When superficial varicose veins reoccur after varicose vein treatment, the most common cause is a problem in one or more perforator veins. Perforator veins that are not functioning properly are referred to as incompetent perforator veins, sometimes abbreviated as IPVs. When this happens, varicose vein treatment must be performed on the incompetent perforator vein(s) to seal it/them off (ablation) or the visible varicose veins can become rapidly worse. Let’s take a closer look at these important veins.
What Are Perforator Veins?
Perforator veins connect the veins near the surface of the skin, the “superficial” veins, with the deep veins. They “perforate,” i.e. penetrate through or poke through, the connective tissue surrounding the muscles known as the muscle fascia. Like other veins, perforator veins have one way valves. In perforator veins, a healthy vein valve directs blood from the superficial veins to the deep veins, never the reverse. When a perforator vein valve becomes damaged and allows reflux, a backward flow, blood from the deeper veins is allowed to penetrate through the perforator veins into the superficial veins due to abnormal back flow. In the legs, this usually occurs in the great saphenous vein system but can also occur in the small saphenous vein system.
Perforator Vein Valve Reflux
When reflux occurs in the perforator vein valves, relatively large amounts of blood can quickly begin to pool in the superficial veins which in turn can cause significant leg edema, i.e. significant swelling in the legs. The reason this can happen so quickly, and to such a large degree, is the deep veins carry far more blood volume than the superficial blood. In the legs, deep veins carry ninety to ninety-five percent of the venous blood volume, whereas superficial veins carry only five to ten percent of the venous blood volume.
Perforator Veins That Often Need Varicose Vein Treatment
While any perforator vein can become damaged and cause varicose veins and edema, there are two sets of perforator veins that are more frequently affected. First, Boyd’s perforator veins connect the great saphenous vein (and tributaries) to the posterior tibial vein and the distal popliteal vein. Problems in these perforator veins can cause large varicose veins behind the knee. Second, large varicose veins in the thigh region are often caused by the Hunterian perforator veins which connect the great saphenous vein to the femoral vein in the upper leg.
Varicose Vein Treatments For Perforator Veins
There are two preferred types of varicose vein treatment for perforator veins today. These are ultrasound guided sclerotherapy and ultrasound guided EVLT (Endovenous Laser Treatment), also known as EVTA (endovascular thermal ablation). A comparison of the pros and cons for these procedures on perforator veins was reviewed in detail in a paper entitled, “Minimally Invasive Treatments For Perforator Vein Insufficiency.” This was published in the journal, Cardiovascular Diagnosis and Therapy, in December 2016.
Here were the bottom line conclusions in this paper. In most cases, ultrasound guided sclerotherapy was preferred over EVLT because it was faster, less expensive, and less painful than EVLT. It is also easier to perform when more than one perforator veins are involved. However, there are exceptions to this such as when a patient is obese and ultrasound guided sclerotherapy is more likely to fail on the first attempt. The authors also concluded that if ultrasound guided sclerotherapy failed, then it would be better to use EVLT on the second attempt to ablate a perforator vein since EVLT had a higher success rate of closure than ultrasound guided sclerotherapy. However, EVLT does require more technical skill than ultrasound guided sclerotherapy in ablating perforator veins so if you need this treatment, you’ll want a highly experienced vein doctor to perform the procedure.
Problems With Perforator Veins Can Cause Leg Ulcers
When perforator vein valves fail, the resulting volume of blood in the superficial veins can be quite high, far more than there would normally be. This can cause extreme edema and damage to superficial veins resulting in discoloration of the skin and leg ulcers, usually in the lower leg. This is considered the most advanced stage of varicose veins, requiring the most immediate and urgent need for varicose vein treatment. Leg ulcers are more dangerous than less advanced stages of varicose veins due to risk of infection. Further, the quality of life is substantially lowered.
Seek Help From Metro Vein Centers
Metro Vein Centers offers the best quality varicose vein treatment in the country, whether you need ultrasound guided sclerotherapy, EVLT, ambulatory phlebectomy, or spider vein treatment. You can get a free evaluation by calling one of their offices and setting up an appointment.
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