Anatomy and embryology of the small saphenous vein: nerve relationships and implications for treatment

Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants

BACKGROUND

Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity.

OBJECTIVES

To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents.

METHODS

An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations.

RESULTS

Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended.

CONCLUSION

Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Termination of the great saphenous vein at variable levels

The assessment of the saphenofemoral junction (SFJ) is important in the diagnosis and treatment of venous reflux of the great saphenous vein (GSV). In the clinical practice of venous medicine, the SFJ is used to represent the region at which the saphenous arch connects with the common femoral vein (CFV). A number of notable variations of the SFJ have been documented, and rare variable courses of the GSV have been described recently. Our case study reports two unusual GSV terminations. In both cases, the SFJ was located below the confluence of the profunda femoris vein (PFV) with the femoral vein (FV). Case 1 showed the SFJ was formed by the GSV and FV; whereas case 2 showed the PFV was joined by the GSV after a transposition with the FV. Anatomical variations of the SFJ are rare; however, they are increasingly diagnosed with the use of duplex ultrasound. The identification of SFJ variants warrants a safe endovenous procedure and prevents surgical complications.

Evaluation of anomalies of major veins of the superficial venous system of lower limb in adults on color doppler: An observational study

Objective

To evaluate the incidence of anomalies in the superficial venous system in lower limb.

Method

Triplex ultrasonography in clinically suspected cases of acute or chronic venous disease or congenital malformation was performed on 3189 lower limbs in 2000 patients (bilateral in 1189 and unilateral in 811) from Jan 2020 to Dec 2020.

Result

(1) Anomalies of great saphenous vein were observed in 496 cases (15.5%), (2) Anomalies of short saphenous vein were observed in 760 cases (23.8%), (3) Anomalies of accessory saphenous veins were seen in 984 (30.88%), 1501 (47%), 1068 (33.5%) and 774 (24.25%) corresponding to the anterior, posterior, lateral systems and posterior accessory vein of leg, respectively.

Conclusion

Anomalies of the superficial venous system in lower limb are very common and must be reported in every doppler study. These anomalous veins may be the cause for residual or recurrent disease in chronic venous insufficiency, which warrants further research.

Comparison of mechanochemical ablation versus ligation and stripping for the treatment of incompetent small saphenous vein

OBJECTIVE

to compare the outcomes of mechanochemical ablation (MOCA) versus saphenopopliteal junction ligation and stripping (OS) for symptomatic small saphenous vein (SSV) insufficiency.

METHODS

This is a retrospective study including symptomatic SSV patients treated with MOCA using the ClariVein catheter (Merit Medical, South Jordan, Utah, USA) or OS from 2015 to 2019.

RESULTS

A total of 60 limbs (73.3% women, mean age 54.7 ± 14.4 years) were treated with MOCA and 58 limbs (63.8% women, mean age 54 ± 11.6 years) with OS. At 18 months follow-up, recurrence rates were 7.5% (4/53) for MOCA vs. 5.7% (3/52) for the OS group. MOCA group was associated with less pain at first postoperative day, and an early return to work (MOCA 3.5 ± 2.3 days vs. OS 14.2 ± 3.8 days, p < .0001). No cases of leg paresthesia/dysesthesia were observed in the MOCA group, while two patients (3.4%) presented neurological symptoms after OS treatment.

CONCLUSION

MOCA and OS are both safe and effective techniques for symptomatic SSV insufficiency. MOCA group demonstrated to be associated with less postoperative pain and early return to work compared to OS.

Vena giacomini – so klein und unscheinbar?

