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Chapter
Small saphenous vein
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1
Anatomy
4
Great saphenous vein
Anterior tibial vein
Posterior tibial vein
Dorsal venous arch
Plantar veins
Venous plexus of sole
Figure 1.6 At the foot, axial veins are prevalent in the plantar region,
where the first pump (although not the most important) mechanism is
present (Léjars sole).
veins, venous disorders, and lymphatic problems in the lower limbs, Oxford University Press,
1997.)
pump). This system is correctly termed the calf muscle pump
or peripheral heart (see Fig. 1.4).
(Adapted from: Tibbs DJ, Sabiston DC, Davies MG et al: Varicose
12
In contrast, posterior deep compartment veins (posterior
tibial and peroneal) and anteroexternal compartment veins
(anterior tibial) are rectilinear, as the surrounding muscles
lean against the bones and have a limited shortening during
contraction.
7
At the knee and thigh, deep leg veins flow into the collecting system (popliteal-femoral veins). They run in the popliteal
crease and adductors canal, and are not enwrapped by a muscular layer as the blood flow to the abdominal cavity has not
been held back by compression.
7
The other thigh veins (profunda femoris and circumflex) are still deep intramuscular
veins. The popliteal vein is also connected by anonymous
muscular veins to the profunda femoris and the sciatic nerve
vein, creating a natural bypass when obstruction occurs to the
femoral vein (thrombosis, extrinsic compression, bone frac-
13
ture).
Thanks to this autonomy, the femoral vein is used as
an alternative conduit when other more accessible superficial
veins are unavailable (see Fig. 1.5).
9
The common femoral vein collects the backflow of the
lower limb and sends it to the pelvis (iliac veins and inferior
vena cava), where aspiration pleurodiaphragmatic forces
prevail, together with vis-a-tergo of the renal veins. The
common femoral vein in particular receives the GSV below
the inguinal ligament where it becomes the external iliac vein.
A potential alternative way of discharge in this area is due
to the obturator vein (normally draining part of the muscles
of the medial thigh) and the sciatic vein, often not
macroscopically evident (first embryonic vein, secondarily
replaced by the femoropopliteal axis, which can be activated
in certain conditions). Together with the superficial veins
they can contribute to limb drainage in case of femoral thrombosis by their connection to the hypogastric vein (see Fig. 1.5).
However, the same system may be the cause of varices
when endopelvic hypertension is transmitted to the superficial limb veins. The sciatic vein may also be involved in congenital venous malformations, typically Klippel-Trenaunay
syndrome.
13
Anatomy of the Superficial Veins
The most important superficial veins are the GSV and the SSV.
It is generally thought that the term saphenous is derived from
the Greek word saphenes, meaning evident, but it could also
come from the Arabic words el safin, which mean hidden or
concealed.
14
Of course, these terms were important in the
practice of blood letting.
Great saphenous vein
This vein begins on the dorsum of the foot as a dorsal venous
arch and internal marginal vein. It passes anterior (10–15 mm)
to the medial malleolus, crosses the tibia at the distal third
and runs along the tibial internal edge. At the knee the vein it
bends posteriorly, running around the condilus femoralis, in
contact with the anterior edge of the sartorius muscle, then
ascends in the anteromedial thigh, crosses the sartorius and
adductor brevis and enters the Scarpa triangle to empty into
the common femoral vein (Fig. 1.7).
9,15
This termination point
is referred to as the saphenofemoral junction (SFJ) but is also
known as the crosse, which is the French description for its
appearance as a shepherd’s crook. The average diameter of a
normal GSV is 3.5–4.5 mm (range 1–7 mm).
16
The GSV receives multiple tributaries along its course.
These usually lie in a less supported, more superficial plane
above the membranous fascia. The posterior arch vein, the
anterior superficial tibial vein and the medial superficial pedal
vein join the GSV in the lower leg. The posterior arch vein
(known as the vein of Leonardo, but now classified as the
posterior accessory saphenous vein) is a major tributary to the
GSV. It enters the GSV below the knee and otherwise communicates with the deep venous system through multiple perforating veins. These are, in ascending order: the Cockett I,
Cockett II and Cockett III perforators and the 24-cm perforating vein, now called the upper, middle and lower posterior
tibial perforators.
In the thigh, two main clusters of perforating veins connect
the saphenous vein to the deep system. Just above the knee,
there is the Dodd group, and in the mid-thigh, the Hunterian
perforators (now called mid-thigh perforators).
