Subfascial Endoscopic Perforator Surgery Research Articles

Surgical treatment of venous malformations in Klippel-Trénaunay syndrome

Purpose: Klippel-Trénaunay syndrome (KTS) is a complex congenital anomaly, characterized by varicosities and venous malformations (VMs) of one or more limbs, port-wine stains, and soft tissue and bone hypertrophy. Venous drainage is frequently abnormal because of embryonic veins, agenesis, hypoplasia, valvular incompetence, or aneurysms of deep veins. We previously reported on the surgical management of KTS. In this article, we update our experience. Methods: Twenty patients with KTS underwent surgical treatment for VMs between July 1, 1987, and January 1, 2000. This group represented 6.9% of 290 patients with KTS who were seen at our institution during this 12.5-year study period. Surgical indications, venous anatomy (determined with duplex scan, contrast phlebography, magnetic resonance imaging or magnetic resonance phlebography), operative procedures, and complications were reviewed, and outcomes were recorded. Results: Twelve male and eight female patients (mean age, 23.4 years; range, 7.7-40.6 years) underwent 30 vascular surgical procedures in 21 lower limbs. All 20 patients (100%) had varicose veins or VMs, 13 (65%) had port-wine stains, and 18 (90%) had limb hypertrophy. Pain was the most common complaint, which was present in 16 patients (80%), followed by swelling in 15 (75%), bleeding in 8 (40%), and superficial thrombophlebitis and cellulitis in 3 (15%). Imaging confirmed patent deep veins in 18 patients, hypoplastic femoral vein in 1, and entrapped popliteal veins bilaterally in 1. Four patients (20%) had large persistent sciatic veins (PSVs). The CEAP clinical classification was C-3 for 17 patients (85%), C-4 for 1 patient (5%), and C-6 for 2 patients (10%). Stripping of large lateral veins, avulsion, and excision of varicosities or VMs were performed on all limbs. Three patients required staged resections. The release of entrapped popliteal veins was performed in both limbs of one patient; another underwent a popliteal-saphenous bypass graft. One patient underwent excision of a PSV. Open and endoscopic perforator vein ligation was performed in one patient each. Two patients (12%) had hematomas that required evacuation. No patients had caval filter placement; none had postoperative deep venous thrombosis or pulmonary embolus. The mean follow-up was 63.6 months (range, 0-138 months). All patients reported initial improvement, but some varicosities recurred in 10 patients (50%), an ulcer did not heal in one, and a new ulcer developed in one, 8 years after surgery. Three patients underwent reoperation for recurrent varicosities. Follow-up CEAP scores were C-2 in 10 patients (50%), C-3 in 6 patients (30%), C-4 and C-5 in 1 patient each (5%), and C-6 in 2 patients (10%). Clinical scores improved from 4.3 ± 2.2 to 3.1 ± 2.3. (P =.03). Conclusions: The management of patients with KTS continues to be primarily nonoperative, but those patients with patent deep veins can be considered for excision of symptomatic varicose veins and VMs. Although the recurrence rate is high, clinical improvement is significant, and reoperations can be performed if needed. Occasionally, deep vein reconstruction, excision of PSVs, or subfascial endoscopic perforator surgery is indicated. Because KTS is rare, patients should receive multidisciplinary care in qualified vascular centers. (J Vasc Surg 2000;32:840-7.)

Duplex ultrasonography in the diagnosis of incompetent Cockett veins

Objective: Incompetent perforating veins of the medial calf, i.e. those of the Cockett groups, play a major role in the developement of chronic venous insufficiency. The aim of the present study was to test the value of duplex ultrasonography (DUS) in the diagnosis of function and localisation of those veins. Methods: Eighty-nine legs with incompetent perforating veins of the medial calf selected for subfascial endoscopic perforator surgery (SEPS) were included in a prospective study. Preoperative DUS was used to determine the number and localisation of the perforator veins. Findings were compared with preoperative ascending phlebography and intraoperative endoscopy during SEPS. Results: Nearly equal numbers of insufficient Cockett veins at each level were detected by DUS and ascending phlebography (Cockett III: n, 76 vs. n, 76, P, 1.0; Cockett: II n=84 vs. n=82, P=0.569; Cockett I: n, 36 vs. n, 37, P=1.0; χ 2-test). Findings were confirmed intraoperatively. Conclusion: The accuracy of DUS is comparable to phlebography for the diagnosis of incompetent perforating veins of the lower leg. DUS is non-invasive and avoids the potential risks of radiologic imaging.

