Mid-term recurrence rate of incompetentperforating veins after combined superficial veinsurgery and subfascial endoscopic perforatingvein surgeryFlorian Roka, MD, Michael Binder, MD, and Kornelia Bohler-Sommeregger, MD, Vienna, Austria

Background: This study investigated the mid-term (mean, 3.7 years) clinical results and the results of duplex Dopplersonographic examinations of subfascial endoscopic perforating vein surgery (SEPS) in patients with mild to severechronic venous insufficiency (clinical class 2-6) and assessed the factors associated with the recurrence of insufficientperforating veins (IPVs).Methods: Eighty patients with mild to severe chronic venous insufficiency undergoing SEPS were evaluated, and duplexfindings, as well as clinical severity and disability scores before and after the operation, were compared. Patients with priordeep vein thrombosis (<6 months) or prior SEPS were excluded from this study.Results: There were 27 men and 53 women with a median age of 59.8 years (range, 34.3-80.0 years). The distribution ofclinical classes (CEAP) was as follows: class 2, 13.1% (12 limbs); class 3, 22.8% (21 limbs); class 4, 19.6% (18 limbs); class5, 21.7% (20 limbs); and class 6, 22.8% (21 limbs). The etiology of venous insufficiency was primary valvularincompetence in 83 limbs (90.2%) and secondary disease in 9 limbs (9.8%). Concomitant superficial vein surgery wasperformed in 89 limbs (95.7%). Twenty (95%) leg ulcers healed spontaneously within 12 weeks after operation, whereasone patient required additional split-thickness skin grafting. Eighteen patients had previous surgery of the great and/orshort saphenous vein before SEPS. During a mean follow-up of 3.7 years, recurrence of 22 IPVs was observed in 20(21.7%) of 92 limbs, and recurrent leg ulcers were observed in 2 (9.5%) of 21 limbs. We performed univariate andmultivariate analyses to predict factors influencing the recurrence of IPVs (recurrent superficial varicosis, secondarydisease, active or healed leg ulcer [C5/6], compression treatment, and previous operation). On multivariate analysis,previous surgery (P � .014) was identified as the only significant factor for the recurrence of IPVs.Conclusions: SEPS is a safe and highly effective treatment for IPVs. Within a median follow-up period of 3.7 years, only2 of 21 venous ulcers recurred, both in patients with secondary disease. Nevertheless, we observed recurrence of IPVs in21.7% of the operated limbs. On multivariate analysis, patients who had undergone previous surgery were found to have

a significantly higher rate of recurrence. ( J Vasc Surg 2006;44:359-63.)

Since its first description by Hauer1 in the 1980s,subfascial endoscopic perforating vein surgery (SEPS) hasbeen accepted as an improved treatment concept in thesurgical treatment of perforator vein insufficiency, particu-larly in cases of advanced skin changes. SEPS is performedin many centers as a component of a comprehensive treat-ment program for venous insufficiency.2

Randomized trials have demonstrated comparable ef-fectiveness but significantly less morbidity with SEPS.2

SEPS in combination with stripping of the great saphenousvein (GSV) has been shown to accelerate ulcer healing3 andto reduce the incidence of new and recurrent ulcers4 com-pared with the best medical management alone.5 The indi-cation for interruption of perforators in varicose vein sur-

From the Department of Dermatology, Division of General Dermatology,Medical University of Vienna.

Competition of interest: none.Reprint requests: Florian Roka, MD, Department of Dermatology, Di-

vision of General Dermatology, Medical University of Vienna, Wae-hringer Guertel 18-20, Vienna, Austria, A-1090 (e-mail: florian.roka@meduniwien.ac.at).

0741-5214/$32.00Copyright © 2006 by The Society for Vascular Surgery.

doi:10.1016/j.jvs.2006.04.028

gery is controversial, but the suggested benefit may be theprevention of recurrences.6,7

The purpose of this study was to evaluate the recur-rence rate of insufficient perforating veins (IPVs) in patientsundergoing SEPS with or without concomitant superficialvein surgery. Medical records were studied to identifypossible risk factors for recurrence at the time of the pri-mary operation.

PATIENTS AND METHODS

Eighty patients (92 limbs) who had undergone SEPSwith or without concomitant superficial vein ablation be-tween May 1997 and February 2002 were retrospectivelyanalyzed. Preoperative assessment included a history, clin-ical examination, and color-coded duplex sonography(ATL/Ultramark9, Philips, Koninklijke, The Nether-lands). IPVs were marked the day before surgery by duplexscan. These examinations were redone 1 week after SEPSand likewise at irregular postoperative intervals (�6months). Patients with evidence of arterial insufficiency orrecent (�6 months) deep venous thrombosis were ex-cluded.

