Treatment of Incompetent Perforators in Varicose Veins
Incompetent perforators in patients with varicose veins should NOT be routinely treated in CEAP class 2 disease, but ultrasound-guided sclerotherapy is the preferred treatment when intervention is indicated for advanced disease (CEAP C4-C6) with venous ulceration or severe lipodermatosclerosis. 1
Evidence-Based Treatment Algorithm
When to Treat Incompetent Perforators
Do NOT treat perforators routinely in CEAP class 2 varicose veins - The 2022 Society for Vascular Surgery/American Venous Forum guidelines explicitly recommend against routine treatment of incompetent perforators in patients with simple varicose veins (CEAP class 2). 1 This represents the highest quality and most recent evidence available.
DO treat perforators in advanced disease (CEAP C4-C6) - Treatment is indicated when patients have:
- Active venous ulceration (CEAP C6) 2
- Severe lipodermatosclerosis (CEAP C4) 2
- Recurrent varicose veins with documented perforator incompetence 3, 4
- Symptoms isolated to the site of incompetent perforators 2
Diagnostic Criteria for Incompetent Perforators
Reflux threshold: >500 milliseconds (0.5 seconds) on duplex ultrasound defines pathologic perforator incompetence. 5, 4 Some sources cite >350 milliseconds for perforating veins specifically. 5
Required ultrasound documentation before treatment includes:
- Precise reflux time measurement in milliseconds at each perforator 6
- Anatomic location of incompetent perforators 5
- Assessment of coexisting axial reflux in saphenous or deep venous systems 2
- Technique used to provoke reflux (pneumatic cuff, manual compression, or Valsalva) 6
First-Line Treatment: Ultrasound-Guided Sclerotherapy
Ultrasound-guided sclerotherapy (UGS) is the preferred treatment for incompetent perforators over surgical options like subfascial endoscopic perforator surgery (SEPS). 2, 4
Treatment efficacy:
- 98% immediate occlusion rate 2
- 75% persistent occlusion at mean 20-month follow-up 2
- Significant reduction in Venous Clinical Severity Score (median 8 pre-treatment to 2 post-treatment, P<0.01) 2
- Significant reduction in Venous Disability Score (median 4 pre-treatment to 1 post-treatment, P<0.01) 2
Technical approach:
- Use color flow duplex scanning to identify incompetent perforators 2
- Inject liquid sclerosant (sodium morrhuate 5% or polidocanol) under real-time ultrasound guidance 3, 2
- Target each incompetent perforator individually 2
Critical Treatment Sequence
Always treat axial reflux FIRST before addressing perforators. 7 The treatment plan must include treatment of saphenofemoral or saphenopopliteal junction reflux with endovenous thermal ablation, as untreated junctional reflux causes persistent downstream pressure leading to perforator recurrence. 7
The proper sequence is:
- Endovenous thermal ablation for great or small saphenous vein reflux (if present) 7, 5
- Ultrasound-guided sclerotherapy for incompetent perforators 2, 4
- Phlebectomy or sclerotherapy for tributary veins 7
Important Clinical Considerations
Perforator recurrence is common and expected:
- 75.8% of limbs develop new incompetent perforators within 3 years after treatment 8
- 40% arise from neovascularization at previously ligated sites 8
- 59% develop from changes in pre-existing perforators at other sites 8
- Recurrence is more frequent in patients with ulcerations 2
Surveillance and re-treatment strategy:
- Perform duplex ultrasound at 6 months, 1 year, and 3 years post-treatment 8
- Repeat ultrasound-guided sclerotherapy for recurrent incompetent perforators 2
- Perforator recurrence correlates with clinical and physiologic severity of venous disease, not with age, gender, or BMI 8
Safety profile of ultrasound-guided sclerotherapy:
- No cases of deep vein thrombosis in the adjacent deep vein 2
- Minimal skin complications (one case of skin necrosis in 80 treated limbs) 2
- Fewer wound healing complications compared to surgical ligation or SEPS 2, 4
When Surgical Treatment May Be Considered
Subfascial endoscopic perforator surgery (SEPS) may be beneficial in:
- Patients with venous ulceration and advanced chronic venous insufficiency 4
- Cases where sclerotherapy has failed 4
However, SEPS carries higher risks of wound complications compared to ultrasound-guided sclerotherapy. 2, 4
Common Pitfalls to Avoid
Do not treat perforators in isolation - Always assess and treat coexisting saphenous reflux first, as isolated perforator treatment without addressing axial reflux leads to rapid recurrence. 7, 2
Do not use perforator treatment as first-line for simple varicose veins - The 2022 guidelines explicitly recommend against routine perforator treatment in CEAP class 2 disease. 1
Do not expect permanent results - Inform patients that perforator recurrence occurs in the majority of cases within 3 years, requiring surveillance and potential re-treatment. 8
Ensure adequate vein diameter for sclerotherapy - Vessels <2.0 mm have only 16% patency at 3 months compared to 76% for veins >2.0 mm. 7 The minimum recommended diameter for sclerotherapy is 2.5 mm. 7