Subfascial Endoscopic Perforator Vein Surgery Research Articles

EFFICIENCY ASSESSMENT OF MINIMALLY INVASIVE TREATMENT OF SEVERE FORMS OF CHRONIC VENOUS INSUFFICIENCY OF LOWER EXTREMITIES

Aim. To improve the results of treatment of severe chronic venous insufficiency (CEAP 4-6) using the methods of minimally invasive phlebology. Materials and methods. The study included 158 patients aged 26-72 (mean age 49,5±1,2) suffering from chronic venous insufficiency (CEAP 4-6). All patients underwent the following examination methods: assessment of subjective and objective symptoms, duplex ultrasound scan and laboratory examinations. Results. Comparative study of endovenous laser hemadostenosis of great and small saphenous veins in combination with subfascial endoscopic perforator vein surgery (SEPS) in the control group and the combined use of endovenous laser coagulation and microfoam echo-sclerotherapy in the main group showed significant benefits in the primary group in the form of a significant reduction of pain syndrome, decrease of postoperative complications, a significant reduction of terms of rehabilitation. The study demonstrated the absence of significant differences between main and control groups of respondents according to the criteria of recurrence of the disease in the late postoperative period (difference in frequency of the detected unsatisfactory effects of the studied medical interventions in the late postoperative period was not statistically significant (p=0,67). Conclusions. Positive dynamics of the combined use of endovenous laser coagulation and microfoam echosclerotherapy of the main group in the immediate postoperative period demonstrate the effectiveness of this method in patients with chronic venous insufficiency (CEAP 4-6).

Treatment options of crural pseudoaneurysms.

Pseudoaneurysms (PAs) of crural arteries represent rare complications of vascular interventions or surgery. Management of crural PAs includes different treatment options, conservative treatment as well as open surgery or endovascular procedures. We reviewed our experience. We retrospectively analysed all patients who were diagnosed with crural PAs since 2003. We evaluated etiology, treatment and outcome. Endpoints were target vessel patency, vascular re-intervention and limb loss. A total of 30 patients were diagnosed with crural PAs. PA was caused by vascular intervention in 27 patients (90 %): open balloon thrombectomy (n = 25), subfascial endoscopic perforator vein surgery (n = 1) and transcutaneous catheter-assisted thrombus aspiration (n = 1). In 3 patients (10 %) it was caused by orthopaedic surgical procedures. Location of crural PAs were peroneal artery (n = 11; 36.7 %), posterior tibial artery (n = 10; 33.3 %), anterior tibial artery (n = 5; 16.7 %), and tibioperoneal trunk (n = 4; 13.3 %). Treatment of crural PAs included open surgery (n = 3; 10 %), endovascular procedures (n = 13; 43.3 %) such as endograft implantation (n = 9) or coil embolisation (n = 4), and conservative management (n = 14; 46.7 %). After a median follow-up period of 7 months (range: 0 - 46 months) 8 of 9 endografts were occluded, in none of these patients a minor or a major amputation was necessary. None of the surgically, endovascularly and conservatively treated patients needed a re-intervention for crural PA. A major amputation was necessary in 4 patients due to progression of peripheral arterial disease; none was a directly consequence of the crural PA. Crural PAs are mainly caused by vascular intervention, most frequently by catheter thrombectomy. As a consequence, we recommend fluoroscopic-assisted balloon thrombectomy over a guide wire as routine technique. In many cases of crural PAs, conservative management is sufficient. The choice of treatment of crural PAs depends on size, location and associated symptoms. Endovascular treatment using endografts is limited by poor long-term patency.

Influence of perforating vein surgery in patients with venous ulceration

The exact role of perforating vein surgery is still unclear. The aim of this study is to analyze the influence of perforating vein surgery in patients with venous ulceration. This study was part of a randomized controlled trial in which conservative and surgical treatment of venous ulceration was compared. It is a secondary analysis of prospectively gathered data. Ninety-seven active leg ulcers were surgically treated with a subfascial endoscopic perforating vein surgery (SEPS) procedure. Concomitant superficial venous incompetence was treated with flush saphenopopliteal ligation and/or saphenofemoral ligation and limited stripping of the great saphenous vein. All patients were also treated with ambulatory compression therapy. Ulcer healing and recurrences are described in detail. To measure the completeness of the SEPS procedure duplex ultrasonography was performed on each patient before and 6 weeks and 12 months after surgery. Also newly formed perforators after surgery were scored and their influence was analyzed. Analyses were performed on 94 ulcerated legs with a mean follow-up of 29 months. In all treated legs, only 45% all perforators were treated. In 55% one (29%) or more (26%) perforators were missed. Healing was not significantly influenced by the number of remaining incompetent perforating veins, but recurrence was significantly higher in patients who had incomplete SEPS procedure (p = 0.007 log-rank). New incompetent perforating veins did not affect ulcer healing or recurrence. The plotted location of new perforators did not show a pattern. Deep vein incompetence and treatment of superficial venous incompetence had no significant influence on healing or recurrence rates in a complete or incomplete SEPS procedure. In this series a well-performed SEPS procedure lowers the venous ulcer recurrence rate significantly, indicating the clinical importance of incompetent perforating veins in patients with an active venous ulcer.

