If You Are Reading This Page, You Have Likely Seen a Specialist and Been Given a Complex Diagnosis — We Can Help
Being told you have incompetent perforator veins can feel daunting. These veins are not always straightforward to understand, and treatment decisions can be complex. At The Vein Clinic, we specialise in managing advanced venous disease and are one of the very few centres in the UK where radiofrequency perforator ablation is both performed and taught on a regular basis. Our team combines experience, evidence‑based practice, and the latest minimally invasive techniques to provide clarity and reassurance at every stage.
Understanding Perforator Veins
Perforating veins are short connections between the deep and superficial veins of the legs. They act like the rungs of a ladder, linking the two venous systems together. In most people these connections do not cause problems, but when the valves within them fail, blood can flow in the wrong direction. This reflux increases pressure in the superficial veins and can contribute to varicose veins, skin changes, and in some cases venous ulceration.
What Problems Do Perforating Veins Cause?
Incompetent perforator veins have been strongly associated with chronic skin changes and venous leg ulcers. Studies suggest that up to two‑thirds of patients with skin damage from chronic venous insufficiency have a component of perforator reflux in addition to superficial or deep venous reflux. Perforators are also implicated in some patterns of recurrence after previous varicose vein surgery, particularly after stripping. This does not necessarily mean that every patient with perforator reflux is at higher risk of ulceration, but it highlights their role in advanced venous disease.
Should Perforating Veins Be Treated?
The decision to treat perforator veins is now guided by modern evidence and international guidelines. Routine treatment of all incompetent perforators is not recommended. In patients with uncomplicated varicose veins, treating the main superficial veins is usually sufficient. However, in patients with recurrent varicose veins, skin changes, or venous ulcers, selective treatment of incompetent perforators can improve healing and reduce recurrence. The traditional operation, subfascial endoscopic perforator surgery (SEPS), demonstrated that removing abnormal perforators could reduce ulcer recurrence, but the procedure required a general anaesthetic and carried risks such as wound infection, bleeding, nerve injury, and deep vein thrombosis. As a result, SEPS has largely been replaced by less invasive techniques.
Modern Minimally Invasive Options
Today, perforator veins can be treated safely and effectively using endovenous methods. Radiofrequency perforator ablation (RFPA) is performed under local anaesthetic as a day‑case procedure. Using ultrasound guidance, a fine needle is introduced into the perforator vein and a radiofrequency stylet delivers controlled heat to seal the vein. The procedure takes around twenty minutes per perforator, leaves virtually no scarring, and patients usually report little or no pain afterwards. Worldwide experience now exceeds fifteen thousand cases, with closure rates averaging between seventy and ninety‑three percent. Complications are uncommon, with deep vein thrombosis and nerve irritation reported rarely, and permanent numbness occurring in about one percent of cases.
Another effective option is ultrasound‑guided foam sclerotherapy. A specially prepared foam sclerosant is injected directly into the incompetent perforator under ultrasound control. The foam displaces blood, coats the vein wall, and causes the vessel to collapse and seal shut. Foam is particularly useful for short vein segments such as perforators, and modern formulations have improved stability and safety. This technique is quick, performed under local anaesthetic, and allows patients to walk immediately afterwards. It can also be repeated if necessary and is often chosen as a first‑line option for perforators in patients with ulcers or recurrent varicose veins.
Our Approach at The Vein Clinic
At The Vein Clinic, we do not treat perforator veins routinely. Instead, we follow an evidence‑based approach, targeting them selectively when they are clearly contributing to skin damage, ulceration, or recurrence. We offer both radiofrequency perforator ablation and foam sclerotherapy, tailoring the choice of treatment to each patient’s anatomy and clinical needs. This ensures that patients receive the safest, most effective, and least invasive option available.