The Lower Limb Perforator Veins

NewsBot · Feb 9, 2022

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The Lower Limb Perforator Veins in Normal Subjects
Brigid G.HillMHealthSc((DMU Vascular))André M.van RijMD FRACS
Journal of Vascular Surgery: Venous and Lymphatic Disorders; 5 February 2022

ARTICLE HIGHLIGHTS
Type of Research: Single centre observational study.

Key Findings: 20 subjects with normal venous function had a mean of 14.2 perforators in each leg examined by ultrasound. Perforators were significantly larger in diameter within the lower third of the calf and functioning valves are more readily seen in them. For each perforator augmentation maneuvers showed no reflux and flow was always from superficial to deep system. At rest spontaneous flow is seen infrequently but following exercise pulsatile flow occurs in the majority with increased velocities and volumes. Isometric foot plantar flexion consistently induces perforator inflow which correlates well with flow observed following exercise but not with the less physiological augmentation.

Take home Message: This study demonstrates that in the normal leg venous perforators only have inward flow. At rest few perforators have spontaneous flow but with exercise most perforators are recruited and demonstrate flow with velocities that are increased and pulsatile. Augmentation maneuvers do not reflect the physiological behaviour of perforators following exercise or isometric plantar flexion.
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Single centre non-randomized study, looking with ultrasound at venous perforator characteristics in lower limbs of 20 subjects with normal venous function. Examines effect of posture, exercise, and isometric foot plantar flexion and compares these with augmentation. Demonstrates that perforators within the lower medial calf were significantly larger in diameter with valves identifiable. All perforators demonstrated unidirectional inward flow. At rest few perforators have spontaneous flow but exercise leads to recruitment and high pulsatile flow.

Abstract
Objective
With the developments in vascular ultrasound technology the opportunity has arisen to re-examine in greater detail the distribution and behavior of the perforators in normal lower limbs and the implications in understanding their normal role.

Methods
The lower limbs of 20 healthy subjects free of any cardiovascular or venous disease, were examined. The anatomical characteristics and distribution as well as the functional features of all ultrasound detectable lower limb venous perforators were evaluated in these normal limbs. Perforator flow was tested at rest, supine, sitting, standing and with exercise. Comparisons were made between standard augmentation and isometric foot plantar flexion.

Results
Twenty individuals (13 females, 7 males, 36.9 ± 12 years) participated in the study. On average each limb had 14.2 (range 8 to 21) perforators identified by ultrasound. with an average size of 1.3 ± 0.56 mm, (range 0.4 to 3.5 mm), most in the medial calf and those in the lower third were larger. With ultrasound valves were observed only within these larger direct perforators (17%, 18/105). All manouvers resulted in flow which was only from superficial to the deep system and no two-way flow was observed.

Spontaneous flow at rest occurred in a small proportion but treadmill walking lead to the recruitment of most perforators with spontaneous pulsatile flow at greatly increased velocities. The estimated total perforator volume flow could be increased by up to 5-fold and accounting for as much as 80 ml /min in a leg. Isometric foot plantar flexion stopped any spontaneous flow and on relaxation resulted in a reproduceable short burst of inflow in the calf perforators. Augmentation by calf or foot cuff compression produced brief variable inward flow but this did not correlate with the perforator flow with the more physiological maneuvers of isometric foot plantar flexion and exercise.

Conclusions
This study has shown that normal perforator veins in the leg are unidirectional from superficial to deep veins. While few perforators have spontaneous flow at rest, most are recruited with exercise to substantially increase spontaneous perforator flow secondary to the increased skin blood flow. The Augmentation maneuver is not comparable to more physiological activity. These normal features should be taken into account in the assessment of the abnormal perforator.
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