New approaches to an old and vexing problem: improving the results of SEPS: an overview

Lipodermatosclerosis and chronic ulceration have been longstanding and vexing problems caused by chronic venous insufficiency (CVI). While traditional approaches have been mainly medical with the use of compression, bedrest, and elevation; operative therapy for CVI has now been shown to cause earlier healing with fewer ulcer recurrences. The development of subfascial endoscopic surgery (SEPS) promises a more elegant approach applicable to outpatient or day surgery. However, in a recent trial, early results showed a 22% ulcer recurrence at 30 months, which did not compare favorably with traditional approaches. We have used extrafascial perforator interruption for SEPS recurrence and have now modified our SEPS approach particularly for low-lying ulcers. This overview suggests use of a combination of SEPS with an extrafascial perforator division when skin change relates to retro or submalleolar perforating veins. Several procedures, rather than one intervention may be required in CVI to prevent or divert transmission of venous hypertension to areas of affected skin, including saphenous stripping, staged valveplasty and treatment of iliac occlusions.