Subfascial endoscopic perforator vein surgery: who benefits?

The advent of minimally invasive endoscopic surgery has rekindled interest in perforator vein ligation. Subfascial endoscopic perforator vein surgery (SEPS) utilizes techniques to interrupt incompetent perforators under direct vision using an endoscopic videocamera and instrumentation placed through small ports remote from the active ulcer or area of diseased skin. The safety and early efficacy of SEPS has been established in several studies, and it yields lower wound complication rates than observed with open surgical techniques such as the Linton procedure. Available results confirm the superiority of SEPS over open perforator ligation, but do not address the its role in the surgical treatment of advanced chronic venous insufficiency (CVI) and venous ulceration. Ablation of superficial reflux by high ligation and stripping of the greater saphenous vein with avulsion of branch varicosities is concomitantly performed in the majority of patients undergoing SEPS. The clinical and hemodynamic improvements attributable to SEPS thus are difficult to ascertain. As with open perforator ligation, clinical and hemodynamic results are better in patients with primary valvular incompetence (PVI) than in those with the postthrombotic (PT) syndrome. Until prospective, randomized, multicenter clinical trials are carried out to answer lingering questions regarding the efficacy of SEPS, the procedure is recommended in patients with advanced CVI secondary to PVI of superficial and perforating veins, with or without deep venous incompetence. The performance of SEPS in patients with PT syndrome remains controversial.