Open Surgical, Endoscopic, and Endovascular Treatment of Perforating Veins Thomas F. O’Donnell, Jr. Treatment of incompetent perforating veins (ICPVs) has evolved through numerous approaches, each holding the promise of being less invasive and as a result associated with reduced morbidity. The goal of ablating ICPVs, however, has not changed. The interruption of ICPVs has been based on the theory that the transmission of deleterious high pressure from the deep venous system through incompetent calf perforating veins contributes significantly to marked superficial venous hypertension, particularly in the subdermal venous plexus of patients with advanced chronic venous insufficiency. The rationale for treating ICPVs has been based on numerous clinical series, whose study design has been observational and, in many instances, subject to multiple sources of design bias. Anatomy and Function of Perforators Perforating veins are distributed throughout the lower extremity. The most clinically relevant ones are found in the calf and the foot. Perforating veins in the calf contain a bicuspid valve, usually located at the subfascial level, that allows blood to flow in one direction from the superficial veins to the deep veins. Pathologic flow in the calf perforating veins is considered outward flow. An important anatomic consideration in calf perforating veins is that below the fascia they usually form one trunk, but above the fascia they arborize into a variable number of branches. In the upper part of the calf, perforating veins pass through the intramuscular septum located between the flexor digitorum longus and soleus and in addition traverse the lamina profunda of the deep fascia of the deep posterior compartment of the leg. Perforating veins have been classified as direct, which connect superficial to deep axial veins, and indirect, which connect superficial veins to muscular veins. The nomenclature of the medial perforating veins had been based on Cockett’s original descriptions. New Nomenclature Under the auspices of the 14th World Congress of the International Union of Phlebology (IUP), Caggiati headed a committee to meet the “need for revision and extension of the official terminologia anatomica with regard to the veins of the lower limb.” The relevant perforators were classified topographically and divided into foot, ankle, and leg perforators. The leg (calf) perforators, which were customarily described by the eponym Cockett perforators, become the medial perforators. These are subdivided into the paratibial perforators, which connect the main trunk of the greater saphenous vein (GSV) or its tributaries with the posterior tibial veins, and posterior tibial perforators, which connect the posterior accessory GSV with the posterior tibial veins. The posterior tibial perforators are defined further topographically as the upper, middle, and lower perforating veins, similar to Cockett’s original description. Common Sites of Perforating Veins Several studies, including those by the author’s group, examined the location ICPVs as observed directly at surgery. ICPVs were located 45% of the time in an area 10 to 15 cm above the medial malleolus, the typical Cockett ⅔ area. Pathophysiology Before the availability of duplex ultrasound, ambulatory venous pressure was the major method for detailing the pathophysiologic changes in advanced chronic venous insufficiency. In his early articles, Linton clearly showed outflow through dilated ICPVs on the inner side of the lower leg. He theorized that the deleterious high ambulatory deep venous pressure was transmitted through these ICPVs to the superficial venous system. With colleagues at St. Thomas’ Hospital, the author carried out a series of clinical studies on 109 legs in 77 patients and 30 healthy volunteers. This clinical investigation detailed how pathology of the great saphenous vein (GSV) or ICPVs in combination or alone affect ambulatory venous pressure patterns and the pathophysiology of chronic venous insufficiency. The percentage drop in superficial venous pressure with exercise (% VP DEC) was used as a method for assessing hemodynamic function. We observed the following in patients after treatment. Ligation and stripping of the GSV alone improved %VP DEC to near normal. Combining subfascial ligation of ICPVs with ligation and stripping in the group with both GSV and ICPV incompetence did not improve the % VP DEC under that observed in the ligation and stripping alone group. Ablation of ICPVs alone in a limb with a normal deep system had minimal improvement in % VP DEC. Ablation of ICPVs in a limb with deep venous reflux resulted in no significant improvement in % VP DEC. These findings were similar to findings in several other hemodynamic studies, which showed little hemodynamic improvement when ICPVs alone were treated. The greatest hemodynamic improvement was observed with GSV ablation. Although these hemodynamic studies employed surrogate endpoints, they question the role of perforator ablation as a form of treatment when GSV or deep venous reflux is present. Diagnosis of