Subfascial Endoscopic Perforating Vein Surgery (SEPS) for the Treatment of Venous Ulcers

  • Wed, 9/3/08 - 10:25am
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Author(s): 
Tae W. Chong, MD; Matthew J. Bott, MD; John A. Kern, MD; Benjamin B. Peeler, MD; Curtis G. Tribble, MD; and Nancy L. Harthun, MD

V enous ulcers are a significant health problem, affecting 2% of the population in Western countries.1 These ulcerations are disabling due to their chronicity, tendency to become infected, and associated pain. Often, patients are affected by venous ulcers during their most productive years of life. Treatment involves significant amounts of medical resources, placing a substantial financial burden on modern healthcare systems.2-4

Venous ulcers typically form posterior to the medial malleolus (see Figure 1). They frequently present in an area of thickened skin and soft tissue described as lipodermatosclerosis. Hemosiderin deposition, a brawny brown pigmentation of the skin, often is seen in a circumferential pattern between the medial malleolus and the upper part of the calf. This distribution of abnormal pigmentation and thickening of the skin and soft tissue is called gaiter distribution. The skin is frequently friable and scaly, leading to venous eczema (see Figure 2).

Etiology

The etiology of venous ulcers is related to venous hypertension in the lower extremity; specifically, ambulatory venous pressure (AVP) is significantly related to the prevalence of ulcers. Ambulatory venous pressure is typically measured by cannulating a dorsal foot vein and transducing a resting venous pressure. The pressure is then measured after muscle contractions (toe raises) with a subsequent fall in pressure as the veins empty. If the AVP is consistently >90 mm Hg, venous ulceration is inevitable. Similarly, ulcers are rare if patients have AVPs that measure <30 mm Hg.5 This association of AVP with occurrence of ulceration is maintained regardless of the specific abnormality in the vein. Increased AVPs can occur as a result of valvular incompetence, chronic obstruction (which usually occurs after a thrombotic event), or a combination of these two factors.

Anatomy

The lower extremity venous system is divided into superficial and deep systems. The deep venous system is located immediately adjacent to the arterial system. The names for these arteries and veins are shared (ie, for every artery there is a pair of deep veins). They include the superficial femoral, popliteal, posterior tibial, anterior tibial, and peroneal veins. The superficial system includes the greater and lesser saphenous veins. The lesser saphenous vein courses between the gastrocnemii muscles in the lower calf, typically entering the deep system in the popliteal fossa. The greater saphenous vein originates at the ankle. It follows a course through the medial aspect of the leg all the way into the upper thigh. At that point, the vein courses in the lateral direction and eventually joins the common femoral vein. Both of these named superficial veins have significant tributaries. One of these branches, the posterior arch vein, courses in the posterior aspect of the calf and joins the greater saphenous vein below the knee. Perforating veins are short-segment veins that join the superficial system to the deep system.6 They are named for the fact that they perforate the muscle fascia. Cockett perforating veins connect the posterior arch vein with the posterior tibial veins.7 Under normal circumstances, they provide a conduit for blood flow from the superficial system to the deep system. Perforating veins also have valves that prevent reflux. When these veins become incompetent, they allow significant reflux into the superficial system. These incompetent perforating veins are associated with both location and prevalence of venous ulceration. Boyd perforating veins are located between the upper calf and lower thigh8 and Dodd’s perforators are located in the thigh.

References: 

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