venous re ux by duplex scanning of
the incompetent long saphenous vein before and a er high ligation
at the saphenofemoral junction , Eur J Surg. 1999 . 165 : 861–864 .
8. Dwerryhouse S , Davies B , Harradine K , Earnshaw J J. Stripping the
long saphenous vein reduces the rate of reoperation for recurrent
varicose veins:Five-year results of a randomized trial, J Vasc Surg.
1999 . 29 : 589–592 .
9. Fischer R , Linde N , Du C , J e a nn er et C , C h a n d l e r J G , S e e b e r P . L a t e
recurrent saphenofemoral junction re ux a er ligation and stripping
of the greater saphenous vein , J Vasc Surg. 2001 . 34 : 236–240 .
10. Nishibe T , Nishibe M , Kudo F , Flores J , Miyazaki K , Yasuda K .
Stripping operation with preservation of the calf saphenous veins for
primary varicose veins:Hemodynamic evaluation , Cardiovasc Surg.
2003 . 11 : 341–345 .
11. Holme JB , Skajaa K , Holme K . Incidence of lesions of the saphenous
nerve a er partial or complete stripping of the long saphenous vein ,
Acta Chir Scand. 1990 . 156 : 145–148 .
12. Morrison C , Dalsing MC . Signs and symptoms of saphenous nerve
injury a er greater saphenous vein stripping: Prevalence, severity,
and relevance for modern practice , J Vasc Surg. 2003 . 38 : 886–890 .
13. Labropoulos N , Giannoukas AD , Delis K , et al.
isolated lesser saphenous vein system incompetence on clinical
signs and symptoms of chronic venous disease , J Vasc Surg. 2000 .
32 : 954–960 .
14. Bass A , Chayen D , Weinmann EE , Ziss M . Lateral venous ulcer and
short saphenous vein insu ciency, J Vasc Surg. 1997 . 25 : 654–657 .
15. Lin JC , Iafrati MD , O’Donnell TF Jr, Estes JM , Mackey WC .
Correlation of duplex ultrasound scanning-derived valve closure
time and clinical classi cation in patients with small saphenous
vein re ux:Is lesser saphenous vein truly lesser?, J Vasc Surg. 2004 .
39 : 1053–1058 .
16. Bergan JJ . Surgical management of primary and recurrent varicose veins. In Gloviczki P , Yao JST , eds. Handbook of venous
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CONVENTIONAL SURGERY FOR CHRONIC VENOUS INSUFFICIENCY • 449
disorders:Guidelines of the American Venous Forum , 2e. NewYork :
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Arnold . 2001 . 289–302 .
17. Mackay DC , Summerton DJ , Walker AJ . e early morbidity of
varicose vein surgery , JR Nav Med Serv. 1995 . 81 : 42–46 .
18. Barwell JR , Davies CE , Deacon J , etal. Comparison of surgery and
compression with compression alone in chronic venous ulceration
(ESCHAR study): Randomized controlled trial , Lancet. 2004 .
363 : 1854–1859 .
19. Hamel-Desnos C , Desnos P , Wollmann JC , Ouvry P , Mako S , Allaert
FA . Evaluation of the e cacy of Polidocanol in the form of foam
compared with liquid form in sclerotherapy of the greater saphenous
vein:Initial results, Dermatol Surg. 2003 . 29 : 1170–1175 .
20. Lurie F , Creton D , Eklof B , etal. Prospective randomized study of
endovenous radiofrequency obliteration (closure procedure) versus
ligation and stripping in a selected population (EVOLVeS Study), J
Vasc Surg. 2003 . 38 : 207–214 .
21. Subramonia S , Lees T . Randomized clinical trial of radiofrequency
ablation or conventional high ligation and stripping for saphenous
varicose veins , Br J Surg. 2010. 97 (3):328–336.
22. Puggioni A , Lurie F , Kistner RL , Eklof B . How o en is deep venous
re ux eliminated a er saphenous vein ablation, J Vasc Surg. 2003 .
38 : 517–521 .
