Chapter 158 - Perforator vein incompetence Flashcards
First description of perforator veins
1794 Justus Christian Von Loder
First suggestion that incompetent perforating veins cause venous ulcers
1917 John Homans
Cockett and Dodd on perforator veins
Physiologial basis for the surgical interruption of IPV
Who came up with surgical approach to IPV in distal calf
Linton 1938
procedure since then abandonned
First description of SEPS
Subfascial endoscopic perforating vein surgery
Hauer 1980’s
Gloviczki and Conrad
PAPS procedure
Ultrasound-guided percutaneous ablation of perforating veins
using sclerosing solution or thermal energy
Number of PV in lower extremity on average
60
most/all have valves
Direction of flow of PV in normal situation
From superficial into deep
Dutch ulcer trial key points
1) surgery vs compression in IPV therapy
2) ulcer healing 83 vs 73%
3) ulcer recurrence same in both 22-23%
design of trial not ideal
controversial
Goals for treating IPV
1) normalization of venous hemodynamics
2) prevention of progression of CVD to more advanced stages
3) resolution of symptoms and decrease disease severity
4) prevention of recurrent varicose veins
5) promotion of ulcer healing
6) prevention of recurrent venous ulcer
Direct vs indirect perforators
Direct: superficial to deep
Indirect: venous sinuses of calf muscles
In the fascial oriface, artery in relation to vein is
proximal
International interdisciplinary consensus committee on venous anatomical terminology 6 groups
1) perforator of the foot (venae perforantes pedis)
2) ankle (tarsalis
3) leg (cruris)
4) knee (genus)
5) thigh (femoris)
6) gluteal muscles (glutealis)
Important perforators
1) direct medial calf perforators
2) PT PV from posterior accessory saphenous vein (arch vein) of calf
3) most distal perforator behind medial malleolus
4) 7-9 cm and 10-12cm from medial malleolus are middle and upper PT PV
5) Cockett perforators
6) paratibial direct perforator “24-cm” (18-22cm from medial malleolus)
7) Boyd perforators
8) posterolateral/peroneal perforators: SSV tributaries to peroneal vein
9) Bassi perforators
10) 12 cm perforator (12-14 cm)
11) Dodd perforators
12) Hunterian perforators
Cockett perforators
posterior arch vein to posterior tibial vein
calf
Boyd perforators
GSV and tributaries to tibial or popliteal veins
below knee
Bassi perforators
5-7 cm from lateral aspect of ankle connecting SSV to peroneal
Dodd perforators
GSV in distal thigh to femoral/popliteal
Hunterian perforator
GSV to femoral proximal thigh
Clinical exam for IPV
1) fascial defect palpation
2) retrograde flow during valsalva or cough
sensitivity very poor even with doppler
AVF/SVS guidelines on IPV
1) treat IPV with reflux 0.5 s and diameter > 3.5 mm located adjacent to ulcer (C5, C6)
2) treat pathologic PV in patients with C4
3) Don’t treat C2
4) percutaneous technique better than open
Definition of pathologic PV
Outward flow > 500 ms
Diameter > 3.5 mm
ESCHAR on IPV treatment
No benefit
presence of IPV didn’t increase ulcer recurrence
Open interruption of IPV success rate and recurrence
5% missed
32% recurrence 3 years
SEPS steps
1) 1-2 endoscopic ports after exanguination of limb and leg elevation
2) tournequet to 300 mmHg at thigh
3) CO2 insufflation in subfascial space pressure 30 mmHg
4) manual expression of CO2 at end of procedure
Complication of SEPS
DVT < 1% superficial thrombophlebitis 3% saphenous neuralgia 7% recurrence 28% 2 years Poor effect in post-thrombotic limbs
Shortcomings of SEPS
1) expensive
2) learning curve
3) inability to access IPV from normal PV intraop
Percutaneous ablation of perforating veins (PAPS) key points
1) access perifascial IPV or superficial segment adjoining
2) perforating artery has to be avoided
3) determine success with duplex or by visualizing the artery dilation
4) cannot visualize well if foam sclerotherapy used and need to wait 24 hours
PAPS techniques
1) laser 0.5 cm away from deep system
2) Closure RFS RFA 0.5 cm away from deep system
3) sclerotherapy for diameter 4-7 mm at level of fascia; 1-2 ml used
Contraindication to sclerotherapy PAPS
1) allergy
2) pregnant or lactating
3) VTE
4) arterial occlusive disease
5) vasculitis
Issues with PAPS
1) success is high but recurrence 23% at 17 months
2) hard to determine if recurrence is due to true recurrence or new perforator
3) lack study to compare different modalities