Surgical Anatomy of the Veins of the Lower Limb

With the advent of new surgical techniques, such as subfascial endoscopic perforator surgery, venous anatomy of the lower limb gained distinguished attention. Here, based on our surgical experience...

Prospective study of safety, patient satisfaction and leg ulcer healing following saphenous and subfascial endoscopic perforator surgery

Subfascial endoscopic perforator surgery (SEPS) is a minimally invasive alternative to conventional techniques for incompetent calf perforators. Although SEPS has been performed for more than a decade, limited and insufficient data have been published regarding its safety, patient satisfaction and results. A prospective follow-up was undertaken of consecutive SEPS operations on 149 legs, performed in 138 patients: 67 legs with ulceration, 34 with skin changes and 48 with varicose veins. Conventional saphenous vein surgery was performed, when indicated, together with the SEPS procedure. Follow-up was performed after 1 week and later by postal questionnaire to assess long-term morbidity, late complications and patient satisfaction. Patients with ulcers were followed continuously. Most operations (n = 107) were performed as day-case surgery. Combined saphenous vein surgery was performed in 89 per cent. No serious complications occurred: wound infection in 7 per cent; severe postoperative pain in 9 per cent; delayed wound healing in 15 per cent. After a median follow-up of 7 (1-31) months, 91 per cent of patients were satisfied. After a median of 32 (14-57) months, ulcer healing had occurred in 30 of 36 patients with open ulceration at the time of operation. SEPS is a safe procedure, suitable for day-case surgery. Patients are generally satisfied with the outcome and the results of leg ulcer healing are promising.

Photoplethysmography and calf muscle pump function after subfascial endoscopic perforator ligation

Objective: Subfascial endoscopic perforator surgery (SEPS) results in acceptable healing and recurrence rates. The role of hemodynamic venous testing in this situation, however, is poorly understood and inconsistently used. Our ongoing experience was reviewed to explore how SEPS affects the photoplethysmographic assessment of the leg. Methods: Preoperative and postoperative venous refill times (VRTs) were measured with photoplethysmography in 30 limbs in 28 patients who underwent SEPS and superficial ablation, when indicated, with complete clearing of the anterolateral surface of the tibia, thus opening the deep posterior compartment from mid calf to close to the malleolus. Postoperative healing and duplex scanning were used to assess clinical and anatomic success, respectively. The VRTs were classified as “interpretable” if the leg emptied or “uninterpretable” if the calf could not empty. The “interpretable” study results were further classified as “normal” if the refill took 20 seconds or more or “abnormal” if less. Results: Before the patients underwent SEPS, six study results (20%) showed inability of the calf to empty and thus were judged uninterpretable. After the patients underwent SEPS, 12 study results (40%) were uninterpretable (NS; P = .09 with the χ 2 test). Of the 24 preoperative interpretable study results, two (8%) were normal, and of the 18 postoperative interpretable study results, seven (39%) were normal ( P < .03). With the consideration of only interpretable study results, the mean VRT increased slightly from 12.0 ± 5.1 seconds (mean ± standard deviation) to 14.3 ± 8.1 seconds (NS). Seventeen of 19 ulcers (89%) had healed at a mean follow-up period of 8.6 ± 4.8 months. Conclusion: Although VRT is unpredictably affected by SEPS, the most consistent finding is the inability of the calf to empty, which invalidates the remainder of the test. In addition, most ulcers heal, even with uninterpretable or abnormal postoperative VRTs. This suggests that photoplethysmography is a poor method of assessment of venous reflux after SEPS. (J Vasc Surg 1999;30:1067-76.)

