1. The Perplexing Perforator: SEPS, PAPS, nothing
The Perplexing Perforator: SEPS, PAPS, nothing? SAVS Postgraduate Course 2008
Bill Marston MD
Division of Vascular Surgery
University of North Carolina at Chapel Hill
Jan 2008

2. Introduction
Incompetent perforating veins have been demonstrated in the majority of patients with severe CVI
Class 3 52%
Class 4 83%
Class 5/6 90%
Stuart et al, J Vasc Surg 32:138

3. Diameter-reflux relationship of perforating veins
Sandri et al J Vasc Surg 1999;30:867-75
As diameter enlarges, increasing incidence of outward flow on compression
Perforator diameter
Incidence of reflux
2.0 mm
10%
2.5 mm
50%
3.0 mm
80%
3.5 mm
4.0 mm
88%

4. The perforator as gate-keeper to the skin
Perforator should only allow inward flow from superficial to deep
Competence of valves in perforators critical to protecting superficial tissues from transiently elevated deep venous pressures

5. Varying viewpoints concerning relevance of perforators
Nihilists
Minimalists

6. Critical perforator vein questions
What is the definition of a clinically significant incompetent perforator?

7. Standard definition of IPV is required
Position of limb
Criteria of reflux
Sybrandy et al
Standing
> 0.3 seconds of reflux
Delis et al
JVS 2001;33:773
Sitting, leg supported
> 0.5 secs of reflux x 3, size > 3.5 mm
Stuart et al
Seated
Any deep to superficial flow
Tawes et al
Not stated
Any reverse flow OR any perforator
> 2.5 mm diam

8. Question #1: definition of a clinically significant incompetent perforator
We don’t know
Perforators of larger diameter are worse
Personal favorite
> 3.5 mm diameter at fascia
> 0.5 seconds of outward flow

9. 2. When should we attempt to correct perforator incompetence?
Whenever they are diagnosed if the patient has significant symptoms
Only after correcting other sources of venous insufficiency if limb remains symptomatic

10. Repair all IPVs Tawes et al J Vasc Surg 2003;37:545
832 patients with IPVs identified and SEPS
55% concomitant saphenous surgery
92% of ulcers significantly improved
4% incidence of ulcer recurrence
“Until level 1 evidence is available, SEPS is advocated as optimal therapy for CVI”

11. How can we separate effect of saphenous surgery from potential effect of perforator ligation? Ablate/Remove superficial system first, then treat IPVs if still necessary

12. Stuart et al, Edinburgh, UK
62 limbs with superficial and perforator incompetence
21% also demonstrated deep insufficiency
Performed superficial surgery only
Postop duplex evaluation of perforators
80% of patients with mainstem reflux abolished had no IPVs remaining
If mainstem reflux (deep or superficial) remained after surgery, 72% still had IPVs
J Vasc Surg 1998;28:834

13. Stuart et al
Most IPVs are found in association with superficial venous reflux
Although the presence of IPVs is associated with venous ulceration… many of these may be corrected by saphenous surgery alone
J Vasc Surg 2001;34:774

14. Hemodynamic results when IPVs not ligated
Mendes et al, Univ of N. Carolina
24 limbs with both superf and perf incomp
IPV defined as > 3mm and >0.5 sec reflux
Superficial surgery performed
IPVs not ligated
APG and Duplex performed pre and post-op
* JVS Nov 2003

15. Mendes et al: Results
On post-op Duplex, 71% of IPVs were no longer incompetent after superficial surgery
Normal < 2 ml/sec
6.0
2.2
Preop Postop
P < 0.001

16. Venous symptom score decreased significantly after superficial ablation

17. Randomized trial of SEPS vs conservative treatment
Dutch SEPS trial: Wittens et al
200 patients randomized, 97 to ambulatory compression, 103 to SEPS + saphenous surgery when indicated
Deep venous insuff present in 55%
Mean follow-up 29 months

18. Conservative group
Surgery group
Rate of ulcer healing
73%
83%
Rate of ulcer recurrence
22%
23%
Dutch SEPS trial conclusions:
-In selected cases with larger ulcers or longer duration
surgery did influence healing and recurrence rates
-Overall, SEPS did not influence healing or cure

