Subfascial Endoscopic Venous Surgery - Indications, Investigations, and Procedure

Creator: Dr. Lakshika Sree. K. V.
Published: 2023-02-09T18:20:14

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The damaged perforated veins of the leg are treated by subfascial endoscopic venous surgery. Read the article to know about the procedure.

Written by

Dr. Lakshika Sree. K. V.

Medically reviewed by

Dr. Pandian. P

February 9, 2023

April 25, 2023

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Contents

What Is Subfascial Endoscopic Venous Surgery?
What Are the Indications for Subfascial Endoscopic Venous Surgery?
What Are the Symptoms That Indicate a Venous Disorder?
Who Are at the Most Risk of Developing a Venous Disorder?
How to Prepare a Patient for Subfascial Endoscopic Venous Surgery?
What Are the Investigations to Be Done before a Subfascial Endoscopic Venous Surgery?
How to Perform a Subfascial Endoscopic Venous Surgery?
How Is the Recovery after Subfascial Endoscopic Venous Surgery?

Introduction

Venous disorders are becoming a common problem among people nowadays. It causes discomfort and can lead to a stage where the walking ability is also affected. There are many conservative methods to treat such conditions. It includes changing their lifestyle, wearing compression stockings, and many more. But, some venous diseases do not heal or take longer to heal. The surgical option opens the door to these patients and provides relief with a shorter healing period. One such surgical procedure is subfascial endoscopic venous surgery.

What Is Subfascial Endoscopic Venous Surgery?

Subfascial endoscopic venous surgery is a minimally invasive surgical technique. It is usually performed in patients with varicose veins or non-healing venous ulcers. The surgery cuts and closes off the damaged perforator veins (the veins that connect the deep to the superficial venous system and allow blood flow in between them). Venous ulcers appear on the leg due to the reverse flow of blood through them. The reverse blood flow occurs due to dysfunction in the valves allowing the blood to flow in the direction opposite to that of the heart. When this condition is left untreated, it progresses to form ulcers in that region that take a long time to heal.

What Are the Indications for Subfascial Endoscopic Venous Surgery?

The most common causes that require subfascial endoscopic venous surgery are:

In patients with chronic venous insufficiency. It is a valvular disease that involves the lower extremities causing swelling, irritation, and a poor quality of life. If the condition is left untreated, it progresses to form ulcers and worsen the disease process.
In patients with lipodermatosclerosis. It is associated with inflammation of fat under the skin, causing skin changes in the lower legs.

What Are the Symptoms That Indicate a Venous Disorder?

The following are the symptoms the patient experiences on developing a venous ulcer:

Pain in the legs that worsens on standing and is relieved on raising the leg.
Swelling of the leg and ankle.
A burning or tingling sensation in the legs.
Reddish-brown skin discoloration.
Itchy and weak legs.
Leg cramps.
Heaviness in the legs.
A feeling of tightness in the calf muscles.
A leathery appearance of skin in the legs.
Ulcers may develop in the legs if left untreated.
Varicose veins (twisted and bulgy superficial veins).

Who Are at the Most Risk of Developing a Venous Disorder?

The risk factors that make the patient more prone to develop a venous disorder are:

A patient with a previous history of deep vein thrombosis.
Presence of varicose veins or with a family history of varicose veins.
In older adults above fifty years of age.
Obesity.
Female.
Pregnancy.
The habit of smoking and alcohol.
In patients who sit or stand for a long time.
Phlebitis (swelling of a superficial vein).
A person with very little physical activity.
Weak muscles in the leg.
Trauma to the leg region.
In patients with May-Thurner syndrome (a condition that compresses a vein in the leg and obstructs the blood flow).

How to Prepare a Patient for Subfascial Endoscopic Venous Surgery?

The doctor will provide all the information regarding the purpose, benefits, and possible risks involved with the procedure. The patient should sign a consent form as approval for the surgery. If the patient is under medications such as Aspirin (blood thinner), it has to be stopped a week before the surgery. Allergies to anesthesia or medications are informed to the doctor to prevent complications. Avoid smoking or alcohol consumption. The doctor prescribes medications the patient must consume before the procedure.

What Are the Investigations to Be Done before a Subfascial Endoscopic Venous Surgery?

The doctor notes the patient's detailed medical and family history. Clinical and physical examination of the site of the venous disorder is done. In addition, the doctor also takes imaging tests to have a detailed view of the vein disorder.

