Subfascial endoscopic perforator vein surgery: indications and results

Subfascial endoscopic perforator surgery (SEPS) is a new, minimally invasiv e technique performed in patients with advanced chronic venous insufficienc y. The objective of the operation is to interrupt incompetent medial calf p erforating veins to decrease venous reflux and reduce ambulatory venous hyp ertension in critical areas above the ankle where venous ulcers most freque ntly develop. Patients with stasis skin changes and healed or active venous ulcerations are potential candidates for the operation. Preoperative evalu ation is performed with duplex scanning of the superficial, deep and perfor ator system, to diagnose both obstruction and valvular incompetence. Result s of the North American SEPS Registry (NASEPS) as well as experience in sev eral individual centers confirmed that the operation has significantly fewe r wound complications than the classic open surgical techniques, and that r apid ulcer healing can be achieved. At the Mayo Clinic an ulcer recurrence rate of 12% was observed, with recurrence significantly more frequent in po st-thrombotic limbs than in patients with primary venous valvular incompete nce. The NASEPS Registry report confirmed a 2-year cumulative ulcer recurre nce rate of 28%; ulcer recurrence was significantly more frequent in post-t hrombotic limbs, especially in those with deep venous obstruction. SEPS is a new, low-risk, outpatient procedure that effectively decreases pe rforator 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 t o provide level I evidence of late efficacy.