Variations of the Saphenopopliteal Junction: An Ultrasonography Study in a Young Population, A Systematic Review and A Meta-Analysis

Saphenopopliteal junction classification has been developing, but still the precise knowledge of junction type is crucial for proper surgical treatment. We examined the saphenopopliteal junction by duplex venous scanning in 244 extremities in healthy volunteers (median age: 23.0 years, 83 females, 39 male) and performed a meta-analysis of 13 studies focusing on structural types of the junction. According to Schweighoffer's classification we distinguished 5 types of the junction and we subdivided type A according to Cavezzi's classification of gastrocnemial veins termination into two. We added type F (small saphenous vein-SSV terminates into popliteal vein-PV), described especially in cadaveric studies. In our study, the most frequent type was A1 (96 cases), followed by C (70), B (48), A2 (20), E (6), D (3) and F (0). The pooled prevalence estimate for types A + B + D + E was 54.7% (95% CI 40.9-69.6%) and for type C 24.4% (95% CI 19.3-29.5%), whereas in 17.1% (95% CI 6.3-27.9%) of cases, the SSV terminated in the PV with no cranial extension present. The knowledge of the saphenopopliteal junction and its variations prevalence can help clinicians to quickly identify the real type of the junction during routine examination. In mid-European population, the main type is A1 and worldwide type A.

The Anterior Saphenous Vein. Part 2. Anatomic considerations in normal and refluxing patients. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum and the International Union of Phlebology

BACKGROUND

The term Anterior Accessory of the Great Saphenous Vein suggest this is a branch tributary vein despite this vessel's anatomic features of a truncal vein. A multisocietal group suggested to designate this the Anterior Saphenous Vein (ASV). This study was aimed to evaluate its ultrasound anatomy in normal and varicose limbs.

METHODS

The clinical anatomy of the ASV was evaluated by narrative review of the literature. Additionally, the course of the ASV was evaluated in 62 limbs with no evidence of venous disease and 62 limbs with varicosities.

RESULTS

The ASV length, patterns of origin and termination are reported in both normal and patients with varicose veins. Discussion of the patterns is supported by the narrative review of the literature.

CONCLUSIONS

The ASV must be considered a truncal vein and its treatment modalities should be the same that for the great and small saphenous veins rather than a tributary vein.

The anterior saphenous vein. Part 1. A position statement endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology

BACKGROUND

There is a lack of clarity regarding the terminology of the anterior accessory saphenous vein (AASV) that can impact treatment outcomes. Although use of the word "accessory" implies that the vein is a superficial tributary, evidence supports its role as a truncal vein, similar to the great and small saphenous veins, and warranting a change in terminology.

METHODS

A multisocietal panel was convened by the American Vein and Lymphatic Society (AVLS), the Union International of Phlebology (UIP), and the American Venous Forum (AVF). The group was charged with reviewing the existing anatomic and clinical literature pertaining to the term "anterior accessory saphenous vein" and to consider the need for alternative terminology.

CONCLUSION

Based on the insights gathered from the literature review and extensive discussions, the panel recommends changing the terminology such that the "anterior accessory saphenous vein" (AASV) now be designated the anterior saphenous vein (ASV).

The anterior saphenous vein. Part 2. Anatomic considerations in normal and refluxing patients. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology

BACKGROUND

The term Anterior Accessory of the Great Saphenous Vein suggests this is a branch tributary vein despite this vessel's anatomic features of a truncal vein. A multisocietal group suggested to designate this the anterior saphenous vein (ASV). This study was aimed to evaluate its ultrasound anatomy in normal and varicose limbs.

METHODS

The clinical anatomy of the ASV was evaluated by narrative review of the literature. Additionally, the course of the ASV was evaluated in 62 limbs with no evidence of venous disease and 62 limbs with varicosities.

RESULTS

The ASV length, patterns of origin and termination are reported in both normal and patients with varicose veins. Discussion of the patterns is supported by the narrative review of the literature.