Redo subfascial endoscopic perforator vein surgery: does it need to be done if necessary?

Background: In this study, we aimed o evaluate the efficacy of redo subfascial endoscopic perforating vein surgery (SEPS) in patients with recurrent venous ulceration who underwent SEPS previously due to venous ulcers with wound healing and relapsed after a period later. Methods: Between May 2003 and November 2011, 32 (7.3%) of a total of 438 patients who underwent SEPS developed recurrence of venous ulcers. All patients were evaluated by venous Doppler and the patients with a history of deep venous thrombosis underwent additional ascending venography. Patients with informed consents was operated by endoscopic method under spinal anesthesia, using 10 mm diameter with a 10 cm incision to medial and with CO2 insufflation 2 cm far from the previous incision scar, re-entering the 10 mm port area of subfascial with the gastrocnemius muscle Perforator veins were ligated using 10 mm titanium clips in subfascial space. Results: Fourteen cases were redo-SEPS. Eighteen patients were treated with wound-care products. Nine of 14 wounds (64.3%) were completely recovered. Five wounds (35.7%) were not healed. None of the patients had any adhesions in the subfascial space. Dissection was able to be constructed easily. Perforator veins which were ligated before were seen at subfascial space. The number of per clip for a new perforator vein was one or two per patient. There was no technical difficulty. There was no complication or mortality. Conclusion: In patients with recurrent venous ulcers despite prior SEPS, redo-SEPS can be safely performed, if necessary.

当科の内視鏡下筋膜下不全穿通枝切離術(SEPS)の治療成績の検討

当科の内視鏡下筋膜下不全穿通枝切離術(SEPS)の治療成績の検討

慢性静脈うっ滞性疾患に対する内視鏡下筋膜下穿通枝切離術

慢性静脈うっ滞性疾患に対する内視鏡下筋膜下穿通枝切離術

Role of Subfascial Endoscopic Perforator Surgery (SEPS) in Management of Perforator Incompetence in Varicose Veins : A Prospective Randomised Study.

The study was carried out to compare the efficacy of subfascial endoscopic perforator surgery (SEPS) and open subfascial ligation of perforators in varicose veins. This study was conducted on 100 patients of varicose veins from January 2006 to December 2010. Clinical scoring and color Doppler were performed in all the patients before surgery. Patients were divided into two groups: Group A and Group B alternately. Management of the perforators was done by subfascial endoscopic perforator surgery (SEPS) in Group A and by open subfascial ligation of perforators in Group B. Fifty patients were treated in each group. All the patients underwent ligation of incompetent saphenofemoral junction with stripping of long saphenous veins wherever the junction was incompetent with multiple ligation of superficial prominent veins. SEPS was done by two-port method without any tourniquet or balloon dissector. Total numbers of perforators ligated were 178 in Group A and 136 in Group B. Patients in both the groups got symptomatic relief of symptoms, but ulcer healing in 33% patients in Group A was faster as compared to Group B. However, at 3months of follow-up the ulcers healed in all the patients in both groups. Incidence of wound infection was higher in group B (16%) as compared to group A (0%). There were residual perforators in 8% of patients on color Doppler at 3months of follow-up in Group B while there was no residual incompetent perforator in Group A. Subfascial endoscopic perforator vein surgery is a safe and effective method for treating incompetent perforating veins. The number of perforators ligated in SEPS was more as compared to the open subfascial ligation group. Possibly some perforators may be missed on Doppler localization and missed ligation, which may be a cause of future recurrence in varicose veins. Early relief of symptoms in terms of ulcer healing was better in the SEPS group with less wound complication rate; however, all the ulcers healed in both the groups at 3months of follow-up. Cosmetic results were equal in both the groups. Major advantage of SEPS was less incidence of wound complications and less incidence of residual incompetent perforators. Hence, SEPS should be added for the management of perforators along with conventional surgery in varicose veins.