Two large tributaries in the upper third of the thigh – the
posteromedial and anterolateral tributaries – join the GSV
proximally. These veins usually enter the GSV before it dives
posteriorly to penetrate the deep fascia at the fossa ovalis. Both
the medial and lateral superficial thigh veins may be so large
that they are mistaken for the GSV itself.
of perforators connect the GSV to the femoral, posterior tibial,
gastrocnemius and soleal veins.
18
17
A variable number
Small saphenous vein
The SSV is the most prominent and physiologically important
superficial vein below the knee (Fig. 1.8).
SSV has a thick wall and usually measures 3 mm in diameter
when normal.19 It begins at the lateral aspect of the foot and
ascends posterior to the lateral malleolus as a continuation of
the dorsal venous arch. It continues up the calf between the
gastrocnemius heads to the popliteal fossa, where it usually
enters the popliteal vein.
The termination of the SSV is quite variable, usually occurring in the popliteal vein, as stated above. However, in 27%
to 33% of the population, it terminates above the level of the
popliteal fossae, either directly into the GSV or into other deep
veins. In 15.3% of patients, the SSV communicates with the
popliteal vein, then continues terminating in the GSV. In 9%
to 10%, the SSV empties into the GSV or the deep veins below
the popliteal fossae.
9,20
The SSV may also join the GSV in the
thigh through an oblique epifascial vein (the Giacomini vein),
or it may continue up under the membranous fascia of the
thigh as the femoropopliteal vein, joining the deep veins in
the thigh at various locations (Fig. 1.9).
Like the GSV, the SSV runs on or within the deep fascia,
usually piercing the deep fascia just below the flexor crease of
the knee as it passes into the popliteal fossa.
petence of the SSV usually occurs only in areas where the SSV
9
Like the GSV, the
21–23
24
Gross incom-
21
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24
23
22
21
20
19
1
2
3
4
5
6
7
8
ALTV
GSV
18
Boyd’s perforator
17
8
16
15
14
A
Figure 1.7 A, Traditional anatomical terms for the lower limb, medial aspect. 1: superficial epigastric vein, 2: pampiniform plexus, 3: external pudendal vein,
4: superficial dorsal vein of the penis, 5: superficial medial circumflex femoral vein, 6: accessory posterior saphenous vein of the thigh, 7: femoropopliteal vein,
8: great saphenous vein, 9: sartorius muscle, 10: anastomoses between the great and small saphenous veins, 11: posterior arcuate vein (posterior saphenous
vein of the leg or vein of Leonard), 12: medial marginal communicating veins, 13: plantar sole, 14: superficial dorsal metatarsal veins, 15: superficial dorsal
venous arch of the foot, 16: venous plexus of the dorsal surface of the foot, 17: anterior vein branch (anterior saphenous vein of the leg), 18: superficial
femoral vein, 19: perforating veins of Dodd, 20: accessory small saphenous vein (anterior accessory saphenous vein), 21: superficial inguinal lymph nodes,
22: superficial lateral circumflex femoral vein, 23: common femoral vein, 24: superficial circumflex iliac veins. B, The great saphenous vein (GSV) and its
tributaries are occasionally well displayed on thin legs. ALTV, anterolateral thigh vein; AVL, anterior vein of the leg (accessory saphenous vein); PAV, posterior
arch vein.
(B, Adapted from Somjen GM: Dermatol Surg 21:35, 1995.)
13
9
10
24 cm perforator
11
Cockett’s III
Cockett’s II
Cockett’s I
12
Linton’s line
AVL
PAV
B
Anatomy of the Superficial Veins
and its tributaries are superficial to the deep fascia, on the
lateral calf and lower third of the leg behind the lateral malleolus. The SSV often receives substantial tributaries from the
medial aspect of the ankle, thereby communicating with the
medial ankle perforators. The SSV may also receive a lateral
arch vein that courses along the lateral calf to terminate in the
SSV distal to the popliteal fossa. It may also connect directly
with the GSV.
Other superficial veins and collateral veins
The superficial collateral or communicating venous network
consists of many longitudinally, transversely and obliquely
oriented veins. These originate in the superficial dermis, where
they drain cuticular venules. These veins are normally of lesser
diameter, but when varicose they can dilate to more than
1 cm. They are thin walled and are more superficial than the
superficial fascia that covers the saphenous trunks. They drain
into deep veins through the saphenous veins, directly through
perforating veins or through anastomotic veins in the abdominal, perineal and gluteal areas.
may become varicose either in combination with truncal varicose veins or independently (Fig. 1.10).