In Giacominis Erstbeschreibung (1873) wurde über eine Vene berichtet, die über die Fossa poplitea zum dorsalen Oberschenkel (ohne in die V. poplitea einzumünden) weiter nach medial zieht, um in die V. saphena magna zu münden. Seither wurden zahlreiche weitere Mündungstypen (auch mit Einmündung in die V. poplitea) publiziert. Im klinischen Alltag erfährt diese Vene hingegen nur wenig Beachtung. Die Wahrscheinlichkeit, eine Insuffizienz der V. giacomini nachzuweisen, ist v. a. bei simultanem Vorliegen einer insuffizienten V. saphena parva um das knapp 12-Fache erhöht. Man unterscheidet 2 Refluxtypen der V. giacomini. Beim retrograden Reflux gelangt venöses Blut über die V. saphena magna, die Beckenvenen oder die Perforansvenen des Oberschenkels in die V. saphena parva. Beim wesentlich selteneren anterograden Reflux kommt es zu einem paradoxen (aufsteigenden) Reflux in der V. giacomini während der muskulären Diastole. Eine ausschließlich V.-saphena-fokussierte chirurgische Therapie ohne Berücksichtigung der Refluxtypen kann möglicherweise in einer Überbehandlung des Patienten enden und sollte im Zeitalter der therapeutischen Vielfalt und eines möglichst venenerhaltenden Vorgehens vermieden werden.

Aufgrund der anatomischen Enge der Fossa poplitea und der in der Vergangenheit zunehmend an Beliebtheit gewonnenen endoluminal-thermischen Verfahren ist die Kenntnis der topografischen Anatomie insbesondere zur Vermeidung von neurologischen Komplikationen von essenzieller Bedeutung.

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.

Feasibility of a fetal anatomy 3D atlas by computer-assisted anatomic dissection

OBJECTIVE

To assess the feasibility of 3D modelisation of fetal anatomy by using the Computer-assisted anatomic dissection (CAAD) based on immunolabeled histologic slices and MRI slices with a specific 3D software.

STUDY DESIGN

For pelvis and lower limbs, subjects came from legal abortion, medical pregnancy termination, or late miscarriage. Specimens were fixed in 10 % formalin, then embedded in paraffin wax and serially sectioned. The histological slices were stained using HES and Masson Trichrome. Protein S-100 and D2-40 markers were used for immuno-labelling. Serial transverse sections were digitalized and manually aligned. Fetal brain slices were obtained from in utero or post-mortem MRI.

RESULTS

CAAD was performed on 10 fetuses: pelvis was modelised with 3 fetuses of 13, 15 and 24 W G, lower limbs with 2 fetuses of 14 and 15 W G and brain with 5 fetuses aged between 19 and 37 W G. Fetal pelvis innervation was analysed after immunolabelling and nerves appeared proportionally bigger than in adults with the same topography. Lower limbs analysis revealed that nerve development was guided by vascular development: the sciatic nerve along the big axial vein, the saphen nerve along the big saphen vein and the sural nerve along the small saphen vein. Fetal brain study allowed to describe the gyration process and the lateral ventricle development.

CONCLUSION

CAAD technique provides an accurate 3D reconstruction of fetal anatomy for lower limbs and pelvis but has to be improved for brain model since midline structures were not amendable for analysis. These results need to be confirmed with larger series of specimens at different stages of development.

Comparison of different approaches to small saphenous vein reflux treatment: a retrospective study in two centers

BACKGROUND

Diagnosis and treatment of small saphenous vein (SSV) insufficiency is of utmost importance for relieving chronic venous insufficiency symptoms.

OBJECTIVES

To investigate the efficacy and safety of five different treatment approaches among patients with SSV insufficiency.

DESIGN AND SETTING

Two-center retrospective clinical study, conducted at cardiovascular surgery clinics in a local training and research hospital and a state hospital.

METHODS

A total of 282 extremities of 268 patients with SSV insufficiency alone who were treated for symptomatic varicose veins between January 2012 and January 2017 were included in the study. All extremities included in the study were divided into five groups as follows: high ligation + stripping; radiofrequency ablation (RFA); cyanoacrylate closure (CAC); and endovenous laser ablation (EVLA) at the wavelengths 980 nm and 1,470 nm.

RESULTS

Although the recurrence rate at six months was similar among the treatment groups, we found significant differences in recurrence rates at one year, with lower rates in the CAC, RFA and 1,470 nm EVLA groups, compared with the other treatments (P = 0.005). No sural neuritis was observed in the CAC group. The pigmentation rate was higher in the two EVLA groups (980 nm and 1,470 nm).