19. Question #2 When should we attempt to correct perforator incompetence?
Cannot yet answer this question based on available evidence
Effect of superficial venous surgery or ablation typically confounds assessment of role of perforator procedures

20. 3. What is the best method of treating IPVs?
SEPS
PAPS
Extrafascial ablation of perforator outflow tract

21. SEPS

22. SEPS: Results North American SEPS registry
146 patients, 84% CEAP class 5 or 6
71% concomitant superficial procedures
88% of ulcers healed 1 year after surgery
Ulcer recurrence
28% at 2 years
46% in post-thrombotic limbs
20% in limbs with primary valvular incomp
Gloviczki et al, J Vasc Surg 1999;29:489

23. Comparative trials of SEPS vs Linton procedure
Pierik et al
39 patients prospectively randomized to SEPS or Linton
Linton n=19
SEPS n=20
P value
Wound infx
10 (53%)
<0.001
Nerve injury
2 (11%)
0.23
Blood loss
170 43
Hosp stay
4 days
1 day

24. Comparative trials of SEPS vs Linton procedure
Sybrandy et al, J Vasc Surg 33:
Linton n=19
SEPS n=20
P value
Ulcer healing
100% at 4 months
85% at 4 months NS
Ulcer recurrence
22% at 48 months
12% at 48 months
New IPVs
45% at 48 months
42% at 48 months
Deep venous insuff increased incidence of new IPVs but not recurrent ulcers

25. Percutaneous Ablation of Perforators
PAPS
Percutaneous Ablation of Perforators

27. RFA perforator ablation
US guided access
Confirm intraluminal site with impedance Ohms
Local tumescence
Apply energy at 85o to 4 quadrants I min each
Withdraw I-2 mm and repeat
Fig E. Radiofrequency Catheters

28. Laser perforator ablation
Use 400 micron fiber
Micropuncture needle access under US at or just below fascia
Aspirate to confirm placement
Tumescent anesth
Ablate at W for 4-5 seconds
Withdraw 1-2 mm and repeat

29. Courtesy Steve Elias, Englewood, NJ
Fig A. Catheter/needle at fascia level
Courtesy Steve Elias, Englewood, NJ

30. Courtesy Steve Elias, Englewood, NJ

31. PAPS - results RFA Lumsden SCVS 34 IPVs treated intravascularly
91% occlusion rate at 3 week f/u visit
2 asymptomatic tibial vein thromboses (6%)
Laser
Elias et al (submitted)
50 IPVs treated with average 120 j energy per segment
90% occlusion rate at 1 month f/u
No significant DVT noted

32. 3. What is the best method of treating IPVs?
SEPS
Success at perf interruption well established
Typically requires OR setup
PAPS
Early results encouraging
Rapid office based procedure
Extrafascial ablation
70-80% of IPVs will correct

33. How can we determine the hemodynamic significance of IPVs?
Difficult to determine due to frequency of coexistent superficial and/or deep insufficiency
Which perforators require correction in absence of superficial disease?
Which perforators should be corrected in the face of uncorrected deep venous insufficiency?

34. Delis et al: JVS 2001;33:773
Proposed that all perforators that demonstrate reflux are not equal
Must look at reflux patterns for hemodynamic importance
Diam 3.1 mm

35. Variability of “incompetent perforators”
Diameter 5.8 mm

36. Consider significance of each IPV in transmitting pressure
Potential differentiators
Size
Reflux velocity and duration
Volume flow of reflux

37. Incompetent perforator in symptomatic patient
Size > 4mm
High V reflux
Size < 4mm
Low velocity reflux

38. Incompetent perforator in symptomatic patient
Size > 4mm
High V reflux
Size < 4mm
Low velocity reflux
Leave alone unless
No other cause of
Venous symptoms
identified

39. Incompetent perforator in symptomatic patient
Size > 4mm
High V reflux
Size < 4mm
Low velocity reflux
Correct IPV reflux
Leave alone unless
No other cause of
Venous symptoms
identified
SEPS
PAPS
EF ablation

40. Incompetent perforator in symptomatic patient
Size > 4mm
High V reflux
Size < 4mm
Low velocity reflux
Correct IPV reflux
Leave alone unless
No other cause of
Venous symptoms
identified
SEPS
PAPS
EF ablation