Incompetent Perforators Research Articles

Steam Vein Sclerosis for Nonsaphenous varicose veins.

The treatment of nonsaphenous varicose veins (NSVV), including incompetent perforating veins (IPV) and recurrent varicose veins (RVV), remains challenging for many reasons, including vein tortuosity, deep location and short vein to be treated. Data and recommendations are lacking. Steam vein sclerosis (SVS) is an endothermal therapy that has been used in the treatment of incompetent saphenous veins, achieving occlusion rates similar to other thermal ablation techniques with good patient tolerance and minimal postoperative pain. We report here the results of a cohort of SVS used to treat NSVV, including RVV and IPV. From October 2017 to March 2020, consecutive patients presenting with NSVV treated with SVS were included. Patients were followed at 3months with both clinical and duplex scan examinations. The primary endpoint was efficacy defined as target vein occlusion at 3months; secondary endpoints were: safety with analysis of per procedural and 3months complications, evolution of functional stage and symptoms between inclusion and 3months. Ninety-six patients were included in the study. Five patients were lost to follow-up. Fifty-nine percent (n=60) were women. Lesions were recurrent (recurrent varicose vein after surgery) in 61% (n=62). The location of the NSVV was sapheno-femoral residual stump in 8% (n=8), inguinal neovascularization in 14% (n=14), sapheno-popliteal residual stump in 12% (n=12), popliteal neovascularization in 7% (n=7), and IPV in 59% (n=60). Complete occlusion after treatment occurred in 86% (n=83) of patients, partial occlusion in 4% (n=4), and complete recanalization in 10% (n=9). The occlusion rate in the IPV group was 93%. Complications at 30days postoperatively were 2 (2%) deep vein thrombosis, 1 (1%) hematoma, and 2 (2%) late paresthesias in the superficial peroneal nerve area. The use of SVS has been shown to be effective and safe in the short-term treatment of NSVV, including IPV and RVV. Further studies are needed to evaluate its long-term effects.

Healing Evaluation of Varicose Leg Ulcers after Injection Sclerotherapy of Pathological Leg Perforator Veins

Abstract Background Scottish Guideline defined the chronic venous leg ulcer “as an open lesion between the knee and the ankle joint that remains unhealed for at least four weeks and occurs in the presence of venous disease”. Venous Leg Ulcers (VLUs) account for 70% of all leg ulcers and estimates 1% of the population with a prevalence that increases with age according Edinburgh study, which was a cross-sectional study of a random sample. Aim of the Work To evaluate the efficacy of injection sclerotherapy of incompetent perforators in the healing of venous leg ulcers. Patients and Methods This study was conducted on 50 patients with chronic venous leg ulcers that had been presented for at least four weeks ago. To evaluate the clinical efficacy of Duplex-guided foam sclerotherapy with compression therapy in comparison with compression therapy alone, we divided the patients with randomization into two groups. Group A was conservatively managed by four-layer compression bandage and Group B was managed by application of duplex guided injection sclerotherapy and four-layer compression bandage. Results In our study, there is statistically significant positive correlation between duration of ulcer, ulcer surface area and duration to complete healing. On linear regression analysis of factors significantly correlated with duration of complete healing, only ulcer surface area at start of treatment was significantly associated with it (β = 1.031, p < 0.001). Increased ulcer surface area at start of treatment by 1 cm2 increases duration of healing by about 1 week. Conclusion Duplex-guided sclerotherapy is a simple procedure, no hospitalization, no anaesthesia, can be done in outpatient clinic and the patient can return home after 45 min and no work off period. The relative healing period and its evident success, make this the first line treatment for venous ulcer and superior to compression alone.

Duplex Guided Injection Foam Sclerotherapy for Incompetent Perforators Combined with Skin Grafting in Venous Leg Ulcer.

Duplex Guided Injection Foam Sclerotherapy for Incompetent Perforators Combined with Skin Grafting in Venous Leg Ulcer.

