the great saphenous vein
DESCRIPTION
By: Paul M. McNeill, M.D. Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.TRANSCRIPT
Disclosure Paul M. McNeill, M.D.
I have no financial relationship(s) to disclose.
The Great Saphenous
Vein
Paul M. McNeill, MD FACS
Capitol Vein and Laser Center
Bethesda, Maryland
Great Saphenous Vein
Path of the GSV
Key branches
Supporting structures
Relationship to nerves
Vein valve function
Pathophysiology
Anatomy impacting treatment
Great Saphenous Vein
Ascends the medial aspect of the leg and thigh
Venous drainage of the skin and subcutaneous tissues
Network of branches
• Subcutaneous space
• Communicate with the deep system
Great Saphenous Vein
Veins of the lower extremity
• Return blood to the central circulation
• Deep venous system
Primary blood return from the leg
• Superficial System
More commonly involved with therapy
• Perforating veins
• Communicating veins
Great Saphenous Vein
Veins of the lower extremity
• Return blood to the central circulation
• Deep venous system
Primary blood return from the leg
• Superficial System
More commonly involved with therapy
• Perforating veins
• Communicating veins
Great Saphenous Vein
Veins of the lower extremity
• Return blood to the central circulation
• Deep venous system
Primary blood return from the leg
• Superficial System
More commonly involved with therapy
• Perforating veins
• Communicating veins
Great Saphenous Vein
Veins of the lower extremity
• Return blood to the central circulation
• Deep venous system
Primary blood return from the leg
• Superficial System
More commonly involved with therapy
• Perforating veins
• Communicating veins
Superficial veins of the foot
Dorsal Venous Arch
• Lateral end of DVA drains into SSV
• Proximal to Metatarsal heads
• Medial end of DVA drains into GSV
Perforating veins of the foot
• Some drain outward to the GSV
Great Saphenous Vein
At the ankle the GSV is apparent on physical examination
The superficial presentation of the vein allows for easy percutaneous access
The prominence of the vein in this location is normal
• Some patients request excision
Great Saphenous Vein –
Leg Branches Duplicate saphenous
vein BK in 30%
Two major branches below the knee
The Posterior Accessory Vein communicates with Posterior Tibial Vein via perforating veins
Medial Calf Perforators
Medial Calf Perforating Veins
Great Saphenous Vein –
Thigh Branches Fascial layers create a
sheath around the GSV
Two major branches above the knee
ISV connects GSV,SSV
Medial Thigh Perforators
Duplicate GSV 8%
Saphenofemoral Junction
Saphenofemoral Junction
Saphenofemoral Junction Variation
Saphenous Compartment
Fascial envelope
Upper calf to groin
Deep fascia
Scarpa’s fascia
GSV: 3-4mm diameter
Duplex identification
Tumescent anesthetic technique
Veins outside the sheath are GSV Tributaries
Images courtesy of Olivier Pichot, MD
Saphenous Nerve
Femoral n branch
Subsartorial canal
Proximal ½ posterior
Lower 1/3 anterior
Adherent to GSV
• Medial malleolus 80%
• Mid leg 97%
Anatomic Overview
Vein Wall
Intima
Media
Adventitia
Endothelia cells prevent thrombosis
Muscular contraction alters vein volume
Anatomic Overview
Compartments of the leg
Superficial and deep compartments
Fascial envelope
• Defines high pressure deep compartment
Veins traverse the compartments
• DV, SV, PV
Anatomic Overview
Calf Muscle Pump
Muscles enclosed in fascial envelope
Muscular contraction raises pressure
Venous compression occurs
Vein valves affect direction of flow
Venous Histology: Vein Valve
Thin sheets of collagen
Smooth muscle
Endothelium
Muscle fibers at base
Elastic fibers
Vein Valves
Blood propelled by calf muscle pump opens the valve in one direction
Blood moving with gravity closes the normal valve
Valve Open Valve Closed
Saphenous Reflux
Disruption of the one way valve system • Primary
• Secondary
Sequential valve failure
High pressure communicated to superficial compartment
Tributary Varicose veins
Valvular Incompetence
Saphenous Vein Reflux
Reflux Schemes
Normal valve function
Perforating vein has one way flow
Fascia separates deep and superficial compartments
GSV normal
Reflux Schemes
Relationship of superficial veins to GSV vein valves
Normal caliber of veins throughout system
Low pressure maintained
Reflux Schemes
Perforator vein incompetence
Dilated GSV
Dilated GSV branch vein
Higher venous pressure in superficial system
Reflux Schemes
Increasing pressure results in valve failure
Additional vein branches become varicose
Further GSV incompetence and dilation
Great Saphenous Vein
Great Saphenous Vein
Great Saphenous Vein
Great Saphenous Vein
Great Saphenous Vein
GSV Tortuosity
GSV Tortuosity
GSV Stenosis
Duplex Assessment
GSV Position – Close to Dermis
Great Saphenous Vein
57M, Denies Symptoms
TSA Search and Refer
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