Sabadosh: Damage to Cranial Extension of the Small Saphenous Vein and Vein of Giacomini in Lower Limb Varicose Vein Disease



Problem statement and analysis of the recent research

In 1873, Carlo Giacomini described the branch of the small saphenous vein (SSV) which extending from its ostial region to the popliteal fossa runs superficially in a proximal direction along the posterior thigh [3]. The vein was named after the author who described it. However, the possibility of the extension of this vein in 2 different directions led to changes in its interpretation. When coursing in the groove between the biceps femoris and semimembranous and semitendinous muscles the vein was termed “a cranial extension of the SSV”. If the vein moved in a medial direction draining into the great saphenous vein (GSV) it was termed the vein of Giacomini that was assigned by the international nomenclature 2001/2002, according to which the vein of Giacomini is “a cranial extension of the SSV that connects the GSV via the posterior thigh circumflex vein” [4]. However, further studies showed that in the popliteal fossa 2 branches may extend simultaneously from the popliteal vein: one branch courses in the groove between the biceps femoris and semimembranous and semitendinous muscles being the cranial extension of the SSV and the other branch gradually moving in the medial direction drains into the GSV. This vein could not be interpreted as a cranial extension of the SSV; furthermore, it did not meet the existing definition of the vein of Giacomini. In this regard, the definition of the vein of Giacomini was revised. Thus, in modern international interdisciplinary nomenclature to interpret the cranial extension of the SSV preliminary definition is used while the vein of Giacomini is interpreted as the vein which “corresponds to the posterior thigh circumflex vein originating from the SSV or its cranial extension and ending in the GSV or the accessory of the GSV” [5]. Thus, currently, the vein of Giacomini and the cranial extension of the SSV are 2 different veins which may exist both simultaneously and independently from each other. The aforementioned interpretations are undoubtedly the most reasonable ones. Nevertheless, the existence of 3 different definitions of the vein of Giacomini creates serious misunderstandings when comparing the results of scientific research.

In the available Ukrainian literature the vein of Giacomini is either identified with the cranial extension of the SSV [1] or interpreted as “a cranial extension of the SSV + the posterior thigh circumflex vein” [2]. In this regard, it is important to study in more detail the role of the cranial extension of the SSV as well as the vein of Giacomini in the spread of pathological refluxes in primary chronic venous disease (PCVD) using modern terminology to interpret these veins.

The objective of the research was to improve the results of treatment of patients with lower limb primary chronic venous disease studying the variation in anatomy and pathology of the vein of Giacomini and the cranial extension of the SSV with subsequent development of differential surgical tactics.

Materials and methods

502 patients with PCVD on 605 legs were examined and treated at the Ivano-Frankivsk Central City Clinical Hospital (ІFCCCH). There were 355 females (70.7%; 95% CI 66.5-74.7 %) and 147 males (29.3 %; 95% CI 25.3-33.5%). The median age of patients was 51 years, the 25th and 75th percentiles - 41 and 59 years. According to C class criteria of the CEAP classification (2004) there were the following classes: С2s, С3s, C4a,s, C4b,s, C5s, C6s.

Each patient underwent preoperative ultrasonographic triplex scanning of the lower limb venous system («LOGIQ e», GE Healthcare, UK) with mapping of all the detected pathological venous refluxes. Special attention was given to the variations in anatomy and pathology of the vein of Giacomini and the cranial extension of the SSV. Hereafter, ultrasonographic data were confirmed intraoperatively.

The obtained data were statistically processed using an advanced analytics software package STATISTICA 10 (StatSoft, USA) and Microsoft R Open (Revolution Analytics, USA). The frequency of quality indicators was presented in absolute (n) and relative (%) frequencies indicating a 95% confidence interval as “n” (%, 95% CI). When analyzing quantitative data the nature of the distribution of indicator values was determined using the Shapiro-Wilk W-test. For quantitative data with abnormal distribution the results were presented as a median (the 25th and 75th percentiles).

Results and Discussion

Among studied limbs the involvement of the vein of Giacomini in the spread of pathological reflux was detected in 23 limbs (3.8%; 95% CI 2.4-5.6%). In 5 cases, due to the absence of the arch of the SSV the vein of Giacomini was the terminal part of the SSV as well. In 2 of these limbs it drained into the GSV in the upper third of the thigh; in 1limb it drained into the GSV in the middle third of the thigh; in the remaining 2 limbs it drained into the GSV in the lower third of the thigh. In 4 out of 5 limbs reflux of the terminal valve of the GSV passed through its trunk to the point where the vein of Giacomini drained into the GSV (the terminal part of the SSV) and spread via the vein of Giacomini along the entire SSV in 2 limbs, to the border between the middle and upper thirds of the tibia in 1 leg and to the border between the upper and middle thirds of the tibia in 1 limb. In the fifth limb reflux spread from the saphenofemoral junction not to the GSV but to the anterior accessory of the GSV from which in the middle third of the thigh it returned to the GSV; then, in the junction between the middle and lower thirds of the thigh it passed to the terminal part of the SSV (i.e. the vein of Giacomini) reaching the border between the upper and middle thirds of the tibia.