Single-center clinical experience of cyanoacrylate embolization method for incompetent perforating veins in treating CEAP-6 patients

ObjectiveThe most severe form of chronic venous insufficiency includes venous leg ulcers in the CEAP-6 stage. The aim of this study is to evaluate the relationship between incompetent perforator veins occluding with cyanoacrylate and closure of perforator veins and healing of venous leg ulcers in patients at the CEAP-6 stage. MethodsA total of 187 patients who underwent cyanoacrylate application to incompetent perforator veins due to venous leg ulcers from 2018 to 2021 were retrospectively reviewed. Twelve months after the procedure, patients were evaluated for perforator vein closure, ulcer diameter, and Venous Clinical Severity Scale. Receiver operating characteristic analysis was used to estimate the probability of postoperative nonocclusion of the perforating vein based on the preoperative ulcers’ diameters and the perforating veins’ mean diameters. Univariate and multivariate binary logistic regression analyses were conducted to identify the risk factors associated with incomplete closure of the perforating vein. ResultsAt the 12 months, 87.1% of patients experienced incompetent perforator veins closure, leading to complete healing of venous leg ulcers. Preoperative ulcer diameter significantly decreased from 7.20 ± 3.48 cm2 to 0.28 ± 0.77 cm2 after the procedure (P < .001). On average, 3.5 ± 1.01 perforating veins were treated, with a diameter of 4.09 ± 0.41 mm. No postoperative paresthesia or deep vein thrombosis occurred. Preoperative Venous Clinical Severity Scale scores decreased significantly from 17.85 ± 3.06 to 8.03 ± 3.53 postoperatively (P < .001). Patients with nonoccluded perforating veins had larger preoperative ulcer diameters (13.77 ± 1.78 cm2) than those with occluded perforating veins (6.24 ± 2.47 cm2; P < .001). The mean perforating vein diameter was also larger in nonoccluded perforating veins patients (4.45 ± 0.41 mm) than in occluded perforating veins patients (4.04 ± 0.38 mm; P < .001). The sensitivity, specificity, and accuracy of the preoperative ulcer diameter cutoff point of 11.25 cm2 for the possibility of postoperative nonocclusion of perforating veins were 100% each. In contrast, those for the preoperative mean perforating vein diameter cutoff point of 4.15 mm were determined as 66.7%, 79.1%, and 77.5%, respectively. The presence of diabetes mellitus increased the likelihood of incompetent perforator veins, remaining open by 3.4 times (95% confidence interval: 1.11-10.44; P = .032), whereas a 1 mm larger mean perforating vein diameter increased this likelihood by 9.36 times (95% confidence interval: 3.47-25.29; P < .001). ConclusionsThis study demonstrates that occlusion of incompetent perforator veins with cyanoacrylate is effective, safe, and associated with low complication rates in CEAP-6 patients. The findings support that cyanoacrylate occlusion of perforator veins may be a valuable option in the treatment of venous leg ulcers.

Редкий вариант варикозной трансформации подкожных вен в подколенной области за счёт несостоятельной перфорантной вены

INTRODUCTION: Localization of varicose-transformed subcutaneous veins in the popliteal space immediately aims both ultrasound diagnostics doctors and surgeons for the pathology of the short saphenous vein. However, this does not always correspond to reality. A rather rare cause of transformation of subcutaneous veins may be an incompetent perforator vein. The article presents a clinical case of varicose transformation of subcutaneous veins of the popliteal region through an incompetent perforator vein. Initially, the patient was diagnosed with the bulge of the subcutaneous veins within the short saphenous vein. Subsequently, during a duplex scan in a specialized department, an incompetent perforator vein of the popliteal region was revealed, which was confirmed intraoperatively. The article also describes the structural features of the perforator vein of this localization. CONCLUSION: An incompetent perforator vein of the popliteal region may be the cause of a false positive diagnosis of varicose transformation in the system of the short saphenous vein. A large arterial branch from the popliteal artery is located next to the perforator vein of the popliteal region at the subaponeurotic level, which requires their separation before resection of the vein.