CONCLUSIONS

The ASV must be considered a truncal vein and its treatment modalities should be the same that for the great and small saphenous veins rather than a tributary vein.

The anterior saphenous vein. Part 1. A position statement endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology

BACKGROUND

There is a lack of clarity regarding the terminology of the anterior accessory saphenous vein (AASV) that can impact treatment outcomes. Although use of the word "accessory" implies that the vein is a superficial tributary, evidence supports its role as a truncal vein, similar to the great and small saphenous veins, and warranting a change in terminology.

METHODS

A multisocietal panel was convened by the American Vein and Lymphatic Society (AVLS), the Union International of Phlebology (UIP), and the American Venous Forum (AVF). The group was charged with reviewing the existing anatomic and clinical literature pertaining to the term "anterior accessory saphenous vein" and to consider the need for alternative terminology.

CONCLUSIONS

Based on the insights gathered from the literature review and extensive discussions, the panel recommends changing the terminology such that the "anterior accessory saphenous vein" (AASV) now be designated the anterior saphenous vein (ASV).

Development of a Tissue Oxygenation Flow-Based Index Toward Discerning the Healing Status in Diabetic Foot Ulcers

Objective: The objective of this study is to characterize breath-hold (BH)-induced oxygenation changes in diabetic foot ulcers (DFUs) and develop an oxygenation flow index (OFI) to discern nonhealing from healing DFUs. Approach: The imaging approach utilizes an innovative BH stimulus that induces vasoconstriction and measures for altering oxygenation flow in and around the tissues of DFUs and controls. The modified Beer-Lambert law was utilized to calculate hemoglobin-based spatiotemporal oxygenation maps in terms of oxygen saturation. Results: We found controls had synchronous BH-induced oxygenation changes across the dorsal (OFI: 29.0%) and plantar (OFI: 57.6%) aspects of the foot. Nonhealing DFUs, however, had less synchronous BH-induced oxygenation changes (OFI <28%). In addition, two complicated healing DFU cases, or cases with underlying issues or poor long-term healing outcomes, were observed to have OFIs <28%. Innovation: An OFI was developed to differentiate nonhealing DFUs from healing DFUs using a single, noncontact, near-infrared optical scanner for spatiotemporal oxygenation monitoring. The OFI has potential to provide immediate feedback on the microcirculation in DFUs, through hemoglobin-based oxygenation parameters. Conclusion: A preliminary threshold (OFI <28%) could differentiate nonhealing and complicated DFUs from healing DFUs. The overall oxygenation flow pattern was less synchronous (or the OFI value reduced) in the nonwound areas of the feet that were nonhealing. In other words, the reduced OFI value (<28%) in the entire foot, excluding the wound region is a possible indicator that the wound may not heal.

Diminished Sphenous Compartment Connective Tissue Elasticity has Little Impact on Low Grade Venous Insufficiency: An Ultrasound Shearwave Elastography Study

BACKGROUND

Greater Saphenous Vein (GSV) courses within saphenous compartment, an adipose-filled space bound by fasciae provides structural support. Ultrasound Shear-Wave Elastography (SWE) provides objective and quantitative data on tissue shear elasticity modulus.

OBJECTIVE

This study aims to analyze possible associations between early stage GSV insufficiency and saphenous intracompartmental SWE measurements.

METHODS

Two-hundred consecutive patients, ages 22 to 81 (mean=44.3) years, with venous insufficiency symptoms underwent Doppler and SWE examinations. Patients had no visible or palpable sign of venous disease or had telangiectasia and reticular veins only. Analyses regarding patient age, gender, presence of venous insufficiency of GSV proper and intracompartmental connective tissue elasticity were performed.

