Background: Despite good outcomes reported with minimally invasive, subfascial endoscopic perforator surgery (SEPS), some patients demonstrate poor healing or recurrence of venous ulcers. The goal of this study was to identify factors that lead to failure of SEPS.

Methods: Forty-eight consecutive patients who had undergone 57 SEPS procedures were analyzed. Mean follow-up was 17 ± 2 months (range 2 weeks to 52 months).

Results: All active ulcers (n = 22) at the time of surgery healed in an average of 99 ± 37 days (range 11 to 670). Eight limbs had poor healing of their ulcer (>40 days); five (9%) new/recurrent ulcers developed postoperatively. Deep venous obstruction was associated with delayed ulcer healing (316 ± 171 versus 51 ± 14 days, P <0.01) and ulcer recurrence (P <0.0001). Poor ulcer healing and recurrence were not associated with lipodermatosclerosis, edema, ulcer duration >3 months, or previous recurrences. Ulcer size >2 cm (P <0.05) and combined ilio-femoral and popliteal/tibial reflux were associated with poor ulcer healing (P <0.05).

Conclusions: SEPS could not prevent recurrent or new ulceration in 9% of limbs. Venous outflow obstruction was associated with ulcer recurrence and prolonged ulcer healing. Multilevel deep venous reflux and ulcer size >2 cm were also associated with delayed healing.