Perforating Veins by Venography at Operation

All types of varicose veins can be treated successfully by a radical stripping operation in which the whole system of diseased veins and related perforating veins is removed (Myers, 1957; Arenander, 1960; Sherman, 1964). Simple procedures such as high ligation, with or without stripping of the main saphenous trunk, though widely practised, are much less successful, even in the early and uncomplicated case. Great saphenous incompetence is usually obvious, and can be convincingly demonstrated by the Brodie-Trendelenburg test. Femoro-saphenous refiux fills the superficial veins with blood at a low pressure only (Cockett, 1956). Incompetent perforating veins, however, are easy to overlook, and their presence cannot be excluded with certainty by any clinical test. They are present in 90% of cases (Sherman, 1949), and are especially important as a cause of varices which persist or recur after operation (Mathiesen, 1953 ; Lofgren, Myers and Webb, 1956; and many others), and as the cause of ulcers. Cockett and Jones (1953) showed that the venous drainage of the lower part of the leg is through short perforating veins to the deep vessels, and only indirectly through the saphenous systems. Thus in this area any superficial venous disease is likely to stem from the perforating vessels, and it is here in the " gaiter-area " that the high intermittent pressures in the deep veins can be transmitted to the surface through incompetent perforating veins, leading to ulceration (Arnoldi, 1966). " Varicose ulceration" due solely to incompetence of superficial veins does not occur, for incompetent perforating veins can be found in association with every venous ulcer (Sarjeant, 1964; Arnoldi, 1966; Haeger, 1966). It is true that saphenous incompetence may be a contributory cause of ulceration and that ulcers may be healed by removal of the saphenous vein, but the effect is unpredictable and healing often only temporary (Moore, 1957; Haeger, personal communication, 1966). It is sometimes thought that stripping out the saphenous trunk destroys the perforating veins, but Sherman (1949) has shown that about one-half of all perforating veins, and most of the incompetent ones, are not directly connected with the saphenous trunks. Radical stripping operations, though repeatedly shown to be very effective, are not practised by the majority of surgeons, who perhaps feel that the time and trouble required and the trauma to the patient are not justified even by a reasonably certain cure. Another prevalent view, that varicosis is a progressive condition essentially unsuited to radical cure, has some basis in fact, but is founded more on a practice of inadequate diagnosis followed by inadequate surgery. Preoperative diagnosis of incompetent perforating veins is difficult. Various clinical signs are described but none is reliable. Surgeons experienced in venous disease commonly find at operation incompetent perforating veins which they have not detected previously. The lesser operations which are commonly practised often leave incompetent perforating veins intact, with the attendant risk of persistent or recurrent varices and ulcers. If it were possible to locate incompetent perforating veins accurately and confidently it is probable that they would be