The National Institute for Health and Clinical Excellence (NICE) issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on subfascial endoscopic perforator vein surgery in June 2004. In accordance with the Interventional Procedures Programme Process Guide, guidance on procedures with special arrangements are reviewed 3 years after publication and the procedure is reassessed if important new evidence is available.

The guidance was considered for reassessment in January 2009 and it was concluded that NICE will not be updating this guidance at this stage. However, if you believe there is new evidence which should warrant a review of our guidance, please contact us via the email address below.


The procedure is used for patients with either healed or active ulcers (CEAP classifications 5 or 6), caused by chronic venous insufficiency, in whom incompetent calf perforating veins are thought to be an important contributing factor, particularly where conservative management (such as leg elevation, compression therapy and medication) has failed. Deep venous occlusion and/or infected ulcers are usually contraindications to SEPS.

SEPS is a minimally invasive alternative to open subfascial perforator vein surgery.

Preoperative evaluation is performed by duplex scanning of the superficial, deep and perforator venous systems to diagnose both valvular incompetence and obstruction. During the operation, the limb is exsanguinated and two endoscopic ports are placed in the subfascial space in the calf at sites remote from the area of venous ulceration. A space-maker balloon is introduced and inflated in this subfascial space to improve access. Carbon dioxide is then insufflated to facilitate dissection. The incompetent perforating veins are clipped and divided with endoscopic scissors or, alternatively, coagulated and divided with an ultrasonic coagulator (harmonic scalpel).

Coding and clinical classification codes for this guidance.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.