Chapter 158 - Perforator vein incompetence

Question 1

First description of perforator veins

Answer 1

1794 Justus Christian Von Loder

Question 2

First suggestion that incompetent perforating veins cause venous ulcers

Answer 2

1917 John Homans

Question 3

Cockett and Dodd on perforator veins

Answer 3

Physiologial basis for the surgical interruption of IPV

Question 4

Who came up with surgical approach to IPV in distal calf

Answer 4

Linton 1938

procedure since then abandonned

Question 5

First description of SEPS

Answer 5

Subfascial endoscopic perforating vein surgery

Hauer 1980’s
Gloviczki and Conrad

Question 6

PAPS procedure

Answer 6

Ultrasound-guided percutaneous ablation of perforating veins

using sclerosing solution or thermal energy

Question 7

Number of PV in lower extremity on average

Answer 7

60

most/all have valves

Question 8

Direction of flow of PV in normal situation

Answer 8

From superficial into deep

Question 9

Dutch ulcer trial key points

Answer 9

1) surgery vs compression in IPV therapy
2) ulcer healing 83 vs 73%
3) ulcer recurrence same in both 22-23%

design of trial not ideal
controversial

Question 10

Goals for treating IPV

Answer 10

1) normalization of venous hemodynamics
2) prevention of progression of CVD to more advanced stages
3) resolution of symptoms and decrease disease severity
4) prevention of recurrent varicose veins
5) promotion of ulcer healing
6) prevention of recurrent venous ulcer

Question 11

Direct vs indirect perforators

Answer 11

Direct: superficial to deep
Indirect: venous sinuses of calf muscles

Question 12

In the fascial oriface, artery in relation to vein is

Answer 12

proximal

Question 13

International interdisciplinary consensus committee on venous anatomical terminology 6 groups

Answer 13

1) perforator of the foot (venae perforantes pedis)
2) ankle (tarsalis
3) leg (cruris)
4) knee (genus)
5) thigh (femoris)
6) gluteal muscles (glutealis)

Question 14

Important perforators

Answer 14

1) direct medial calf perforators
2) PT PV from posterior accessory saphenous vein (arch vein) of calf
3) most distal perforator behind medial malleolus
4) 7-9 cm and 10-12cm from medial malleolus are middle and upper PT PV
5) Cockett perforators
6) paratibial direct perforator “24-cm” (18-22cm from medial malleolus)
7) Boyd perforators
8) posterolateral/peroneal perforators: SSV tributaries to peroneal vein
9) Bassi perforators
10) 12 cm perforator (12-14 cm)
11) Dodd perforators
12) Hunterian perforators

Question 15

Cockett perforators

Answer 15

posterior arch vein to posterior tibial vein

calf

Question 16

Boyd perforators

Answer 16

GSV and tributaries to tibial or popliteal veins

below knee

Question 17

Bassi perforators

Answer 17

5-7 cm from lateral aspect of ankle connecting SSV to peroneal

Question 18

Dodd perforators

Answer 18

GSV in distal thigh to femoral/popliteal

Question 19

Hunterian perforator

Answer 19

GSV to femoral proximal thigh

Question 20

Clinical exam for IPV

Answer 20

1) fascial defect palpation
2) retrograde flow during valsalva or cough

sensitivity very poor even with doppler

Question 21

AVF/SVS guidelines on IPV

Answer 21

1) treat IPV with reflux 0.5 s and diameter > 3.5 mm located adjacent to ulcer (C5, C6)
2) treat pathologic PV in patients with C4
3) Don’t treat C2
4) percutaneous technique better than open

Question 22

Definition of pathologic PV

Answer 22

Outward flow > 500 ms

Diameter > 3.5 mm

Question 23

ESCHAR on IPV treatment

Answer 23

No benefit

presence of IPV didn’t increase ulcer recurrence

Question 24

Open interruption of IPV success rate and recurrence

Answer 24

5% missed

32% recurrence 3 years

Question 25

SEPS steps

Answer 25

1) 1-2 endoscopic ports after exanguination of limb and leg elevation
2) tournequet to 300 mmHg at thigh
3) CO2 insufflation in subfascial space pressure 30 mmHg
4) manual expression of CO2 at end of procedure

Question 26

Complication of SEPS

Answer 26

DVT < 1%
superficial thrombophlebitis 3%
saphenous neuralgia 7%
recurrence 28% 2 years
Poor effect in post-thrombotic limbs

Question 27

Shortcomings of SEPS

Answer 27

1) expensive
2) learning curve
3) inability to access IPV from normal PV intraop

Question 28

Percutaneous ablation of perforating veins (PAPS) key points

Answer 28

1) access perifascial IPV or superficial segment adjoining
2) perforating artery has to be avoided
3) determine success with duplex or by visualizing the artery dilation
4) cannot visualize well if foam sclerotherapy used and need to wait 24 hours

Question 29

PAPS techniques

Answer 29

1) laser 0.5 cm away from deep system
2) Closure RFS RFA 0.5 cm away from deep system
3) sclerotherapy for diameter 4-7 mm at level of fascia; 1-2 ml used

Question 30

Contraindication to sclerotherapy PAPS

Answer 30

1) allergy
2) pregnant or lactating
3) VTE
4) arterial occlusive disease
5) vasculitis

Question 31

Issues with PAPS

Answer 31

1) success is high but recurrence 23% at 17 months
2) hard to determine if recurrence is due to true recurrence or new perforator
3) lack study to compare different modalities