The place of subfascial endoscopic perforator vein surgery (SEPS) in advanced chronic venous insufficiency treatment.

In spite of medical science development and initiation of new technologies in minimally invasive surgery, treatment of advanced chronic venous insufficiency at the 5th and 6th degree of CEAP classification is still a great clinical challenge. In case of no satisfactory results of non-surgical treatment of recurrent venous ulcers, scientists search for alternative therapeutic methods which could be more effective and lasting. Subfascial endoscopic perforator vein surgery (SEPS) as a method of reducing venous pressure in the superficial venous system could provide healing of the recurrent venous ulcer. In this study we present a review of contemporary opinions about the place and significance of subfascial endoscopic perforator vein surgery as a treatment of advanced chronic venous insufficiency.

Technical procedure of two-port system subfascial endoscopic perforator vein surgery (TPS-SEPS)

It has long been noted that incompetent perforating veins contribute to the development of chronic venous insufficiency and recurrent varicose veins that are complicated by skin ulcerations or liposcleroderma. For these conditions, severing of incompetent perforating veins is an effective surgical treatment. However, severing of incompetent perforating veins by a direct approach has become less commonly performed because of the excessive invasiveness of the procedure itself. We referred to 37 cases (44 legs) of varicose veins with or without active venous dermatitis, who underwent the two-port system subfascial endoscopic perforator surgery, which we devised (hereafter referred to as TPS-SEPS). According to this method, incompetent perforating veins can be severed without surgical intervention in the lesion. The criteria for insufficiency of the perforating veins (IPVs) are reverse flow demonstrated on a color-flow duplex and a caliber more than 3 mm in diameter. One hundred forty one out of one hundred fifty two IPVs were processed. A mean of 3.21 perforating veins per patient was severed using ultrasonic coagulation-incision apparatus. From these 37 cases we conclude that TPS-SEPS provides a useful tool for the surgeon interested in treating severe chronic venous insufficiency same as the single-port technique. Our TPS-SEPS is a relatively simple operation, but its skill is dependable and provides lower invasiveness than other operation procedure. From now on, it is necessary to unify the authorized name of the endoscopic surgery of perforating veins and is also important to define the indication of this method for the primary varicose veins without stasisdermatitis.

One Hundred One Experiences of Subfascial Endoscopic Perforating Vein Surgery (SEPS) in Patients with Stasis Ulcerations: How to get the knack of simplified SEPS for beginners

One Hundred One Experiences of Subfascial Endoscopic Perforating Vein Surgery (SEPS) in Patients with Stasis Ulcerations: How to get the knack of simplified SEPS for beginners

Leg ulcer treatment

Venous ulcers continue to cause problems for patients and health care systems. These are painful and unpleasant for the patient and expensive for health care providers to treat. This brief review highlights effective methods of management. There is level 1 evidence of the efficacy of compression (bandaging or stockings) in healing ulcers as well as maintaining healing. Patients with superficial saphenous reflux, with or without perforating and deep vein incompetence, benefit from superficial venous surgery. This does not speed ulcer healing but is effective at preventing recurrence after healing with compression. Minimally invasive methods of managing incompetence of superficial saphenous trunks, including endovenous laser ablation, radiofrequency ablation, and foam sclerotherapy are probably also effective in treating patients with venous leg ulcers. Perforating vein ligation is commonly combined with superficial venous surgery for leg ulcer patients, but no systematic data are available to define the role of this treatment. Some centers use deep vein reconstruction to restore competence to deep vein valves. Insufficient data have been published to allow any general recommendation to be made for this treatment. A limited number of drugs have efficacy in promoting leg ulcer healing. They may be used in combination with compression treatment in patients with ulcers refractory to other methods of management. No particular ulcer dressing has been shown to be effective in speeding ulcer healing.

