What is it about?

All doctors agree that the two main superficial veins in the leg, the great saphenous vein and the small saphenous vein, need to be treated in varicose vein surgery if blood is leaking out of the deep system into these veins. This occurs when the valves stopped working in these veins and they become "incompetent". However, there are approximately 150 other veins that connect the deep and superficial system called perforating veins. These perforate through the muscle and take blood from the superficial veins into the deep veins to be pumped back to the heart. Just as in the great and small saphenous vein, the valves inside these perforating veins can fail, allowing the blood to flow the wrong way. When this happens, these veins are called "incompetent perforating veins". All great many cases, the blood refluxing out of these veins causes varicose veins, skin damage, eczema and even leg ulcers. Despite Mark Whiteley and Judy Holdstock having invented the TRLOP technique to treat these incompetent perforating veins in 2001, most doctors still do not treat incompetent perforating veins. This published debate sets out the argument from Prof Mark Whiteley explaining, with evidence and references, why doctors who do not treat incompetent perforating veins are likely to see far higher recurrence rates in their patients who they treat for varicose veins.

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Why is it important?

Patients undergoing varicose vein surgery are all aware that varicose veins can come back again in the future. However, most are not aware that the risks of varicose veins recurring again after treatment can be reduced significantly by treating any incompetent perforating veins that are causing varicose veins or skin damage. Although there is no randomised controlled study to prove this one way or the other, there is now overwhelming evidence in the view of the author to show that incompetent perforating veins causing a clinical problem such as varicose veins should be treated. As this can now be performed under local anaesthetic using the TRLOP technique, there is very little reason that doctors should not be looking for incompetent perforating veins and treating them when found.


This article was published as a debate with Prof Mark Whiteley clearly explaining the logical progression of how venous disease deteriorates and how it is successfully treated. There is now very clear evidence that severe venous disease, such as venous leg ulcers and skin damage, requires any incompetent perforators to be treated as part of the cure. Therefore it is quite incredible that knowing this, any specialist understanding venous disease cannot see the same argument holds for the less severe patterns of the same disease. After all, if these are left untreated, they merely become the more severe forms at a later date! The treatment of incompetent perforating veins has been one of the key developments of the Whiteley Protocol, which is aimed at reducing the risk of recurrent varicose veins after treatment to a minimum. Other published work from The Whiteley Clinic has shown very clearly that when patients come to the clinic having had unsuccessful varicose vein surgery elsewhere, one of the biggest causes of the recurrent varicose veins is the presence of incompetent perforating veins. This debate was published to try and encourage venous surgeons to understand how to look for incompetent perforating veins and to learn the TRLOP technique to treat them when found. At the current time, the guidelines for treating varicose veins do not support the treatment of any incompetent perforating veins. The author believes that this is not logical, and is merely based on the fact that no randomised controlled studies have currently shown whether the incompetent perforator veins should be treated or not. This is a classic case where the lack of any evidence is not the same as saying that there is evidence against doing something. Therefore at the moment, it is very much up to the doctor as to whether they look for incompetent perforating veins at the time of the varicose vein surgery, and if they find them, whether they treat them. It is also very much up to the patient to choose their doctor with care when consenting to have varicose vein surgery.

Professor Mark S Whiteley
The Whiteley Clinic

Read the Original

This page is a summary of: Debate: Whether venous perforator surgery reduces recurrences, Journal of Vascular Surgery, September 2014, Elsevier,
DOI: 10.1016/j.jvs.2014.06.102.
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