Iatrogenic Leg Ulcer after Subfascial Endoscopic Perforator Surgery (SEPS)

Iatrogenic Leg Ulcer after Subfascial Endoscopic Perforator Surgery (SEPS)

Iatrogenic Leg Ulcer after Subfascial Endoscopic Perforator Surger (SEPS)

Objective: To report a case of iatrogenic leg ulcer after subfascial endoscopic perforator surgery (SEPS). Design: Case report. Setting: Department of Vascular Surgery, Milton Keynes Hospital, a district general hospital. Patient, intervention and results: A 57-year-old woman underwent SEPS for a venous ulcer secondary to an incompetent perforating vein. Post-operatively she developed a new ulcer directly over the site of the divided perforator. The ulcer healed completely with conservative bandaging treatment after 4 months. Conclusion: We describe a complication of SEPS not previously reported. The perforating artery might have been divided inadvertently instead of the perforating vein. It is important to positively identify the perforating vein during SEPS before its division, especially in the presence of mixed arteriovenous disease.

Redone endoscopic perforator surgery: Feasibility and failure analysis

Purpose: In many hospitals and medical practices, subfascial endoscopic perforator surgery (SEPS) has become the treatment of choice in patients with incompetent perforator veins and active venous ulcers. A substantial number of surgeons consider SEPS to be an operation that can be performed only once because extensive scarring and narrowing of the subfascial space make a second endoscopic operation impossible. It is the purpose of this report to prove the feasibility, efficacy, and safety of a second SEPS procedure. Methods: Within a period of 30 months, 105 primary SEPS procedures were performed in patients with healed or still active ulcers. In addition to these cases, within a period of 30 months, a consecutive number of 19 patients were examined and scheduled for a second SEPS procedure. All patients were in class 5 with healed ulcers or in class 6 with still active ulcers. The CEAP classification of the American Venous Forum was used to evaluate the results and to calculate the clinical, disability, and outcome scores. The redone operation was performed by using CO 2 insufflation, a dual-port technique, and subfascial balloon dissection. Results: In two patients conversion to a conventional procedure was necessary. There were no major complications, but there was a 21% incidence of minor problems, such as hematoma or cellulitis. The mean total clinical score improved after surgery from 7.91 to 3.23 ( P < .01), the disability score changed from 1.10 to 0.57 after surgery ( P < .02), and the clinical outcome score was 1.47 after surgery ( P < .001). Cumulative ulcer healing could be achieved in 85.8% of class 6 patients. Failure analysis revealed that an incomplete subfascial dissection had been performed during the first endoscopic operation. A septum intermusculare medialis or an intact deep posterior fascia with incompetent Cockett II perforators were major factors contributing to the initial treatment failures. In addition to incompetent perforators, postthrombotic deep venous reflux was seen in eight (42.1%) patients, and four (21%) patients had a combination of secondary reflux and obstruction. Conclusion: Subfascial endoscopic procedures can be redone safely. In addition to exploring the superficial posterior compartment, the deep posterior compartment must be opened to prevent recurrent symptoms in patients with incompetent perforator veins. (J Vasc Surg 1999;30:720-6.)

Ultrasound-guided Percutaneous Coil Embolization of Incompetent Perforating Veins: Not Effective for Treatment of Venous Ulcers and Recurrent Varicosities

To investigate the feasibility of ultrasound-guided percutaneous coil embolization of incompetent perforating veins as minimally invasive treatment for venous ulcers and recurrent varicosities in the lower leg. This could be an alternative to surgical ligation of perforating veins. In 15 patients (six women, nine men; mean age, 50 years), 18 incompetent perforating veins in the lower leg were treated by ultrasound-guided percutaneous placement of embolization coils. Successful vein occlusion with one or more coils was achieved in 12 of the 18 veins (technical success rate, 67%). Clinical symptoms improved in only three of the 15 patients (clinical success rate, 20%). During follow-up (2-12 months), recanalization of coil embolized veins occurred in nine of the 12 initially occluded veins. Percutaneous ultrasound-guided coil embolization does not appear to be as effective as subfascial endoscopic perforator surgery in the treatment of incompetent perforator veins.

