Incompetent perforator veins (IPVs) are encountered frequently during ultrasound assessment of the venous system in chronic venous disease (CVD). The total number of IPVs increases significantly with the severity[1, 2]. Some studies have shown that concomitant treatment of truncal and perforator incompetence improves ulcer healing [3, 4], yet a Cochrane review was unable to determine the potential benefits of perforator surgery in venous ulcer management due to poor quality evidence[5]. This study aims to establish the exact role of concomitant IPV and truncal reflux treatment in patients with CVD.

A systematic search of online databases including MEDLINE, Embase and Cochrane Central Register of Controlled Trials was last performed in March 2022. All studies comparing the outcomes of concomitant superficial venous plus perforator surgery with standard therapy (inclusive of compression and/or truncal therapy were included. Each included study was subject to an evaluation of methodological quality using Downs and Black assessment tool[6]. Primary outcomes assessed included ulcer healing and ulcer recurrence. Disease severity and quality of life (QoL), vein occlusion rates, number of IPVs on Duplex Ultrasound (US) post treatment, re-intervention, complication rates and time to healing were also analysed. Data were pooled with a random effects model.

Seven studies (872 limbs) were included for analysis. Included studies were of reasonable methodological quality. Ulcer healing rates were similar in each group (relative risk [RR] 1.07 [95% CI 0.96-1.19], p=0.23). Ulcer recurrence was significantly lower in the concomitant group (3.7% vs 44%) when compared with standard therapy (RR 0.21 [95% CI 0.07- 0.65], p=0.007, I2=43%, p=0.17). QOL was reported in only one study using the Aberdeen Varicose Vein Questionnaire and found no difference between groups beyond post-operative week one. The total number of perforator veins identified at follow up Duplex was significantly lower in the concomitant group (22.4% vs 89%) compared to standard therapy (RR 0.31 [95% CI 0.19 - 0.53], p<0.0001, I2= 88%, p=0.0002). There was no difference between groups for occlusion rates of treated great saphenous vein or incompetent perforators (RR 2.22 [95% CI 0.10-49.74], p=0.61). Reported minor complications (RR 0.98 [95% CI 0.63-1.52], p=0.92) and thrombotic complications (RR 2.04 [95% CI 0.59-6.99], p=0.26) were also similar between groups.

Concomitant truncal and perforator surgery is comparable to standard therapy in terms of ulcer healing, safety and efficacy. Meta-analysis suggests that concomitant treatment significantly improves ulcer recurrence rates and reduces the number of incompetent perforator veins at follow-up assessment, but included studies were subject to some biases. Concomitant treatment may be considered to prevent recurrence rather than improve ulcer healing.

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