Sir
I read with interest the article by Zukowski and colleagues (Br J Surg 1991 ; 7 8 : . The role of calf perforating veins in the aetiology of venous hypertension remains the subject of controversy, and their paper demonstrates the difficulties encountered when addressing this issue.
The authors have assiduously investigated their patients using ascending phlebography, ambulatory venous pressure measurements and Doppler ultrasonography. On the basis of these investigations they have allocated patients to groups with superficial or deep venous insufficiency, with or without calf perforator incompetence. Substantial reliance is placed on the accuracy with which these investigations distinguish between deep and superficial venous insufficiency. As the authors concede, to explain the findings obtained from venous pressure measurements in the groups with superficial venous disease and incompetent perforators, unidentified deep vein incompetence in the calf must be assumed. So the impression gained from the title of the article and abstract that the problems identified by the authors are attributable to calf perforating veins is a little misleading.
The study shows that in some patients with superficial venous disease and 'incompetent' perforating veins there is a severe functional deficit. The only way to determine what the perforators alone contribute to this deficit would be to ligate them and repeat the investigation or, alternatively, to treat the superficial disease and assess the effect on venous function. I would be most interested to hear whether surgical treatment of this nature influenced the indices of venous function in these patients.
It might have been better not to attribute the functional venous abnormalities to the perforating veins, as this may lead surgeons to assume that surgical ligation of these vessels will lead to improvement of the calf muscle pump. As the authors acknowledge, it is still unclear whether this procedure would be of benefit.