Subfascial Endoscopic Perforator Surgery Conserves Hospital Resources

Innovations in the management of venous disorders have included subfascial endoscopic perforator surgery (SEPS). Information on resource utilization of this procedure is limited. Comparison of sequential cohorts of patients treated for leg venous hypertension by SEPS versus open perforating vein ligation (OPL) was performed to quantify the impact on hospital resource utilization and length of stay. At the Jobst Vascular Center, the last OPL was performed in June 1995 and the first SEPS was performed in January 1994. The authors compared the last 34 consecutive OPL procedures with the first 33 consecutive SEPS operations. Both groups had similar clinical indications. Variables describing utilization of hospital resources were assessed from a computer database compiled at time of treatment and compared by use of t test and chi-square statistics. Charges were selected as representation of hospital resources. SEPS length of stay, 2.3 ±1.8 (sd) days was significantly less than OPL, 4.5 ±2.7 days (p &lt; 0.001) with concomitant reduction in physician bedside visits, 4.8 ±3.9 for SEPS versus 8.0 ±5.3 for OPL (p = 0.007). Total hospital charges in dollars, adjusted for sequential annual increments, were similar: 8,093 +3,811 for OPL versus 7,278 ±1,716 for SEPS (p=0.27). When OPL and SEPS were compared respectively, there were no significant differences in patient age, 58 ±14 versus 53 ±12 years; gender distribution, 62% women versus 42%; active ulcer status, 88% versus 85%; advanced admission testing, 41% versus 58%; use of venography, 97% versus 88%; use of general anesthesia, both 82%; or concomitant vein stripping, 65% versus 58% (p &gt;0.1). SEPS anesthesia time was longer, 136 ±10 versus 122 ±28 minutes (p = 0.01), but not clinically significant. SEPS reduced length of hospital stay and number of physician bedside visits compared with OPL. Total hospital charges may be further reduced as experience with this procedure accumulates.

A new approach to an old and vexing problem: subfascial endoscopic perforator surgery.

Chronic venous insufficiency with venous hypertension causes leukocyte trapping, lipodermatosclerosis, and finally, skin ulceration involving the lower extremity. Perforator vein incompetence has been identified as an important contributing factor to ulceration when abnormally elevated pressure is transmitted to areas of affected skin, usually at the ankle medially. Surgical techniques for ligation of incompetent communication veins were first popularized by Linton and Dodd from 1940 to 1950. Early techniques used extensive longitudinal incisions for subfascial ligation through indurated skin. These procedures were plagued with wound complications: delayed healing, skin necrosis, and infection. Techniques continued to evolve that used minimally invasive incisions and avoided zones of affected skin. With the availability of endoscopic, fiberoptic, and laparoscopic advances in surgery, instrumentation has been developed for minimally invasive endoscopic approach to accomplish subfascia endoscopic perforator surgery (SEPS) under direct vision. SEPS is now used alone and in combination with other venous interventions to reduce transmission of venous hypertension to affected skin areas. The SEPS procedure, its indications, and the history of surgical treatment of perforator vein incompetence are discussed. Unique problems related to short hospital stays and postoperative care are outlined. This review will help the vascular nurse understand the rationale and techniques of SEPS. This comprehension will enable provision of accurate information to the patient and a knowledge-based plan of care.

Subfascial endoscopic perforator vein surgery: indications and results.

