Percutaneous electrocoagulation (PAPS-PEC) for incompetent perforator veins: a cost-effective technical innovation for venous ulcer healing

INTRODUCTION: Incompetent perforator veins (IPVs) are a critical driver of refractory venous leg ulcers (VLUs). Guideline-endorsed endovenous thermal ablation techniques face substantial implementation barriers due to high device costs and incompatibility with value-based payment models, creating a significant treatment gap. This report introduces Percutaneous Ablation of Perforator Veins using Electrocoagulation (PAPS-PEC)-a novel adaptation of the PAPS principle that leverages ubiquitous electrosurgical equipment to offer a safe, effective, and economically sustainable solution. CASE REPORT: We present PAPS-PEC application in a 68-year-old male with a recurrent VLU (30×50 mm, CEAP C6) subtended by two IPVs. The office-based procedure was performed under local anesthesia. An 18-gauge electrosurgical needle was guided into each IPV to deliver targeted direct-current energy (10 W, 15 s per quadrant), achieving immediate occlusion confirmed by intraprocedural sonography. RESULTS: The procedure was well-tolerated with no adverse events. Complete ulcer re-epithelialization was achieved at 3 months. At one year, duplex ultrasound confirmed sustained IPV occlusion with no ulcer recurrence. The patient's clinical status improved markedly, with the Venous Clinical Severity Score (VCSS) decreasing from 14 to 4 and the CIVIQ-14 score from 50 to 22. CONCLUSION: PAPS-PEC is a safe, effective, and exceptionally cost-effective office-based modality for treating IPV-related VLUs. By repurposing existing technology, it directly addresses the economic and accessibility barriers of current standards. These promising findings warrant larger prospective studies to validate its role as a standard-of-care option in managing advanced chronic venous insufficiency, especially in resource-constrained settings.