Overview
Definition:
Perforator vein ablation, commonly known as Subfascial Endoscopic Perforator Surgery (SEPS), is a minimally invasive surgical technique used to ligate and ablate incompetent perforating veins of the lower limb
These veins connect the superficial and deep venous systems and, when incompetent, contribute to venous hypertension and the development of venous stasis ulcers and other symptoms of chronic venous insufficiency (CVI)
SEPS utilizes an endoscope inserted through a small incision to visualize and ligate these perforating veins under the fascia.
Epidemiology:
Chronic venous insufficiency (CVI) affects a significant portion of the adult population, with prevalence increasing with age
Approximately 10-20% of individuals in Western populations exhibit symptoms of CVI, and incompetent perforator veins are a significant underlying pathology in a substantial subset of these patients, particularly those with active or healed venous ulcers
SEPS is considered in patients refractory to conservative management.
Clinical Significance:
Incompetent perforating veins are a critical component of CVI pathophysiology, leading to increased venous pressure in the superficial system, edema, skin changes (pigmentation, lipodermatosclerosis), and potentially venous ulceration
Effective treatment of these perforators, as achieved by SEPS, is crucial for alleviating symptoms, promoting ulcer healing, and preventing recurrence of ulceration
It offers a targeted approach to a specific anatomical problem in venous disease, complementing other treatments for superficial venous reflux.
Indications
Indications For Seps:
SEPS is primarily indicated for patients with chronic venous insufficiency and venous ulceration that is refractory to conservative management (compression therapy, wound care)
Specific indications include:
Documented incompetence of perforating veins, often confirmed by duplex ultrasound, particularly those in the gaiter region.
Active venous ulceration that is not healing with optimal wound care and compression.
Recurrent venous ulceration after previous treatments.
Patients with symptoms of venous claudication or significant edema attributed to perforator incompetence.
Contraindications:
Absolute contraindications are rare and generally include active deep vein thrombosis (DVT) in the ipsilateral limb, severe arterial insufficiency precluding wound healing, and patient refusal
Relative contraindications might include severe comorbidities, extensive cellulitis, or a very short life expectancy
Patients with predominantly superficial venous reflux and no significant perforator incompetence may not benefit from SEPS.
Patient Selection Criteria:
Careful patient selection is paramount
This involves a thorough history, physical examination to assess the extent and severity of venous disease, and detailed duplex ultrasound mapping to identify and characterize incompetent perforators
The severity of venous stasis, the presence and characteristics of ulceration, and the response to conservative measures are all crucial in determining candidacy for SEPS
The ulcer should be primarily caused by perforator incompetence, not other etiologies.
Preoperative Preparation
Diagnostic Workup:
Preoperative assessment typically includes a comprehensive venous duplex ultrasound to map superficial and deep veins, identify incompetent perforators, and assess reflux
Venous pressure measurements (e.g., foot volumetry) may be used in select cases
Arterial assessment of the lower limbs is essential to rule out significant arterial disease that could impair healing.
Conservative Management Trial:
A trial of conservative management, including compression therapy (graduated compression stockings) and adequate wound care for ulcers, is usually a prerequisite for considering SEPS
Failure to achieve healing or significant symptom relief despite optimal conservative measures is a key indicator for surgical intervention.
Patient Counseling:
Patients should be counseled regarding the nature of the procedure, its benefits, potential risks (including infection, bleeding, nerve injury, recurrence), and alternatives
Realistic expectations about healing times and the need for continued compression postoperatively are crucial.
Anesthesia Considerations:
SEPS can be performed under local anesthesia with sedation, regional anesthesia (spinal or epidural), or general anesthesia, depending on patient factors and surgeon preference
The choice of anesthesia should be discussed with the anesthesiologist.
Procedure Steps
Endoscopic Access:
The procedure begins with identifying the site of incompetent perforators, typically guided by preoperative ultrasound
A small incision (usually 1-2 cm) is made over the planned access point, usually in the distal calf or ankle region
A blunt dissector is used to create a subfascial tunnel, and a trocar is inserted through the incision to create a pneumoperitoneum or carbon dioxide insufflation within the subfascial space, allowing for visualization.
Perforator Identification And Ligation:
The endoscope is inserted into the subfascial space
Using endoscopic instruments, the perforating veins are carefully identified
They are then ligated, typically using sutures or clips, and transected to obliterate their lumen
Multiple perforators can be addressed through a single access site or multiple sites as needed.
Wound Closure:
Once all targeted perforators are ligated, the endoscopic instruments and trocar are removed
The small incision is then closed with sutures
Compression dressings are applied to the limb to minimize edema and promote healing.
Postoperative Care And Follow Up
Immediate Postoperative Management:
Patients are typically monitored for bleeding and pain
Ambulation is encouraged early, usually within 24 hours, to promote venous return and reduce the risk of DVT
Compression bandaging or stockings are applied immediately after surgery.
Wound Care:
Wound care is generally straightforward, with dressings changed as needed
Patients are instructed on signs of infection and advised to keep the wounds clean and dry.
Compression Therapy:
Long-term, consistent use of graduated compression stockings is essential after SEPS to maintain venous hemodynamics, prevent recurrence of reflux, and support ulcer healing
The type and strength of compression should be tailored to the individual patient.
Follow Up Schedule:
Follow-up appointments are scheduled to assess wound healing, evaluate symptom improvement, monitor for complications, and ensure adherence to compression therapy
Duplex ultrasound may be performed at follow-up to assess the durability of the perforator ligation and identify any new areas of reflux.
Complications
Early Complications:
Immediate complications can include bleeding, hematoma formation, infection at the incision site, superficial venous thrombosis, and nerve irritation or injury (leading to paresthesia or transient motor deficits)
Deep vein thrombosis is a rare but serious complication.
Late Complications:
Late complications can include recurrence of venous insufficiency due to recanalization of ligated perforators or development of new incompetent perforators, chronic pain, persistent edema, skin changes, and poor wound healing if underlying venous hypertension is not adequately managed postoperatively
Scarring at the incision sites can also occur.
Prevention Strategies:
Meticulous surgical technique, appropriate patient selection, prophylactic antibiotics if indicated, early ambulation, and strict adherence to postoperative compression therapy are key to preventing complications
Careful identification and ligation of all incompetent perforators are critical for long-term success and preventing recurrence
Thorough preoperative arterial assessment helps prevent complications related to poor wound healing.
Key Points
Exam Focus:
SEPS targets incompetent perforating veins in CVI, particularly for ulcer management
Key imaging modality is duplex ultrasound
Postoperative compression is paramount for success
Recurrence is a significant concern if compression is not maintained.
Clinical Pearls:
Consider SEPS in recalcitrant venous ulcers where perforator incompetence is the primary driver
Never neglect arterial assessment in patients with venous disease
The success of SEPS is highly dependent on patient compliance with long-term compression therapy.
Common Mistakes:
Failing to adequately assess for arterial disease preoperatively
Incomplete ligation of all significant incompetent perforators
Insufficient or non-adherent postoperative compression therapy
Misattributing ulcer etiology solely to perforator incompetence without considering other factors.