Subfascial endoscopic perforator surgery (SEPS) is a new, minimally invasive technique performed in patients with advanced chronic venous insufficiency. The objective of the operation is to interrupt incompetent medial calf perforating veins to decrease venous reflux and reduce ambulatory venous hypertension in critical areas above the ankle where venous ulcers most frequently develop. Patients with stasis skin changes and healed or active venous ulcerations are potential candidates for the operation. Preoperative evaluation is performed with duplex scanning of the superficial, deep and perforator system, to diagnose both obstruction and valvular incompetence. Results of the North American SEPS Registry (NASEPS) as well as experience in several individual centers confirmed that the operation has significantly fewer wound complications than the classic open surgical techniques, and that rapid ulcer healing can be achieved. At the Mayo Clinic an ulcer recurrence rate of 12% was observed, with recurrence significantly more frequent in post-thrombotic limbs than in patients with primary venous valvular incompetence. The NASEPS Registry report confirmed a 2-year cumulative ulcer recurrence rate of 28%; ulcer recurrence was significantly more frequent in post-thrombotic limbs, especially in those with deep venous obstruction. SEPS is a new, low-risk, outpatient procedure that effectively decreases perforator reflux in patients with venous ulcerations, and should be added to our armamentarium to treat patients with advanced chronic venous disease. Long-term prospective and randomized studies are, however, still required to provide level I evidence of late efficacy.

Atlas of Endoscopic Perforator Vein Surgery

Section 1: Fundamental Considerations Historical Perspectives Surgical Anatomy of Perforating Veins Epidemiology of Chronic Venous Insufficiency Pathophysiology of Chronic Venous Insufficiency.- Section 2: Clinical Features Clinical Presentation and Classification of Chronic Venous Disease Plethysmographic Evaluation of Venous Function Preoperative Evaluation of Chronic Venous Insufficiency with Duplex Scanning and Venography.- Section 3: Surgical Interventions Correction of Superficial Reflux Linton's Operation and Modification of the Open Techniques Technical Armamentarium for Endoscopic Perforator Vein Surgery Subfascial Endoscopic Perforator Surgery with Gas Insufflation Subfascial Endoscopic Perforating Surgery: The Open Technique. Additional Maneuvers for Subfascial Endoscopic Perforator Vein Surgery Creation of Subfascial Space Subfascial Dissection, Perforator Division and Ultrasonic Coagulation Comparison of Open Linton Operation with Subfascial Endoscopic Perforator Surgery Deep Venous Thrombosis Prophylaxis.- Section 4: Supportive Therapy Compression Therapy for Treatment of Lower Extremity Chronic Venous Insufficiency and Venous Stasis Ulcers The Medical Management of Chronic Venous Ulcers Local Management of Chronic Leg Ulcers.- Section 5: North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry Results of the NASEPS Registry.

Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: Lessons learned from the North American Subfascial Endoscopic Perforator Surgery registry

Purpose: The safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery (SEPS) for the treatment of chronic venous insufficiency were established in a preliminary report. The long-term clinical outcome and the late complications after SEPS are as yet undetermined. Methods: The North American Subfascial Endoscopic Perforator Surgery registry collected information on 148 SEPS procedures that were performed in 17 centers in the United States and Canada between August 1, 1993, and February 15, 1996. The data analysis in this study focused on mid-term outcome in 146 patients. Results: One hundred forty-six patients (79 men and 67 women; mean age, 56 years; range, 27 to 87 years) underwent SEPS. One hundred and one patients (69%) had active ulcers (class 6), and 21 (14%) had healed ulcers (class 5). One hundred and three patients (71%) underwent concomitant venous procedures (stripping, 70; high ligation, 17; varicosity avulsion alone, 16). There were no deaths or pulmonary embolisms. One deep venous thrombosis occurred at 2 months. The follow-up periods averaged 24 months (range, 1 to 53 months). Cumulative ulcer healing at 1 year was 88% (median time to healing, 54 days). Concomitant ablation of superficial reflux and lack of deep venous obstruction predicted ulcer healing ( P < .05). Clinical score improved from 8.93 to 3.98 at the last follow-up ( P < .0001). Cumulative ulcer recurrence at 1 year was 16% and at 2 years was 28% (standard error, < 10%). Post-thrombotic limbs had a higher 2-year cumulative recurrence rate (46%) than did those limbs with primary valvular incompetence (20%; P < .05). Twenty-eight of the 122 patients (23%) who had class 5 or class 6 ulcers before surgery had an active ulcer at the last follow-up examination. Conclusions: The interruption of perforators with ablation of superficial reflux is effective in decreasing the symptoms of chronic venous insufficiency and rapidly healing ulcers. Recurrence or new ulcer development, however, is still significant, particularly in post-thrombotic limbs. The reevaluation of the indications for SEPS is warranted because operations in patients without previous deep vein thrombosis are successful but operations in those patients with deep vein thrombosis are less successful. Operations on patients with deep vein occlusion have poor outcomes. (J Vasc Surg 1999;29:489-502.)