23. Padberg FT Jr, Pappas PJ , Araki CT , ompson PN , Hobson RW
2nd. Hemodynamic and clinical improvement a er super cial vein
ablation in primary combined venous insu ciency with ulceration ,
J Vasc Surg. 1996 . 24 : 711–718 .
24. Marston WA , Brabham VW , Mendes R , Berndt D , Weiner M ,
K e a g y B A . e importance of deep venous re ux velocity as a determinant of outcome in patients with combined super cial and deep
venous re ux treated with endovenous saphenous ablation , J Vasc
Surg. 2008 . 48 : 400–406 .
25. Stuart WP , Asam DJ , Bradbury AW , Ruckley CV . Subfascial
endoscopic perforator surgery is associated with signi cantly less
morbidity and shorter hospital stay than open operation (Linton’s
procedure), Br J Surg. 1997 . 84 : 1364–1365 .
26. Pierik EGJ M, van Urk H , Hop WCJ , Wittens CHA . Endoscopic
versus open subfascial division of incompetent perforating veins in
the treatment of venous leg ulceration:Arandomized trial , J Vasc
Surg. 1997 . 26 : 1049–1054 .
27. Iafrati MD , Pare GJ , O’ Donnell TF , Estes J . Is the nihilistic approach
to surgical reduction of super cial and perforator vein incompetence for venous ulcer justi ed?, J Vasc Surg. 2002 . 36 : 1167–1174 .
28. Tawes RL , Barron ML , Coello AA , Joyce DH , Kolvenbach R .
Optimal therapy for advanced chronic venous insu ciency ,
Surg. 2003 . 37 : 545–551 .
29. Mendes RR , Marston WA , Farber MA , Keagy BA . Treatment
of super cial and perforator venous incompetence without deep
venous insu ciency:Is routine perforator ligation necessary?, J Vasc
Surg. 2003 . 38 : 891–895 .
30. Delis KT , Husmann M , Kalodiki E , Wolfe JH , Nicolaides AN . In
situ hemodynamics of perforating veins in chronic venous insu ciency , J Vasc Surg. 2001 . 33 : 773–782 .
J Vasc
450 • CHRONIC VENOUS INSUFFICIENCY
53.
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SUBFASCIAL ENDOSCOPIC PERFORATOR
VEIN SURGERY SEPS FOR CHRONIC VENOUS
INSUFFICIENCY
Peter Gloviczki , Manju Kalra , and Alessandra Puggioni
urgical interruption of incompetent perforating
veins was rst suggested by Linton in 1938
S
patients with venous ulcers. e rationale for ligating incompetent perforators was to decrease ambulatory
venous hypertension in patients with advanced venous disease by decreasing abnormal transmission of pressure from
the deep to the super cial veins. Linton’s original operation,
that required a long skin incision, resulted in a high rate
of wound complications. Subsequently proposed operations using shorter skin incisions were either incomplete or,
similar to Linton’s operation, resulted in frequent wound
complications. Subfascial endoscopic perforator vein surgery (SEPS) was developed to replace the open techniques
and it became instantly popular because of the minimally
invasive nature of the procedure combined with a lesser rate
of wound complications. SEPS has been an e ective, minimally invasive technique to interrupt incompetent medial
perforating veins of the leg.
SURGICAL TECHNIQUE
SEPS was rst performed in Germany by Hauer in 1985,
who used a simple one-port endoscopic instrument to interrupt perforating veins.
been developed.
e rst has been a perfection of the original technique
of Hauer, by Fischer,
Bergan and colleagues,
It uses a single scope with channels for both the camera and
working instruments (see Figure 53.1). Improvement in
instrumentation for this technique resulted in using carbon
dioxide insu ation through the single working channel to
in ate and enlarge the subfascialspace.
e second technique of SEPS uses instrumentation from laparoscopic surgery, and it was introduced by
2–25
2
Two main techniques for SEPS have
3,5,14
with further development by
9,11,18
and Wittens and Pierik.
