Surgery of the perforating veins

The perforating veins supply blood through the muscular aponeurosis to the superficial and deep venous systems. These veins are numerous, from 80 to 140 per leg, their diameters not exceeding 2 mm. The valves are normally in the sub-aponeurotic area.The best way of identifying incompetent perforating veins in the leg is still undecided. Echo-Doppler scans seem the most reliable, though the examination procedure is still debated. A reflux is defined as pathological if it lasts more than 1 s and the caliber of the perforating vein is more than 2 mm.

The severity of the CVI in relation to incompetent perforating veins is based on the number of perforating veins involved and whether more than one system is affected.

Elimination of the incompetent perforating veins in combination with drainage of the varicose veins and restoration of the saphenous return in patients with severe CVI is an important therapeutic approach for trophic disorders of the skin.117.118

The indication for surgical treatment is elective in patients with incompetent perforating veins of the leg and active or healed ulcers (CEAP classes C5-C6). Treatment of perforating veins due to superficial vein inadequacies is reserved for cases with symptomatic cutaneous dystrophy (CEAP class C4).

There are 2 main surgical procedures for perforating veins:

- the traditional supra and subfascial approach;

- subfascial, by endoscopy.

The traditional methods (according to Linton, Cockett, Felder, De Palma) give broadly similar results, with 9-16.7% of patients having recurring ulcers when followed up for 5-10 years. The more recent endoscopic approach for perforating veins may employ a single access (1 trochar) or 2 (operating and optical trochars). A number of studies report 0-10% of recurrent ulcers at five-year follow-up.

Endoscopic surgery is often combined with high ligation and saphenous strippingI and the percentage of relapsing ulcers at 5 years seems similar. However, in one multicentre trial comparing endoscopic surgery alone with endoscopy plus superficial venous stripping and high ligation the proportion of relapsing ulcers at 2 years was smaller in the combination group.

Since it is less invasive, involves fewer postoperative complications, and permits access far from the ulcer itself, the endoscopic technique is currently preferred to traditional surgery for perforating veins.

Recommendations

In patients with post-thrombotic syndrome it is important to treat the incompetent perforating veins, with sclerotherapy, traditional surgical techniques or endoscopy. Grade B For varicose veins with no specific cause it is essential to distinguish the hemodynamic role of the perforating veins of the thigh (Dodd perforating veins) and the Boyd perforating veins. When these are incompetent they must always be closed or removed. For any other perforating veins in the leg, the clinical aspects and the radiological findings must be taken into account. Grade C