Subfascial endoscopic perforator surgery.

Subfascial endoscopic perforator surgery.

Endoscopic perforator vein division with ablation of superficial reflux improves venous hemodynamics

Purpose: Hemodynamic consequences of incompetent perforator vein interruption have not been well documented. The effects of perforator interruption, with or without ablation of superficial venous reflux, on venous function in patients with advanced chronic venous insufficiency was studied. Methods: Calf muscle pump function, venous incompetence, and outflow obstruction were assessed by means of strain-gauge plethysmography (SGP) before and within 6 months after subfascial endoscopic perforator surgery (SEPS). SEPS was performed with laparoscopic instrumentation and CO 2 insufflation. Concomitant high ligation or saphenous vein stripping was performed in 24 limbs (77%). Results: Twenty-six patients, 18 women and 8 men, with a mean age of 50 years (range, 20 to 77 years) underwent SEPS. Preoperative evaluation confirmed superficial reflux in 65% of limbs, deep venous reflux in 77% of limbs, and perforator incompetence in 97% of limbs. All limbs had advanced venous dysfunction (C3, C4, C5, C6). All active ulcers (C6, n = 12) healed after surgery (mean, 32 ± 3 days), and only 1 recurred during a mean follow-up period of 11 months (range, 1 to 43 months). Clinical score improved from 6.58 ± 0.50 to 2.19 ± 0.25 ( P < .0001). Improved calf muscle pump function was demonstrated by means of postoperative SGP and was indicated by increased refill volume (RV: 0.27 ± 0.06 vs 0.64 ± 0.10 mL/100 mL tissue, P < .01). Venous incompetence also improved, as evidenced by prolonged duration to refill after exercise (T90: 7.71 ± 1.20 vs 16.71 ± 1.98 seconds, P < .001) and a decrease in RV after passive drainage (3.23 ± 0.19 vs 2.63 ± 0.15 mL/100 mL tissue, P < .01). Improved refill rate (RR) correlated with improvements in clinical scores ( P < .01, r = 0.77). Conclusion: SEPS with ablation of superficial reflux improved calf muscle pump function, reduced venous incompetence, and produced excellent midterm clinical results. However, functional improvement directly related to SEPS requires further investigation. This study supports adding SEPS to ablation of superficial reflux in patients with advanced chronic venous insufficiency. (J Vasc Surg 1998;28:839-47.)

Saphenous surgery does not correct perforator incompetence in the presence of deep venous reflux

Purpose: To determine which patients require subfascial endoscopic perforator surgery (SEPS) in addition to saphenous surgery to correct pathologic outward flow within incompetent medial calf perforating veins (IPVs). Methods: Sixty-two limbs of 47 patients undergoing sapheno-femoral ligation, stripping of the long saphenous vein in the thigh, and multiple phlebectomies (n = 51), sapheno-popliteal ligation and multiple phlebectomies (n = 10), or both (n = 1) were examined with color flow duplex ultrasound scan immediately before and a median of 14 weeks (range, 6 to 26 weeks) after the operations. Indications for surgery were varicose veins (n = 47, Clinical, Etiologic, Anatomic, Pathophysiologic grades C 2&3), skin changes (n = 5, C 4), and ulceration (n = 10, C 5). Results: Surgery resulted in a significant reduction in the total number of limbs in which IPVs were imaged (40/62 or 65% preoperatively vs 23/62 or 37% postoperatively, P <.01, χ 2 test), a significant reduction in the proportion of perforators imaged that were incompetent (68/130 or 52% preoperatively vs 34/120 or 28% postoperatively, P <.01, χ 2 test), and a reduction in median IPV diameter (4 mm, with a range of 1 to 11 mm preoperatively, vs 3, with a range of 1 to 8 mm postoperatively, P <.01, Mann-Whitney U test). IPVs remained in 8 of 41 (20%) limbs in which main stem reflux was abolished, compared with 15 of 21 (72%) limbs in which superficial or deep reflux remained ( P <.01, χ 2 test). Conclusion: Eradication of main stem saphenous reflux corrects IPV reflux in most cases in which reflux is confined to the superficial system. However, in patients with superficial reflux that persists postoperatively, or when there is coexistent deep venous reflux, saphenous surgery alone fails to correct IPVs reflux. In these circumstances, the only way of reliably correcting pathologic outward flow in medial calf perforating veins is to perform SEPS. (J Vasc Surg 1998;28:834-8.)