CONCLUSIONS

Our study results showed that although CAC, RFA and EVLA at 1,470 nm seemed to be effective methods for treating SSV insufficiency alone, CAC and RFA had better aesthetic results than EVLA at 1,470 nm. We consider that endovenous non-thermal techniques for treating SSV insufficiency may be preferable because of relatively low risk of nerve injury.

Level and modalities of origin of the small saphenous vein: toward codification of the proximal approach level

PURPOSE

The proximal approach to the small saphenous vein (SSV) must be performed according to precise anatomical landmarks to respect the esthetic profile of venous insufficiency surgery. In this work, we propose the tip of the lateral malleolus and the lateral edge of the calcaneal tendon as palpable landmarks from which to easily identify the situation of this vein.

METHODS

This was a cadaveric dissection study involving 62 members of fresh and embalmed anatomical subjects. We used a horizontal line passing through the tip of the lateral malleolus and the lateral edge of the calcaneal tendon as reference marks. Once the origin of the SSV as dissected, the distances between the saphenous vein and the landmarks were measured.

RESULTS

We found that the small saphenous vein was often unique. The origin of this small saphenous vein projected, on average, to 4.40 cm from the horizontal passing through the tip of the lateral malleolus and 1.2 cm from the lateral edge of the calcaneal tendon.

CONCLUSION

These two measurements constitute the orthogonal coordinates for the situation of the small saphenous vein origin.

Mini-invasive foam sclerotherapy-assisted ligation versus surgical flush ligation for incompetent sapheno-popliteal junction treatment

Objectives

Comparison of a flush sapheno-popliteal junction ligation versus a mini-invasive foam sclerotherapy-assisted ligation.

Methods

Forty-eight chronic venous disease patients underwent sapheno-popliteal junction flush ligation (group A). Forty-one patients underwent small saphenous vein ligation by means of mini-invasive incision with foam sclerotherapy of the popliteal stump (group B).

Results

At 4.1 ± 3.3 years mean follow-up, sapheno-popliteal junction recurrence was detected in four patients of group A (4/48; 8.3%) and in two cases of group B (3/41; 7.3%) ( P= ns). Mean procedural time was 36 ± 11 minutes versus 21 ± 6 minutes ( p<0.0001). A mild post-operative paresthesia lasting more than 24 h was reported in 6.3% (3/48) of group A versus 2.4% (1/41) ( p<0.009) of group B. At one-year check-up, Aberdeen Varicose Vein Questionnaire significantly improved in both groups with no significant difference between group A and B.

Conclusions

Foam-assisted mini-invasive sapheno-popliteal ligation represents a time and clinical-effective option, associated with a decrease in post-operative paresthesia risk.

Secondary lymphedema after high ligation of the great saphenous vein surgery: A case report

A 56-year-old male patient with secondary lymphedema in a single lower extremity presented to our hospital.He received high ligation of great saphenous vein 3 years ago. Severe infection was observed in affected limb on postoperative day 10, and rapidly progressive pain and erythema spreading to inguinal region. He was diagnosed with secondary lymphedema after 3 years of high ligation of great saphenous vein. Compression treatment was given in affected limb to promote the lymphatic return.The patient was followed up for 3 months now, the edema in right leg showed attenuation compared with before.

Hydrodisplacement of sural nerve for safety and efficacy of endovenous thermal ablation for small saphenous vein incompetence

Background

Endovenous radio frequency ablation for small saphenous vein incompetence by and large appears to be superior and safer than conventional open surgery. Small saphenous vein ablation from approximately mid-calf to the point proximally where the small saphenous vein dives into the popliteal fossa is considered to be safe, as the sural nerve is in most cases separated from this segment of the small saphenous vein by the deep fascia. The outcome of the distal incompetent small saphenous vein remains unclear. Efficacy of the endovenous radio frequency ablation can be enhanced by increasing the length of the ablatable small saphenous vein segment.