Lateral Subfascial Endoscopic Perforating Vein Surgery as Treatment for Lateral Perforating Vein Incompetence and Venous Ulceration

The aim of this study was to evaluate the clinical results of lateral subfascial endoscopic perforating vein surgery (SEPS). Our study was conducted from February 2002 to January 2007. Sixty-three patients with lateral incompetent perforating veins (IPVs) and venous ulceration were allocated to two groups. Group 1 comprised 31 patients (33 limbs) who underwent only routine surgery (saphenofemoral or saphenopopliteal ligation, stripping, phlebectomies, endovascular laser treatment [EVLT], medial SEPS, and skin grafting). Group 2 comprised 32 patients (35 limbs) who underwent our routine surgery with the addition of lateral SEPS. Bidirectional ultrasonography was performed before the operation, and 6 weeks, 6 months, and 1 year after surgery. Clinical score and disability score were collected at the same time. Twenty-nine (87.9%) of 33 limbs with active ulcers in group 1 healed, with recurrence in four (12.1%) limbs at follow-up at 25.9 +/- 10.0 months. All 35 limbs in group 2 healed, with recurrence in 0 (0.0%) limbs at follow-up at 25.4 +/- 10.1 months. Lateral SEPS could reduce the rate of recurrence of ulcers (Kaplan-Meier analysis). Patients in group 2 also showed improvement in clinical and disability scores, although they were not statistically significant differences (t test, p > 0.05). A significantly higher proportion of patients in group 1 had IPVs on the lateral aspect of the lower leg on ultrosonography imaging. Lateral SEPS could contribute to ulcer healing and reduce ulcer recurrence. The addition of lateral SEPS to routine surgery did reduce the number of IPVs. Lateral SEPS may be safe and effective for lateral perforating vein incompetence and venous ulceration.

Meta-analysis of subfascial endoscopic perforator vein surgery (SEPS) for chronic venous insufficiency

The degree of benefits and risks, and the role of subfascial endoscopic perforator vein surgery (SEPS) in the management for chronic venous insufficiency (CVI) remains uncertain. A multiple health database search was performed including Medline, Embase, Ovid, Cochrane Database of Systematic Reviews, and Cochrane Database of Abstracts of Reviews of Effectiveness, on all studies published between 1985 and 2008 that reported on health outcomes in patients with CVI treated with SEPS and comparing this therapy with the conventional Linton procedure. Three studies, which compared SEPS with conventional surgery, were included in the present meta-analysis. Between SEPS and Linton groups, there was a significant lower rate of wound infections for SEPS (odds ratio [OR] 0.06 [95% confidence interval (CI) 0.02 to 0.25]) and a significantly reduced hospital stay for SEPS (OR -8.96 [95% CI -11.62 to -6.30]). In addition, SEPS was associated with a significant reduced rate of recurrent ulcers (mean follow-up 21 months) (OR 0.15 [95% CI 0.04-0.62]). There was no significant difference between the groups in the following dimensions: rate of hospital re-admission (OR 0.21 [95% CI 0.03-1.31]), death at six months (OR 3.00 [95% CI 0.11-78.27]), ulcer healing rate at four months (OR 0.44 [95% CI 0.09-2.12]), and the rate of deep vein thrombosis (DVT) (OR 0.35 [95% CI 0.01-8.85]). From the level of evidence available by now it seems that SEPS, used as a part of a treatment regimen for severe CVI, benefits most patients in the short term regarding ulcer healing and the prevention of ulcer recurrence. It can be safely performed with less early postoperative complications compared with the Linton procedure. However, further prospective randomized trials are required to define the long-term benefits of SEPS.

Evaluation of subfascial endoscopic perforator vein surgery (SEPS) using harmonic scalpel in varicose veins: An observational study

Introduction Conventional modalities used to treat varicose veins with incompetent perforators and subsequent stasis ulceration have proved to be effective, however there are associated morbidities, such as postoperative pain, limited mobility, wound infection and dehiscence. Recent advances have been made in minimally invasive vein surgery techniques to decrease operative morbidity, number and size of incisions, recovery time, and operative time. Methods A prospective study of 21 patients of varicose veins with incompetent perforators undergoing subfascial endoscopic perforator vein surgery (SEPS) using harmonic scalpel was designed and various parameters were studied. Results All ulcers healed in 8 weeks with no recurrence in 11.9 months follow-up period. One case of wound infection and each saphenous nerve neuropraxia were the only postoperative complications noted. Conclusion Use of ultrasonic scalpel in SEPS is technically feasible, causes less tissue damage as it generates a low thermal effect, and is associated with minimal morbidity.

Use of Ultrasonic Scalpel in Subfascial Endoscopic Perforator Vein Surgery: A Novel Approach

The aim of this study was to determine the feasibility of using the ultrasonic scalpel in subfascial endoscopic perforator vein surgery (SEPS) and study the results of ulcer healing and reversal of skin changes. From January 2003 to November 2005, we performed 47 SEPS in 42 patients under spinal anesthesia, using the two-port technique. All patients had chronic venous insufficiency ranging from class IV to VI. Duration of surgery for SEPS averaged 30 minutes, with no postoperative mortality. One patient developed a wound infection at the port site, which was managed conservatively. None of the procedures required a conversion to open surgery. We have had no recurrence of venous ulcer, so far. Barring 1 patient, all patients returned to normal routine within 5 days of surgery. In more then 90% of patients, ulcer healing was achieved within 8 weeks of surgery. Our study clearly shows that the ultrasonic scalpel is a very safe, reliable tool in SEPS, as there was very low morbidity regarding wound complications and other per- or postoperative complications, which can be there when one uses the metallic clips or electrocautery for SEPS.

