Incompetent Perforator

We work closely with the local wound care centers and collaborate with the centers to chose the best approach to treat each ulcer aggressively and effectively. We are local experts in treating the most common cause of vein ulcers is typically from and incompetent perforator vein.

What are Perforator Veins?

Perforator veins serve as connections between the two networks of veins in the extremities, the superficial venous system and the deep venous system. Perforators connect the two parallel systems, somewhat like the rungs of a ladder connect the side rails, and normally drain blood from the superficial veins to the deep veins as part of the process of returning oxygen-depleted blood to the heart.

Perforator veins have one-way valves designed to prevent backflow of blood down towards the superficial veins. When those valves no longer function properly and reflux occurs, the buildup of blood and pressure can cause not only the superficial veins but the perforators themselves to become incompetent. Perforator veins in the lower leg and ankle are particularly vulnerable to distention and incompetence, and the resultant circulatory problems create an increased likelihood of edema, skin discoloration, dermatitis and skin ulcers in the immediate area.

Leg Ulceration Treatment

Venous ulcers are leg wounds that can be superficial (top layers of the skin) or deep in nature. Venous ulcers are caused by chronic venous insufficiency (venous reflux disease) that occurs due to damaged vein valves that allow blood to pool in the legs. People who have venous ulcers may or may not have varicose veins. Depending upon the patient's anatomy and the severity of the wound, venous ulcers may be treated with compression stockings or ClosureFast procedure.

Radiofrequency perforator ablation (RFPA)

The RFPA procedure is performed under a local anaesthetic as a minimally invasive, outpatient procedure. Using ultrasound guidance,a fine needle is passed into the perforating vein through the skin. The radiofrequency current heats the inside of the perforator causing it to shrink down and remove the abnormal flow between the deep and varicose veins. The whole process takes approximately 10 minutes per perforating vein. Cosmetic appearances are superior to the SEPS procedure with hardly any scarring and patients usually report little or no pain afterwards. Complications include deep vein thrombosis and nerve damage causing numbness. Only about 1% of cases of numbness become permanent.

Over 15,000 procedures have been performed worldwide with closure rates that average 70% to 93%.. The radiofrequency stylet is the only such device cleared by the FDA  for the treatment of incompetent perforating veins.

Symptoms

High superficial venous pressures from incompetent perforators may cause varicose veins or skin ulcers, particularly in the lower leg and ankle.

Incidence and Causes

Nearly 70% of all women and 30% of men will develop some type of venous disorder. Incompetent perforator veins may be the source of reflux causing varicose veins or skin ulcers.  If the patient has pain, swelling, or an ulcer, a duplex ultrasound is performed to make a complete diagnosis.  The ultrasound will determine the presence of truncal/saphenous insufficiency, as well as perforator incompetence. 

Contributing factors include:

  • Heredity
  • Pregnancy
  • Hormonal changes
  • Being Overweight
  • Standing or sitting for prolonged period of time
  • Advancing Age
  • Trauma

Anatomy

Since humans walk upright, our leg veins contain valves that normally allow one-way blood flow from the feet up to the heart. They close and prevent backward blood flow when resting in the standing position. When the valves fail, there is backward blood flow (venous “insufficiency” or “reflux”) that results in very high venous pressure. Because veins have very thin walls, this high pressure causes significant stretching and elongation – resulting in the formation of varicose and spider veins.

RF ABLATION WITH THE VENEFIT RFS CATHETER is the only endovenous device FDA specifically cleared for treatment of incompetent perforators.

Pre-Procedure Protocol

The location and malfunction of perforator veins will be determined by duplex ultrasound. If a perforator vein is found to be feeding a large varicose vein or is underlying a skin ulcer, then treatment will be recommended.

Depending on the size and depth of the perforator, one of two treatments will be provided. If the vein is short or small, then foam sclerotherapy injection under ultrasound guidance is performed. A small needle enters the perforator vein and a small amount of foam sclerosant material is injected. If the perforator vein is longer or larger, then a small catheter is inserted, and radiofrequency energy with a proprietary catheter  is used to seal the vein shut. Both treatments obliterate the source of high venous pressure.

Post Procedure Protocol

Once the procedure is complete, a compression stocking is placed on the treated leg for 7 days.  Under normal conditions the patient may return to work the following day.

The following are common physician recommendations:

  • Wear compression stockings for a period of one week all the time, then 3 more weeks during the day
  • Abstain from high impact activities such as running or step aerobics for a period of 3 weeks
  • Walking is encouraged, as it will aid in the healing process

A repeat ultrasound will be done in 3-7 days to check the deep leg veins, and again in 4 weeks to ensure that the treated veins are sealed. Occasionally, a treated vein will reopen, requiring either repeat injection of foam sclerotherapy or repeat laser treatment. The vast majority of treated veins are sealed shut at 1-year follow-up.

As with any procedure, some mild side-effects might occur.  You may experience a slight redness to your skin tone in the treated area, which will fade away within a few days.  You might also notice a slight swelling in the treated area. 

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