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Swollen ankle from incompetent perforator veins

by – January 16, 2016

A swollen ankle can be due to varicose veins. Having varicose veins and ankle swelling is one of the indications to get varicose veins treated. This is in the NICE guidelines CG 168 which were published in July 2013 (see guidelines here).

Swollen ankle on left leg due to recurrent varicose veins which are caused by incompetent perforating veins only

Swollen ankle on left leg due to recurrent varicose veins which are caused by incompetent perforating veins only

The duplex ultrasound scan shows that the great saphenous vein has been successfully treated and there is no flow in it at all.

Venous Duplex Ultrasound scan showing incompetent perforator veins causing recurrent varicose veins and ankle oedema CEAP C3

Venous Duplex Ultrasound scan showing incompetent perforator veins causing recurrent varicose veins and ankle oedema CEAP C3

However since that operation had been performed, the patient has developed new varicose veins. These are called recurrent varicose veins because they have occurred in a leg that has previously had successful varicose vein surgery.

There are many causes for recurrent varicose veins, and research performed by The Whiteley Clinic has shown that incompetent perforating veins are a major cause of recurrent varicose veins.

Duplex ultrasound scan of this gentleman’s leg shows clearly that the varicose veins are being caused by an incompetent perforating vein in the thigh. In addition there is another incompetent perforating vein lower down in the leg.

Not only does this man have recurrent varicose veins caused by incompetent perforating veins, but the condition has deteriorated and after cause swelling of the ankle. This swelling is a fluid collection in the tissue. It is called venous oedema.

Incompetent perforator vein causing recurrent varicose veins in the thigh

Incompetent perforator vein causing recurrent varicose veins in the thigh

 

Venous oedema is technically known as CEAP clinical grade C3. Any patient with CEAP C3 should have referral to a vascular service that specialises in vein surgery such as The Whiteley Clinic.

As per the NICE guidelines, a proper vascular service specialising in veins is made up of a team of specialists that can perform duplex ultrasonography of the veins and can offer all of the vein treatments.

It is not a single doctor sitting in a room doing their own scan and then offering treatment by themselves. The NICE guidelines are clear that there should be a team bringing all the different specialities for the diagnosis and treatment to a patient.

Incompetent perforating veins causing varicose veins, swollen ankle and leg ulcers

Swollen ankle due to recurrent varicose veins caused by incompetent perforating veins

Swollen ankle due to recurrent varicose veins caused by incompetent perforating veins

Traditionally, doctors treating varicose veins do not look for nor treat incompetent perforating veins. This is because in the past, poorly performed research suggested that incompetent perforating veins disappear after normal varicose vein surgery.

In 2001, Mark Whiteley published that there was a link between incompetent perforating veins and recurrent varicose veins (see link).

In 2007, research from The Whiteley Clinic showed this is not the case. If patients are examined for a whole year following varicose vein surgery, incompetent perforating veins reappear after vein surgery if they have not been specifically closed at the time of surgery (see link).

Further research from The Whiteley Clinic in published 2014 showed that the failure of doctors to identify and treat incompetent perforating veins was a major cause of why patients get varicose veins back again in the future (see link).

TRLOP treatment for incompetent perforating veins

Before the 1980s, incompetent perforating veins had to be treated through large incisions. These were called the Cockett procedure or the Linton procedure.

In the 1980s, a German surgeon called Hauer invented a technique to treat incompetent perforating veins using keyhole surgery. This was called SEPS or subfascial endoscopic perforating vein surgery (see research).

However this was superseded in 2001 by the TRLOP technique (transluminal occlusion of perforators) which was invented by Prof Mark Whiteley and Judy Holdstock of The Whiteley Clinic. This is a pinhole surgical technique which can be performed under local anaesthetic.

TRLOP can be performed using laser, radiofrequency or other techniques that close veins. The Whiteley Clinic has published results at both one-year and five-years after TRLOP showing excellent results.

Incompetent perforating veins and varicose veins

Prof Mark Whiteley is a recognised world expert in understanding varicose veins – how they form and how best to treat them. His opinions on incompetent perforating veins have been published both in America and in Europe in a transatlantic debate (see link).

The identification and treating of incompetent perforating veins is one of the many reasons that patients treated with the Whiteley Protocol have such a low risk of getting recurrent varicose veins and also why patients treated at The Whiteley Clinic have such high patient satisfaction rates.

Links:

NICE Guidelines for Varicose Veins: https://www.nice.org.uk/guidance/cg168/chapter/1-recommendations#referral-to-a-vascular-service-2

SEPS: http://www.ncbi.nlm.nih.gov/pubmed/3175833

TRLOP: https://thewhiteleyclinic.co.uk/procedures/trlopseps/

1 Year results of TRLOP: http://www.ncbi.nlm.nih.gov/pubmed/20348454

5 Year results of TRLOP: http://www.ncbi.nlm.nih.gov/pubmed/19299275

Transatlantic debate on treating incompetent perforating veins: https://thewhiteleyclinic.co.uk/research/published-research/incompetent-perforator-veins-recurrent-varicose-veins-trlop/

 

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