All About Perforators- Treating Popliteal Perforators - P.23 by VeinExperts.org

Chapter 2 All About Perforators Ron Bush, MD, FACS

This chapter will deal with perforators, symptoms, and treatment. By definition, a perforator is any vein that connects a vein of the deep venous system to a vein of the superficial venous system. The superficial system may include the GSV, SSV, AAGSV, or any superficial varicosity. The term pathologic perforator as described by Mark Meissner, MD, will be used in this chapter. These pathologic perforators are the etiology of primary or recurrent disease or in association with venous ulcerations. A pathologic perforator should be greater than 3.5 mm in size and have both antegrade and retrograde flow with distal compression. Note should be made that some pathologic perforators will revert to normal after the superficial insufficiency is corrected. For varicosities that are in continuity with a proximal and distal perforator; one of these perforators, may be purely an exit perforator. The first section of this chapter will deal with perforators not commonly recognized but very important in the pathogenesis of venous disease. The perforators to be discussed are not infrequently involved with commonly found patterns of varicosities. The first perforator that will be discussed is the perforator associated with the lateral reticular system. In most cases, the pathologic perforator is located on the upper lateral aspect of the thigh where you see the first visible varicosity. The varicosities may also be associated with another perforator below the knee or one that empties into the soleus muscle vein below mid calf. These are usually

exit perforators and a result of the increased flow in the superficial system.

The lateral reticular perforator is treated with SotradecolďŁ¨ 1% foam injection. This can be US guided, which is our preferred method, or alternatively the foam can be delivered through the superior superficial varicosity using a butterfly needle. As in all perforators treated with foam, we, under US guidance, place tumescent solution around the perforator. This helps keep the foam in contact with the lumen of the perforator and prevents escape of foam into the deep system. These lateral reticular perforators are in continuity with either the femoral vein or a branch of the femoral vein. Most commonly, there are the results of long standing pressure and many times occur 10-20 years after pregnancy. Laser treatment has no role in the treatment of this perforator due to the length, 4

tortuous course, and the need to avoid injury to deeper structures. If you do not address these perforators, the patient will have recurrent disease within 1 to 2 years. The recurrent varices will mimic the original pattern. The next figures show US guided foam sclerotherapy in a perforator and the technique of tumescent compression.

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The next perforator to be discussed is the perforator of the gastrocneimus vein. This perforator can originate throughout the course of the vein in the gastrocneimus muscle. More commonly, the origin is about 2-3 cm proximal to entrance into the popliteal vein. The gastrocneimus veins are characteristically the dumbbells shaped veins on either side of the lower popliteal fossa. The gastrocneimus perforator pierces the muscle fascia to the subcutaneous tissuegiving rise to multiple varicosities. I have never seen bilateral perforators coexisting. There may or may not be gastrocneimus vein reflux. There may be a reentry point to either the gastrocneimus vein or soleus vein distally in the leg on rare occasion. The only treatment is foam sclerotherapy with phlebectomy. If there is SSV reflux, this will usually subside after the phlebectomy. Surgical and thermal ablative procedures are not warranted. In our clinic, there has never been a complication related to the deep venous system.

Image retrieved online January 21, 2012, from http://alturl.com/oy5a4

11/28/12 Lateral Reticular Venous System Exit and Entry Perforators â&#x20AC;&#x201C; How I scan and treat these patients

This video demonstrates a large dilated lateral reticular venous system. The origin is from a perforator that connects to either the femoral or profunda femoral vein. This video shows how we identify the perforator, which is usually connected to the most superior visible varicosity. Scanning inferiorly, one can see the superficial varicosities and then a re-entry point into a perforator from a gastroneimus perforator just superior to the soleus muscle that can also be seen in the video. There is no need to treat this perforator, since it is a point of re-entry. This perforator will become nonfunctional once the lower most phlebectomy is done which connects to this perforator. This is in contrast to the exit perforator in the thigh which will still reflux if not addressed at time of phlebectomy. There are two treatment options:

Ultrasound guided sclerotherapy of the incompetent perforator with 1% Sotradecol foam followed by phlebectomy or foam alone of the varicosities and perforator followed by compression for at least 2 weeks. I prefer the first option, since I believe it is a better cosmetic result. If the perforator is not occluded, the patient has a risk to develop recurrent varices almost in the same location. I have seen this occur before when the perforator was not addressed. Lasers have no role in the treatment of this perforator and you should not even consider this.