Although many collateral veins are unnamed, some promi-
nent or consistent superficial veins are, for example, the Giaco-
25
Therefore, collateral veins
15
mini vein, which connects the proximal GSV to the SSV. This
vein has been found by duplex examination in 70% of limbs
with chronic venous insufficiency.
26
Other examples include
the lateral anterior accessory saphenous vein (AASV), which
runs from the lateral knee to the SFJ, the anterior crural veins,
which run from the lower lateral calf to the medial knee, and
the infragenicular vein, which drains the skin around the knee.
Geniculate perforators, although small, may contribute significant reflux (see Figs 1.7, 1.8).
A lateral subdermal plexus of reticular veins, first described
by Albanese et al,
27
has its origin through perforating veins at
the lateral epicondyle of the knee (Fig. 1.11). It has been speculated that it represents a remnant of the embryonic superficial
venous system that fails to involute. This system of veins has
its importance in the development of telangiectasia. These
veins may become varicose even in the absence of truncal
varicosities.
Duplex ultrasound anatomy
The venous anatomy of the leg is theoretically simple;
however, its peculiarity is due to its extreme variability between
individual normal subjects. Normal non-varicose limbs
show such different patterns that it is rare to see two identical anatomical arrangements in two different limbs. If
5
Chapter
Telangiectasia
Varicose
Femoral vein
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1
Anatomy
1
10
8
2
3
9%
32.5%
4
GSV
GSV
GSV
Iliac vein
Gluteal vein
9
8
12 cm perforator
Bassi’s perforator
7
Figure 1.8 Traditional anatomical terms for the lower limb, posterior
aspect. 1: Great saphenous vein, 2: popliteal vein, 3: tibial nerve, 4: deep
fascia, 5: small saphenous vein, 6: lateral marginal communicating veins, 7:
lateral malleolus, 8: perforating veins, 9: gastrocnemius point, 10: common
peroneal nerve.
tributary
51.5%
5
Cockett’s III
7%
Cockett’s II
Cockett’s I
6
SSV
SSV
A
Figure 1.9 Variations in the termination of the small saphenous vein (SSV).
A, Termination into the saphenopopliteal junction; B, termination into
the great saphenous vein (GSV); C, termination into the gluteal vein.
B
C
Inferior gluteal
vein
Perforators
SSV
Perforating vein
Small saphenous vein
Figure 1.10 Schematic diagram of subcutaneous venous anatomy
showing four types of flow from subcutaneous veins (SCV). SCV to GSV/SSV
to SFJ/SPJ to deep system; SCV to GSV/SSV to perforator to deep system;
SCV to perforators to deep system; SCV to deep system. GSV, great
saphenous vein; SSV, small saphenous vein; SFJ, saphenofemoral junction;
SPJ, saphenopopliteal junction.
JP: J Dermatol Surg Oncol 19:940, 1993.)
6
(From Somjen GM, Ziegenbein R, Johnston AH, Royle
Dermis
Reticular
vein
Perforating
vein
Superficial
fascia
Deep fascia
Deep vein
Figure 1.11 Lateral subdermal plexus commonly seen on the lateral thigh
arising from perforator veins from the femoral vein.
we consider varicose limbs, these differences are greatly
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enhanced.
The most striking progress in the knowledge of venous
anatomy for phlebologists is related to the easy visibility of
the fascial sheets by DUS imaging. This DUS anatomical ‘dissection’ has offered the key for interpretation of these variations providing a simple universal language for the easy
identification of veins (Fig. 1.12).
28,29
The result is that leg veins are not just ‘deep’ or ‘superficial’,
but are arranged in three levels: deep (beneath the aponeurotic fascia), intermediate (between the aponeurotic fascia and
the superficial fascia) and subcutaneous (between the superficial fascia and the skin) (Fig. 1.13).
8,28
The subcutaneous space in which all superficial veins run
is divided by a fascial sheet, called superficial or membranous
fascia, into two layers: a superficial layer of loculated fatty
tissue (Camper’s fascia) and a deep layer of collagen and
elastic tissue that provides stronger support (Scarpa’s fascia).
The superficial fascia is homologous with Scarpa’s fascia of
the anterior abdominal wall and may be considered as a
single unit.