Factors influencing recurrent varicose vein formation after radiofrequency thermal ablation for truncal reflux performed in two high-volume venous centers

ObjectiveRecanalization of the saphenous vein trunk after endovenous radiofrequency ablation (RFA) is often associated with recurrent varicose veins (RVVs) or recanalization. This study aimed to assess the long-term results of RFA of the great saphenous vein (GSV) and identify the risk factors for GSV recanalization and RVVs during follow-up for patients presenting to dedicated outpatient vein centers. MethodsAll consecutive patients with incompetent GSVs who underwent RFA between 2009 and 2019 were retrospectively analyzed. The primary study end points were freedom from GSV recanalization and the RVV rate during follow-up. The secondary study end points were the postoperative complication rate and the risk factors for GSV recanalization and RVVs. Univariate and multivariate analyses were performed to identify the potential risk factors for GSV recanalization and RVVs. ResultsDuring the study period, 1568 limbs were treated in 1300 consecutive patients (mean age, 53.5 ± 12.9 years; 71.9% women; CEAP [clinical, etiology, anatomy, pathophysiology] C2-C6; venous clinical severity score >5). Technical success was achieved in 99.7% of cases. At a mean follow-up of 57.2 ± 25.4 months, the GSV occlusion and freedom from reintervention rates were 100% and 100% within 1 week, 97% and 95.7% at 1 year, 95.2% and 93.1% at 3 years, and 92.4% and 92.8% at 5 years, respectively. The recurrence rate was 10% (n = 158) during the follow-up period. On multivariate analysis, a direct confluence of the accessory saphenous vein into the saphenofemoral junction (odds ratio [OR], 1.561; 95% confidence interval [CI], 1.0-7.04; P = .032), a history of pregnancy >2 (OR, 3.68; 95% CI, 1.19-11.36; P = .023), C4 (OR, 6.41; 95% CI, 1.36-30.28; P = .019), and preoperative GSV diameter >10 mm (OR, 1.82; 95% CI, 1.65-4.03; P = .043) were risk factors for GSV recanalization. Moreover, age >70 years (OR, 1.04; 95% CI, 1.01-1.06; P = .014) and incompetent perforator veins (OR, 1.17; 95% CI, 0.65-2.03; P = .018) were also risk factors for RVVs. ConclusionsRFA is a safe technique to ablate the GSV with a low complication rate and durability during 5 years of follow-up. However, patients with a high clinical score and those with direct confluence of the accessory saphenous vein into the saphenofemoral junction experienced higher long-term GSV recanalization and RVV rates.

COMPARISON OF FOAM SCLEROTHERAPY AUGMENTED PHLEBECTOMY VERSUS AMBULATORY PHLEBECTOMY IN THE MANAGEMENT OF ISOLATED BELOW KNEE INCOMPETENT PERFORATORS

Background &amp; Objectives:Among the patients who underwent Foam Sclerotherapy Augmented Phlebectomy (FSAP) and Ambulatory Phlebectomy (AP) a) To determine the number(proportion) patient seeking for post operative pain (greater than 3 according to visual analog scale in 1 months of procedure) b) To determine median number of days to resume normal activities c) To assess the healing of venous ulcer using CEAP classification and revised venous clinical severity scoring system. d) To identify any recurrence at the same site of Earlier Phlebectomy (FSAP or AP) using duplex scan after 6 months of procedure Methods: Patients satisfying inclusion criteria are enrolled within 24 hrs of admission afterinformed consent. All the patients with isolated below knee perforator incompetence will be evaluated with through clinical examination, radiological and laboratory investigations. Those who require surgery will be admitted and appropriate surgery will be performed and analyzed for in term of post operative pain, operative time, hospital stay, number of days to resume normal activities, healing of venous ulcer, recurrence. Results: Majority of patients belonged to the age group 41- 50 years. M: F is66% males and 34% females. number of days to resume normal activities by the patient mean days among FASP group 9.4% and AP group is 12.8%Post Procedure VAS pain score in 1 month among study participants mean vas score among Foam Sclerotherapy Augmented Phlebectomy 4.5% and Ambulatory Phlebectomy 5.1%length of hospital study in FSAP group mean 5.1% and in AP group 5.3%, Recurrence among the patients underwent FSAP group 4.7% and in AP group 14.5%. Interpretation &amp; Conclusion:FSAP is associated with less post operative pain, shorter duration pf hospital stays and a quicker recovery, shorter duration of surgery, earlier return to work and not associated with major postoperative complications. There is less recurrence in FSAP compared with AP in the follow up period of six months.