RESULTS

Ninety-six patients had Doppler evidence for either bilateral or unilateral insufficiency of GSV proper at mid-thigh level. Intracompartmental elasticity of patients with venous insufficiency (mean=4.36±2.24 kilopascals; range 1.55 to 10.44 kPa) did not differ significantly from those with normal veins (mean=4.82±2.61 kPa; range 2.20 to 12.65 kPa) (p=0.231). No threshold for predicting the presence of venous insufficiency could be determined. Neither were there any correlations between age, gender and intracompartmental elasticity. In patients with unilateral insufficiency, however, elastography values around insufficient veins were significantly lower compared to contralateral normal GSV (p<0.001).

CONCLUSION

Many intrinsic and patient factors affect intracompartmental connective tissue elastography measurements; thus, cut-off values obtained from specific populations have limited generalizability. Nevertheless, statistically significant intrapatient differences of intracompartmental elasticity among diseased and normal saphenous veins indicate that lack of elastic support from surrounding connective tissues contributes to venous insufficiency in early stages.

Blood flow from competent tributaries is likely contributor to distally increasing reflux volume in incompetent great saphenous vein

OBJECTIVE

Venous reflux is the sole pathophysiologic process in primary chronic venous disease and its progression. We hypothesize that the reflux volume increases along a great saphenous vein (GSV) in a distal direction. We aimed to compare simultaneously measured reflux volume in the upper and lower GSV segments in a thigh.

METHODS

Patients meeting the inclusion criteria were enrolled (70 limbs of patients with primary incompetence of the GSV) and consented to this single-center study. Patients were stratified into two groups: incompetent terminal valve (TV_i) and competent terminal valve (TV_c). A cross-section area of the GSV was measured at the upper (CSA₁, cm²) and distal (CSA₂, cm²) points in a thigh. A cross-section area of each tributary that joined with the GSV between the points was measured, and their total cross-section area was calculated (CSA_trib). After a distal cuff compression-decompression maneuver, a time average mean velocity (TAMEAN, cm/sec) and reflux duration (RT, sec) were measured at both points simultaneously. Reflux volume RV, ml was calculated for each point (RV₁ and RV₂). The difference in absolute values of _ΔRV (ml) and its relative changing (_ΔRV, %) were calculated.

RESULTS

The main result was RV increases caudally from saphenofemoral junction to the knee level (RV₁ 12.7 ± 8.4 and RV₂ 20.5 ± 14.0 ml, P < .0001). There was no difference between CSA₁ and CSA₂ (0.34 ± 0.17 and 0.33 ± 0.17 cm², respectively, P = .9) but TAMEAN was a statistically significant different in two points (7.3 ± 3.9 and 11.4 ± 5.7 cm/sec, respectively, P < .0001). All of the tributaries between the points were competent.

CONCLUSIONS

Reflux volume in the great saphenous vein increases caudally from saphenofemoral junction to the knee level. Observed reflux volume was an aggregate of all GSV tributaries' flow and the flow via the SFJ if incompetent.

A plea for extension of the anatomical nomenclature: Vessels

This article is the fourth and last part of a series aimed at extending and correcting the anatomical nomenclature. Because of the rapid development of internet and the use of electronic formats in communication in anatomy, embryology, histology, medical education, and clinical medicine, an appropriate, precise, and concise anatomical nomenclature is required. Such tool enables to avoid any potential confusion and possible scientific/medical mistakes. The up-to-date official anatomical terminology, Terminologia Anatomica, is available longer than 20 years and needs to be refined and extended. The authors have collected and listed 210 terms and completed them with definitions and/or explanations. We aimed to start a discussion about their potential incorporation into the new revised version of the Terminologia Anatomica. This article is primarily focused on the vessels of the human body (arteries, veins, and lymphatic system).

