38S Gloviczki et al

Guideline 13. Treatment of perforating veins

JOURNAL OF VASCULAR SURGERY

May Supplement 2011

formed superficial and perforator ablations in 11 limbs and used air plethysmography, foot volumetry, and duplex scanning to assess results. At a median follow-up of 66 months, expulsion fraction and half-refilling time had both improved significantly in patients, with no ulcer recurrence. Rhodes et al,95 from Mayo Clinic, used strain-gauge plethysmography to quantitate calf muscle pump function and venous incompetence before and after SEPS. Significant improvement was noted in both calf muscle pump function and venous incompetence in 31 limbs studied 6 months after SEPS. Saphenous stripping was done in addition to SEPS in 24 of the 31 limbs. Although the seven limbs undergoing SEPS alone had significant clinical benefits, the hemodynamic improvements were not statistically significant. It is important to note also that Akesson et al371 failed to show additional benefit in ambulatory venous pressure, when perforator interruption was performed after saphenous vein ablation.

Percutaneous ablation of perforators. PAPS is a new technique, and most publications had a small number of patients with short follow-up, who were treated frequently for mild disease (CEAP class C2-C3).357 Most data provided are on safety and surrogate end points such as perforating vein occlusions but less so on clinical and functional end points. A systematic review of five recently published cohort studies and seven unpublished case series by O’Donnell356 found a mean occlusion rate of 80% and a mean follow-up of 2 months.

Ultrasonographically guided sclerotherapy is gaining rapid acceptance because perforating veins can be accessed easily with a small needle without much pain to the patient. Masuda et al351 reported clinical results with ultrasonographically guided sclerotherapy using morrhuate sodium in 80 limbs with predominantly perforator incompetence alone. The authors noticed a significant improvement in VCSS, and ulcers rapidly healed in 86.5%, with a mean time to heal of 36 days. The ulcer recurrence rate was 32% at a mean of 20 months despite low compliance (15%) with compression hose. New and recurrent perforators were identified in 33% of limbs, and ulcer recurrence was statis-

tically associated with perforator recurrence as well as presence of postthrombotic syndrome.

Conclusions. Current data do not support adding perforator ablation to ablation of the superficial system in patients with simple varicose veins,361,362 and the Committee recommends against treatment of perforators in patients with CEAP class C2 disease (GRADE 1B). In patients with advanced CVI, current data provide moderate evidence that large ( 3.5 mm), high-volume, incompetent “pathologic” perforators (reflux 500 ms), located in the affected area of the limb with outward flow on duplex scanning in patients with class C5 or C6 disease, can be treated by experienced interventionists, unless the deep veins are obstructed (GRADE 2B).22,56,87 Clinical data on the efficacy of perforator ablations were obtained primarily by using the SEPS procedure, but ultrasonographically guided sclerotherapy or thermal ablations, when performed with similar low complication rates, can be suggested as alternative therapy for perforator treatment (GRADE 2C).

Pelvic varicosity and pelvic congestion syndrome

Valvular incompetence and retrograde flow to the ovarian veins and/or the internal iliac vein and its tributaries may give rise to pelvic congestion syndrome and pelvic varicosities, which may occur alone or together. Pelvic congestion syndrome is associated with symptoms of pelvic pain or heaviness, dyspareunia, and dysuria. Varicose veins in the vulvar and perivulvar area are most often secondary to previous pregnancy and are often associated with perimenstrual symptoms.

Evaluation. The appearance of varices in the region of the pubis, labia, perineum, or buttocks suggests a pelvic source of reflux. Several noninvasive diagnostic tests are available, including lower extremity, transabdominal, and transvaginal ultrasonography as well as CT and MR venography.372 All have been reported to be useful in documenting pelvic venous reflux, although the selection of the most appropriate test largely depends on local institutional expertise. An ovarian vein diameter of 6 mm on ultrasonography has been reported to have a 96% positive-predictive