Does Concomitant Truncal and Perforator Surgery Improve Outcomes For Patients With Chronic Venous Disease? Systematic Review and Meta-Analysis

Objective: Incompetent perforator veins (IPVs) are encountered frequently during ultrasound assessment of the venous system in chronic venous disease (CVD). The total number of IPVs increases substantially with the severity.1,2 Some studies have shown that concomitant treatment of truncal and perforator incompetence improves ulcer healing,3,4 yet a Cochrane review was unable to determine the potential benefits of perforator surgery in venous ulcer management due to poor quality evidence.5 This study aims to establish the exact role of concomitant IPV and truncal reflux treatment in patients with CVD.

Outcomes of thermal ablation combined with u/s guided foam sclerotherapy in treatment of superficial venous reflux in patients with postphlebitic venous leg ulcer

Background Venous leg ulcers are a considerable health problem because of their high incidence, slow healing, high recurrence rate, and high cost of treatment. Minimally invasive treatments such as endovenous thermal ablation and foam sclerotherapy proved to be safe and effective. However, there is a paucity in studies focusing on the management of postphlebitic venous ulcers using endovenous thermal ablation of the superficial system in combination with foam sclerotherapy. Objectives The aim of our study was to assess the healing time, procedure-related complications and recurrence rate in patients having a postphlebitic venous leg ulcer after being treated with EVLA associated with ultrasound-guided foam sclerotherapy to incompetent perforators with compression therapy. Subjects and methods This is a prospective observational study, conducted at Ain Shams University Hospitals and Nasser institute hospital in Cairo on 30 patients presented with postphlebitic venous leg ulcers. Results After one year, 90% of cases had a totally healed ulcers, 10% with ulcer decrease in size of more than 50%, and recurrence rate 6.7%. The adverse events of this procedure were DVT (6%), hematoma (6%), ecchymosis (43%), thrombophlebitis (6%), and pain (70%). There was significant improvement of the VCSS as regard pain, edema, inflammation, ulcer size, and number. There was highly significant (P &lt; 0.0001) improvement in the mean (SD) VCSS (preoperative 18 [2.808] vs. postoperative 6.367 [2.3449]). Conclusion Patients with totally recanalized deep venous system post deep venous thrombosis, presenting with nonhealing venous leg ulcers, may benefit from thermal ablation of superficial varicose veins combined with ultrasound-guided foam sclerotherapy. This combined approach is a feasible, safe, and effective modality in terms of improved healing rate, low recurrence rate, low complications, and significant improvement in quality of life.

Comparative study on outcome of surgical management of varicose veins with and without great saphenous vein stripping