1
to treat
7,13,20,25
23
O’Donnell.
this technique simultaneously by Conrad in Australia
by our group at the Mayo Clinic.
nique employs one port for the camera and a separate port
for instrumentation, thereby making it easier to work in the
subfascial space. e 5-mm port is placed more posterior,
halfway between the main port and the ankle. First the limb
is exsanguinated with an Esmarque bandage and a thigh
tourniquet is in ated to 300mmHg to provide a bloodless
eld. A10-mm endoscopic port next is placed in the medial
aspect of the calf 10cm distal to the tibial tuberosity, proximal to the diseased skin (see Figure53.2). Aballoon dissector is used to widen the subfascial space and facilitate access
a er port placement. e distal 5-mm port is placed halfway between the rst port and the ankle (about 10–12cm
apart), under direct visualization with the camera. Carbon
dioxide is insu ated into the subfascial space and pressure
is maintained around 30mmHg to improve visualization
and access to the perforators. Using laparoscopic scissors
inserted through the second port, the remaining loose connective tissue between the calf muscles and the super cial
fascia is sharply divided.
e subfascial space is then explored from the medial
border of the tibia to the posterior midline, down to the
level of the ankle, and up to the level of the 10-mm port. All
direct and indirect perforators encountered are occluded
and divided with a harmonic scalpel or electrocautery,
or the vein is cut with scissors between clips. Aparatibial
fasciotomy next is made by incising the fascia of the posterior deep compartment, close to the tibia, to avoid injury
to the posterior tibial vessels and the tibial nerve. e
posterior tibial perforators (Cockett II and Cockett III)
are frequently located within an intermuscular septum, or
frankly, in the deep posterior compartment, behind the
paratibial fascia (see Figure 53.3). is has to be incised
before identi cation and division of the perforators can be
Carbon dioxide insu ation was added to
8,15,21
e two-port tech-
6
and
451
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Figure53.1 Olympus endoscope for the subfascial perforating vein
interruption. e scope can be used with or without carbon dioxide
insu ation. It has an 85-degree angle eld of view, and the outer sheath
is either 16 or 22mm in diameter. e working channel is 6× 8.5mm,
with a working length of 20cm.
39
accomplished. e medial insertion of the soleus muscle on
the tibia may also have to be exposed to visualize proximal
paratibial perforators. e paratibial fasciotomy can aid in
distal exposure, but reaching retromalleolar Cockett Iperforator endoscopically is usually not possible, and if incompetent, may require a separate small incision over it to gain
direct exposure.
A er completion of the endoscopic portion of the pro-
cedure the instruments and ports are removed, the CO
is
2
manually expressed from the limb. Twenty ml of 0.5% marcain solution is instilled into the subfascial space for postoperative pain control. e tourniquet can be le in ated
during the time stab avulsion of varicosities is performed
on the foot, ankle, or calf. A er de ating the tourniquet,
Lower posterior
tibial perforator
Great saphenous vein
Paratibial
perforator
Posterior accessory
great saphenous vein
Figure53.3 e anatomy of the medial perforating veins of the
leg. PTVs=posterior tibial veins, SPC=super cial posterior
compartment
Middle posterior
tibial perforator
40
SPC
Upper posterior
tibial perforator
laser or radiofrequency ablation or, occasionally, high ligation and stripping of the great or small saphenous vein, if
incompetent, is performed. All stab wounds and the area
surrounding the saphenous vein is in ltrated with tumescent diluted anesthetic solution. e port sites are closed
in two layers with dissolvable sutures, the stab wounds
are closed with paper tapes, and the limb is wrapped with
an elastic bandage. Asingle dose of low molecular weight
heparin is given subcutaneously during the procedure to
decrease the risk of perioperative deep vein thrombosis.
Elevation is maintained at 30 degrees postoperatively for
3h, a er which ambulation is permitted. SEPS is an outpatient procedure, and patients are discharged the same
day or within 24 hours following overnight observation. In
the long term they are instructed to use a rm compression
(30 to 40mmHg) elastic garment.
Figure53.2 Two-port technique of SEPS. One 10-mm port (A)for the
camera and a 5-mm port (B)for instrumentation are inserted. Carbon
dioxide is insu ated into the subfascial space (C), and pressure is
maintained around 30mmHg. All perforators encountered are divided
with the harmonic scalpel (D). Note the thigh tourniquet (E)and the
leg holder (F)to facilitate the operation.
