TRLOP perforators – Pros & cons

The advantages and disadvantages of TRansLuminal Occlusion of Perforators (TRLOP)

The biggest alternative to treating incompetent perforating veins (IPV) with transluminal occlusion of perforators (TRLOP) is to leave them completely alone and not treat them at all. Unfortunately, at the current time, this is a very common event and there is a great many doctors who perform vein surgery but still do not treat incompetent perforating veins (IPV).
This is very surprising as there is good theoretical reasons to do so (see “Understanding Venous Reflux: the cause of varicose veins and venous leg ulcers” an educational book from The College of Phlebology) as well as a great number of research studies that have shown that recurrent varicose veins are often associated with incompetent perforating veins (IPV). As such, there are very few true venous specialists who would now not treat incompetent perforating veins (IPVs) as part of their treatment of venous reflux disease.
Before 1985, doctors who wanted to treat perforating veins would have to do so by cutting open the leg and tying the veins off using surgical ties (ligations). This technique is clearly inferior to transluminal occlusion of perforators (TRLOP) for several reasons. Firstly even the smallest surgical incisions will be larger than the single needle hole needed for the transluminal occlusion of perforators (TRLOP) procedure and therefore would produce a worse cosmetic result as well is an increased risk of pain and infection. In addition, as with vein stripping, the open surgical technique with tying of the vein results in damage to the vein itself and therefore stimulation of the body to regrow the vein. In addition, many surgical ties are designed to dissolve in time, allowing the vein to reopen and the vein problem to re-occur.
In 1985 a surgeon called Hauer invented a procedure called sub-fascial endoscopic perforating vein surgery (SEPS) which was revolutionary in its time. Under general anaesthetic, a surgical endoscope was passed through an incision (usually between 1 and 3 cm) under the fat and above the muscle. The muscle layer has a lining called “fascia” which is like a tight stocking around the muscle itself. The endoscope was passed just under this “fascia” and just above the muscle. As it was passed forwards, perforating veins could be seen to pass across this space. At this point the veins can either be cut, burnt externally or clipped.
Perf-2 Closing incompetent perforating veins (IPVS) with SEPS
  • Metal clip placed on the incompetent perforating vein (IPV) stopping venous reflux
  • The SEPS scope is inserted through a 2cm incision in the skin
Until transluminal occlusion of perforators (TRLOP) was invented in 2000, sub-fascial endoscopic perforating vein surgery (SEPS) was the best way to treat incompetent perforating veins (IPV). However since the invention of transluminal occlusion of perforators (TRLOP), there is no need for sub-fascial endoscopic perforating vein surgery (SEPS).
Transluminal occlusion of perforators (TRLOP) is a local anaesthetic pin-hole technique causing minimal pain and no down-time. Sub-fascial endoscopic perforating vein surgery (SEPS) is a general anaesthetic technique with a larger scar that has a higher chance of infection, and has more pain – especially with the bruising of the muscle as the endoscope pushes past it. The bruising and discomfort usually lasts a couple of weeks. In terms of results, research published shows that the results of transluminal occlusion of perforators (TRLOP) are equivalent to sub-fascial endoscopic perforating vein surgery (SEPS) at both 1 year and 5 years after the procedure.
Recently some doctors have tried to use Foam Sclerotherapy to close incompetent perforating veins (IPV). Although this is also done under local anaesthetic, is minimally invasive, and also cheaper than transluminal occlusion of perforators (TRLOP), there are some questions that need to be answered before it is used in preference to transluminal occlusion of perforators (TRLOP).
Firstly, if the incompetent perforating vein (IPV) is a normal size for this condition (about 4 mm diameter) and normal length (often 1–2 cm especially around the ankle), it is almost impossible to fill the target vein adequately without foam going into the deep vein, risking damage of deep vein thrombosis (DVT). In addition, it is very hard, if not impossible, to get good compression on a vein that is diving deep to the surface, which is essential for good results with foam sclerotherapy.
Advocates of foam sclerotherapy for incompetent perforating veins (IPV) do say that, by treating the veins that the incompetent perforating vein (IPV) refluxes blood into, on the surface by using foam sclerotherapy, the whole system is subsequently treated increasing the efficacy of this treatment. However this is a theoretical advantage only and so this is one of the situations in medicine that we should await good studies before using – especially as foam sclerotherapy is rarely successful (or even attempted) in short and wide incompetent perforating veins (IPV).
This website was last updated on 11/10/16.