Advanced Vascular: CH 19 BOOK

Table 19-2, Anatomic Variants of the Great Saphenous Vein (GSV), Percent of Distribution: Thigh: single medial dominant

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Table 19-2, Anatomic Variants of the Great Saphenous Vein (GSV), Percent of Distribution: Thigh: closed-loop double system

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Table 19-2, Anatomic Variants of the Great Saphenous Vein (GSV), Percent of Distribution: Thigh: complete double system

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Table 19-2, Anatomic Variants of the Great Saphenous Vein (GSV), Percent of Distribution: Thigh: single lateral dominant

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Table 19-1, Venous Nomenclature: Current Terminology: anterior accessory great saphenous vein

Previous terminology: -Accessory saphenous vein

Table 19-1, Venous Nomenclature: Current Terminology: posterior accessory great saphenous vein

Previous terminology: -Accessory saphenous vein -Leonardo's vein -Posterior arch vein

Table 19-1, Venous Nomenclature: Current Terminology: great saphenous vein

Previous terminology: -greater saphenous vein -long saphenous vein

Table 19-1, Venous Nomenclature: Current Terminology: s mall saphenous vein

Previous terminology: -lesser saphenous vein -short saphenous vein

Table 19-1, Venous Nomenclature: Current Terminology: cranial extension of the small saphenous vein

Previous terminology: -vein of Giacomini

extensive reviews of both ultrasound and venographic data have revealed

a complex system variability in both the thigh and calf

Anatomy, The Great Saphenous Vein: in approximately 7% of cases, the great saphenous vein may have

a loop of tributary veins that is contained within the thigh

Key Terms: great saphenous vein

a superficial vein forming at the level of the medial malleolus, coursing medially along the calf and thigh, and terminating into the common femoral vein at the saphenofemoral junction

Key Terms: small saphenous vein

a superficial vein that courses along the posterior aspect of the calf terminating at the popliteal fossa into the popliteal vein

Key Terms: perforating vein

a vein that connects the superficial venous system to the deep venous system

Key Terms: recanalization

a vein that was previously thrombosed

these details provide by ultrasound imaging

allow for the selection of the optimal vein

Anatomy, The Great Saphenous Vein: cutaneous tributaries are of little significance to the surgeon

and are usually ligated during an open procedure

Anatomy, The Great Saphenous Vein: sometimes, the anteriolateral system may be slightly larger

and in others, the posteriomedial system may be larger

Anatomy, The Great Saphenous Vein: during this form of in situ bypass, most of the thigh is kept intact (closed),

and instrumentation is passed up the thigh from more distal segments to disrupt valves

Anatomy, The Great Saphenous Vein: these tributaries include the anterior (lateral)

and posterior (medial) accessory and circumflex veins

Anatomy, The Great Saphenous Vein: these double systems begin as a single vein at the ankle level

and split into two veins int he lower calf

Anatomy, The Great Saphenous Vein: in the calf, it courses slightly anteriorly near the tibia and then continues up into the thigh as a single trunk coursing medially

and terminating into the common femoral vein

the utilization of venous ultrasound has increased greatly

and the applications have also expanded

Anatomy, The Great Saphenous Vein: these intricate systems involve both anterior and posterior accessory veins

and the main trunk of the great saphenous vein

Anatomy, The Great Saphenous Vein: in 65% of cases, the calf portion is a single dominant system

and this is almost always positioned anteriorly near the medial border of the tibia

relevant anatomy, scanning techniques, tips, diagnostic criteria, and pathologic characteristics

are reviewed

vein patency, position, depth, and size

are some of the characteristics assessed preoperatively

proper knowledge of the anatomy of the superficial veins may alter the planned surgery

as well as the surgical approach used

Anatomy, The Great Saphenous Vein: normally, the main trunk of the saphenous vein lies in what is termed the saphenous compartment

bounded by the saphenous fascia superficially and deeply by the muscular fascia

Anatomy, The Great Saphenous Vein: again, the more posterior system in theses cases is likely the posterior accessory great saphenous vein

but it is just confined to the calf level

Anatomy, The Great Saphenous Vein: this is a common configuration for the great saphenous

but multiple variants exist

Anatomy, The Great Saphenous Vein: more complex variations can occur in the thigh

but this is very rare (usually less than 1% occurrence)