Experience with SEPS continues to grow, and results from
several centers are summarized in Table53.1. e safety and
e cacy of SEPS has been established in the North American
SEPS Registry
In a randomized trial SEPS had a lower wound complication rate (0%) than traditional open surgical techniques
(53%) at 21months a er surgery.
e North American SEPS (NASEPS) registry compiled data from 146 patients, 101 of whom had active ulcers
(C6) at the time of operation (see Figures53.4 and 53.5).
Wound complication rate was 6%, and one deep venous
thrombosis occurred at 2months a er surgery. e midterm
(24months) results of the NASEPS registry demonstrated
an 88% cumulative ulcer healing rate at 1year. e median
time to ulcer healing was 54days. Cumulative rate of ulcer
38
452 • CHRONIC VENOUS INSUFFICIENCY
recurrence was signi cant: 16% at 1 year, 28% at 2years,
RESULTS OFSEPS
17,24
and in nonrandomized case series.
25
2–16,18–23
17,24
Table53.1 PUBLISHED RESULTS OF SUBFASCIAL ENDOSCOPIC PERFORATOR VEIN SURGERY SEPS*
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FIRST AUTHOR,
YEAR
Jugenheimer and
Jung inger
Pierik etal.
Bergan etal.
Rhodes etal.
4
1992
29
1995 40 40 16 10 0 0 0 3 100 1 46
9
1996 31 25 15 100 2 2 0 6 93 0 NR
30
1998 31 25 12 77 3 2 2 2 100 1 11
Gloviczki etal.
31
Lee etal.
2001 36 19 NR 92 0 0 2 4 89 2 14
Sybrandy etal.
32
Baron etal.
Iafrati etal.
Ciostek etal.
Kalra etal.
Bianchi etal.
2001 45 45 37 40 0 0 0 0 89 0 10
33
2002 51 51 29 55 1 2 0 0 74 7 38
34
2002 146 74 36 90 0 0 19 5 86 11 56
21
2002 103 76 42 72 5 5 4 14 90 21 39
35
2003 74 74 58 77 0 3 0 9 91 4 44
17
20
LIMBS
NO.
103 NR 17 NR 3 6 10 0 94 0 27
1999 146 122 101 60 0 0 10 5 84 26 24
2001 20 20 20 70 0 0 0 0 85 2 46
*From Reference 38, with permission
**CEAP Classes 5and6
Disease Class6
φ Recurrence calculated for Class 5and6
LIMBS
WITH
HISTORY
OF
ULCER
NO.**
LIMBS
WITH
ACTIVE
ULCER
N O.
SAPHENOUS
ABLATION
%
WOUND
DEHISCENCE/
SEROMA
NO.
HEMATOMA
NO.
PAR ES THESIA
NO.
INFECTION/
CELLULITIS/
THROMBOPHLEBITIS
NO.
ULCER
HEA L IN G
%
LIMBS WITH
ULCER
RECURRENCE
NO. 𝞍
MEAN
FOLLOWUP
MONTHS
100
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80
60
%
40
20
Limbs at risk 101 52 34 25 21 15 9 7 5
Figure53.4 Cumulative ulcer healing in 101 patients a er subfascial
endoscopic perforator vein surgery. e 90-day, 1-year, and 1.5-year
healing rates are indicated. e standard error is less than 10% at all time
24
points.
78%
0
0369
Days
88%
Median 54 days
12 15
93%
18
but still compared favorably with results of nonoperative
management. Higher rate of ulcer healing was observed in
those who underwent SEPS with saphenous vein stripping,
compared with limbs that underwent SEPS alone:3- and
12-month cumulative ulcer healing rates of 76% and 100%
versus 45% and 83% ( P < 0.01), respectively.
In a prospective study Nelzen etal. reported on results
19
of 149 SEPS procedures in 138 patients.