Subfascial endoscopic perforator vein surgery (SEPS) modified technique: Subaponeurotic approach without balloon

Subfascial Endoscopic Perforator Vein Surgery (SEPS) is one of the best procedures and a minimally invasive option for treating chronic venous insufficiency. We explain our experience with SEPS, which has been turned into a subaponeurotic approach without balloon, and assess the possible advantages of this technique. The subaponeurotic space was entered using the Visiport Plus® (Autusuture, Tyco Healthcare) video‐assisted technique, which shows how the trocar enters through the subcutaneous tissue and superficial aponeurosis of the leg. A blunt retractor was inserted which, together with CO2 insufflation (20 mm Hg), enabled the veins to be dissected. Ligation was performed using tripolar sealing. In no case was a balloon used. There were no incidents such as haemorrhage or subcutaneous emphysema during the procedure. The patients (n = 206) remained in the hospital for less than 24 hours and suffered no post‐surgical complications. Active ulcers were cured, with no relapses, in 100% of cases. This is a very effective method for treating advanced chronic insufficiency because it prevents local damage and the rate of post‐surgical complications is low. Technically it has more advantages because the fact that it does not use a balloon means that it exerts less pressure on the tissues.

Results of Subfascial Endoscopic Perforating Vein Surgery (SEPS) with or without Superficial Venous Ablation (SVA) in Patients with Stasis Ulcerations and the Subjects to Popularize SEPS±SVA

Results of Subfascial Endoscopic Perforating Vein Surgery (SEPS) with or without Superficial Venous Ablation (SVA) in Patients with Stasis Ulcerations and the Subjects to Popularize SEPS±SVA

Lokale operative Ulkustherapie

Leg ulcer is a polyaetiologic condition the successful treatment of which is decisively influenced by correct diagnosis of the underlying cause. About 76% of leg ulcer cases are due to chronic venous insufficiency. Nonhealing venous leg ulcers are the domain of local surgical therapy with a variety of symptomatic and causal surgical methods. Shave therapy is the treatment of choice, with relatively low invasiveness and good long-term results. Today subfascial endoscopic perforator vein surgery and the surgical treatment of fascia cruris (fasciotomy, fasciectomy) are used rarely but increasingly indicated. Long-lasting healing is decisively influenced by thorough follow-up treatment with complex physical compression treatment and exercises following the surgical treatment of nonhealing venous leg ulcers.

Subfascial endoscopic perforator vein surgery using balloon dissector and saphenous vein surgery in chronic venous insufficiency

Subfascial endoscopic perforator vein surgery (SEPS) has recently been a popular alternative to classical surgical methods in the treatment of severe venous insufficiency of the lower extremity. Yet, there are not many reports concerning this less invasive operation, and many modified methods are applied. We would like to report the clinical results of our country's first SEPS operations performed by using balloon dissector. The SEPS via two ports and using balloon dissector with saphenous vein stripping and phlebectomy in patients with severe venous insufficiency. Pneumatic tourniquet has never been applied. Twenty-eight operations were performed on 28 patients (13 female, 15 male). Active open ulcers were present in four legs, ulcer scars were present in two patients, skin changes were present in 12 legs and severe oedema was present in 10 legs. An improvement in all clinical findings and complaints was determined following the operations. A significant drop was determined in chronic venous insufficiency scores. No serious complication requiring rehospitalization of the patients was observed. All the patients were followed up for six months, and none presented again with any complaints. SEPS using balloon dissector with saphenous vein surgery we performed is an effective, reliable and promising method.

Transcutaneous Oxygen Pressure (tcPO<sub>2</sub>) Predicts Venous Ulcer Healing in Chronic Venous Insufficiency Patients Treated by Subfascial Endoscopic Perforator Vein Surgery

Transcutaneous Oxygen Pressure (tcPO<sub>2</sub>) Predicts Venous Ulcer Healing in Chronic Venous Insufficiency Patients Treated by Subfascial Endoscopic Perforator Vein Surgery