Variant Anatomy and Its Terminology

Variant anatomy, which is an integral part of anatomical science, is related to abnormalities in the human body structure. Our understanding of variant anatomy is based on thousand years of anatomical experience. These abnormalities generally do not interfere with the function of the human body and do not typically manifest as pathological nosological units. However, under certain conditions, these abnormalities can worsen existing pathological states or even evoke new ones. Understanding variant anatomy is a basic skill not only of mere anatomists, but also of clinicians who work in fields involving both diagnostic techniques and therapeutic interventions. To gain and retain a good knowledge of the most frequent and clinically relevant anatomical variations, a simple, clear, and exactly defined nomenclature of variant structures is needed. A list of items comprising variant anatomy, which have been incorporated into the internationally accepted nomenclatures Terminologia Anatomica (1998) and Terminologia Neuroanatomica (2017), is described and analyzed. Examples of the most common anatomical variations related to terminology are mentioned, and variant anatomy as a whole and its role in understanding current anatomy are discussed.

The venous perforators of the lower limb - A new terminology

Latin anatomical terminology of venous perforators (communications between superficial and deep venous systems of the lower limb) was adopted as late as 2001 as an appendix to the official nomenclature following the clinicians’ request. Terminologia Anatomica, last version of the Latin anatomical nomenclature, published in 1998, unfortunately contains no terms concerning these veins. During the 14th World Congress of the International Union of Phlebology, a consensus document was laid to expand the nomenclature of the lower limb veins, above all 36 new terms for perforators of the lower limb, both in Latin and English languages. This consensus document will be incorporated in the next version of the Terminologia Anatomica. But there are more constant and well-described ones, especially in the foot, and this article reviews in particular the current knowledge on the anatomy of the venous perforators of the whole lower limb.

A plea for an extension of the anatomical nomenclature: Organ systems

This article is the third part of a series aimed at correcting and extending the anatomical nomenclature. Communication in clinical medicine as well as in medical education is extensively composed of anatomical, histological, and embryological terms. Thus, to avoid any confusion, it is essential to have a concise, exact, perfect and correct anatomical nomenclature. The Terminologia Anatomica (TA) was published 20 years ago and during this period several revisions have been made. Nevertheless, some important anatomical structures are still not included in the nomenclature. Here we list a collection of 156 defined and explained technical terms related to the anatomical structures of the human body focusing on the digestive, respiratory, urinary and genital systems. These terms are set for discussion to be added into the new version of the TA.

Systematic review and meta-analysis of the anatomic variants of the saphenofemoral junction

BACKGROUND

The aim of this systematic review was to provide comprehensive data on the prevalence of variations of the saphenofemoral junction (SFJ) to prevent misidentification of the SFJ or the incomplete ligation of the tributaries of the great saphenous vein.

METHODS

A systematic review was conducted using the PubMed, Embase, and Cochrane Library databases through September 14, 2017. To be included in the meta-analysis, a study had to report prevalence data on the morphology of the SFJ or the presence of venous tributaries.

RESULTS

A total of 16 studies (7433 legs) were included. The majority of studies were performed during varicose vein surgery (74.14%), with fewer studies by means of computed tomography venography and cadaveric dissection. The pooled prevalence estimate (PPE) for a duplication of the SFJ with a bifid junction was 9.6% (P = .001). The PPE for a duplication of the SFJ with two separate junctions was 1.7%. The PPE for ectasia of the SFJ was 2.3% in type 1, 1.2% in type 2, and 1.7% in type 3. The distribution of the PPE for the number of venous SFJ tributaries was approximately normal with a slight right skew; a higher rate was observed in the group with four venous tributaries to the SFJ.

CONCLUSIONS

This analysis found high heterogeneity in the prevalence of SFJ anatomic variants and the number of venous SFJ tributaries. For this reason, it is highly recommended that a preoperative Doppler ultrasound assessment of the SFJ and great saphenous vein be performed.

