Varicose veins - incompetent perforators

Case contributed by Dennis Odhiambo Agolah


Swelling lower limbs previously diagnosed with deep venous thrombosis of the right leg. Currently to assess for DVT.

Patient Data

Age: 35 years
Gender: Female

Predominantly vertically and near-vertical to obliquely oriented dilated vascular structures (perforators) are noted coursing into the deep subcutaneous tissues of the lower limbs right from the proximal thighs and downwards to the ankle joints resulting into superficial subcutaneous venous varicosities (measuring up to 3.7 mm in diameters; grade II-III) and subcutaneous tissue edema bilaterally. The mentioned near vertically aligned vessels (perforators) involve the proximal thighs (Hunterian), distal thighs (Dodd), the popliteal fossae (Boyd), proximal, medial and distal calves (Cockett I, II & III) and the ankle joints (Kustners and May perforators). 

In the erect position (exerted pressure) they measure up to 5.2 mm in diameter. A small (3.3 x 1.9 mm in diameter)  hyperechoic and posteriorly shadowing focus (pointed with arrow) is noted at the right medial leg deep subcutaneous tissues along the variceal line consistent with a calcified thrombus. The bilateral long and shorter saphenous veins are moderately engorged as well demonstrating color aliasing on mapped out color flow study.

Case Discussion

Perforators (a.k.a communicating veins) bridge the deep venous systems (below the muscular fascia) and the superficial systems (above the muscular fascia). The lower limbs have approximately 150 perforators that direct blood flow from the superficial to the deep venous systems right all the way from the feet (dorsal, medial, metatarsal, plantar, lateral perforators) to the ankle joints (anterior, posterior, medial & lateral perforators) to the legs (posterior tibial, paratibial, medial & lateral gastrocnemius perforators) to the knee joints (popliteal, anterior, lateral & medial perforators) to the thighs (medial, lateral, posterior & anterior femoral perforators) up to the inguinal regions, inguinal ring perforators 1,2.

When the intra-perforator or the deep/superficial bicuspid valves are incompetent, the affected communicating/perforator veins appear engorged and sonographically are depicted as vertically or obliquely coursing from the superficial to the deep venous systems as above. Best practice habits (where applicable) is when the patient is scanned in the erect/standing posture since reflux requires pressure gradient and is gravity dependent 3.

Occasionally, the incompetent perforators may go hand-in-hand with the superficial/deep vascular systems (like above where the greater and the lesser saphenous veins as well as the perforators exhibit positive features of incompetence) while in some cases, they happen in isolation.

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