Forty- ve percent of limbs had venous ulceration (C6–thirty-six limbs,
C5–thirty-one limbs) and deep venous insu ciency was
present in 7% of limbs. During a median follow-up of
32months, thirty-two of thirty-six ulcers healed, more than
half (19/36) within 1month. ree ulcers recurred, one of
which subsequently healed during follow-up. At a median
follow-up of 7months following surgery, 91% of patients
were satis ed with the results of the operation.
Our results at Mayo Clinic were reported by Kalra etal.
21
One hundred and three consecutive SEPS procedures were
performed over a 7-year period. Venous ulceration a ected
74% of limbs (C6–forty-two limbs, C5–thirty-four limbs),
100
80
60
%
40
20
0
01
Limbs at risk 106 74 63 57 33 22 13
Figure53.5 Cumulative ulcer recurrence in 106 patients of the North
American Registry a er subfascial endoscopic perforator vein surgery
(SEPS). e 1-, 2-, and 3-year recurrence rates are indicated. All class
5 limbs at the time of SEPS and class 6 limbs that subsequently healed
are included. e start point (day 0)for time to recurrence in class 6
patients was the date of initial ulcer healing. e standard error is less
than 10% at all time points.
16%
Years
24
28%
2
39%
3
100
80
60
%
40
20
0
012
72 64 46 34 18 12
Figure53.6 Cumulative ulcer recurrence in seventy-two patients in the
Mayo Clinic series a er subfascial endoscopic perforator vein surgery
(SEPS). e 1-, 3-, and 5-year recurrence rates are indicated. All class
5 limbs at the time of SEPS and class 6 limbs that subsequently healed
are included. e start point (day 0)for time to recurrence in class 6
patients was the date of initial ulcer healing. e standard error is less
than 10% at all time points.
4%
21
20%
34
YearsLimbs at risk
and deep venous incompetence was present in 89% of
limbs. On life-table analysis 30-, 60-, and 90-d cumulative
ulcer healing rates were 41%, 71%, and 80% with a median
time to ulcer healing of 35 d. ese results compare favorably with the 65% ulcer healing rates at 6months, reported
in the ESCHAR study that randomized patients to conservative management versus super cial venous surgery.
Mean follow-up in the SEPS study at Mayo was 3.25years
and 1-, 3-, and 4-year cumulative ulcer recurrence rates were
4%, 20%, and 27% (see Figure53.6).
In the most recent report from the Mayo Clinic,
Puggioni et al. demonstrated excellent healing rates a er
SEPS in patients without previous deep vein thrombo-
27
Eighty-eight SEPS procedures were performed in
sis.
eighty-one patients with active (n=50) or healed (n=38)
ulcers. Median follow-up was 35months. Forty-four ulcers
healed, for a crude ulcer healing rate of 88%. Median time
to ulcer healing was 35days, 90-d and 1-year cumulative
ulcer healing rates were 79% and 88%. All six ulcers that
did not heal by the time of last follow-up had previous deep
vein thrombosis. Ulcer healing in postthrombotic limbs at
1year was 73% versus 100% in primary valvular incompetence (p=0.02). Not surprisingly, healing rates were higher
in those patients who had SEPS with super cial ablation
versus those who had SEPS alone. Also, limbs with femoropopliteal re ux have decreased healing rates. SEPS with
or without ablation of the incompetent super cial system
was e ective in decreasing ulcer recurrence as well. Eighteen
ulcers recurred during follow-up, for an overall crude ulcer
recurrence rate of 18/82 (22%). Freedom from ulcer recurrence at 1, 2, and 3years were 96%, 90%, and 74%. Patients
with primary valvular incompetence did very well, with
freedom from ulcer recurrence at the same time intervals
of 98%, 94%, and 85%, versus rates in postthrombotic syndrome of 90%, 78%, and 50% (p=0.06). Factors associated
with ulcer recurrence were active smoking and a previous
deep venous thrombosis.
27%
5
26
454 • CHRONIC VENOUS INSUFFICIENCY
Hemodynamic improvement a er SEPS was previ-
https://t.me/med1917
ously reported by Rhodes and colleagues used strain-gauge
plethysmography to quantitate calf muscle pump function and venous incompetence before and a er SEPS.
