Perforators: when to, when not to, and how to.

This Vein and Lymphatic University Grand Rounds session, moderated by Dr. Lowell Kabnick (USA), features a comprehensive discussion on incompetent perforator veins with Dr. Edward Mackay (USA) as the primary speaker and expert discussion by Dr. Mark Whitley (United Kingdom) and Dr. Álvaro Orrego (Chile). The session reviews current U.S. and international guidelines, insurance considerations, and real-world clinical decision-making for perforator vein treatment. Through case-based examples and panel discussion, the faculty analyze when to treat, when not to treat, and how to select the optimal treatment modality, including endovenous ablation, foam sclerotherapy, and emerging technologies. Key learning points: • Indications for perforator vein treatment differ between guideline-based, insurance-driven, and clinical judgment models. • Isolated incompetent perforators can be clinically significant even in the absence of saphenous reflux. • Treatment sequencing in venous ulcer disease should address axial reflux, perforators, and the subdermal plexus. • Endovenous techniques, foam sclerotherapy, and ulcer-bed treatment each play complementary roles in ulcer healing. • Careful documentation and adherence to medical necessity criteria are essential to ensure patient safety and compliance. This session provides practical insights for clinicians managing complex chronic venous disease in daily practice.