Role of Subfascial Endoscopic Perforator Vein Surgery (SEPS) in Patients with Stasis Dermatitis and Ulceration: Long-term Clinical Outcome

Abstract

Purpose: The safety, feasibility, and early efficacy of subfascial endoscopic perforator vein surgery (SEPS) for chronic venous insufficiency have been reported, but the longterm clinical outcome after SEPS is still undetermined. This study was undertaken to investigate the long-term rates of ulcer healing and recurrence.

Materials and Methods: We performed TPS-SEPS (two port system SEPS) on 446 limbs of 360 patients (118 men and 242 women with an average age of 58.9 years). Forty-five limbs were Class 6 according to the CEAP classification. Among these 45 limbs, 3-5 limbs of 33 patients (20 men and 13 women with a mean age of 54.3 years; range: 27 to 74 years) were followed up for longer than 1 year. All of them had active ulcers at the time of operation, and the ulcer healing rate and recurrence rate were documented. Twenty-five limbs (71%) underwent concomitant superficial venous ablation (stripping, high ligation, varicose ablation, and sclerotherapy). Seven out of ten limbs that were treated by SEPS without superficial venous ablation had a past history of saphenous vein stripping. All patients underwent duplex US scanning to document reflux in the deep, superficial, and perforating venous systems. Three patients had a past history of deep venous thrombosis.

Results: The follow-up period for the 33 patients averaged 33 months (range: 12 to 56 months). There were no deaths and no cases of pulmonary embolism. The size and number of ulcers did not influence the healing rate significantly, but single ulcers with a diameter of less than 2 cm were more likely to be healed by SEPS. On the other hand, the duration of ulceration had a significant influence on healing after SEPS. In 91.4% of the limbs (32/35), ulcers healed within 7 to 256 days (average: 50.0 days, median: 27 days). In 8.6% of the limbs (3/35), ulcers failed to heal. Ulceration recurred in 3 limbs (9% (3/33)) of three patients. One of these three patients underwent repeat SEPS, but obtained no additional benefit from the operation. One of the recurrent ulcers was cured by split-thickness skin grafting. Finally, 5 of the 35 limbs (14.3%) had active ulcers, and the healing rate was 85.7% (30/35) at the latest follow-up examination.

Conclusion: The results suggest that including the SEPS procedure in the overall treatment plan for patients with CVI can achieve active healing with a minimum of postoperative complications. However, long-term prospective and randomized studies are still required to provide level I evidence of late efficacy.