Duplex Ultrasound - An imaging technique that uses sound waves to determine the speed and direction with which the blood flows through the veins. In this procedure, a transducer (a hand-held device used to transmit the signals) is placed on the skin, records the blood flow, and displays the image on a computer.
Venogram - An intravenous radiocontrast dye is injected into the vein to make the veins appear opaque on a radiograph. This helps to visualize the blood vessel configuration and detect any damage in the wall of the veins.

How to Perform a Subfascial Endoscopic Venous Surgery?

General or spinal anesthesia is administered to the patient for a painless procedure. The operation site is cleaned with an antiseptic solution, and the procedure is done under sterile conditions.

An incision or a cut is made near the calf muscle of the affected leg. Through the incision, an instrument is inserted, and a large balloon is inflated with water to create space. The water is then replaced with air. An endoscope (a long thin tube with a camera attached at one end to visualize the inner structures in detail from the outside) is also introduced through the incision. The affected veins are gently cut and removed without damaging the surrounding structures. After completing the procedure, a suction drain is placed to clear the excess fluid, and all the instruments are removed. The wound is then closed, and sutures are placed.

How Is the Recovery after Subfascial Endoscopic Venous Surgery?

The patient is discharged one or two days after the surgery. They have a faster recovery, and the ulcer shows signs of healing. The patient can wear compression stockings for at least three to four weeks after surgery. Painkillers prescribed by the doctor must be consumed regularly. Do not make the operating site wet by taking a bath. Bathing of the leg is avoided for at least two weeks. Consult the doctor when to take off the bandages and the compression stockings. Avoid heavy exercises that cause strain to the body. Walk slowly for a few minutes and increase the pace gradually. Do not put too much pressure on the legs. The overall recovery is good if the doctor’s instructions and regular checkups are followed.

Conclusion

Subfascial endoscopic venous surgery is a highly effective and safe surgical technique for patients with perforator veins or other non-healing venous disorders. The complications associated with the procedure are fewer, requiring only a short hospital stay. Additional treatment or retreatments are usually not required. It is finally up to the doctor and the patient to decide the correct treatment to manage the damaged veins.

Frequently Asked Questions

1. What Are the Advantages of Utilizing Subfascial Implants?

The following are the advantages :
- The subfascial placement provides a more natural appearance and better contouring.
- By positioning the implant beneath the fascia, the risk of implant edges or rippling being visible through the skin is minimized.
- Subfascial implants can produce a softer and more natural feel than other implant placement techniques.

2. In Which Location Is the Subfascial Implant Typically Inserted?

The subfascial implant is typically inserted in the lower breast region, specifically within the subfascial plane. This plane is between the breast tissue and the fascia, a layer of connective tissue covering the muscles. Placing the implant in this location allows for optimal aesthetic outcomes and natural-looking results. It also provides adequate support and coverage for the implant, resulting in improved long-term stability and reduced risk of visibility or palpability.

3. What Are the Indications for Performing Subfascial Endoscopic Perforator Surgery (SEPS)?

Subfascial Endoscopic Perforator Surgery (SEPS) is indicated in cases of chronic venous insufficiency with associated venous ulcers or other complications. It is commonly performed when there are perforator veins that are causing reflux or incompetence. SEPS can be recommended for patients who have failed conservative management or when other surgical options, such as vein ligation or stripping, are not feasible or appropriate. The procedure aims to treat the underlying venous pathology and improve venous circulation, leading to wound healing and symptom relief.

4. What Are the Potential Complications Associated with Subfascial Endoscopic Perforator Surgery?

Potential complications associated with this may include:
- Bleeding: There is a risk of bleeding during or after the procedure, which may require intervention.
- Infection: As with any surgical procedure, there is a potential risk of infection at the incision sites.
- Nerve Injury: There is a slight possibility of nerve damage during the surgery, which can lead to sensory or motor deficits.
- Wound Healing Issues: Delayed wound healing or breakdown can occur, particularly in individuals with compromised tissue perfusion or underlying medical conditions. Close monitoring and appropriate wound care are essential to mitigating these risks.

5. How Is a Perforator Vein Treated?

Treatment options for a perforator vein depend on the specific condition and symptoms. In some cases, conservative measures such as compression therapy and lifestyle modifications may be sufficient. However, medical interventions may be necessary if the perforator vein is causing significant symptoms or complications. These can include endovenous procedures such as endovenous laser treatment (EVLT), radiofrequency ablation (RFA), or sclerotherapy to seal off or remove the affected vein. In certain cases, surgical options like subfascial endoscopic perforator surgery (SEPS) may also be considered.