12/22/12 Stasis changes from two different etiologies Interesting case with a video This is an interesting case, which demonstrates two separate areas of stasis changes. The green arrow points to an area of stasis that was a result of SSV insufficiency. The SSV was occluded using a 1470 nm laser (Dornier). The red arrow points to the location of an incompetent posterior tibial perforator (Cockettâ&#x20AC;&#x2122;s). This can be seen in Figure 2. The blue arrow represents stasis secondary to the incompetent perforator. Figure 3 shows a video of the US image (Terason), with foot compression. Notice the outward and inward flow. So the milder stasis changes are the result of an incompetent posterior tibial perforator. The lower GSV does not reflux. I think this is a very interesting case because it shows two different degrees of stasis changes. One posterior, secondary to SSV reflux and the other secondary to posterior tibial reflux. My choice of treatment for the posterior tibial perforator is a combination of ablation at the fascial level with simultaneously injecting Sotradecol 1% foam. For the ablation, I use a 400 micron filament(Dornier) through a 19-gauge needle after the laser filament is placed, I inject Sotradecol foam through a separate needle stick. I then apply tumescent and fire the laser at 10 watts for 3 consecutive treatments at around 10 seconds. The basis for this is that dual injury (sclerotherapy combined with laser at the same setting), is always superior to single injury treatment such as sclerotherapy alone or laser alone. You must always remember that the calf muscle pump tends to keep these perforators open after treatment due to the high pressure from the calf muscle pump mechanism.

Click on image to see the video

1/11/13 17

Lateral Reticular Perforator This case illustrates a very common perforator especially when there is a dilated lateral reticular venous system. Our approach is to cannulate the most proximal varicosity in association with the perforator and inject Sotradecol速 1% foam. This is a very easy way to access these perforators. Sufficient volume can easily be given to cause occlusion of the perforator. A phlebectomy is then done of the remaining varicosities. If the lateral reticular perforator is not addressed, recurrence is possible of the varicose veins.

Finger points to location of perforator

Click on image to view video

2/1/13 Treating Popliteal Perforators Anytime a patient presents with varicosities in the posterior fossa, usually at or just above the crease look for 4 different etiologies. In this patient, the source is a popliteal perforator. The superficial varicosity is connected to the popliteal vein by this incompetent perforator as shown in Fig. 1. The perforator appears fragmented but it is not. It is somewhat tortuous so you are just seeing parts of the perforator on this ultrasound image. Another etiology can be a gastroneimus vein perforator, which presents in the same fashion as a popliteal perforator. An incompetent perforator from the posterior medial thigh circumflex branch is also possible but the varicosities are usually higher in the posterior thigh. Perforators from the soleus vein or inferior gastroc veins are usually at mid-calf level, but varicose branches can extend superiorly. The treatment in this case was Sotradecol 1% foam injected into the most proximal varicosity (3cc) with good backflow into the perforator with immediate tumescent compression. I used this percutaneous approach rather than US guided deeper directed injection, because in the prone position, the perforator was not visible. Only on standing was it dilated, hence, I could not do an injection with the patient standing so the next best option was to inject the most proximal varicosity connected to the perforator. This patient also had Factor V deficiency and Protein S abnormality. There was no deep venous problems because adequate precautions were taken which included 3-4 minutes of foot dorsi-flexion after the perforator was injected and tumescent applied.

Ultrasound Image Occluded Popliteal Perforator – Copyright  2013 by www.veinexperts.org