Methodology

To optimise endovenous radio frequency ablation outcome, the distal small saphenous vein may be made amenable to ablation if safety of the sural nerve can be assured. The sural nerve was successfully located using duplex ultrasound in 100% of our cohort in this study. The standard entry point for venous access was just above the lateral malleolus. After introduction of the introducer sheath, the radio frequency catheter was advanced proximally; the sural nerve was displaced from the small saphenous vein by approximately 1 cm with the administration of tumescent anaesthesia ( hydrodisplacement). A total of 118 patients underwent extended endovenous radio frequency ablation of 124 incompetent small saphenous vein trunks using the method described.

Results

Successful extended ablation of the small saphenous vein was achieved in 100% of cases and it was confirmed by duplex scanning at one and six weeks. Two neurological events were recorded during the study:  1. One patient with temporary foot drop lasting for less than 6 h with complete recovery.  2. A second patient with a sural nerve sensory deficit reported by the patient at day 2–3, which remains current at six weeks.

Conclusions

Extended endovenous radio frequency ablation of the small saphenous vein to optimise length of the ablatable vein segment is feasible with careful identification and hydrodisplacement of the sural nerve. This method is shown to be associated with fewer neurological complications than other methods reported in the literature.

The sural nerve: Sonographic anatomy, variability and relation to the small saphenous vein in the setting of endovenous thermal ablation

Background Neurological complications are well documented in association with both surgical stripping or disconnection and thermal ablation of the small saphenous vein. The sural nerve (medial sural cutaneous nerve) is most vulnerable due to its close relationship to the small saphenous vein. Objective This is a cross-sectional observational study of the sonographic anatomy of 115 Australian patients to determine the course of the sural nerve and its relationship to the small saphenous vein, and to identify its relevance in the thermal ablation of the small saphenous vein. Method Sonographic mapping of the right sural nerve was performed with a Philips L12.5 and Sonosite 10.5 MHz ultrasound machine on 115 patients. The sural nerve was traced proximally from the level of the lateral malleolus to the popliteal fossa in order to measure its distance from the small saphenous vein at four reference points in the lower leg. Results A total of 115 patients were studied (females 82, males 33). The sural nerve was identified in 100% of patients; 64 patients (55.7%) showed usual sural nerve anatomy, while 51 patients (44.3%) demonstrated a range of anatomical variations, including the sural nerve becoming epifascial at a higher point than usual. Conclusion The sural nerve was identifiable on duplex ultrasound in 100% of cases. Classic anatomical relations and the perceived protection of the sural nerve conferred by the deep fascia of the upper calf are unreliable. Preoperative strategies can help to approach and protect the sural nerve in the endovenous ablation setting.

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.

Consensus for the Treatment of Varicose Vein with Radiofrequency Ablation

The objective of this paper is to introduce the schematic protocol of radiofrequency (RF) ablation for the treatment of varicose veins. Indication: anatomic or pathophysiologic indication includes venous diameter within 2–20 mm, reflux time ≥0.5 seconds and distance from the skin ≥5 mm or subfascial location. Access: it is recommended to access at or above the knee joint for great saphenous vein and above the mid-calf for small saphenous vein. Catheter placement: the catheter tip should be placed 2.0 cm inferior to the saphenofemoral or saphenopopliteal junction. Endovenous heat-induced thrombosis ≥class III should be treated with low-molecular weight heparin. Tumescent solution: the composition of solution can be variable (e.g., 2% lidocaine 20 mL+500 mL normal saline+bicarbonate 2.5 mL with/without epinephrine). Infiltration can be done from each direction. Ablation: two cycles’ ablation for the first proximal segment of saphenous vein and the segment with the incompetent perforators is recommended. The other segments should be ablated one time. During RF energy delivery, it is recommended to apply external compression. Concomitant procedure: It is recommended to do simultaneously ambulatory phlebectomy. For sclerotherapy, it is recommended to defer at least 2 weeks. Post-procedural management: post-procedural ambulation is encouraged to reduce the thrombotic complications. Compression stocking should be applied for at least 7 days. Minor daily activity is not limited, but strenuous activities should be avoided for 2 weeks. It is suggested to take showers after 24 hours and tub baths, swimming, or soaking in water after 2 weeks.