Incompetent perforators were classified as insufficient

if the diameter of the vein at the level of the fascia exceeded

359

JOURNAL OF VASCULAR SURGERYAugust 2006360 Roka, Binder, and Bohler-Sommeregger

3.9 mm and the outward flow exceeded 0.5 seconds.8 Adecision for SEPS was made either on the basis of thenumber of perforators or progressive skin changes. Patientswith varicose veins only (C2) received SEPS treatment onlyif preoperative duplex scan revealed three or more IPVs. Amean of 2.5 (range: 1-6) perforating veins per leg werecoagulated and divided under video assistance. These in-cluded paratibial perforators and posterior tibial perfora-tors. Because the endoscope is not accessible to the retro-malleolar region, medial ankle perforators were disregardedin our study. A Storz 10-mm endoscope attached to a videocamera (Karl Storz, Tüttlingen, Germany) was used inconjunction with the basic SEPS technique as described byFischer et al.9 Concomitant fasciotomy was performed in10 limbs (10.9%; 10 patients).

In the case of venous ulcers, compression treatment wascontinued until healing was completed. Patients with sec-ondary disease were advised to wear compression stockingsindefinitely. Clinical severity and disability scores as pro-posed by the American Venous Forum Executive Commit-tee were registered before and after surgery.10,11

Continuous data were compared by using the t test orthe Mann-Whitney test, where appropriate, and the �2 testwas used for the comparison of proportions. Survival anal-yses were performed according to the method described byKaplan and Meier. A Cox proportional hazard analysis wasused for multivariate analysis to explore the effect of vari-ables on disease-free survival. All statistical analyses wereundertaken by using the SPSS 10.0 software package (SPSSInc, Chicago, Ill). All given P values are two tailed, and aP value of �.05 was regarded to indicate statisticalsignificance.

RESULTS

Limbs were classified according to the CEAP classifica-tion, as shown in Table I. There were 27 men and 53women with a median age of 59.8 years (range: 34.3-80.0years). Superficial reflux exceeding 0.5 seconds was con-

Table I. Patient characteristics according to the CEAPclassification

Variable No. Limbs %

Clinical signs (1-6)(2) Varicose veins 12 13.1(3) Edema without skin changes 21 22.8(4) Skin changes ascribed to venous disease 18 19.6(5) Skin changes with healed ulceration 20 21.7(6) Skin changes with active ulceration 21 22.8

EtiologyPrimary venous insufficiency 83 90.2Secondary venous insufficiency 9 9.8

Anatomic distributionDeep-system incompetence 9 9.8Superficial-system incompetence 91 98.9Perforator-system incompetence 92 100

Pathophysiologic dysfunctionReflux disease 92 100

firmed in 89 (96.7%) of 92 limbs. The etiology of venous

insufficiency was primary valvular incompetence in 83 limbs(90.2%) and secondary disease in 9 limbs (9.8%). Concom-itant major superficial vein ablation was performed in 89limbs (96.7%): 71 GSVs, 4 short saphenous veins, 8 com-bined great and short saphenous veins, and 10 revisions ofthe saphenofemoral junction. In three limbs, SEPS was theonly procedure performed. Eighteen patients (24 limbs;25.8%) had previously undergone major vein surgery (GSV,small saphenous vein, or both). For details, see Table II.

At the time of the operation, 21 limbs (22.8%) pre-sented with active ulceration. These ulcers had been uni-formly present for more than 12 weeks. Twenty (95%) ofthese healed by the 12th postoperative week, whereas onepatient required additional split-thickness skin grafting.

Postoperative complications were uncommon and con-sisted of wound infection or wound dehiscence in fivepatients and major subfascial hematoma in one patient.

During a mean follow-up period of 3.7 years (range,1.2-7.0 years), 22 recurrent IPVs were observed in 20(21.7%) of 92 limbs (Fig 1). None of the current perforat-ing veins had been present at duplex scan 1 week aftersurgery. In the case of primary venous insufficiency, 17(20.5%) of 83 limbs tested positive for recurrent IPVs,compared with 3 (33.3%) of 9 limbs in patients withsecondary disease. The distribution between the differentclinical classes is shown in Table III. Among patients withearly disease (C2), only 1 patient (8.3%) developed recur-rence of IPVs, compared with 9 recurrences (22.0%) in 41limbs of patients with healed or active leg ulcers (C5/6).