Among 605 limbs the involvement of the cranial extension of the SSV in the formation of pathways of pathological reflux spread was detected in 10 cases (1.7%; 95% CI 0.8-3.0%). In 5 cases, due to the absence of the arch of the SSV it was the terminal part of the SSV as well. In 1 out of these 5 limbs reflux spread to the cranial extension of the SSV from two muscular veins of the posterior surface of the thigh and reached the lateral malleolus (total reflux of the SSV). In other 4 limbs reflux spread to the cranial extension of the SSV (i.e. the SSV itself) from the femoral vein. In 1 limb reflux of the SSV was total; in 3 limbs it was proximal: in the first case it spread to the border between the middle and lower thirds of the tibia; in the second case it spread to the border of its upper and middle thirds; in the third case it was found below the popliteal crease spreading to the branch of the SSV. In 2 out of 4 limbs reflux spread from the trunk of the SSV via the branch outside the saphenous compartment to the GSV causing distal reflux from the upper third of the tibia in one case and from the middle third of the tibia in another one.

As you can see, in all 10 patients with the vein of Giacomini or the cranial extension of the SSV being the terminal part of the SSV, pathological reflux was observed in the GSV and SSV simultaneously indicating severe damage. Damage to the vein of Giacomini was characterized by the spread of reflux from the GSV to the SSV (5 cases), while damage to the cranial extension of the SSV was characterized by the spread of reflux from the SSV to the GSV (2 cases).

Different patterns were observed in limbs where the vein of Giacomini and the cranial extension of the SSV being involved in the spread of pathological refluxes were not the part of the SSV but only its ostial side branches. Such limbs were detected in 21cases. In 16 cases only the vein of Giacomini was involved in the spread of pathological refluxes; in 3 cases only the cranial extension of the SSV was involved in the spread of pathological refluxes; in 2 cases both veins were involved. The arch of the SSV was present in the absolute majority of limbs. Only in 1 case (the pathology of the vein of Giacomini) it coursed to unchanged cranial extension of the SSV.

Among 16 patients with the vein of Giacomini being involved in the spread of pathological refluxes only in 2 patients it originated from the cranial extension of the SSV (in 1 case the cranial extension of the SSV was the terminal part of the SSV due to the absence of its arch) while in the remaining patients it originated from the ostial region of the SSV (Fig. 1, Fig. 2).

Fig. 1.

Origin of the vein of Giacomini from the ostial region of the SSV and its drain into the GSV at the middle third of the thigh (case history N0 1884/07, ІFCCCH).

gmj-23-gmj.2016.3.21-g1.jpg
Fig. 2.

Origin of the vein of Giacomini from the ostial region of the SSV (case history No 9875/06, ІFCCCH).

gmj-23-gmj.2016.3.21-g2.jpg

1 - the small saphenous vein

2 – the arch of the small saphenous vein

3 – the point where the arch of the small saphenous vein drains into the popliteal vein

4 – origin of the vein of Giacomini from the ostial region of the small saphenous vein

In one case the vein of Giacomini drained into the posterior accessory of the GSV. In the other case the vein of Giacomini coursed in the saphenous compartment close to the trunk of the GSV and then, without draining into the GSV it was divided into 2 torturous branches approximately 3 mm in diameter which winding across the GSV ascended to the popliteal fossa and then, reconnecting, drained into the superficial epigastric vein. In 5 persons the vein of Giacomini drained into the ostial region of the GSV. In the remaining 9 cases in drained into the GSV at different levels of the thigh.

There were the following variations in the involvement of the vein of Giacomini in the spread of pathological reflux in the presence of the arch of the SSV and without the pathology of the cranial extension of the SSV:

  1. the spread of reflux from the GSV to the vein of Giacomini from which the latter: spread nowhere in 3 cases (Fig. 3b); spread to the ostial region of the SSV resulting in the incompetence of its terminal valve in the presence of competent trunk in 3 cases (Fig. 3c); spread to the larger or smaller segment of the SSV without leading to the incompetence of its terminal valve in 2 cases (Fig. 3d); spread to the trunk of the SSV resulting in the incompetence of its terminal valve in 3 cases (Fig. 3f); similar to 2 previous cases but with the spread of reflux via the intersaphenous vein to the trunk of the GSV in 2 cases (Fig. 3e, g); spread to the sciatic perforating vein originating from the cranial extension of the SSV in one case (Fig. 3h);

  2. reflux from the terminal valve of the SSV intensified the antegrade flow of blood within the vein of Giacomini resulting in reflux in the GSV distal to the point where the vein of Giacomini drained into the great saphenous vein in 2 cases (Fig. 3i).

Fig. 3.

