Question
Does anybody have experience doing Subfascial Endoscopic Perforator Surgery (SEPS) in chronic venous insufficiency patients?
I have recently started performing this surgery and find it quite effective and easy approach.
All Answers (11)
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I do. Actually I stopped performing it, not because it is ineffective but because I am not a vascular surgeon and referral for this kind of surgery is not common. I found it also a tedious operation.
Several years ago I presented some videos in a few congresses proposing to use ultrasound dissection for sealing the perforators: very effective, you only need one instrument (no more get in and get out with clips dissector, scissors and again dissector) and also cost effective if you compare disposable to disposable, of course) -
I used to - now use TRLOP - local anaesthetic and easy to perform -
Ask Cees Wittens, professor of venous surgery at the University of Maastricht. He performed SEPS for more than 10 years. -
SEPS has no advantage and this procedure will now be obsolete. -
Having been perfoming SEPS since 1996 and then inventing TRLOP in 2001, I find the simple "SEPS has no advantage" answer worrying. Although some poorly performed studies sugggest that no advantage can bee seen from SEPS, this is actually due to the problems of neovascularisation and poor open surgery hiding the advantages. As we now ablate veins, better studies will get rid of these confounding variables and the role of the IPV and the advantages of treating them properly will become apparent.
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I have a past experience performing SEPS since 1995. In many patients was employed a spacemaker to perform perforator vein section associated to safenectomy. -
I have some experience of the procedure and spent a little time looking at the role of perforator ablation in the management of CVI.
The first stumbling block is demonstrating any impact from venous surgery of the more severe forms of CVI. The ESCHAR trial showed an impact on ulcer recurrence rates, but little effect on time to ulcer healing.
The biggest issue with venous disease is the huge capacity for collateral channels to open up after ablation or occlusion. This is very helpful in the case of massive DVT or deep vein harvest for arterial reconstruction, but significantly lessens the effects of any surgery to improve venous function.
Neovascularisation is also a major factor. Even adequately performed saphenous extirpation will result in a 10-20% recurrence rate for simple varicose veins. Add to this the deep vein incompetence associated with 40-60% of patients with skin changes of CVI, and you can be sure that whatever you may achieve will be an incomplete correction of lower limb venous return with a significant risk of deterioration to the pre-existing state within in a few years.
Does this mean that SEPS is either effective or not? Hard to be sure , but it seems unlikely that there will be any significant benefit over and above adequate superficial venous surgery. The only group that may show significant benefit from SEPS are those with incompetent perforators, ablated superficial systems and deep system disease without infra-inguinal occlusion. If have not made any difference to any of the three patients, from this small clinical group, that I have treated by SEPS. -
Dear Dr.Shahzad, we performed this technique in the late 90's but nowaday we are successfully performing radiofrequency ablation of the perforant veins. We recently published our experience about this technique with good results in terms of complete occlusion of the treated veins with low recurrences rate and optimal pain control for the patients. You can find our paper on PubMed:Radiofrequency ablation of the great saphenous vein with the ClosureFASTTM procedure: mid-term experience on 400 patients from a single centre.
There is also another technique for perforant vein surgery named CLARIVEIN a twisting microcatether infusing lauromacrogol at 2% leading to a mechano-chemical occlusion of the vessels. We are now collecting the early data with 20 patients. -
in my practice, SEPS has a clear role in chronic venous disease (CVD) with ulceration, especially when it happens after a first superficial vein stripping/ablation surgery. It has only one major advantage: no skin incision near an ulcer or on diseased skin (melachrosis-lipodermatosclerosis) of severely affected CVD patients with dermal complications. -
I have replaced SEPS with Ultrasound guided foam sclerotherapy -
We have single center experience of more than 100 SEPS procedures. Despite recently popularized opinion about the useless of SEPS we obtain good results in majority of patients. The patient selection is important. The optimal indication to my opinion is Ep C6 recurrence after saphenous ablation, and perforators with large diameter (> 5 mm) situated in the ulcer area. Endovenous ablation of perforators is a new and very attractive method which probably may replace SEPS in the future. But in my limited experience large diameter of perforators may lead (> 5 mm) to non-oclusion after ablation.
