Clinical meaning of incompetent perforators in the setting of post-thrombotic syndrome commentary

In this issue of Phlebological Review Zolotukhin et al. [1] present the results of their study on recurrence of venous leg ulcers in post-thrombotic patients after endovenous laser ablation of incompetent lower leg perforators. They have found that not only the recurrence rate of these perforators was very high, but also that the procedure did not reduce the ulcer recurrence.
This lack of clinical efficacy in terms of recurrence was different from the results of the well-known ESCHAR study [2]. In the ESCHAR study surgical ablation of incompetent superficial veins resulted in less frequent recurrences. From a hemodynamic and pathophysiological point of view a thermal ablation (such as laser endovenous treatment) should not differ greatly from surgical removal of incompetent veins. However, in the ESCHAR study ulcer patients presented with superficial vein pathology, while in this study the main pathology concerned deep veins (with a possible additional burden associated with incompetent perforators). At the moment there are two different and conflicting opinions regarding lower leg perforators. Most phlebologists believe that incompetent perforating veins allow venous outflow from the deep venous system into superficial veins, which in turn evokes venous congestion in subcutaneous veins. Others, however, argue that actually the so-called incompetent perforators allow blood refluxing in incompetent superficial veins to re-enter the deep venous system, thus decongesting superficial veins [3–8].
A body of evidence supports both opinions. On one hand it is known that bi-directional flow in perforating veins is more common in venous patients than in normal subjects, that the number of incompetent perforators and their diameter increases with the severity of chronic venous disease, and that patients with recurrent varicose veins have both a higher prevalence and a greater number of incompetent perforating veins than patients with primary varicose veins. All of these observations suggest that refluxing perforators play a pathological role. On the other hand, it is known that incompetent perforating veins are usually associated with reflux in the superficial veins, indicating that deep venous reflux is rarely the primary cause of insufficiency of these perforators, that residual varicose veins after varicose vein surgery are not significantly related to the presence of pre-operatively incompetent perforators, and that treatment of incompetent...


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