Background: Varicose veins of lower limb are multiple elongated dilated and tortuous veins. It is a progressive disease that worsens as the day passes. The treatment modalities available are conservative, surgical and endovenous therapies. It is accepted that surgical treatment is required for symptomatic varicose veins, to relieve symptoms and to prevent the long-term sequelae of eczema, lipodermatosclerosis and venous ulceration. Different surgical interventions may be used, but most preferred treatment applied is saphenofemoral flush ligation and ligation of incompetent perforators. Methods: This prospective comparative study was conducted on 60 patients in the department of general surgery, Mamata general hospital from July 2020 to June 2022. 60 patients were allocated into two groups of 30 patients each, who underwent flush ligation of saphenofemoral junction with stripping of long saphenous varicose vein and Trendelenburg surgery alone (flush ligation of sapheno femoral junction) respectively. Results: The hematoma formation in the thigh was seen in 23.33% of patients who underwent venous stripping whereas it was seen only in 3.33% who underwent Trendelenburg procedure alone. These wounds were examined in the postoperative period. Delayed wound healing was observed in 26.66% in patients with venous stripping and it was 10% with Trendelenburg procedure alone. There was no significant difference in postoperative ambulation, hospital stay and pain relief after 2 months. Conclusions: From this study with the observed variables, it is concluded that the Trendelenburg procedure with incompetent perforators ligation without venous stripping appears to be better than Trendelenburg procedure with incompetent perforators ligation with venous stripping.

Successful Healing Treatment of Varicose Vein with Perforator Incompetence and Ulcerative Gangrene Using Yoga Prana Vidya (YPV) System

A 42 years old male was diagnosed with varicose vein with perforator incompetence and ulcerative gangrene in left leg leading to bleeding, puss, severe pain, numbness and frequent infections. He was not able to walk and perform his day to day activities because of this situation. He had a history of varicose vein since 2010 and was operated 3 times for the same between 2010 to 2019. In 2022, he was again suggested to go for surgery as the situation was worsened. He came in contact with Yoga Prana Vidya (YPV) healer and decided to go for Yoga Prana Vidya (YPV) healing. This paper presents the case of Varicose Vein with perforator incompetence and ulcerative gangrene treated successfully using Yoga Prana Vidya healing protocol. Methods: This is the case study method with detailed analysis of medical records and photos of affected leg of patient’s health condition pre and post Yoga Prana Vidya (YPV) healing treatment applied as alternative medicine. This is the case of a 42 years old male diagnosed with varicose vein with perforator incompetence and ulcerative gangrene in left leg in May 2022. The initial symptoms were bleeding, puss, severe pain, numbness and frequent infection in left leg. The pain was so severe that he was not able to walk properly or perform his day to day activities. He was on heavy antibiotics and painkillers prescribed by doctor earlier. Doctor suggested to go for surgery for varicose vein. Results: Analysis of the patient’s health condition, photos of his leg and medical case documents pre and post treatment shows that he got cured with Yoga Prana Vidya (YPV) healing method for Varicose Vein with Perforator Incompetence and ulcerative gangrene. Conclusion: This case study documents the evidence on the effective use of Yoga Prana Vidya (YPV) in treating Varicose vein with perforator incompetence and ulcerative gangrene. There is ample scope to conduct further research on the application of YPV as alternatively effective and low cost medicine for various medical conditions.

Evaluation of stab avulsion versus subfascial endoscopic perforator surgery in the management of chronic venous insufficiency resulting from incompetent leg perforators in primary varicose veins

Chronic venous insufficiency (CVI) resulting from incompetent perforators due to varicose veins is a common surgical condition present in at least 10% of the general population. This study was planned to evaluate stab avulsion vs subfascial endoscopic perforator surgery in the management of incompetent perforators resulting in CVI. Forty patients of CVI resulting from primary varicose veins, falling into class 4 to 6 as per the clinical part of CEAP classification, along with Duplex assessment with proven incompetent perforators of lower extremity, irrespective of the status of saphenousfemoral or saphenous-popliteal junction status, were included in the study. All the patients were randomized into two groups, A and B, by a computer-generated draw. Group A patients underwent stab avulsion, and group B patients underwent SEPS for incompetent perforators. The following parameters were evaluated: (i) pain score using a visual analog scale at 1 hour, 12 hours and 24 hours after surgery, (ii) ulcer healing 1 month and 3 months after surgery, (iii) reversal of skin changes after 1 month and 3 months of surgery during follow-up, and (iv) wound-related complications. Early relief of symptoms in terms of ulcer healing, reversal of skin changes, and decreased incidence of wound complications was found to be better in the subfascial endoscopic perforators surgery (SEPS) group.