Anatomy, The Great Saphenous Vein: double venous systems in the calf

can be seen in approximately 35% of cases

Anatomy, The Great Saphenous Vein: often, these duplicated systems may not

course in the same anatomic plane (fig. 19-3)

Anatomy, The Great Saphenous Vein: of importance to surgeons is the location of

deep perforating veins (fig 19-6)

Key Terms: varicosities

dilated tortuous superficial veins

Anatomy, The Great Saphenous Vein: the notation of planar arrangement on the ultrasound report will be

discussed later in the chapter

Anatomy, The Great Saphenous Vein: typically, there is a large posteriomedial tributary which terminates into the

distal two-thirds of the thigh portion of the dominant venous system

Anatomy, The Great Saphenous Vein: in about 7% of patients, the posterior accessory great saphenous vein is

dominant over the more anterior system of the calf

Anatomy, The Great Saphenous Vein: one of three common arrangements can be

found in the calf (fig. 19-4)

Anatomy, The Great Saphenous Vein: it is important when evaluating a patient for venous conduits to always examine a leg even if a prior venous

harvest, ablation or stripping has been performed

Anatomy, The Great Saphenous Vein: the great saphenous vein in the calf

has much less variability than the thigh portion

Anatomy, The Great Saphenous Vein: these perforating veins must always be

identified and ligated

Anatomy, The Great Saphenous Vein: some cutaneous tributaries may be harvested

if only a small segment of vein is needed as patch material

Anatomy, The Great Saphenous Vein: this closed loop system can present the vascular surgeon with particular difficulties during an

in situ bypass procedure, especially if a closed vein exposure technique is used

Anatomy, The Great Saphenous Vein: this keeps the main saphenous system

intact for future use

material pertaining to the great saphenous, small saphenous, basilic, and cephalic veins

is also presented

Anatomy, The Great Saphenous Vein: prior to discussing the saphenous anatomy

it is important to briefly review the nomenclature of the venous system

Anatomy, The Great Saphenous Vein: however, when followed away from the saphenous vein

it will perforate the fascia and terminate into a vein of the deep venous system (fig 19-7)

Anatomy, The Great Saphenous Vein: they remain as two separate systems and

join back together into a single vein at the knee

Anatomy, The Great Saphenous Vein: most anatomy textbooks display the great saphenous vein beginning at the ankle

just posterior to the medial malleolus

Anatomy, The Great Saphenous Vein: the small saphenous vein is the correct name for the vein

known as the lesser or short saphenous vein

Anatomy, The Great Saphenous Vein: therefore, it is important to mark the locations of these perforating veins so that a surgeon can

ligate them prior to completion of the arterial bypass graft

autogenous vein is the preferred conduit of choice for

lower extremity arterial bypass procedures

Anatomy, The Great Saphenous Vein: it is very important to identify which system

may be larger

Anatomy, The Great Saphenous Vein: the saphenous vein may have two separate large systems running both

medially and laterally throughout the entire length of the thigh

Anatomy, The Great Saphenous Vein: in about 60% of cases, this vein is a single trunk that runs

medially in the thigh

information on the venous configuration will help to

minimize the amount of surgical dissection needed

Anatomy, The Great Saphenous Vein: if an in situ procedure is being performed with limited vein exposure

most cutaneous tributaries can be simply left intact because they will spontaneously thrombose

Anatomy, The Great Saphenous Vein: the remaining configurations in the thigh all demonstrate the presence of

multiple large tributaries that interconnect

Anatomy, The Great Saphenous Vein: this is simply a smaller tributary that is typically

not large enough to be used as a bypass conduit

superficial veins are used for a variety of types of bypass procedures

not the least of which is coronary artery bypass grafting

Anatomy, The Great Saphenous Vein: perforators have valves to ensure the one-way movement

of blood from the superficial to the deep system

Anatomy, The Great Saphenous Vein: table 19-2 summarizes the various anatomic distributions

of the great saphenous vein

Anatomy, The Great Saphenous Vein: there are multiple cutaneous tributaries

of the great saphenous vein (19-5)

Anatomy, The Great Saphenous Vein: the posterior system can drain into a larger vein that will continue up the thigh to join a duplicated thigh system

or it can have tributaries which may extend further posteriorly to connect into the small saphenous vein

