Redone endoscopic perforator surgery: Feasibility and failure analysis

Purpose: In many hospitals and medical practices, subfascial endoscopic per forator surgery (SEPS) has become the treatment of choice in patients with incompetent perforator veins and active venous ulcers. A substantial number of surgeons consider SEPS to be an operation that can be performed only on ce because extensive scarring and narrowing of the subfascial space make a second endoscopic operation impossible. It is the purpose of this report to prove the feasibility, efficacy, and safety of a second SEPS procedure. Methods: Within a period of 30 months, 105 primary SEPS procedures were per formed in patients with healed or still active ulcers. In addition to these cases, within a period of 30 months, a consecutive number of 19 patients w ere examined and scheduled for a second SEPS procedure. All patients were i n class 5 with healed ulcers or in class 6 with still active ulcers. The CE AP classification of the American Venous Forum was used to evaluate the res ults and to calculate the clinical, disability, and outcome scores. The red one operation was performed by using CO2 insufflation, a dual-port techniqu e, and subfascial balloon dissection. Results: In two patients conversion to a conventional procedure was necessa ry. There were no major complications, but there was a 21% incidence of min or problems, such as hematoma or cellulitis. The mean total clinical score improved after surgery from 7.91 to 3.23 (P < .01), the disability score ch anged from 1.10 to 0.57 after surgery (P < .02), and the clinical outcome s core was 1.47 after surgery (P < .001). Cumulative ulcer healing could be a chieved in 85.8% of class 6 patients. Failure analysis revealed that an inc omplete subfascial dissection had been performed during the first endoscopi c operation. A septum intermusculare medialis or an intact deep posterior f ascia with incompetent Cockett II perforators were major factors contributi ng to the initial treatment failures. In addition to incompetent perforator s, postthrombotic deep venous reflux was seen in eight (42.1%) patients, an d four (21%) patients had a combination of secondary reflux and obstruction . Conclusion: Subfascial endoscopic procedures can be redone safely. In addit ion to exploring the superficial posterior compartment, the deep posterior compartment must be opened to prevent recurrent symptoms in patients with i ncompetent perforator veins.