Saphenous vein stripping surgical technique and frequency of saphenous nerve injury

Objectives

Saphenous nerve injury is the most common complication after surgical treatment of varicose veins. The aim of this study was to establish its frequency at great saphenous vein long stripping when four methods of surgery were applied.

Methods

Eighty patients were divided into four groups depending on different stripping methods. Sensory transmission in saphenous nerve and sensory perception of shank were examined before surgery and two weeks, three and six months afterwards with clinical neurophysiology methods.

Results

In 36% of patients, surgeries caused the injury of saphenous nerve mainly by proximal stripping without invagination (65%, group I). Transmission disturbances ceased completely after three months in patients undergoing distal stripping with invagination (group IV), while in group I they persisted for six months in 35%. Group IV patients were the least injured and group I the most.

Conclusion

Neurophysiological findings may suggest that distal stripping with vein invagination gives the best saphenous nerve sparing.

[Quality standards for ultrasound assessment of the superficial venous system of the lower limbs. Report of the French Society for Vascular Medicine]

The quality standards of the French Society for Vascular Medicine for the ultrasound assessment of the superficial venous system of the lower limbs are based on the two following requirements: technical know-how (mastering the use of ultrasound devices and the method of examination); medical know-how (ability to adapt the methods and scope of the examination to its clinical indications and purpose and to rationally analyze and interpret its results).

AIMS OF THE QUALITY STANDARDS

To describe an optimal method of examination in relation to the clinical question and hypothesis; to achieve consistent practice, methods, glossary terminologies and reporting; to provide good practice reference points and to promote a high quality process.

THEMES OF THE QUALITY STANDARD

The three levels of examination. Their clinical indications and goals. The reference standard examination (level 2) and its variants according to clinical needs. The minimal content of the examination report, the letter to the referring physician (synthesis, conclusion and management suggestions) and iconography. Commented glossary (anatomy, hemodynamics, semiology). Technical basis. Ultrasound devices settings. We discuss of use of Duplex ultrasound for the assessment of the superficial veins of the lower limbs in vascular medicine practice.

Anatomy of the veno-muscular pumps of the lower limb

OBJECTIVE

To study the anatomy of the veno-muscular pumps of the lower limb, particularly the calf pump, the most powerful of the lower limb, and to confirm its crucial importance in venous return.

METHODS

In all, 400 cadaveric limbs were injected with green Neoprene latex followed by an anatomical dissection.

RESULTS

The foot pump is the starter of the venous return. The calf pump can be divided into two anatomical parts: the leg pump located in the veins of the soleus muscle and the popliteal pump ending in the popliteal vein with the unique above-knee collector of the medial gastrocnemial veins. At the leg level, the lateral veins of the soleus are the bigger ones. They drain vertically into the fibular veins. The medial veins of the soleus, smaller, join the posterior tibial veins horizontally. At the popliteal level, medial gastrocnemial veins are the largest veins, which end uniquely as a large collector into the popliteal vein above the knee joint. This explains the power of the gastrocnemial pump: during walking, the high speed of the blood ejection during each muscular systole acts like a nozzle creating a powerful jet into the popliteal vein. This also explains the aspiration (Venturi) effect on the deep veins below. Finally, the thigh pump of the semimembranosus muscles pushes the blood of the deep femoral vein together with the quadriceps veins into the common femoral vein.

CONCLUSION

The veno-muscular pumps of the lower limb create a chain of events by their successive activation during walking. They play the role of a peripheral heart, which combined with venous valves serve to avoid gravitational reflux during muscular diastole. A stiffness of the ankle or/and the dispersion of the collectors inside the gastrocnemius could impair this powerful pump and so worsen venous return, causing development of severe chronic venous insufficiency.