Treatment of issues with perforator veins
In the 1950s and 1960s, several doctors became famous for their treatment of incompetent perforating veins including Linton and Cockett. These techniques were performed under general anaesthetic. In essence, the lower leg was incised from skin down to muscle. The layer of connective tissue surrounding the muscle called the facia was peeled back and the incompetent perforating veins could be seen easily passing through this fascia and into the muscle. It was then a simple task surgeon to tie the veins and cut them.
A surgeon called Edwards developed a technique for this can be done minimally invasively. Once again under general anaesthetic, an incision was made down to muscle and an instrument passed into the gap between the fascia layer and the muscle. This instrument was then used to cut the veins. As the veins were not tied off, blood within the into the area causing extensive pain and bruising. In addition, the presence of the blood clot and stimulate the veins to heal and grow back again, allowing the problem to recur (veins that regrow never have working valves in them).
In 1985, a German surgeon called Hauer invented a minimally invasive technique called subfascial endoscopic perforating vein surgery (SEPS). Under general anaesthetic, an endoscope (a tube with a light and an optical system) was inserted through an incision and passed into the space between the connective tissue called facia and muscle. This endoscope was then moved backwards and forwards, identifying the incompetent perforating veins which passed through the facia and into the muscle. Through the endoscope, these veins could be clipped and cut or coagulated depending on the preference of the surgeon. Although this needed a general anaesthetic, the incision is often only 2 to 3 cm long and studies shows the techniques to be approximately 80 to 85% successful.
SEPS was the optimal way to treat incompetent perforating veins until the year 2000 when a new minimally invasive technique called TRLOP was invented by Mark Whiteley and Judy Holdstock of The Whiteley Clinic in the UK.
Transluminal occlusion of perforating veins – TRLOP.
When endovenous surgery started in 1998 and 1999, it became possible to treat the great saphenous vein (GSV) through a single pinhole in the lower leg. Under ultrasound control, a radiofrequency ablation catheter and then later and endovenous laser ablation catheter could be passed into this vein under ultrasound control, allowing minimally invasive treatment. Within a few years, these techniques were improved so that they could be used in other veins such as the small saphenous vein (SSV) and could also be used under local anaesthetic for true walk-in, walk-out surgery.
In the year 2000, treatment of the great saphenous vein (GSV) by radiofrequency ablation was possible, giving excellent results in terms of successful ablation of the veins, minimal pain and discomfort, and scars that were barely visible within months. However in the patients who had incompetent perforating veins (approximately 40% of patients with first-time varicose veins and approximately 60% in those with recurrent varicose veins) the incompetent perforating veins still needed to be treated SEPS. This still necessitated a general anaesthetic, and a large 3 cm incision compared to the pinhole incision of radiofrequency ablation, and considerable muscular pain from passing the endoscope over the naked muscle.
With the increasing accuracy of finding the veins and getting needles into them under ultrasound control, Mark Whiteley and Judy Holdstock of The Whiteley Clinic started treating incompetent perforating veins in the same manner. An ultrasound scan was used to identify the incompetent perforating veins and a large needle with a sheath over it called a “cannula” was then passed accurately directly into this vein. Once in position, the radiofrequency ablation catheter could be passed directly into the incompetent perforating vein. Local anaesthetic was then injected around the vein to stop any heat damage to any surrounding structures such as muscle nerves, and the radiofrequency was switched on ablating the incompetent perforating vein.
They called this technique TRLOP (TRansluminal Occlusion of Perforators) and used it for all patients with incompetent perforating veins from year 2000 onwards. They presented their results widely in the UK, Europe and America. A company called VNUS worked with them to develop a specific radiofrequency instrument called the RFS (radiofrequency stylet) but they advised against using the forward firing laser at this time. The reason for this is that with the radiofrequency ablation catheter, it is the part of the vein in contact with the catheter that is treated and so any treatment is precise. With forward firing laser, damage can occur up to 2 cm in front of the end of the laser. In such a small vein as an incompetent perforator, this put the deep veins at risk.
Researchers at The Whiteley Clinic have continued to develop the TRLOP technique and have shown excellent results and quicker treatment using the RFiTT radiofrequency device and the radial firing endovenous laser which treats the vein at the side of the tip of the laser rather than in front of it.
In approximately 2004, TRLOP was “reinvented” in the United States and was called PAPS (perforator ablation procedures). This followed presentation of the TRLOP technique at some American meetings. As there is no difference between the two techniques, the term perforator ablation procedures (PAPS) should be discarded and the correct term transluminal occlusion of perforator (TRLOP) should be used when describing ultrasound cannulation of perforators enclosure using a thermal device.
Research has shown that TRLOP under local anaesthetic is as effective as SEPS, closing approximately 80 to 85% of all treated incompetent perforating veins.