The Management of Chronic Venous Ulcers and the Benefit of Subfascial Endoscopic Perforator Vein Surgery

Elastic compression is the primary treatment modality of venous ulcers. Local ulcer treatment is important to enhance granulation and prevent or treat infection, while surgical treatment is aimed at correcting the underlying venous stasis and ambulatory venous hypertension. This debate reviews the pros and cons of surgical treatment for venous incompetence and discusses current evidence to support the use of subfascial endoscopic perforator vein surgery (SEPS). Ablation of superficial reflux with high ligation and stripping of the incompetent saphenous vein, done together with avulsion of varicose veins, remains the main surgical treatment of chronic venous insufficiency. Level 1 evidence of clinical and hemodynamic improvement directly related to interruption of incompetent perforators is currently not available. The North American SEPS registry experience and reports from larger centers, however, provide data on rapid ulcer healing, low morbidity, and decreased wound complications from endoscopic perforator interruption. SEPS, together with ablation of the superficial reflux, when present, can be offered to surgical candidates with advanced chronic venous insufficiency and venous ulcers. While improvement in post-thrombotic patients may be modest, those with primary valvular incompetence will have a predictably good clinical outcome and improved hemodynamic results. The superiority of surgical treatment over optimal medical management remains to be established in a prospective randomized, multi-center trial. The North American Venous Ulcer Surgery (NAVUS) Trial has been designed to answer the role of ablation of the superficial reflux, with or without SEPS, in the treatment of venous ulcers.