Table II. Surgical procedures in patients with previoussuperficial vein surgery requiring SEPS

PatientNo. Previous operation Reoperation

1 GSV stripping SFJ revision, SSV stripping,SEPS

2 GSV stripping SFJ revision, SEPS3 GSV partial stripping

(calf )GSV stripping (thigh),

SEPS4 GSV stripping SSV stripping, SEPS5 GSV stripping SFJ revision, SEPS6 GSV stripping SEPS7 GSV, SSV stripping SEPS8 GSV, SSV stripping SFJ revision, SEPS9 GSV stripping SSV stripping, SEPS

10 GSV stripping SSV stripping, SEPS11 GSV stripping SFJ revision, SEPS12 GSV, SSV stripping SEPS13 SSV stripping GSV stripping, SEPS14 SFJ ligation SFJ revision, stripping

(GSV � SSV)15 SSV stripping, SFJ

ligationSFJ revision, GSV stripping

16 GSV stripping SFJ revision, SSV stripping17 SFJ ligation SFJ revision, GSV stripping18 SFJ ligation SFJ revision, GSV stripping

SEPS, Subfascial endoscopic perforating vein surgery; GSV, great saphenousvein; SFJ, saphenofemoral junction; SSV, small saphenous vein.

Six (26%) of 23 patients with clinically recurrent superficial

JOURNAL OF VASCULAR SURGERYVolume 44, Number 2 Roka, Binder, and Bohler-Sommeregger 361

veins developed recurrent IPVs, as did 18 (23%) of 76patients who were noncompliant with compression ther-apy. The highest rates of recurrence were found in patientswho had undergone previous vein surgery (9 [37.5%]of 24; Table IV).

To identify predictors for the recurrence of IPVs, weperformed univariate and multivariate analyses that in-cluded the following parameters: recurrent varicose veins,secondary disease, active or healed leg ulcer (C5/6), lack ofcompression treatment, and previous surgery. Univariateanalysis revealed that none of these factors was significantfor the development of recurrent IPVs after SEPS. How-ever, on multivariate logistic regression analysis, previoussurgery was identified as the only independent risk factorfor relapse. As shown in Fig 2., patients without previoussurgery had a significantly longer disease-free survival ascompared with patients who had undergone (repeated)previous surgery.

During the observation period, recurrent ulcerationwas observed in two patients, both of whom had secondaryvenous disease. One of these patients tested positive forrecurrent IPVs. Both patients underwent repeated skingrafting and were healed at the time of examination.

The clinical score and disability score before surgery were5.96 and 1.94, respectively, vs 2.1 and 0.56 at follow-up. Forpatients with recurrent IPVs, mean clinical and disabilityscores were 5.5 and 1.8, respectively, before operation and2.0 and 0.6 at follow-up. The respective values for patients

Fig 1. Kaplan-Meier curves for insufficient perforating vein–freesurvival.

without evidence of recurrent IPVs were 5.9 and 2.2,

respectively, before operation and 1.8 and 0.5 at follow-up(not significant).

DISCUSSION

Despite extensive interest in the contribution of perfo-rating veins to chronic venous insufficiency, their hemody-namic role remains controversial.12-14 Still, their prevalenceincreases linearly with the clinical severity of chronic venousinsufficiency, stratified according to the CEAP classifica-tion.15 They not only increase in number, but also progres-sively dilate.16 This suggests a secondary phenomenon dueto recirculating blood volumes, which increase venous pres-sure. The necessity for surgical correction of incompetentperforator veins has been debated for years.17,18

It has been shown that after elimination of saphenousreflux, IPVs regain competence as a result of the normal-ization of venous circulation.19,20 This might hold true foruncomplicated primary venous insufficiency (C2), becausecompromised valves may regain function after major sites ofreflux have been removed. In case of progressive disease,including patients with chronic skin changes, perforatingveins remain incompetent in 25.5% of patients even afterelimination of superficial venous reflux.20 Stuart et al21

confirmed that eradication of the main stem saphenousreflux corrected perforator vein reflux only if reflux wasconfined to the superficial system. However, in case ofcoexisting deep venous reflux, the correction of perforatorvein reflux failed.

The clinical value of perforator vein surgery has beenshown for progressive venous disease.13 In these patients,the most reliable and careful way of correcting pathologicoutward flow is SEPS. Because of the avoidance of incisionsin an area of already-compromised skin, wound complica-tions can be dramatically reduced as compared with trans-cutaneous surgery. Proebstle et al22 reported 40 limbs thatwere treated by superficial reflux ablation earlier withouteffect; the SEPS procedure resulted in hemodynamic im-provement in 58%. Nine of 16 ulcers that had been activefor up to 21 years healed within 14 to 50 days. Although, inmost studies, the outcome of SEPS is masked by theoverlapping beneficial effect of concomitant superficial veinsurgery, cumulative ulcer healing rates of up to 88% havebeen reported after SEPS.13,23-25

In our study, the accuracy of SEPS was confirmed bypreoperative duplex mapping of insufficient perforator

Table III. Incidence of recurrent IPVs according to theCEAP classification

Clinical class No. Limbs with IPVs %

2 (varicose veins) 1 8.33 (edema) 5 23.84 (skin changes) 5 27.85 (skin changes and healed ulcer) 4 20.06 (skin changes and active ulcer) 5 23.8

IPV, Insufficient perforating vein.

veins, which were all accessible to SEPS. It is possible that

JOURNAL OF VASCULAR SURGERYAugust 2006362 Roka, Binder, and Bohler-Sommeregger

duplex sonography performed 1 week after surgery wasimpaired by minor hematoma in the subfascial space. How-ever, no perforator veins meeting the criteria for insuffi-ciency, as mentioned previously, were noticed at that time.