Perforator Incompetence The duplex criteria for determining whether a perforating vein is incompetent is essential in selecting patients for possible ablation of ICPVs, but the criteria for incompetence appear variable. Although some physicians employ a simple qualitative color-flow demonstration of outward flow in the perforating vein for the diagnosis of incompetence, most use either duration of outward flow or a pathologic increase in diameter, or a combination of both, to establish the diagnosis of incompetence. An outward flow that exceeds 0.5 seconds is the general criterion for incompetence. Using the gold standard of outward flow (bleed back) from a divided perforating vein, Yamamoto’s group examined the diagnostic criteria of both reflux time and diameter for incompetence. A criterion of a reflux greater than 0.5 seconds was associated with a sensitivity of 87.7% and specificity of 75.3%. True ICPVs had a diameter of 3.5 ± 0.94 mms, and true competent perforating veins had a diameter of 2.6 ± 0.91 mm. Other investigators have validated these findings. These observations show how critical the values are for declaring a perforator incompetent. If the diagnostic criteria are strict, fewer perforators appear incompetent. Alternatively, if the criterion is more liberal or several criteria are used to declare incompetence, more perforators may be declared incompetent. Clinical Outcomes Following Perforator Ablation Determining the Role of and Indication for Ablation Traditionally, ICPV ablation is employed for reducing superficial venous hypertension in limbs rated C5/6 in the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification and thereby healing or preventing recurrence of venous ulcers. Preventing the recurrence of varicose veins by ICPV ablation in limbs rated C2 or C3, however, has no proven benefit and generally is not a recognized indication. The author published two recent systematic analyses on subfascial endoscopic perforator surgery (SEPS) and superficial venous surgery for C5 and C6 chronic venous insufficiency and on direct percutaneous thermal ablation of ICPVs, which assessed the safety and efficacy of ICPV ablation. These reviews demonstrated that there is no current evidence derived from properly done randomized, controlled trials to prove that ablating ICPVs is of conclusive value in the management of venous ulcers A systematic approach to determining the strength of this choice helps to reduce biases inherent in any study or an analysis of a group of studies. SEPS has the largest number of studies that can be analyzed and has been the index procedure to determine the value of ablating ICPVs. ICPV ablation alone should improve the chance of healing a venous ulcer and preventing ulcer recurrence. These results should be superior to an alternative treatment, such as compression and wound care or GSV ablation. Effect of Interrupting ICPVs on Ulcer Healing and Recurrence The Dutch ulcer trial conducted in 12 centers has been the only randomized clinical trial to directly examine the role of ICPV ablation in a large population of patients with venous ulcers. Two hundred patients with CEAP category C6 limbs (open ulcer) were randomized into either treatment with elastic compression alone or SEPS (±GSV treatment) with elastic compression. The ulcer-free period was employed as the primary outcome, and secondary endpoints included ulcer healing, ulcer recurrence, quality of life, and cost-effectiveness. Over a median study follow-up length of nearly 2 years, the ulcer-free period was comparable between the SEPS group (72%) and the compression group (53%), as were ulcer recurrence and ulcer healing. A post-hoc analysis with its known limitations, however, identified certain factors in favor of the SEPS arm for ulcer-free survival: recurrent ulcer, medially located ulcer, and surgery carried out in a specialized center. Unfortunately, this trial had two problems: Concomitant treatment of the GSV along with SEPS in 54% of the limbs confounded whether the clinical results were because of treatment of the GSV, the CPVs, or both, and 65% of the patients were treated at one of the 12 centers, which can be a common source of bias in surgical trials where the surgical learning curve for a specialized technique may be shorter and results better at a high-volume center, even if the surgical and comparator groups are randomized within that center. The secondary outcomes, such as ulcer healing (compression group, 73%; surgical group, 83%) and ulcer recurrence were similar for the two groups. Finally, a subsequent presentation by the investigators showed a relatively high number of “missed” (untreated) ICPVs on postoperative follow-up duplex scans, and this would appear to greatly influence results. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join Tags: Current Therapy in Vascular and Endovascular Surgery Aug 25, 2016 | Posted by admin in CARDIOLOGY | Comments Off on Open Surgical, Endoscopic, and Endovascular Treatment of Perforating Veins Full access? 