In the early nineteenth century two French anatomists,
Cruveilhier
30
and Bayle,31 described for the first time that both
saphenous veins lie in the deeper compartment of the subcutaneous space and are covered, for their entire length, by the
superficial fascia. All other superficial veins (tributaries or collaterals of the saphenous) run into the superficial compartment, between the superficial fascia and the skin, in what is a
true subcutaneous position. Despite evidence from anatomical dissection (Fig. 1.14),
32
the importance of the superficial
fascia as an anatomical classification marker had been largely
ignored until DUS became an established tool for venous
investigation of leg vein anatomy.
29
It was proposed to name the interfascial compartment in
which the GSV runs the ‘saphenous compartment’, and the
superficial fascia that covers it, ‘saphenous fascia’ (Fig. 1.15).
28
The superficial fascia is a marker for distinguishing the two
levels of superficial veins. A few constant, and named, superficial veins run through specific intrafascial compartments
(intermediated veins), covered by fascial sheet, and belong to
the intermediate level. These intrafascial veins are (Fig. 1.16):
3,33
• the GSV
• the proximal part of the AASV
• the SSV and its thigh extention (Giacomini or
femoropopliteal vein)
• the medial and lateral marginal veins of the foot
• the dorsal foot arch.
These veins are longitudinal ‘blood transfer’ vessels of
major importance in understanding varicose hemodynamics.
Their position inside the close fibroelastic ensheathing and
adventitial anchoring may explain the absence of varicosity in
these veins (they enlarge but do not become varicose).
34
A
pump mechanism during muscular contraction can also be
another explanation with caliber reduction due to the fascial
compression effect enhancing blood flow
8
(Fig. 1.17); similar,
but less efficient to what happens in the deep compartment.
Every vein running superficially to the fascial sheet should
be considered a collateral or tributary vein (Fig. 1.18). Its identification is consequently of paramount importance when
treatment must be provided in a varicose condition. Varicose
veins typically belong to this superficial layer.
3,8
Anatomy of the Superficial Veins
Skin
Superficial
compartment
Deep
compartment
Figure 1.12 The easy visibility of the fascial
sheets by ultrasound imaging offers the key for
interpretation of the frequent variations of normal
anatomy, providing a simple universal language
for the easy identification of the veins. Here it is
the immediate recognition of the great
saphenous vein on the left and the small
saphenous vein on the right.
Accessory
saphenous veins
Superficial fascia
Saphenous/
intermediate
compartment
Muscular fascia
Figure 1.13 Diagrammatic representation of the compartments enclosing the saphenous and deeper veins. Ultrasound shows that lower limb veins are
arranged in three levels: deep (beneath the aponeurotic fascia), intermediate (between the aponeurotic fascia and the superficial fascia) and subcutaneous
(between the superficial fascia and the skin).
vein
MuscleSaphenous
7
Chapter
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1
Anatomy
Figure 1.14 Transverse section from the medial aspect of the thigh
showing the fibrous envelope that ensheathes the great saphenous vein
and holds it against the deep fascia.
61:198, 1979. Copyright The Royal College of Surgeons of England. Reproduced with
permission.)
(From Thompson H: Ann R Coll Surg Engl
AASV
GIA
GSV
Figure 1.16 The interfascial veins are: the great saphenous vein (GSV),
the proximal part of the anterior accessory saphenous vein (AASV), the
small saphenous vein (SSV) and its thigh extension (TE) (Giacomini or
femoropopliteal vein; GIA), the medial and lateral marginal veins of the foot
and the dorsal foot arch.
ambulatory phlebectomy. In: Goldman MP, Georgiev M, Ricci S, editors, Ambulatory
phlebectomy , Boca Raton, 2005, Taylor
GIA
(Ricci S, Georgiev M, Goldman MP: Anatomical bases of
TE
SSV
& Francis)
Figure 1.15 The interfascial compartment in which the great saphenous
vein (GSV) runs has been called ‘saphenous compartment’, and the
superficial fascia that covers it (continuous line), ‘saphenous fascia’. The
interrupted line follows the muscular fascia, the dotted line underlines a type
of vein ligament that fixes the GSV inside the compartment.
With a thorough understanding of this scheme, all possible
venous anatomical variations may be correctly understood.
