Perforating veins are short veins that pass through the deep fascia to connect the superficial veins of the leg (great and small saphenous systems) with the deep veins. Their valves normally allow blood to flow only from superficial to deep, so the calf muscle pump can empty the superficial system. Important groups include the posterior tibial perforators on the inner calf (formerly called Cockett perforators) and the paratibial perforators near the tibia.
| Origin | Tributaries of the great and small saphenous veins in the subcutaneous tissue |
|---|---|
| Course | Pierce the deep fascia, often obliquely, to join the posterior tibial, fibular, anterior tibial, gastrocnemius or soleal veins |
| Branches |
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When perforator valves fail, the high pressure generated in the deep veins during walking is transmitted outward to the superficial veins and skin. This contributes to varicose veins, skin pigmentation, eczema, lipodermatosclerosis and ulcers, typically around the inner ankle (the gaiter area). Incompetent perforators near an ulcer may be treated by ultrasound-guided foam sclerotherapy, thermal ablation or subfascial endoscopic perforator surgery.
Faulty valves in perforating veins let blood flow outward from deep to superficial veins, causing local varicosities and venous hypertension of the skin, especially above the medial ankle.
Long-standing venous hypertension, often from combined superficial, perforator and deep vein incompetence, breaks down the skin near the medial malleolus. Compression therapy is the mainstay of treatment.
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