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Open Surgical, Endoscopic, and Endovascular Treatment of Perforating Veins Thomas F. O’Donnell, Jr. Treatment of incompetent perforating veins (ICPVs) has evolved through numerous approaches, each holding the promise of being less invasive and as a result associated with reduced morbidity. The goal of ablating ICPVs, however, has not changed. The interruption of ICPVs has been based on the theory that the transmission of deleterious high pressure from the deep venous system through incompetent calf perforating veins contributes significantly to marked superficial venous hypertension, particularly in the subdermal venous plexus of patients with advanced chronic venous insufficiency. The rationale for treating ICPVs has been based on numerous clinical series, whose study design has been observational and, in many instances, subject to multiple sources of design bias. Anatomy and Function of Perforators Perforating veins are distributed throughout the lower extremity. The most clinically relevant ones are found in the calf and the foot. Perforating veins in the calf contain a bicuspid valve, usually located at the subfascial level, that allows blood to flow in one direction from the superficial veins to the deep veins. Pathologic flow in the calf perforating veins is considered outward flow. An important anatomic consideration in calf perforating veins is that below the fascia they usually form one trunk, but above the fascia they arborize into a variable number of branches. In the upper part of the calf, perforating veins pass through the intramuscular septum located between the flexor digitorum longus and soleus and in addition traverse the lamina profunda of the deep fascia of the deep posterior compartment of the leg. Perforating veins have been classified as direct, which connect superficial to deep axial veins, and indirect, which connect superficial veins to muscular veins. The nomenclature of the medial perforating veins had been based on Cockett’s original descriptions. New Nomenclature Under the auspices of the 14th World Congress of the International Union of Phlebology (IUP), Caggiati headed a committee to meet the “need for revision and extension of the official terminologia anatomica with regard to the veins of the lower limb.” The relevant perforators were classified topographically and divided into foot, ankle, and leg perforators. The leg (calf) perforators, which were customarily described by the eponym Cockett perforators, become the medial perforators. These are subdivided into the paratibial perforators, which connect the main trunk of the greater saphenous vein (GSV) or its tributaries with the posterior tibial veins, and posterior tibial perforators, which connect the posterior accessory GSV with the posterior tibial veins. The posterior tibial perforators are defined further topographically as the upper, middle, and lower perforating veins, similar to Cockett’s original description. Common Sites of Perforating Veins Several studies, including those by the author’s group, examined the location ICPVs as observed directly at surgery. ICPVs were located 45% of the time in an area 10 to 15 cm above the medial malleolus, the typical Cockett ⅔ area. Pathophysiology Before the availability of duplex ultrasound, ambulatory venous pressure was the major method for detailing the pathophysiologic changes in advanced chronic venous insufficiency. In his early articles, Linton clearly showed outflow through dilated ICPVs on the inner side of the lower leg. He theorized that the deleterious high ambulatory deep venous pressure was transmitted through these ICPVs to the superficial venous system. With colleagues at St. Thomas’ Hospital, the author carried out a series of clinical studies on 109 legs in 77 patients and 30 healthy volunteers. This clinical investigation detailed how pathology of the great saphenous vein (GSV) or ICPVs in combination or alone affect ambulatory venous pressure patterns and the pathophysiology of chronic venous insufficiency. The percentage drop in superficial venous pressure with exercise (% VP DEC) was used as a method for assessing hemodynamic function. We observed the following in patients after treatment. Ligation and stripping of the GSV alone improved %VP DEC to near normal. Combining subfascial ligation of ICPVs with ligation and stripping in the group with both GSV and ICPV incompetence did not improve the % VP DEC under that observed in the ligation and stripping alone group. Ablation of ICPVs alone in a limb with a normal deep system had minimal improvement in % VP DEC. Ablation of ICPVs in a limb with deep venous reflux resulted in no significant improvement in % VP DEC. These findings were similar to findings in several other hemodynamic studies, which showed little hemodynamic improvement when ICPVs alone were treated. The greatest hemodynamic improvement was observed with GSV ablation. Although these hemodynamic studies employed surrogate endpoints, they question the role of perforator ablation as a form of treatment when GSV or deep venous reflux is present. Diagnosis of