Notwithstanding, reassessment of the medial leg perfo-rators by duplex sonography after a median follow-upperiod of 3.7 years revealed 22 IPVs in 20 (21.7%) of 92limbs. After conventional transcutaneous surgery, Blomgrenet al17 reported a recurrence rate of 41% after 2 years and32% after 2 months. Possibly, recurrent IPVs after transcu-taneous dissection are not true recurrences but can partlybe attributed to incomplete surgical removal because per-forating veins can easily be confounded with tributaries inthis area. This might explain why dissection of IPVs subfas-cially under video guidance can be performed with superioraccuracy.

In our study, the recurrence rate of IPVs was low inpatients with varicose veins only (C2; 8.3%) and leveled offin patients with increasing severity of venous disease (C3-6;20.7%). Comparing the recurrence rates between patients

Table IV. Factors influencing IPV recurrence and statistic

Variable Recurrence %

Recurrence of varicose veins 6 26Secondary disease 3 33C5/6 9 22Previous operation 9 37Lack of compression therapy 18 23

IPV, Insufficient perforating vein.

Fig 2. Kaplan-Meier curves for insufficient perforating vein–freesurvival. Patients with previous surgery (dashed line) had a shorterdisease-free survival than patients without previous surgery(straight line).

with primary venous insufficiency and secondary disease,

the respective values were 21.7% and 33%. Multivariateanalysis included accepted risk factors for severity or pro-gression of venous disease. On multivariate analysis, onlypatients who had undergone previous vein surgery had astatistically higher risk of developing IPVs. This is notsurprising, because this group of patients often experiencesvenous disorders for a prolonged period of time; therefore,the likelihood of regression of morphologic and hemody-namic changes decreases with time.

The main finding in this study is that, although SEPS isthe superior procedure in eradication of IPV, it does notprevent IPV recurrence. Recurrence rates of 33% in second-ary disease might partly be explained by the persistence ofdeep venous reflux. However, in primary disease, recur-rence rates of 21.7% are most likely associated with progres-sion of the disease. In our study, quality of life, as assessedby measuring the clinical score and disability score, im-proved dramatically and was long-lasting after correctivevein surgery. This might be independent of IPV recurrenceand underscores the superior importance of axial vein refluxcorrection compared with perforator vein surgery. Thisfinding is also supported by the recurrence of only 2 of 21ulcers in the observation period. Whereas both cases fea-tured deep venous reflux, perforator vein recurrence wasnoted in one patient.

Still, in patients with venous leg ulcers, elimination ofall identifiable incompetent transfascial connections shouldbe sought, as should axial reflux correction to optimize ve-nous flow and pressure. Even if this condition can be achievedfor only a limited time, this might suffice to provide ulcerhealing.25 This concept could also be confirmed by ourfindings, because 20 (95%) of 21 chronic venous ulcershealed within 12 weeks after surgery.

CONCLUSION

Although SEPS is associated with a lower recurrencerate of IPVs compared with conventional transcutaneoussurgery, it does not prevent disease progression. Multivar-iate analysis identified previous vein surgery to be associatedwith a statistically higher risk for the development of IPVs.Nevertheless, recurrence of IPVs did not affect quality oflife, which significantly improved after treatment of reverseflow in the superficial and perforator system. In patientswith venous leg ulcer, SEPS in addition to superficial refluxablation promotes ulcer healing and results in a low mid-term ulcer recurrence rate due to meticulous elimination of

nificance on multivariate analysis

No recurrence % P value Exp (B)

17 74 .287 0.5206 67 .237 2.817

32 78 .129 2.10315 63 .014 3.69058 77 .919 1.060

al sig

pathologic venous flow.

JOURNAL OF VASCULAR SURGERYVolume 44, Number 2 Roka, Binder, and Bohler-Sommeregger 363

AUTHOR CONTRIBUTIONS

Conception and design: KB-SAnalysis and interpretation: FR, MBData collection: KB-SWriting the article: FRCritical revision of the article: MB, KB-SFinal approval of the article: MB, KB-SStatistical analysis: MBOverall responsibility: KB-S

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Submitted Dec 12, 2005; accepted Apr 10, 2006.