Long-term results of minimally invasive deep reflux correction in patients with post-thrombotic disease

The OBJECTIVE was to trace the long-term results of the operation of a dosed narrowing of the femoral vein in the lower third of the thigh proposed by Professor P. G. Shvalb.METHODS AND MATERIALS. The study included 30 patients (20 men and 10 women) with post-thrombotic disease of the veins of the lower extremities of the recanalized form, C4–C6, who underwent surgical correction of deep reflux in the period from 2012 to 2013. In 23 patients, additional phlebectomy of superficial and perforating veins was performed. The research method was duplex scanning (DS). The ratio of antegrade and retrograde blood velocities was used to quantitatively characterize deep reflux. Additionally, the state of the popliteal-tibial segment of the deep veins was determined using the Psatakis reflux index.RESULTS. The positive effect of the operation was noted in 96.7 % of patients at a follow-up period of 4 years. During follow-up periods of up to 8 years, the numbers decreased to 60.7 %. Relapse of trophic ulcers occurred in 39.3 % of patients. However, all patients noted that ulcers were much smaller in size than before surgery. According to DS data, incompetent perforator veins were detected in 16 patients: in all nine patients with recurrent ulcers and in seven patients without worsening. Vein diameter, maximum and average velocities of retrograde blood flow were greater in patients with worsening: diameter – 4.2±0.5 mm, υ (m) 91.2±19.8 cm/s, υ (average) 90.5±18.5 cm/s versus a diameter of 2.9±0.5 mm, υ (m) 39±15.6 cm/s, υ (average) 35±9 cm/s (p&lt;0.05).CONCLUSIONS. Operation of dosed narrowing of the femoral vein had good clinical results in 96.7 % of follow-up periods up to 4 years, 60.7 % – after 8 years. Isolated correction of deep reflux with the preservation of insufficient perforator veins can lead to recurrence of trophic ulcers.

To evaluate the outcome of varicose vein surgery with and without venous stripping

Aim: The aim of this study to evaluate the outcome of varicose vein surgery with and without venous stripping.Material and methods: This research covered 100 varicose vein operations across all surgical units. This research included all varicose vein patients between the ages of 18 and 70 who also had incompetent perforators and the saphenofemoral valve. The research excluded individuals with age extremes between 18 to 70, deep vein thrombosis, concomitant short saphenous vein varicosity, venous ulcer or other skin abnormalities, and recurring varicosity.Results: The left leg was more commonly involved than the right side. The left limb was involved in 64% and the right limb was involved in 36% of patients in group 1 and 70% and 30% in group 2. 30% of patients who had venous stripping experienced hematoma development in the thigh, compared to 6% of patients who received the Trendelenburg operation alone without venous stripping. 18% of patients had haemorrhage. Due to the tissue stress that occurs during venous stripping, there is an increased risk of hematoma development in the thigh in individuals who undergo stripping. The ineffective perforators in the legs of both groups were accessed by making a transverse incision at the preoperatively indicated spot under Doppler guidance. In the days after the operation, these wounds were checked. In each group, 6% of patients had slower wound healing. On the first post-operative day, when patients were urged to walk, 70% of those who had had stripping and 90% of those who had undergone ligation alone were able to do so comfortably. It was discovered that there was increased discomfort, tissue stress, hematoma development, and bruising in the case of venous stripping.Conclusion: There is no noticeable difference between the two processes with regards to wound healing, hospital stay, or pain treatment. It would seem that the Trendelen burg technique with incompetent perforator’s ligation without venous stripping is preferable to the Trendelenburg method with incompetent perforator’s ligation with venous stripping, based on the observed characteristics.