15
e authors observed signi cant improvement in both
calf muscle pump function and venous incompetence in
thirty-one limbs studied within 6 months a er SEPS.
Twenty-four of the thirty-one limbs underwent saphenous stripping in addition to SEPS. Normalization of
venous incompetence occurred in up to 50% of limbs
studied, and this improvement was associated with a
favorable clinical outcome. Although limbs undergoing
SEPS alone had signi cant clinical bene ts, the hemodynamic improvements did not reach statistical signi cance.
is is likely related to both the small number of patients
and the predominance of postthrombotic syndrome in
this subgroup.
Patients with primary valvular incompetence have
better clinical outcome and also signi cantly better
hemodynamic improvement compared with those with
postthrombotic limbs. Proebstle et al., using light re ection rheography before and 8 weeks following SEPS,
showed signi cant improvement in limbs with primary
16
valvular incompetence.
Using foot volumetry, Stacey and
coworkers demonstrated that perforator vein ligation with
ablation of saphenous re ux improved calf muscle pump
function in limbs with primary valvular incompetence,
although the relative expelled volume did not return to
28
normal.
However, no hemodynamic bene t was found in
postthromboticlimbs.
Although the role of SEPS in postthrombotic syndrome
remains controversial, most patients still show marked
symptomatic improvement in disability (pain and swell-
21
ing), when assessed with the venous clinical scores.
Also,
recurrent ulcers are usually smaller, more super cial, and
single more o en than multiple, and heal again easily with
conservative management.
In a meta-analysis of twenty published studies on SEPS,
Tenbrook et al. analyzed the bene ts and risks of surgical
treatment in 1,140 limbs with advanced chronic venous
36
insu ciency.
A er SEPS, with or without super cial
venous ablation, ulcers in 88% of limbs healed. e recurrence rate in 611 limbs was 13% at a mean time of 21months
(see Figure53.7). Risk factors for no healing and recurrent
ulcers included new or recurrent incompetent perforator
veins, postthrombotic syndrome, deep vein obstruction and
ulcers larger than 2cm in diameter. Surgical complications
included wound infection (6%), hematoma (9%), neuralgia (7%), and deep venous thrombosis (1%). Randomized
controlled trials are still needed to de ne the role of SEPS
in the treatment of venous ulcer disease. Unpublished data
of the Dutch randomized trial indicate bene ts of SEPS in
patients with large medial ulcers, in those with recurrent
ulcers, and in patients who undergo the SEPS procedure in
37
expert venous centers.
100
80
60
40
Recurrence (%)
20
0
# Limbs
# Studies
Figure53.7 Cumulative ulcer recurrence a er subfascial endoscopic
perforator surgery (SEPS) in a meta-analysis of 611 limbs with C5 and
C6 disease. Horizontal lines , point estimates; boxes , 95% con dence
intervals; error bars , ranges for individual studies that contributed to
each estimate; class 5 , recurrence in limbs with class 5 disease at SEPS;
class 6 , recurrence in limbs with class 6 disease at SEPS in which ulcers
subsequently healed; combined , recurrence in limbs with class 5 and class
6 disease. Number of limbs and studies in class 5 and class 6 disease do
not total those in the combined group, because not all studies reported
data separately for limbs with class 5 and class 6 disease.
4%
Class 5
144
11
Class 6
391
15
16%16%
Combined
611
18
36
C O N C L U S I O N S
Initial exuberance with SEPS focused much needed attention to chronic venous disease and the underlying venous
anatomy and pathophysiology. Limitations of perforator
ablations alone in treating patients with ulcers were also
soon recognized. Without doubt, SEPS should be combined with ablation of the incompetent super cial system,
performed either as staged or as combined procedures.
Results have been excellent on both ulcer healing and recurrence in primary valvular incompetence without associated
femoropopliteal re ux, but long-term ulcer healing could
not be achieved in half of the operated patients with postthrombotic syndrome. Incompetent perforators are but one
of the contributing factors to ambulatory venous hypertension, and in patients with postthrombotic syndrome and
deep vein occlusion they likely are important out ow channels that should be preserved to assure the collateral venous
circulation. Introduction of less invasive techniques for perforator ablation, such as ultrasound-guided sclerotherapy
or radiofrequency ablation may diminish the role of SEPS
in the future, but results should be compared and analyzed
before we diminish the use of a safe and e ective endoscopic
technique for ablation of the perforatingveins.
