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.