The Terminologia Histologica after 10years: Inconsistencies, mistakes, and new proposals

This article details our experience with the Terminologia Histologica (TH) and its utility in the teaching of histology, cytology, and clinical medicine (e.g., pathology and hematology). Latin histological nomenclature has been used for 43years, and the latest version of the TH has been in use for 15years (although it was only issued publicly within the past 10years). The following findings and ensuing proposals allow us to discuss key points pertaining to the TH and make important suggestions for potential changes to the TH (such as the exclusion and inclusion of various terms). We classify these changes into six groups: 1.) mistakes in the TH, 2.) discrepancies among various Terminologiae, 3.) discrepancies within the TH, 4.) the repetition of terms, 5.) synonyms in the TH, and 6.) missing terms in the TH. Surprisingly, unlike the anatomical nomenclature, the histological nomenclature has been neglected in the literature. This article addresses this problem by reviewing and summarizing the state of this field, pointing out key discrepancies, offering solutions, and highlighting topics for further discussion.

A plea for an extension of the anatomical nomenclature: The locomotor system

Anatomical nomenclature is the main tool of communication in morphology, anatomy and other medical disciplines as well as in medical education, and thus needs to be exact, flawless, elaborate and correct. The Terminologia Anatomica (TA) is a thorough and extensive list of anatomical terms and their definitions, and the current standard for human anatomical terminology. Although several revisions to the TA have been made in the last 20 years, some important anatomical structures are still not included. This article is aimed at correcting and extending the anatomical nomenclature described in the TA. We gathered and presented a list of anatomical terms, with their definitions and explanations, to provoke a discussion about correcting and extending the TA. Our list comprises of 96 terms related to the locomotor system of the human body, i.e., the bones, joints, muscles and related structures.

The clinical ultrasound report: Guideline for sonographers

The reporting roles of sonographers in Australasia vary considerably. A large number of sonographers already routinely produce formal reports, while others are moving into clinical ultrasound roles where reporting is expected. This article summarises the best practice in reporting of ultrasound examinations based on international literature and addresses key topics including report structure, clinical content, style and language. Numerous examples and sample phrases are provided and common pitfalls are discussed.

A potential therapeutic pitfall in the treatment of venous reflux due to variant planar anatomy of varicose segments

Purpose To elaborate on a planar anatomic variant of great saphenous vein as a potential therapeutic pitfall in the treatment of venous reflux. Materials and methods Lower extremity veins in 568 limbs with great saphenous vein insufficiency were sonographically mapped. A rather overlooked variation, the saphenous bow, was studied with emphasis on anatomic clarification and its involvement in venous insufficiency. Results This variation, observed in 5.1% (n = 29) of limbs, comprised two segments; one uninterrupted great saphenous vein proper coursing throughout saphenous compartment and one extra-compartmental segment originating distally from and proximally fusing with it. Venous arch remains within compartment only briefly during take-off and re-entry. Extra-compartmental venous arch had reflux either alone (10.3%) or together with intra-compartmental segment (75.9%). Conclusion This variation, part of saphenous segmental aplasia/hypoplasia complex, is associated with venous insufficiency. Meticulous mapping of great saphenous vein territory and identification of such variants during planning stage is indispensable for optimal clinical outcomes of treatment.

Contribution to the anatomical nomenclature concerning general anatomy and anatomical variations

Nomenclature of the general and variant anatomy belongs to the most neglected parts of the Latin anatomical nomenclature in Terminologia Anatomica. Although many important small structures are included in Terminologia Anatomica, when describing and teaching particular anatomy of any part of the human body, the general terms are necessary, such as planes, lines and flexion grooves. Moreover, Terminologia Anatomica contains only 149 terms of variant structures, enlisted in the parentheses to differentiate them from constant ones. They are only a rather representative selection and some more should be added, both from the educational and clinical point of view. The authors present some terms, completed with their definitions or explanations concerning the general and variant anatomy to evoke broader discussion on this topic which should issue in incorporation of proposed terms (or their equivalents) into the Terminologia Anatomica.

Proposal for Classification of the Great Saphenous Vein Aplasia by the B-mode Ultrasound

BACKGROUND

The lack of the great saphenous vein (GSV) in its compartment is rarely mentioned in literature, although it happens in individuals with or without insufficiency of it. With the help of the B-mode ultrasound examination this vein can be easily identified. The aim of this study was to propose a classification for the findings.