Perforator Incompetence The duplex criteria for determining whether a perforating vein is incompetent is essential in selecting patients for possible ablation of ICPVs, but the criteria for incompetence appear variable. Although some physicians employ a simple qualitative color-flow demonstration of outward flow in the perforating vein for the diagnosis of incompetence, most use either duration of outward flow or a pathologic increase in diameter, or a combination of both, to establish the diagnosis of incompetence. An outward flow that exceeds 0.5 seconds is the general criterion for incompetence. Using the gold standard of outward flow (bleed back) from a divided perforating vein, Yamamoto’s group examined the diagnostic criteria of both reflux time and diameter for incompetence. A criterion of a reflux greater than 0.5 seconds was associated with a sensitivity of 87.7% and specificity of 75.3%. True ICPVs had a diameter of 3.5 ± 0.94 mms, and true competent perforating veins had a diameter of 2.6 ± 0.91 mm. Other investigators have validated these findings. These observations show how critical the values are for declaring a perforator incompetent. If the diagnostic criteria are strict, fewer perforators appear incompetent. Alternatively, if the criterion is more liberal or several criteria are used to declare incompetence, more perforators may be declared incompetent. Clinical Outcomes Following Perforator Ablation Determining the Role of and Indication for Ablation Traditionally, ICPV ablation is employed for reducing superficial venous hypertension in limbs rated C5/6 in the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification and thereby healing or preventing recurrence of venous ulcers. Preventing the recurrence of varicose veins by ICPV ablation in limbs rated C2 or C3, however, has no proven benefit and generally is not a recognized indication. The author published two recent systematic analyses on subfascial endoscopic perforator surgery (SEPS) and superficial venous surgery for C5 and C6 chronic venous insufficiency and on direct percutaneous thermal ablation of ICPVs, which assessed the safety and efficacy of ICPV ablation. These reviews demonstrated that there is no current evidence derived from properly done randomized, controlled trials to prove that ablating ICPVs is of conclusive value in the management of venous ulcers A systematic approach to determining the strength of this choice helps to reduce biases inherent in any study or an analysis of a group of studies. SEPS has the largest number of studies that can be analyzed and has been the index procedure to determine the value of ablating ICPVs. ICPV ablation alone should improve the chance of healing a venous ulcer and preventing ulcer recurrence. These results should be superior to an alternative treatment, such as compression and wound care or GSV ablation. Effect of Interrupting ICPVs on Ulcer Healing and Recurrence The Dutch ulcer trial conducted in 12 centers has been the only randomized clinical trial to directly examine the role of ICPV ablation in a large population of patients with venous ulcers. Two hundred patients with CEAP category C6 limbs (open ulcer) were randomized into either treatment with elastic compression alone or SEPS (±GSV treatment) with elastic compression. The ulcer-free period was employed as the primary outcome, and secondary endpoints included ulcer healing, ulcer recurrence, quality of life, and cost-effectiveness. Over a median study follow-up length of nearly 2 years, the ulcer-free period was comparable between the SEPS group (72%) and the compression group (53%), as were ulcer recurrence and ulcer healing. A post-hoc analysis with its known limitations, however, identified certain factors in favor of the SEPS arm for ulcer-free survival: recurrent ulcer, medially located ulcer, and surgery carried out in a specialized center. Unfortunately, this trial had two problems: Concomitant treatment of the GSV along with SEPS in 54% of the limbs confounded whether the clinical results were because of treatment of the GSV, the CPVs, or both, and 65% of the patients were treated at one of the 12 centers, which can be a common source of bias in surgical trials where the surgical learning curve for a specialized technique may be shorter and results better at a high-volume center, even if the surgical and comparator groups are randomized within that center. The secondary outcomes, such as ulcer healing (compression group, 73%; surgical group, 83%) and ulcer recurrence were similar for the two groups. Finally, a subsequent presentation by the investigators showed a relatively high number of “missed” (untreated) ICPVs on postoperative follow-up duplex scans, and this would appear to greatly influence results. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join Tags: Current Therapy in Vascular and Endovascular Surgery Aug 25, 2016 | Posted by admin in CARDIOLOGY | Comments Off on Open Surgical, Endoscopic, and Endovascular Treatment of Perforating Veins Full access? 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