The anatomy of the small saphenous vein: Fascial and neural relations, saphenofemoral junction, and valves

PurposeVaricose veins are a frequent burden, also in the small saphenous system. Yet its basic anatomy is not described consistently. We therefore investigated the fascial and neural relationships of the small saphenous vein (SSV) as well as the frequency and position of valves and the different junctional patterns, also considering the thigh extension.Materials and MethodsWe dissected the legs of 51 cadavers during the regular dissection course held in winter 2007 at Innsbruck Medical University, with a total of 86 SSVs investigable proximally and 94 SSVs distally.ResultsA distinct saphenous fascia is present in 93 of 94 cases. It starts with a mean distance of 5.1 cm (SD 1.2 cm) proximal to the calcaneal tuber, where the tributaries to the SSV join to form a common trunk. The neural topography at the level of the gastrocnemius muscle's origins shows the medial sural cutaneous nerve in 88% medially and in 12% laterally to the SSV, the tibial nerve in 64% medially and in 36% laterally, and the common fibular nerve in 98% medially and in 2% laterally to the vein. The saphenopopliteal junction (SPJ) resembled in about 37% type A (UIP-classification), 15% type B, and 24% type C. A total of 17% of specimens showed a venous web or star at the popliteal fossa and 6% had a doubled junction. A thigh extension could be demonstrated in about 84%. A most proximal valve was present in only 94% at a mean distance of 1.2 cm (SD 1.4 cm) to the SSVs orifice. A consecutive distal valve was only present in 65% with a mean distance of 5.1 cm (SD 2.3 cm).ConclusionTwo fascial points or regions can be described in the SSVs' course and its own saphenous fascia is demonstrated macroscopically in almost all cases. The neural topography is highly individual. The SPJ is highly individual where we found hitherto unclassified patterns in a remarkable number of veins. Venous valves are not as frequent as we supposed them to be. Furthermore, not all most proximal valves seem to be terminal valves.Clinical RelevanceOur study's aim is to support the basic understandings of the small saphenous system by providing exact anatomic data. This will help to understand physiology as well as pathophysiologic possibilities at the small saphenous system. On the other hand, our study especially can provide assistance for the vascular surgical approach at the popliteal fossa and also distally to the beginning of the trunk of the short saphenous vein itself

Seitenäste der Vena femoralis communis im saphenofemoralen Mündungsgebiet als mögliche Ursache von Varizenrezidiven im Krossenbereich

Problem: Grundsätzlich werden zwei Hauptursachen von Leistenrezidiven diskutiert. Einerseits vermeidbare technische Fehler bei der Erstoperation, andererseits die sogenannte Neovaskularisation. Jedoch könnten auch dilatierte präexistente Seitenäste der V. femoralis communis (VFC) als Neovaskularisation missinterpretiert werden. Methode: Anzahl und Lokalisation dieser Venen, wurde daher an 59 anatomischen Präparaten untersucht. Ergebnis: Venen proximal der SFM münden durchschnittlich zwischen 2 und 4 cm in die VFC ein, während distale Gefäße zwischen der SFM und 3 cm zu finden sind. Der Durchmesser dieser Seitenäste reicht von wenigen Millimetern bis fast einem Zentimeter. Beispielsweise ist zu 57% zumindest ein Seitenast im unmittelbaren Bereich der SFM zu finden. Diskussion: Dies zeigt, dass im Bereich der SFM kleine und kleinste Seitenäste der VFC wesentlich häufiger vorkommen. Damit sind die anatomischen Grundlagen für eine Rezidiventwicklung aus übersehenen Seitenästen gegeben

Significant differences in patients with a complete insufficiency of the great versus small saphenous vein

Objectives Most studies on diagnostics and therapy of saphenous veins focus on great saphenous vein or sum up great and small saphenous vein. This study compares patients with an insufficiency of the great saphenous vein versus small saphenous vein. Methods Prospective study including 50 patients with untreated insufficiency of the great saphenous vein or small saphenous vein, respectively. Patients got a standardised phlebological examination and filled a vein-specific life quality questionnaire (SQOR-V). Results Great saphenous vein patients were significantly younger (p = 0.001), had more visible varicose veins (p < 0.001), a higher Venous Clinical Severity Score (p = 0.002) and had more symptoms, especially at midday (p = 0.0030) and evening (p = 0.078). They had significantly more concerns about worsening of their varicose veins (p = 0.009) and a vein disease in family members (p = 0.005). Conclusion Great saphenous vein patients have more and sooner symptoms than small saphenous vein patients. This study discusses if the difference in symptoms is related to the difference in tributaries and a therapy of the tributaries is able to reduce the symptoms

Surgical thrombectomy for iliofemoral deep vein thrombosis: Patient outcomes at 8.5 years.

