Trans-Atlantic Debate: Whether Venous Perforator Surgery Reduces Recurrences

Abstract

In the midst of this spirited discussion there is one issue on which our debaters agree, namely the role of incompetent perforator vein (IPV) interruption in promoting venous ulcer healing or preventing recurrence. This is consistent with the Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum, which recommend “treatment of pathologic perforating veins that includes those with outward flow ≥500-ms duration, with a diameter ≥3.5 mm, located beneath healed or open venous ulcer (class C5-C6)”.1Gloviczki P. Comerota A.J. Dalsing M.C. Eklof B.G. Gillespie D.L. Gloviczki M.L. et al.The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.J Vasc Surg. 2011; 53: 2S-48SAbstract Full Text Full Text PDF PubMed Scopus (971) Google Scholar However, the same document does not recommend treatment of IPVs in patients with simple varicose veins (class C2), based on a “moderate” level of evidence. This area of contention has prompted this discussion by the experts, and it is evident that there are several areas of disagreement. In his argument in favor of interruption of IPVs to reduce varicose vein recurrence, Professor Whitely outlines the literature describing an association between IPVs and varicose veins but readily admits that a causal relationship has not been definitely proven as is the case with venous ulcerations. He proposes a common pathophysiology and shared role of IPVs between venous ulcers and varicose veins that, he argues, would validate IPV surgery with varicose veins as it does with venous ulcers. Interruption of IPVs is possible with a high degree of success (>80%) with increasingly less invasive techniques, including those pioneered by Professor Whitely, but is it necessary? He argues that it is necessary and is supported by “overwhelming circumstantial evidence”. Dr. O'Donnell counters with the argument that venous stasis ulcers and varicose veins do not share a common pathophysiology, and IPVs are not the major cause of recurrent varicosities, which are a result of the natural history of the disease itself, irrespective of IPV status. Regardless, he argues, IPV surgery is not as successful as its proponents claim, with missed veins and less than optimal durability. This leaves us without a definitive answer. Whereas the role for perforator vein surgery in advanced venous disease, or venous ulcers, seems clear, it remains less so with lesser degrees of disease or varicose veins. Although IPV surgery can be done with some success via less invasive techniques the question remains as to whether it has any value in decreasing the risk of recurrent varicosities. The current level of evidence does not support its routine use in C2 disease and we should await further evidence prior to recommending its wider adoption.