1. What are the perforators?

Varicose veins are abnormally tortuous [dilated, swollen] veins, which are visible just below the skin surface, especially on the erect position. They are always caused by a fault in the one-way valves inside the veins at the point where the superficial veins communicate with the deep veins [which convey all of the blood towards the heart]. If the valve leaks, then blood will flow backwards [reflux, reverse flow] towards the area with low pressure, assisted by gravity on standing. This reverse flow increases pressure in the superficial veins, which, as blood stagnates, become swollen and varicose.

The superficial veins start from the ankle and join the deep system at two sites, in the groin [long saphenous vein] and behind the knee [short saphenous vein].

Furthermore, the deep and superficial systems are interconnected through small veins, like the steps of a ladder, called “perforators” or perforating veins as they pierce the fascia covering the muscles to join the deep veins. They course only a short distance, they vary in number and always have one-way valves.

2. How do the perforators function?

The perforators serve as an alternative route to guide blood into the deep veins, especially with the help of sucking action of the calf muscle pump as the muscles contract and release.

If these perforators are incompetent [quite often because of incompetence of the two major superficial venous systems or deep venous thrombosis], then blood paddles in the lower leg, followed by vein enlargement, pain, swelling and probably hyperpigmentation [skin discoloration].

Long –lasting perforator incompetence has been linked to a severe form of chronic venous insufficiency and venous ulceration.

3. How can perforator incompetence be treated?

·                       Conservative treatment consists in elasticated compression stockings, usually grade 3 [24-28mmHg or 35-44mmHg], in order to reduce fluid stasis on the calf.

·                       Old-fashioned surgery [Cockett’s or Linton’s approach].  Involves a long incision along the medial or posterior aspect of the calf and blind division of the perforators. Has a high chance of haematoma and chronic skin changes and is rarely used today.

·                       Localised subfascial ligation with the help of ultrasound marking. This is probably the technique that causes less damage and discomfort, as in most cases only one or two perforators are incompetent. The sonographer marks the site the perforator junction with the deep veins site just before surgery, directing the surgeon there, who thus uses a small incision [2-3cm]. The perforator is tied under the fascia and the skin is closed. The technique is quite effective and can be employed in any patient with perforator incompetence, without any contraindications. It is also commonly used with the classical surgery for primary veins, in patients who also have localised perforator incompetence.

• Subfascial Endoscopic Perforator Surgery [SEPS]. This is a new technique that uses the camera [endoscopic] and two incisions below the knee. It is usually employed in patients with severe perforator incompetence and skin changes that may make open approach difficult. Subfascial, means under the fibrous tissue [fascia] that covers the muscles.
  • Contraindications. SEPS cannot be used in patients with
    • Arterial disease [blockages in arteries]
    • Infected ulcers [high risk of spreading infection
    • Presence of deep venous thrombosis
    • Lymphoedema or large legs
  • Technique
    The sonographer marks the perforators on the skin with ultrasound help before surgery. A tight tourniquet is applied to the thigh to minimise the bleeding. A cut is made at the upper calf and a special port is inserted under the fascia. Carbon dioxide is blown through the this port to improve visualisation. Another cut is made to insert another instrument to clip the perforators and a scissors to divide them. The wounds are then closed and a bandage is applied. After surgery the leg is elevated for 30 degrees for 3 hours, after which walking is allowed.  The patient goes home either the same day or the next morning. He can start work at 7-10 days.

    Prons & Cons

    ·         It is an expensive method

    ·         Has not shown to be more effective than the localised ligation

    ·         It will still need open surgery to remove the prominent veins

    ·         Has a higher risk of haematoma and/or infection

    ·         May be used in conjunction with the standard surgery for varicose vein [primary veins that need the main trunk ligation and stripping]

    ·         It is far better with better results than the old fashioned classical technique, and is probably the best in selected cases with severe skin changes.

4. How about the future?

If the ulcers are due only to perforator incompetence, healing may be rapid and 50% heal within 3 months, with 80% healing up to 2 years. However, if there was a previous deep venous problem, the healing rate is only 50%. Recurrence of the ulcer varies from 20-50%.

If the perforator ligation was done in conjunction with primary varicose vein surgery, the result is usually excellent. However,  you should be warned that not every visible vein will disappear after surgery. Occasionally, adjuvant sclerotherapy or avulsions may be performed for these residual veins. There is also a small chance [10% for primary, 20-25% for recurrent or when the vein was not stripped] in the future that further varicose veins may develop.

The taking of regular exercise, modification of your life style, the wear of light support stockings and the avoidance of risk factors and becoming overweight will all help prevent you being troubled by varicose veins in the future.