Surgical treatment of the superficial and perforating veins

Objective: To review the techniques and results of surgical treatment of th e superficial and perforating veins in patients with chronic venous insuffi ciency. Methods: The current techniques used at the Mayo Clinic for treatment of si mple varicose veins and venous ulcers are presented. Results of subfascial endoscopic perforator vein surgery (SEPS) are discussed and data from large centres are tabulated. Results are compared with those reported following non-operative management. Synthesis: High ligation and invagination stripping of the incompetent segm ent of the saphenous vein, with stab avulsion of branch varicosities, is th e optimal surgical technique to ablate superficial venous incompetence. SEP S is safer than open perforator vein ligation and is the technique of choic e to interrupt incompetent perforating veins. A review of 12 series on SEPS , that included 361 limbs, found an ulcer recurrence rate of 10% in those 2 11 patients who underwent ablation of superficial reflux together with SEPS . One hundred and fifty limbs had SEPS alone, without saphenous stripping: ulcer recurrence in this group at a mean of 23 months was 12%. Results in p rimary valvular incompetence were significantly better than in post-thrombo tic syndrome. Conclusions: Ablation of superficial reflux remains the main surgical treat ment of all forms of chronic venous insufficiency. SEPS is safe and effecti ve to interrupt medial calf perforators and results in rapid ulcer healing and low recurrence in patients with primary valvular incompetence. The trea tment of post-thrombotic syndrome remains a challenge. Results of the North American Venous Ulcer Surgery (NAVUS) trial, a prospective, randomised, mu lticentre study, will be required to provide level 1 evidence of the effect iveness of surgical treatment over medical therapy in the treatment of veno us ulcers.