A Study of Demographic Factors and Clinical Profile of Varicose Veins in Adults

BACKGROUND&#x0D; Varicose veins in lower limbs cause a lot of morbidity in humans and a significant financial burden on the health care system. Varicose veins do not threaten life and are seldom disabling. A high prevalence of varicose veins has been documented in India. Hence, we decided to conduct a study on the demographic factors and clinical profile of varicose veins in adults.&#x0D; METHODS&#x0D; It is an observational study. 200 patients aged&gt;12 years with varicose veins of the lower limbs were studied. Statistical Analysis was performed with help of Epi Info (TM) 7.2.2.2.&#x0D; RESULTS&#x0D; 200 patients were studied, of whom 87.5 % were aged ≥ 35 Years; 74.5 % were males, 25.5 % were females; 70.0 % had normal BMI, 75.9 % were from the urban area, 11.5 % had a family history of varicose veins, 10.5 % had addictions, 57.0 % had a duration of standing &gt;5 hours. 62.0 % were examined at OPD, 82.5 % were unilateral and 17.5 % bilateral. The heights of the patients were significantly higher than the normal height of average Indians. The most common symptoms were varicosities and pain present in 80.85 % and 71.49 % of cases respectively. Out of 235 lower limbs, 48.93 % had the involvement of only GSV, 18.72 % only SSV, 32.35 % both; incompetent saphenofemoral junction was present in 67.24 % clinically and 74.89 % radiologically; 150 mid-thigh, 62 above-knee, 55 below-knee, 106 calf, 72 ankle perforators were incompetent clinically; 165 mid-thigh, 80 above-knee, 65 below-knee, 118 calf, 95 ankle perforators were incompetent radiologically; 65 (27.66 %) belonged to C2 class, 60 (25.53 %) to C4 class and 60 (25.53 %) to C6 class.&#x0D; CONCLUSIONS&#x0D; Age &gt; 35 years, male gender, tall height, and prolonged standing are associated with increased risk of varicose veins whereas obesity, family history and addictions do not have any association. Varicose veins are more commonly unilateral with the involvement of a great saphenous vein. Colour Doppler is better at detecting incompetent perforators compared to clinical assessment.

Comparison of Radiofrequency Ablation and Conventional Surgery in the Treatment of Varicose Veins

Background: This retrospective study was aimed to compare the outcomes between radiofrequency ablation (RFA) and conventional surgery which included the Trendelenburg procedure, multiple perforator ligation, hook phlebectomy and stripping for the treatment of varicose veins using Clinical, Etiological, Anatomical, and Pathophysiological classification (CEAP) and Venous Clinical Severity Score (VCSS) in a tertiary care centre. Materials and Methods: The pre-operative and post-operative CEAP classification and VCSS were calculated. The satisfaction from the surgery was assessed using a structured questionnaire and data analysed using IBM SPSS software. Results: The majority of the patients in the study belonged to the age group of 41–50 years. Females comprised 58% and housewives comprised 35% of the total patients. Patients with a body mass index of 18.5–24.9 constituted almost 44%. Twenty-four individuals had a family history of varicose veins. Doppler studies showed that at 83%, the most common pathology was sapheno-femoral junction (SFJ) and perforator incompetence. Five per cent of individuals had perforator incompetence alone. Thirty-four per cent of the individuals underwent RFA. The improvement in CEAP was 3.03 ± 1.513 in RFA group and 2.91 ± 1.279 in conventional surgery group; statistical analysis did not show any significant difference between the groups. The post-operative VCSS improved from 7.94 ± 1.718 in conventional surgery group and 7.38 ± 1.706 in RFA group to 1.52 ± 1.070 and 1.03 ± 0.577, respectively. The most common problem after surgery was saphenous neuralgia (8%). The severity of pain in the 1st week after the intervention was 'very mild' for most of the patients who underwent RFA (47.1%), and moderate for those in conventional surgery group (37.9%). The average days to return to normal activity were 10.26 ± 3.96 and 3.44 ± 1.637 in conventional surgery and RFA groups, respectively, whereas the average days to return to work were 17.41 ± 5.418 and 9.50 ± 1.846 days, respectively. Conclusion: The results indicate that both RFA and conventional surgeries in the form of the Trendelenburg procedure, stripping, phlebectomy and perforator ligation provide comparable relief of symptoms and clinical improvement when applied for the treatment of varicose veins. However, RFA may offer a significant advantage over conventional surgery in terms of faster recovery and early return to normal life and work.

