What is Subfascial Endoscopic Perforator Surgery (SEPS) and when is it preferred over other surgical options for treating symptomatic varicose veins with incompetent perforating veins?

What is SEPS and When to Choose It Over Other Surgeries

Definition of SEPS

Subfascial Endoscopic Perforator Surgery (SEPS) is a minimally invasive endoscopic procedure that interrupts incompetent perforating veins under direct vision using a videocamera and instruments placed through small ports remote from active ulcers or diseased skin. 1, 2

SEPS utilizes CO₂ insufflation, typically a dual-port technique, and subfascial balloon dissection to access and ligate incompetent perforators in the subfascial space 1. The procedure allows visualization and treatment of perforators in both the superficial and deep posterior compartments of the leg 1.

When to Choose SEPS Over Other Surgeries

Primary Indication: Advanced Venous Disease with Perforator Incompetence

SEPS should be chosen for patients with CEAP class 5 (healed venous ulcers) or class 6 (active venous ulcers) who have documented incompetent perforating veins on duplex ultrasonography. 1, 2, 3

The procedure is particularly indicated when:

• Venous ulceration is present on the medial side of the lower leg with documented perforator incompetence 3
• Multiple incompetent perforators are identified that require ligation - SEPS allows identification and treatment of more perforators compared to open techniques (178 perforators ligated via SEPS versus 136 via open surgery in one study) 2
• Patients have primary valvular incompetence (PVI) of superficial and perforating veins, with or without deep venous incompetence 4

Advantages Over Open Subfascial Ligation (Linton Procedure)

SEPS demonstrates superior outcomes compared to open perforator ligation, with significantly lower wound complication rates and comparable long-term ulcer healing. 2, 3, 4

Key advantages include:

• Zero wound infection rate with SEPS versus 16% with open subfascial ligation 2
• No residual incompetent perforators on follow-up Doppler with SEPS versus 8% residual perforators with open technique 2
• Faster ulcer healing in 33% of SEPS patients compared to open surgery, though all ulcers healed by 3 months in both groups 2
• Lower postoperative wound complications overall - the minimally invasive approach with small ports remote from diseased tissue reduces infection and dehiscence risk 4, 5
• Comparable long-term results - mean follow-up of 46-50 months shows ulcer recurrence rates of 12% with SEPS versus 22% with open Linton procedure 3

Treatment Algorithm for Perforator Incompetence

First-line treatment for symptomatic varicose veins remains endovenous thermal ablation for saphenous reflux, with SEPS reserved as an adjunctive procedure for perforator incompetence in advanced disease. 6, 7, 8

The treatment sequence should be:

1. Address saphenofemoral or saphenopopliteal junction reflux first with endovenous thermal ablation (radiofrequency or laser) if present 7, 8
2. Perform SEPS concomitantly or subsequently for documented incompetent perforators in patients with CEAP class 5-6 disease 2, 4
3. Complete with stripping of long saphenous veins where the junction is incompetent, plus multiple ligation of superficial prominent veins 2

Patient Selection Criteria

SEPS is most beneficial for patients with primary valvular incompetence rather than postthrombotic syndrome, though it can be performed in both populations. 4

Optimal candidates include:

• Patients with advanced chronic venous insufficiency (CEAP 5-6) secondary to primary valvular incompetence 4
• Those with documented perforator incompetence on duplex ultrasonography - reflux >350 milliseconds in perforating veins 8
• Patients who have failed conservative management including compression therapy for at least 3 months 8, 9

Important Caveats and Limitations

The role of SEPS in postthrombotic syndrome remains controversial, with clinical and hemodynamic results being inferior compared to primary valvular incompetence. 4

Critical considerations:

• Deep venous incompetence significantly influences development of new incompetent perforators (7 of 10 patients with DVI developed new incompetent perforators versus 3 of 10 without DVI) 3
• Incomplete subfascial dissection during initial SEPS is a major cause of treatment failure - the deep posterior compartment must be opened to access Cockett II perforators 1
• Conversion to open procedure may be necessary in approximately 10% of cases due to extensive scarring or technical difficulties 1
• SEPS can be safely repeated if initial surgery fails, though this requires expertise in managing scarred subfascial spaces 1

Technical Considerations

SEPS using harmonic scalpel demonstrates technical feasibility with minimal morbidity - generating low thermal effect and causing less tissue damage 5. The procedure typically results in:

• Minimal postoperative complications - wound infection rates of 0-21% and rare nerve injury 1, 5
• Early mobilization and faster recovery compared to open techniques 5
• All ulcers healing within 8 weeks in appropriately selected patients 5

When NOT to Choose SEPS

SEPS should not be the primary intervention for uncomplicated varicose veins without ulceration or significant perforator incompetence. 6, 7, 8

Standard endovenous thermal ablation or sclerotherapy remains first-line for:

• CEAP class 2-4 disease without active or healed ulceration 6, 8
• Isolated saphenous reflux without documented perforator incompetence 7, 8
• Patients who have not completed conservative management trials 8, 9