Factors affecting clinical outcome following endoscopic perforator vein ablation

Background: Despite good outcomes reported with minimally invasive, subfascial endoscopic perforator surgery (SEPS), some patients demonstrate poor healing or recurrence of venous ulcers. The goal of this study was to identify factors that lead to failure of SEPS. Methods: Forty-eight consecutive patients who had undergone 57 SEPS procedures were analyzed. Mean follow-up was 17 ± 2 months (range 2 weeks to 52 months). Results: All active ulcers (n = 22) at the time of surgery healed in an average of 99 ± 37 days (range 11 to 670). Eight limbs had poor healing of their ulcer (>40 days); five (9%) new/recurrent ulcers developed postoperatively. Deep venous obstruction was associated with delayed ulcer healing (316 ± 171 versus 51 ± 14 days, P <0.01) and ulcer recurrence ( P <0.0001). Poor ulcer healing and recurrence were not associated with lipodermatosclerosis, edema, ulcer duration >3 months, or previous recurrences. Ulcer size >2 cm ( P <0.05) and combined ilio-femoral and popliteal/tibial reflux were associated with poor ulcer healing ( P <0.05). Conclusions: SEPS could not prevent recurrent or new ulceration in 9% of limbs. Venous outflow obstruction was associated with ulcer recurrence and prolonged ulcer healing. Multilevel deep venous reflux and ulcer size >2 cm were also associated with delayed healing.

Subfascial endoscopic perforator surgery is associated with significantly less morbidity and shorter hospital stay than open operation (Linton's procedure)

Subfascial endoscopic perforator surgery is associated with significantly less morbidity and shorter hospital stay than open operation (Linton's procedure)

Early Benefits of Subfascial Endoscopic Perforator Surgery (SEPS) in Healing Venous Ulcers

Efficacy of subfascial endoscopic perforator vein surgery (SEPS) in assisting the healing of venous ulcers was determined. During the period June 1995 to May 1996, 19 limbs in 17 patients were treated by SEPS. Thirteen limbs had open ulcers (class 6), five limbs had healed ulcers (class 5), and one limb had severe lipodermatosclerosis (class 4). There were nine male and eight female patients (average age 58, range 33-86). One male had bilateral open ulcers and one female had one open and one healed ulcer. Open ulcers had been present for an average duration of 4.4 years (range 1-14 years). The average ulcer size was 2.8 x 2.2 cm (range 1 x 1 cm to 12 x 6 cm). All operations were conducted on an outpatient basis. At surgery an attempt was made to correct all superficial venous pathophysiology. In addition to SEPS, 12 limbs (63%) had greater saphenous vein (GSV) stripping and 15 patients (79%) had stab avulsion of painful varicose veins. The average number of perforators ligated during SEPS was 3.68 (range 2-8). All active ulcers healed within 90 days. The mean time to healing was 30.5 days (range 6-90 days). Minor postoperative complications (one groin hematoma, three wound infections) occurred in four limbs (21%). There have been no ulcer recurrences during follow-up (mean 8.6 months, range 3-16 months). Outpatient SEPS is an important adjunct in the treatment of chronic venous insufficiency. Experience in this group of 19 limbs strongly suggests that SEPS appears to accelerate the healing of venous ulcers compared to historical controls.