The role of perforators in chronic venous insufficiency

The treatment of incompetent calf perforating veins (ICPVs) has been ascribed an important role in the therapeutic strategy for reducing superficial venous hypertension in patients with advanced chronic venous insufficiency (C4-C6). Since the open approach to ligation of ICPVs was developed by Linton over 70 years ago, there has been an evolution toward less invasive techniques with lower morbidity. This paper will review the evidence for interruption of ICPVs through a series of systematic analyses of (1) subfascial endoscopic perforating surgery (SEPS) and (2) percutaneous thermal ablation techniques (PAPS). The effectiveness and morbidity of each approach will be discussed as well as the strength of evidence supporting that technique. While there are numerous case series that suggest that SEPS is beneficial for ulcer healing and for the prevention of ulcer recurrence, the sole two RCTs that have compared either open division or SEPS for ICPVs have failed to show a statistical advantage for ICPV ablation. The results of these studies are clouded by the inclusion of patients who received concomitant treatment of their great saphenous vein (GSV). The evidence for PAPS is based on a few (n = 5) case series in peer-reviewed journals, which are limited by small patient populations, limited follow-up, and a focus on surrogate outcomes (occlusion of the perforator) rather than clinical or functional outcomes. Moreover, most of these series were carried out in patients with mild disease. Sclerotherapy of ICPVs, by either liquid or foam, shows promise, but requires greater evidence. Our current approach for limbs with C4-C6 disease is to treat the GSV first and limit treatment of ICPVs to those with high volume flow and large-diameter ICPVs. [corrected]