Schematic illustration of blood flow within the vein of Giacomini under normal conditions (a) and in different variations in the spread of pathological reflux (b-i).

gmj-23-gmj.2016.3.21-g3.jpg

1 – the deep vein

2 – the GSV

3 – the perforating veins

4 – the SSV

5 – the intersaphenous vein

6 – projection of the muscular fascia

7 – the arch of the SSV

8 – the vein of Giacomini

9 – the cranial extension of the SSV

The arrows are:

blue – normal antegrade flow of blood

red – pathological retrograde flow of blood (reflux)

green – overload of the antegrade flow of blood

The involvement of the cranial extension of the SSV in the spread of pathological reflux in the absence of the pathology of the vein of Giacomini was observed in 3 limbs (Fig. 4b-d). Reflux in the cranial extension of the SSV originated from its ostium or the perforating vein ascending from it or it was caused the overload of the antegrade blood flow in the presence of the incompetence of the terminal valve of the SSV. In the distal direction, as in case of damage to the vein of Giacomini, it could drain into the ostium of the SSV or result in the valvular insufficiency of its trunk. It should be noted that in all 3 patients various segments of the GSV were affected while the SSV was affected in 2 persons only.

Fig. 4.

Schematic illustration of blood flow within the cranial extension of the SSV under normal conditions (a) and in different variations in the spread of pathological reflux (b-d).

gmj-23-gmj.2016.3.21-g4.jpg

1 – the deep vein

2 – the GSV

3 – the perforating veins

4 – the SSV

5 – the intersaphenous vein

6 – projection of the muscular fascia

7 – the arch of the SSV

8 – the vein of Giacomini

9 – the cranial extension of the SSV

10 – the ostium of the cranial extension of the SSV

The arrows are:

blue – normal antegrade flow of blood

red – pathological retrograde flow of blood (reflux)

green – overload of the antegrade flow of blood

The pathology of both the vein of Giacomini and the cranial extension of the SSV was detected in 2 persons. Fig. 5b-c presents the spread of pathological refluxes in these patients.

Fig. 5.

Schematic illustration of blood flow within the superficial venous system under normal conditions (a) and in different variations in the spread of pathological reflux (b-c).

gmj-23-gmj.2016.3.21-g5.jpg

1 – the deep vein

2 – the GSV

3 – the perforating veins

4 – the SSV

5 – the intersaphenous vein

6 – projection of the muscular fascia

7 – the arch of the SSV

8 – the vein of Giacomini

9 – the cranial extension of the SSV

10 – projection of the saphenous fascia

The arrows are:

blue – normal antegrade flow of blood

red – pathological retrograde flow of blood (reflux)

green – overload of the antegrade flow of blood

In the presence of a greater number of patients with the pathology of the vein of Giacomini and the cranial extension of the SSV more variations in the spread of pathological refluxes could exist. However, having examined only 32 limbs with the pathology of the aforementioned veins, we detected 13 variations in the spread of pathological reflux through them.

Conclusions

  1. The pathology of the vein of Giacomini was observed in 3.8% of patients with PCVD (95% CI 2.4-5.6%), while the pathology of the cranial extension of the SSV was diagnosed in 1.7% of patients (95% CI 0.8-3.0%).

  2. In the presence of the pathology of the vein of Giacomini and/or the cranial extension of the SSV there are at least 13 variations in the spread of pathological refluxes.

  3. Surgical tactics in every patient with the pathology of the vein of Giacomini and the cranial extension of the SSV has to be clearly differentiated and hemodynamically justified.

Prospects for further research

The verification of variations in anatomy and pathology of the vein of Giacomini and the cranial extension of the SSV allows us to develop differential surgical treatment including the removal of only the affected areas of the superficial venous system in every individual case as well as to study the results of such treatment.

References

1 

VI Rusyn, VV Korsak, PO Boldizhar, et al. Varykotromboflebit. Uzhhorod: Karpaty; 2012. 288p. Ukrainian.

2 

AA Guch, LM Chernukha, AO Bobrova, et al. Osobennosti topografiyi i putey rasprostraneniya reflyuksa v basseyne maloy podkozhnoy veny. Klinichna flebolohiia. 2011;4(2):10-17. Russian.

3 

TD Konstantinos, LK Alison. Prevalence, anatomic patterns, valvular competence, and clinical significance of the Giacomini vein. J Vasc Surg. 2004;40(6):1174-1183. doi:10.1016/j.jvs.2004.09.019

4 

A Caggiati, JJ Bergan, P Gloviczki, J Gorges, CP Wendell-Smith, H Partsch, et al. Nomenclature of the veins of the lower limbs: An international interdisciplinary consensus statement. J Vasc Surg. 2002;36(2):416-422. doi:10.1067/mva.2002.125847. Cited in: PubMed; PMID 12170230

5 

A Caggiati, JJ Bergan, P Gloviczki, B Eklof, C Allegra, H Partsch, et al. Nomenclature of the veins of the lower limb: Extensions, refinements, and clinical application. J Vasc Surg. 2005;41(4):719-724. doi:10.1016/j.jvs.2005.01.018



Copyright (c) 2017 Rostyslav Vasyliovych Sabadosh

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