Incompetent perforators do care!

The problem with all reviewed papers is that the results are influenced by concomitant treatments and the assumption that the incompetent perforating veins were treated properly. The study of van Gent and Wittens 1 van Gent W. Wittens C. Influence of perforating vein surgery in patients with venous ulceration. Phlebology. 2015; 30: 127-132 Crossref PubMed Scopus (14) Google Scholar showed that, if you treat the incompetent perforators well, the recurrence rate of an ulcer decreases significantly. This finding shows the importance of persistent incompetent perforating veins in ulcer recurrence. Therefore, in this well-performed systematic review we miss the information; for if indeed all incompetent perforators were occluded and we can only conclude that, with the existing techniques and gathered documentation, we do not have proof that incompetent perforators need to be treated. However, the right conclusion needs to be that incompetent perforators do matter in the pathophysiology of a venous leg ulcer, but that we failed to treat them properly with existing techniques. Therefore, we need to improve existing techniques and especially we need to check after 3 months and 1 year to determine whether the treated incompetent perforators remain occluded and if so document what the outcome is. 2 Ho V.T. Adkar S.S. Harris E.J. Systematic review and meta-analysis of management of incompetent perforators in patients with chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2022; 10: 955-964 Google Scholar Systematic review and meta-analysis of management of incompetent perforators in patients with chronic venous insufficiencyJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 10Issue 4PreviewIncompetent perforator veins (IPVs) contribute to venous pathology and are surgically treated based on hemodynamic measurements, size, and the CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) classification. The objective of the present study was to systematically review and synthesize the current literature regarding the surgical management of IPVs, including open ligation, subfascial endoscopic perforator surgery (SEPS), endovascular laser ablation, ultrasound-guided sclerotherapy, and radiofrequency ablation. Full-Text PDF

Diameter reflux relationship in perforating veins of patients with varicose veins and its correlation with clinical severity of disease

Treatment of chronic venous insufficiency requires understanding of the hemodynamics of perforating veins. Color Doppler analysis is the best modality to understand the hemodynamics of perforators. Perforating veins were categorized as competent or incompetent depending on the duration of reflux. Perforating veins in which duration of reflux was more than 0.5 seconds were categorized as incompetent perforating veins and perforating veins with reflux less than 0.5 seconds were categorized as competent perforating veins. The average diameter of incompetent perforators was increasing with increasing severity of disease. The number of incompetent perforator per limb also increased with worsening of disease severity and it was significantly higher in CEAP classes 4–6 compared to CEAP classes from 1 to 3 (p&lt;0.05). The average diameter of incompetent perforator in the present study was 3.8mm.

Current Best Practice in the Management of Varicose Veins.

This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.

Feasibility of incompetent perforator vein excision using stab avulsion.

ObjectivesWhether incompetent perforator veins (IPVs) require treatment remains controversial. We retrospectively evaluated the feasibility of IPV excision performed using the stab avulsion technique without ligation and sutures in patients undergoing endovenous ablation (EA).MethodsThis was a single-center, retrospective, observational cohort study. EA was performed in 1503 consecutive patients, including 33 patients with ulcers, between December 2014 and May 2021. Varicectomy was performed using the stab avulsion technique; IPV cases were included.ResultsStab avulsion was performed at a mean number of 11.4 ± 7.8 sites. No deep vein thromboses or pulmonary emboli were noted. The incidence of nerve injury was 0.3%. All 33 (100%) patients with ulcers achieved healing by 1 year (median: 55.5 days; range: 13–365 days).ConclusionsIPV excision via stab avulsion may be a viable option for treating varicose veins and ulcers. This technique offers multiple advantages, including simplicity, safety, and reduced healthcare costs.