Figure 1

Perforating veins connect the superficial venous system to the deep veins. All veins in the leg - superficial, perforator, and deep - have valves (Figure 1). These valves are composed of two leaflets and allow blood to flow in only one direction to prevent it from falling back (refluxing) into the leg after the leg muscles have helped to propel the blood toward the heart. Valves within the calf and thigh perforators prevent blood from refluxing (flowing back) into the superficial venous system. If these valves become damaged and fail to function properly (become incompetent), blood can flow down the veins (in the wrong direction) and puddle in the lower leg. This leads to vein enlargement (varicose veins), pain, leg swelling, hyperpigmentation (skin discoloration), and even skin ulcers (breakdown of the skin), generally in the part of the leg around the ankle. Incompetent perforating veins have been linked to chronic venous insufficiency and its most severe manifestation, venous ulceration.

Figure 1. Deep and perforating veins of the lower extremity.
(From Gloviczki P, Yao, JST, eds. Handbook of Venous Disorders, 2nd ed. London: Arnold, 2001:18, Fig. 2.9.)

The valves in the deep veins can become incompetent by virtue of vein wall laxity, by elongation and laxity of the valve leaflets themselves, or by direct destruction such as can occur in a patient with deep venous thrombosis (clots within the veins that lead to scarring and destruction of the valves). The first two causes leave the valve structure intact and are considered primary venous insufficiency.

A minimally invasive surgical technique, subfascial endoscopic perforator surgery (SEPS), is used for patients with chronic venous insufficiency. Subfascial means under the fibrous tissue beneath the skin, and endoscopic refers to the narrow instrument used to examine the inside of a cavity in the body.