6. In the Context of Surgery, What Is Meant by a Perforator?

In surgery, a perforator refers to a blood vessel that connects deeper vessels, such as deep veins or arteries, to more superficial ones. These vessels pass through or perforate the muscles, fascia, or other tissues. Perforators are important for maintaining circulation and tissue perfusion. In surgical procedures, perforators can be targeted for ligation, coagulation, or manipulation to address specific conditions or pathologies, such as venous insufficiency or tissue reconstruction. Understanding the anatomy and function of perforators is crucial for surgeons when planning interventions and optimizing patient outcomes.

7. Are Perforator Veins Situated Deep Within the Body or Closer to the Surface?

Perforator veins are deep within the body and closer to the surface. The location of the perforator vein depends on the specific anatomical region. In some areas, such as the lower extremities, perforator veins are predominantly located deep within the muscles and connect deep veins to superficial veins. However, perforator veins may be situated closer to the surface in other regions, such as the upper extremities or certain anatomical regions of the torso. The distribution and depth of perforator veins can vary throughout the body.

8. Can a Perforator Vein Exhibit Normal Characteristics?

Yes, a perforator vein can exhibit normal characteristics. Like other veins, a healthy perforator vein should have proper blood flow, adequate valve function, and normal vessel structure. It should effectively connect the deep and superficial venous systems without any signs of reflux or obstruction. However, it is important to note that perforator veins can also be affected by various pathological conditions or abnormalities that can alter their characteristics, such as venous insufficiency or reflux.

9. How Many Perforator Veins Are Typically Found in the Leg?

The number of perforator veins found in the leg can vary among individuals, but typically, multiple perforator veins are present. The leg contains a complex network of perforator veins connecting deep veins to superficial ones. The number and distribution of perforator veins can vary based on individual anatomy and variations in venous drainage patterns. The leg can have numerous perforator veins, ranging from a few to several dozen, facilitating blood flow and maintaining venous circulation in the lower extremities.

10. What Are the Two Primary Types of Perforators?

The two primary types of perforators are named based on their anatomical location and direction of blood flow. The first type is "proximal" or "muscular" perforators, which connect the deep veins to the muscles in the surrounding area. These perforators typically allow blood to flow from the deep veins to the superficial veins. The second type is "distal" or "subcutaneous" perforators, which connect the deep veins to the subcutaneous tissue or skin. These perforators generally carry blood from the superficial veins to the deep veins.

11. What Is the Significance of Perforator Veins?

Perforator veins have significant clinical importance in the field of venous disease. They connect channels between the deep and superficial venous systems, allowing for efficient blood circulation and drainage. Dysfunction or incompetence of perforator veins can lead to venous insufficiency, varicose veins, or venous ulcers. Understanding the anatomy and function of perforator veins is crucial for diagnosing and treating these venous disorders. Surgical interventions targeting perforator veins, such as ligation or endoscopic procedures, can help restore proper venous function and alleviate associated symptoms.

12. What Is the Usual Size of Perforator Veins?

The size of perforator veins can vary, but they generally fall within a certain range. Perforator veins typically have a diameter ranging from a few millimeters to a centimeter or more. The exact size can depend on anatomical location, individual variation, and the specific venous pathology involved. Imaging modalities such as ultrasound or venography can assess the size and characteristics of perforator veins, aiding in diagnosis and treatment planning for venous disorders.

13. What Is Considered the Normal Diameter of a Perforating Vein?

The normal diameter of a perforating vein can vary depending on the anatomical location and individual factors. Generally, a normal perforating vein has a diameter ranging from 2 to 6 millimeters. However, it's important to note that various factors, including venous disease, anatomical variations, and individual characteristics, can influence the diameter of perforating veins. Imaging techniques, such as ultrasound, can help assess the diameter and integrity of perforating veins, aiding in diagnosing and managing venous conditions.

14. How Many Valves Do Perforating Veins Typically Possess?

Perforating veins typically possess one or two valves. These valves are crucial in maintaining proper blood flow and preventing backward or reflux. Valves in perforating veins help to direct blood from the superficial veins toward the deep veins, aiding in efficient venous return. However, it's important to note that the number and functionality of valves can vary among individuals and may be affected by venous diseases or anatomical variations.

15. What Role Do Perforators Play With Deep Vein Thrombosis (DVT)?

Perforator veins can contribute to the development and progression of deep vein thrombosis (DVT). In DVT, perforators are potential pathways for thrombus (blood clot) extension from the superficial venous system to the deep veins. If a clot forms in the superficial veins, it can travel through the perforator veins and reach the deep veins, leading to a more severe and potentially life-threatening condition. Identifying and assessing the status of perforator veins is crucial in evaluating the risk and managing DVT cases, as appropriate interventions may be necessary to prevent clot migration and complications.

Sources

Dr. Pandian. P

General Surgery

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