IntroductionDeep vein thrombosis (DVT) is a frequent burden and a post-thrombotic syndrome (PTS) can be a serious long-term consequence. Iliofemoral DVT should be associated with severe forms of PTS. Therefore an early thrombus removal has been recommended in specific conditions. The aim of this study was to find out both, the long-term results after surgical thrombectomy of iliofemoral DVT in respect of the development of PTS as well as the venous hemodynamics after surgery concerning venous reflux and venous obstruction.MethodsSixty-seven patients who underwent surgical thrombectomy between the years 2000 and 2014 were included in this study; iliofemoral DVT was present in 52 of these patients. 35 patients could be reinvestigated after a mean follow-up of 8.5 years. CEAP (Clinical-Etiological-Anatomical-Pathophysiological) and Villalta scores were recorded in order to describe and assess PTS. Follow-up examinations included a detailed duplex mapping. Venous hemodynamics were measured by digital photoplethysmography and venous occlusion plethysmography.ResultsThe primary patency rate of the iliofemoral segment was 88% after 8.5 years. 48% of all patients showed reflux in deep vein segments. Mild or moderate PTS occurred in 57% of all patients. Notably, there was no patient with an active ulcer or severe PTS. The mean venous outflow volume of all patients in the treated legs was 66.1 ml/100ml/min and significantly less than in the controlled contralateral non-treated legs (pConclusionEven though venous hemodynamics are significantly inferior in the treated legs, this study demonstrates excellent patency rates and good clinical outcome after surgical thrombectomy of iliofemoral veins

Perioperative changes of response to antiplatelet medication in vascular surgery patients.

IntroductionReduced antiplatelet activity of aspirin (ALR) or clopidogrel (CLR) is associated with an increased risk of thromboembolic events. The reported prevalence data for low-responders vary widely and there have been few investigations in vascular surgery patients even though they are at high risk for thromb-embolic complications. The aim of this prospective observational monocentric study was to elucidate possible changes in ALR or CLR after common vascular procedures.MethodsActivity of aspirin and clopidogrel was measured by impedance aggregometry using a multiple electrode aggregometer (Multiplate®). Possible risk factors for ALR or CLR were identified by demographical, clinical data and laboratory parameters. In addition, a follow-up aggregometry was performed after completion of the vascular procedure to identify changes in antiplatelet response.ResultsA total of 176 patients taking antiplatelet medications aspirin and/or clopidogrel with peripheral artery disease (PAD) and/or carotid stenosis (CS) were included in the study. The prevalence of ALR was 13.1% and the prevalence of CLR was 32% in the aggregometry before vascular treatment. Potential risk factors identified in the aspirin group were concomitant insulin medication (p = 0.0006) and elevated C-reactive protein (CRP) (p = 0.0021). The overall ALR increased significantly postoperatively to 27.5% (p = 0.0006); however, there was no significant change in CLR that was detected. In a subgroup analysis elevation of the platelet count was associated with a post-procedure increase of ALR incidence.ConclusionThe incidence of ALR in vascular surgery patients increases after vascular procedures. An elevated platelet count was detected as a risk factor. Further studies are necessary to analyse this potential influence on patency rates of vascular reconstructions

Surgical thrombectomy for iliofemoral deep vein thrombosis

$\bf Introduction$ Deep vein thrombosis (DVT) is a frequent burden and a post-thrombotic syndrome (PTS) can be a serious long-term consequence. Iliofemoral DVT should be associated with severe forms of PTS. Therefore an early thrombus removal has been recommended in specific conditions. The aim of this study was to find out both, the long-term results after surgical thrombectomy of iliofemoral DVT in respect of the development of PTS as well as the venous hemodynamics after surgery concerning venous reflux and venous obstruction. $\bf Methods$ Sixty-seven patients who underwent surgical thrombectomy between the years 2000 and 2014 were included in this study; iliofemoral DVT was present in 52 of these patients. 35 patients could be reinvestigated after a mean follow-up of 8.5 years. CEAP (Clinical-Etiological-Anatomical-Pathophysiological) and Villalta scores were recorded in order to describe and assess PTS. Follow-up examinations included a detailed duplex mapping. Venous hemodynamics were measured by digital photoplethysmography and venous occlusion plethysmography. $\bf Results$ The primary patency rate of the iliofemoral segment was 88% after 8.5 years. 48% of all patients showed reflux in deep vein segments. Mild or moderate PTS occurred in 57% of all patients. Notably, there was no patient with an active ulcer or severe PTS. The mean venous outflow volume of all patients in the treated legs was 66.1 ml/100ml/min and significantly less than in the controlled contralateral non-treated legs (p<0.05). The mean venous refilling time was 16.3 seconds, while the mean value of the non-treated contralateral legs was 25.6 seconds and therefore significantly higher (p<0.05). $\bf Conclusion$ Even though venous hemodynamics are significantly inferior in the treated legs, this study demonstrates excellent patency rates and good clinical outcome after surgical thrombectomy of iliofemoral veins