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

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Presentation on theme: "The Perplexing Perforator: SEPS, PAPS, nothing? SAVS Postgraduate Course 2008 Bill Marston MD Division of Vascular Surgery University of North Carolina."— Presentation transcript:

1 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 352% Class 483% Class 5/690% Stuart et al, J Vasc Surg 32:138

3 Diameter-reflux relationship of perforating veins Sandri et al J Vasc Surg 1999;30: As diameter enlarges, increasing incidence of outward flow on compression Perforator diameterIncidence of reflux 2.0 mm10% 2.5 mm50% 3.0 mm80% 3.5 mm80% 4.0 mm88%

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 NihilistsMinimalists

6 Critical perforator vein questions 1.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 alStanding> 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 alSeatedAny deep to superficial flow Tawes et alNot statedAny 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 alJ 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 P < Normal < 2 ml/sec Preop Postop

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=19SEPS n=20P value Wound infx10 (53%)0<0.001 Nerve injury2 (11%)00.23 Blood loss17043<0.001 Hosp stay4 days1 day<0.001

24 Comparative trials of SEPS vs Linton procedure Sybrandy et al, J Vasc Surg 33: Linton n=19SEPS n=20P value Ulcer healing 100% at 4 months 85% at 4 months NS Ulcer recurrence 22% at 48 months 12% at 48 months NS New IPVs45% at 48 months 42% at 48 months NS Deep venous insuff increased incidence of new IPVs but not recurrent ulcers

25 PAPS Percutaneous Ablation of Perforators

26

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

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

30

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 Low velocity reflux Size > 4mm High V reflux

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

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

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


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