METHODS

Prospective study carried out for a period of 6 months in a sample of 2,665 lower limbs with ages ranging from 17 to 85, being that 1,286 patients are female. These patients underwent B-mode ultrasound examination as recommended by the literature. This evaluation determined whether there was a GSV aplasia by the analysis of its location in the saphenous compartment.

RESULTS

After images were taken they were classified as: type I-aplasia only along the thigh, type II-aplasia only along the calf, type III-aplasia in the distal section of the thigh and proximal calf, type IV-vein in the saphenous compartment in the thigh and aplasia in the whole calf, type V-vein in the saphenous compartment only in a short segment in the proximal thigh, and type VI-vein with short segment in the saphenous compartment in the distal calf. From the total of 2,665 limbs, aplasia was found in 442 (16.6%).

CONCLUSIONS

These anatomic findings attain an important role in daily practice, influencing the surgical decision, particularly with the arrival of endovascular procedures, such as the use of laser and thermoablation.

Anatomy and physiology of the lower-extremity deep and superficial veins

A thorough understanding of venous anatomy and physiology is foundational to the diagnosis and management of venous disease. Compared with the arterial system, there is significantly greater developmental variation in the venous system. The veins of the lower extremity include the superficial and deep veins, which are defined by their respective relationships to the muscular fascia. Perforating veins traverse the muscular fascia to connect superficial and deep veins. Communicating veins connect veins within the same venous compartment, either deep to deep or superficial to superficial. The deep veins of the lower extremities primarily drain muscles and are encompassed by muscular fascia. The veins located between the skin and the muscular fascia are considered superficial veins. Superficial veins drain the cutaneous microcirculation. The pelvic venous system is a complex transitional outflow pathway between the lower extremities, the pelvic structures, and the inferior vena cava. The terminology used to describe lower-extremity, pelvic, and abdominal vasculature conforms to published international standards.

The history of Latin terminology of human skeletal muscles (from Vesalius to the present)

PURPOSE

The aim of this literary search was to chart the etymology of 32 selected human skeletal muscles, representative of all body regions.

METHODS

In researching this study, analysis of 15 influential Latin and German anatomical textbooks, dating from the sixteenth to the nineteenth century, was undertaken, as well as reference to four versions of the official Latin anatomical terminologies. Particular emphasis has been placed on the historical development of muscular nomenclature, and the subsequent division of these data into groups, defined by similarities in the evolution of their names into the modern form.

RESULTS

The first group represents examples of muscles whose names have not changed since their introduction by Vesalius (1543). The second group comprises muscles which earned their definitive names during the seventeenth and eighteenth century. The third group is defined by acceptance into common anatomical vernacular by the late nineteenth century, including those outlined in the first official Latin terminology (B.N.A.) of 1895. The final group is reserved for six extra-ocular muscles with a particularly poetic history, favoured and popularised by the anatomical giants of late Renaissance and 1,700 s.

CONCLUSIONS

As this study will demonstrate, it is evident that up until introduction of the B.N.A. there was an extremely liberal approach to naming muscles, deserving great respect in the retrospective terminological studies if complete and relevant results are to be achieved. Without this knowledge of the vernacular of the ages past, modern researchers can find themselves 'reinventing the wheel' in looking for their answers.

The deep venous system of the lower extremity: new nomenclature

The correct and precise nomenclature of the veins of the lower extremity is a necessary tool for communication. Three important changes have been done over the last 13 years. Terminologia Anatomica, the latest version of the Latin anatomical nomenclature, was published in 1998, extended in the area of the lower extremity veins with two consensus documents, in 2001, during the 14th World Congress of the International Union of Phlebology and in 2004 during the 21st World Congress of the International Union of Angiology. This article is a free continuation of two previous articles, reviewing the detailed anatomy and correct nomenclature of the superficial veins of the lower extremities and veins of pelvis. Now, it is concentrated on the deep venous system, in which 15 new terms have been added in both Latin and English languages.