R E F E R E N C E S
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SEPS FOR CHRONIC VENOUS INSUFFICIENCY • 455
4. Jugenheimer M , Junginger T . Endoscopic subfascial sectioning of
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24. Gloviczki P , Bergan JJ , Rhodes JM , Canton LG , Harmsen S , Ilstrup
DM . Mid-term results of endoscopic perforator vein interruption
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456 • CHRONIC VENOUS INSUFFICIENCY
54.
https://t.me/med1917
ULTRASOUND GUIDED SCLEROTHERAPY OF
PERFORATING VEINS IN CHRONIC INSUFFICIENCY
Fedor Lurie , Alessandra Puggioni , and Robert L. Kistner
orrection of clinically important hemodynamic
abnormalities, such as re ux and obstruction, is
C
chronic venous disease. Achieving this goal theoretically
should convert the patient into being asymptomatic, eliminate or reverse existing signs, and prevent progression to
more advanced stages of venous disease. Practical challenges
that face the surgeon who will treat a patient with chronic
venous disease include selection of which vein to treat and
which technique to employ.
in the super cial venous system have established a new standard:patients can be treated in the o ce without a need for
general anesthesia, can ambulate immediately a er treatment, have insigni cant postoperative pain, and have almost
no negative impact on quality of life immediately a er
treatment. At the time when venous stripping was the only
choice for patients with saphenous insu ciency, surgical
interruption of perforating veins either by subfascial endoscopic surgery (SEPS) or through small incisions was considered minimally invasive. In a new clinical environment,
invasiveness and wound complication risk of these surgical
techniques exceeds that of treatment of saphenousveins.
option for incompetent perforating veins, ultrasound-guided
sclerotherapy, which combines the precision of surgical
approach with minimal invasiveness of an injection.
e rst description of the perforating veins of the lower
extremities is attributed to J.C. Von Loder, a German anatomist who worked at the end of the eighteenth century.
But it was not until the work of John Homans that the role
of incompetent perforators was postulated, followed by
the major treatment objective in patients with
Recent development of new treatment options for re ux
is chapter presents a review of a nonsurgical treatment
HISTORICAL PERSPECTIVE
development of surgical treatment.
nition of principles for perforator control was formulated
in the 1930s by Robert R.Linton of Boston, and detailed
investigations were performed by Frank Cockett of London,
their modi cations of perforator ligation became a universally accepted component of treatment of chronic venous
disease. In the 1970s, DePalma and Edwards independently
introduced a minimally invasive approach to perforator
treatment addressing the problem of wound complications a er subfascial ligation of incompetent perforators.
Popularization of endoscopy in surgery inspired development of SEPS.
signi cantly decreased with SEPS, but the presence of other
complications, such as deep venous thrombosis (DVT; less
than 1%), super cial thrombophlebitis (3%), and saphenous neuralgia (7%),
of the SEPS procedure and its high cost, stimulated interest
in alternative techniques.
Compression sclerotherapy of incompetent perforating
veins was introduced by Fegan in the 1950s.
esized that, in order for this technique to be e ective, patients
must continuously wear postoperative compressive bandages.
In one of his late publications, in 1979,
e success of injection compression sclerotherapy
depends on the facts: (1) that in the majority of
patients with varicose veins and, in almost all those
with symptoms incompetent perforating veins are
present; and (2)that if these incompetent perforating veins are permanently occluded the super cial
veins, no longer subjected to an abnormal blood
ow, are capable of regaining their normal tone and
1
diameter and the valves in them regain their competence. e aim of the injection technique is to prevent abnormal pressures and retrograde ow from
the deep to the super cial venous system.
3,4
Incidence of wound complications was
5,6
as well as the technical complexity
2
A er the precise de -
7
8
he reported:
He rst hypoth-
457
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