Perforators in primary chronic venous insufficiency (CVI) are widely considered as an enemy to fight. The original sin is probably due to the general misinterpretation of the classic article by Cockett in The Lancet. Its hypothesis was that venous hypertension was transmitted to the cutaneous tissue by perforators and caused venous ulcers. The blowout hypothesis mainly referred to post-thrombotic legs. This hypothesis can be reasonably applied even to the hemodynamic consequences described by Rich in the only large series on the followup of post-traumatic venous reconstruction [2, 3]. In secondary cases, outward flow during muscular diastole may occur in the distal leg perforators thus deterrnining the microcirculatory overload which, in turn, leads to the cascade of events typical of secondary CVI. However, most surgeons were fascinated by the Cockett vision and, despite the fact that it was not supported by relevant scientific data, the era of perforator vein surgery began.
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