Perforating veins pass through the muscle sheath to link the surface veins with the deep ones. When their valves fail, high pressure from the deep system is pushed outward into the skin at the ankle, which is where venous ulcers form.
Perforator ligation closes the perforating veins that connect the surface and deep venous systems when their valves have failed. It is used mainly where there is skin damage or a venous ulcer at the ankle that has not settled after treating the main trunk veins and using compression. The veins can be tied through a small cut or closed from within using ultrasound guidance.
Blood is meant to travel from the surface veins inward to the deep veins and then up the leg, pushed along by the calf muscles. Perforating veins are the short connections that let this happen, and each has a valve that should allow flow in one direction only.
When a perforator valve fails, every calf muscle contraction pushes high pressure blood outward instead, straight into the small veins of the skin. Over years this damages the skin at the ankle: it darkens, thickens, becomes itchy and eczematous, and eventually breaks down into an ulcer that will not heal while the pressure continues.
Treating the main trunk veins and using proper compression settles most of these legs. Perforator ligation is considered for the ones that do not settle, where ultrasound shows a specific incompetent perforator sitting under or close to the damaged skin.
This is a second line treatment. Compression and treating the trunk veins come first, and most legs never need it.
Duplex ultrasound locates each incompetent perforator and marks it on the skin, noting its relationship to the damaged area.
Usually local anaesthetic with sedation, or a spinal anaesthetic if other work is being done at the same time.
Where possible the perforator is reached through healthy skin rather than through the ulcer area, which heals badly.
The perforator is either tied through a small incision, or closed from within under ultrasound guidance without an open cut.
The leg is bandaged firmly before you leave, and compression continues afterwards as the mainstay of treatment.
You walk the same day. Discomfort is usually modest and controlled with simple painkillers.
Dressings and compression are reviewed. Any ulcer is dressed as before. Walking is encouraged.
The ulcer, where present, should be visibly contracting. Compression continues without interruption.
Most ulcers that are going to heal have done so. Long term compression continues to prevent recurrence.
Where a large incompetent perforator sits directly under an ulcer that will not heal, closing it can be the step that allows healing. The evidence is not as strong as it is for treating the saphenous trunks, and the procedure is not a substitute for compression, which continues afterwards. Skin that is already darkened and hardened does not return to normal. The realistic aim is a healed ulcer and a skin envelope that stays intact, not skin that looks untouched.
Operating through skin that is already damaged carries its own difficulties, which is part of why the technique has moved away from open surgery.
Compression after this procedure is not optional. It is the treatment; the procedure only removes one obstacle to it working.
Compression is the treatment. The procedure removes one obstacle to it working. Stopping compression is the commonest reason a healed ulcer comes back.
Most venous ulcers heal with compression and treatment of the trunk veins. Perforator surgery is for the minority that do not.
Pigmentation and hardening from years of venous pressure are largely permanent. The aim is intact, healed skin rather than normal looking skin.
Ulcer legs are assessed as a whole: arterial supply, deep vein patency, trunk reflux and perforators, in that order. Closing a perforator in a leg whose real problem lies elsewhere achieves nothing, and that assessment is what decides whether this is offered.
Cost depends on the number of perforators treated and on the technique used. Treatment of venous ulceration is commonly covered by health insurance and government schemes. A written estimate follows the duplex assessment.
Most of these come from people who have had an ulcer for a long time.
Ask your question →It can, where the ulcer has stalled and ultrasound shows a large incompetent perforator sitting under it. It is not a guarantee. Compression continues to do most of the work, and an ulcer that is not shrinking afterwards needs the whole leg reassessed rather than another procedure.
Yes, and usually for life. Stopping compression is the single commonest reason a healed venous ulcer breaks down again.
Because the ulcer is a symptom of pressure, not the problem. Skin grafted onto a leg with untreated venous hypertension breaks down again. The pressure is dealt with first.
Usually modest, and simple painkillers are enough. Many legs with long standing ulcers are already uncomfortable, and patients often find compression more comfortable once the ulcer starts to close.
There is no fixed number, but an ulcer that has not visibly improved after about six weeks of proper compression, with the trunk veins already treated, is the point at which perforators are usually reconsidered.
Seeing patients from across the city and beyond: read about the practice on the plastic surgeon in Surat page, or check what a written estimate covers on the costs and insurance page.
