Active perforator vein reflux points the way to reducing recurrence after varicose vein surgery

What is it about?

It is widely known that "varicose veins always come back" after treatment. There are several reasons for the high recurrence rates found after varicose vein treatments in most clinics and hospitals. One of the commonest is that most doctors only scan and treat the main 2 veins of the leg - the great saphenous vein and the small saphenous vein. These take venous blood from the skin and superficial tissues into the deep veins of the leg, to be pumped back to the heart. However, there are 150 perforator veins that do the same job. Moreover, as with the great and small saphenous veins, when the valves in the perforator veins fail, they become incompetent and can allow blood to flow back from the deep system into the superficial tissues. This outflow or "reflux" is a cause of varicose veins, spider veins, venous eczema, brown stains (haemosiderin) and even venous leg ulcers. Unfortunately, as finding incompetent perforator veins (IPVs) takes time and skill with the duplex ultrasound scanner, and treating them takes training and time to use the TRansLuminal Occlusion of Perforator (TRLOP) technique, most doctors just ignore them - hence getting high recurrence rates. As such, many doctors try to justify this by claiming that IPVs do not contribute to significant venous reflux. Indeed, some leading venous surgeons claim that IPVs do not actually reflux blood as the speed of blood going up the deep veins "sucks" the blood in through the perforators using the Venutri effect. This research uses infrared imaging to show that when the calf muscles are active, venous blood is pumped out of the deep veins and into the surface varicose veins. This shows that IPVs are indeed a cause of reflux, and the Venturi effect does not suck blood back into the deep veins through the perforators.

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Photo by JENN ARDOR on Unsplash

Photo by JENN ARDOR on Unsplash

Why is it important?

For the last 25 years, The Whiteley Protocol has determined that when patients are assessed and treated for leg varicose veins or associated conditions such as spider veins, venous eczema, brown stains and venous leg ulcers, it is essential to identify and treat any IPVs. However, many (if not most) doctors have resisted this message, and most doctors treating varicose veins do not look for, nor treat, IPVs. This is often justified by quoting papers that seem to show that IPVs become competent after the main saphenous veins are treated. However, this is incorrect, as reflux recurs in the medium- to long-term. The appearance that the IPVs become competent after the saphenous veins have been treated is due to acute thromboses and haemodynamic changes in the immediate post-operative period, which settle when the leg heals and most of the IPVs re-appear. Other doctors, particularly those following the idea of "haemodynamic venous surgery" or CHIVA, argue that the speed of blood pumped up the deep veins "sucks" blood in through the perforator veins by the Venturi effect. Hence, they claim perforator veins can never be incompetent. This case shows that they are wrong. The pressure produced by the calf muscles to pump the blood up the deep veins towards the heart overcomes any Venturi effect, and blood is forced outwards through the IPV and into surface varicose veins. This is as predicted in the book "Understanding Venous Reflux - The Cause of Varicose Veins and Venous Leg Ulcers" - 2011.

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