Anatomy, The Great Saphenous Vein: lastly, in the remaining 17% of cases

partial double systems may be present in the thigh

Anatomy, The Great Saphenous Vein: there is often a posterior vein which is the

posterior accessory great saphenous vein previously mentioned in the discussion of thigh anatomy

lastly, continued interest in creating hemodialysis access fistulas in lieu of dialysis grafts

presents yet another reason why the status of the superficial veins must be assessed

Anatomy, The Great Saphenous Vein: table 19-1 lists several of the major changes

regarding saphenous vein terminology

Anatomy, The Great Saphenous Vein: a multidisciplinary panel published a consensus paper in which nomenclature was

revised and standardized in an attempt to avoid some commonly confused terms

Anatomy, The Great Saphenous Vein: a sonographer or vascular technologist

should become familiar with this revised terminology

Anatomy, The Great Saphenous Vein: owing to the low resistance of the venous bed,

significant blood flow can be diverted through this type of fistula

Anatomy, The Great Saphenous Vein: in many patients, these accessory systems are

suitable for use as a conduit

Anatomy, The Great Saphenous Vein: it initially can be seen as a vein that appears to be a

superficial tributary emptying into the saphenous vein

when planning to use a segment of superficial vein for procedure

surgeons gather as much information as possible to aid in the successful performance of these surgeries

Anatomy, The Great Saphenous Vein: often in patients who previously had a portion or all of the great saphenous vein removed

the accessory systems in the thigh and calf dilate to accommodate venous outlfow

the early application of ultrasound in the venous system had centered mainly on

the detection of thrombus within the deep venous system

Anatomy, The Great Saphenous Vein: a perforating vein is a term reserved for a vein tha perforates or penetrates

the muscular fascia of the leg and connects the superficial system to the deep system

Anatomy, The Great Saphenous Vein: it is very importnant to identify which vein is dominant so that

the surgeon can select the most appropriate vein

the superficial venous systems were of interest to assess both

their competency and their suitability as a bypass conduit

Anatomy, The Great Saphenous Vein: even though these systems are separate

there are often small veins which communicate between the systems

Anatomy, The Great Saphenous Vein: as with the other forms of double systems

these partial double systems may share smaller communicating tributaries

soon after clinicians realized the usefulness of deep venous ultrasound

they began to extend ultrasound to evaluate the superficial venous systems

Anatomy, The Great Saphenous Vein: less commonly in only 8% of cases, the great saphenous is a single trunk that courses anteriorly and laterally in the thigh

this is likely a dominant version of the anterior accessory saphenous vein

Anatomy, The Great Saphenous Vein: these double systems remain separate from each other and extend below the knee

this pattern occurs in 8% of cases

Anatomy, The Great Saphenous Vein: if the vein is arterialized as a bypass conduit and a perforating vein is left intact,

this will create an arteriovenous fistula connecting the bypass to the deep venous sytem

Anatomy, The Great Saphenous Vein: there are several groups of perforating veins

throughout the leg

Anatomy, The Great Saphenous Vein: the thigh portion of the great saphenous vein has been found

to have five common configurations (Fig. 19-2)

this chapter describes the techniques involved in

ultrasonic evaluation of the superficial venous systems

Anatomy, The Great Saphenous Vein: in the case of a closed loop, the surgeon may inadvertently pass instruments

up through the smaller venous segment of the loop resulting in vein injury

Anatomy, The Great Saphenous Vein: the exact number and level of these tributaries

vary among limbs

ultrasound has been used to evaluate the

venous system for over 35 years

Anatomy, The Great Saphenous Vein: some perorating veins connect directly to the main trunk of the saphenous vein

whereas others connect to the accessory saphenous systems

Anatomy, The Great Saphenous Vein: one system may be superficial to the fascia (this is likely the superficial accessory great saphenous vein)

whereas the other system may lie in the normal anatomic plane

Anatomy, The Great Saphenous Vein: the anterior system is dominant in 85% of cases

whereas the posterior system in dominant in the remaining 15%

Anatomy, The Great Saphenous Vein: it curves slightly toward the inner thigh and typically has several large tributaries

which empty into the vein before it joins the common femoral vein

Anatomy, The Great Saphenous Vein: the great saphenous vein is the standard name for the vein

which had been referred to as the greater or long saphenous vein

Anatomy, The Great Saphenous Vein: this is the posterior accessory great saphenous vein

which has been previously referred to as "Leonardo's vein" or the posterior arch vein.

Anatomy, The Great Saphenous Vein: the so-called "triplicate systems" of three large veins

with multiple communicating veins have been identified