Duplex Ultrasound Markers for
Vein Identification
The veins of the intermediate level have constant relationships
with the surrounding anatomical structures – fascial sheets,
muscles, bones, deep vessels – which are easily recognized by
DUS and are therefore ultrasound ‘markers’ for vein identifica-
3,33
tion.
It is from these markers that the following ultrasound
identification signs derive.
The ‘eye’ sign
Bailly first described, in 1993, the ‘eye’ sign as the ultrasound
marker for identification of the GSV in the thigh.
8
29
This sign
is due to the fact that the superficial fascia is echo-lucent and
easily observed by USI. In transverse scan the compartment in
which the GSV runs resembles an Egyptian eye, where the
saphenous lumen is the iris, the superficial fasci, the superior
eyelid and the aponeurotic fascia the inferior eyelid (see Fig.
1.15). The description of the ‘saphenous eye’ could well be
considered the beginning of ultrasound vein anatomy. The eye
sign is always present and allows immediate and certain identification of the saphenous vein and its separation from parallel running subcutaneous collaterals.
The ‘alignment’ sign
This sign, also suggested by Bailly,37 helps recognize and distinguish the AASV from the GSV.
thigh on transverse scan into the ‘eye’ there are often two veins
instead of one: the GSV and the AASV. The latter lies anterior
(lateral) to the GSV
35
39–41
and is identified by its subfascial position and by the fact that in transverse scan it lies over (is
aligned with) the common femoral vessels (artery and vein)
(Fig. 1.19A). In addition to the alignment sign, in some cases
the AASV has, in transverse scan, its own ‘eye’
However, it is the alignment sign that shows that in some
cases the only vein visible in the ‘eye’ is the ASV, while the
GSV is not visible (absent or hypoplastic) (Fig. 1.19C).
36,38
In the upper third of the
8
(Fig. 1.19B).
The tibia-gastrocnemius angle sign
This sign allows one to recognize the GSV below the knee,
where fascial sheets are often so close to each other that the
intrafascial compartment in which the GSV runs may be
difficult to recognize.
guished from other closely running veins by its position, on
a transverse scan, in the angle formed by tibial and medial
gastrocnemius muscle (Fig. 1.20A, B). This sign allows one to
36,42
In such cases the GSV is distin-
38
A
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Figure 1.17 The great saphenous vein finds a shelter from its position below the superficial fascia, but also a pump mechanism during muscular
contraction can be hypothesized, with caliber reduction due to the effect of fascial compression enhancing blood flow. (From Franceschi C, Zamboni P: Principles of
hemodynamics, Nova Science, New York, 2009. With permission from Nova Science Publishers, Inc.)
B
Duplex Ultrasound Markers for Vein Identification
A
Figure 1.18 A, C, Under ultrasound, the apparent ‘eye’ that can be seen is the great saphenous vein (GSV). In B the prevailing vein is outside the
compartment and must be classified as a tributary vein, while inside the compartment a hypoplastic GSV may be recognised (arrow). In C two veins are
visible but only the one inside the compartment is the GSV.
AASV
GSM
FM
A
Figure 1.19 A, Two veins are present at the (left) groin. The GSV is medially sited, the anterior accessory saphenous vein (AASV) is lateral and aligned over
the femoral vessels. B, Same as in A but more distal. The two veins may have their own separate ‘eye’. C, Only one vein is present here, but its position over
the deep vessels suggests that it is an AASV, while the GSV is non visible (hypoplastic).
B C
FV
FV
B C
9
Chapter
Saphenous space
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1
A
Anatomy
B C
Figure 1.20 A, At the knee level the saphenous space is very narrow and can be identified in the angle between the tibia and the gastrocnemius
(T-G angle). B, The vein inside the T-G angle is the great saphenous vein (GSV). C, If the T-G angle is empty, we can say that the GSV is hypoplastic and
that a tributary has prevailed.
LSV
FP
SP
Gastrocnemius
(From Ricci S, Georgiev M: Ultrasound anatomy of the superficial veins of the lower limb J Vasc Technol 26:183, 2002).
A
T
Figure 1.21 The intermuscular grooves along which the small
saphenous vein (B) and its thigh extension (A) run are covered by
a thick fascial sheet and appear as a characteristic triangle-shaped
compartment on a transverse scan. Distal to the gastrocnemius
muscle the fascial sheet is still present (C), although less evident.
(Adapted from Cavezzi A, Labropoulos N, Partsch H et al: Duplex ultrasound
investigation of the superficial veins and perforators in chronic venous disease of
the lower limbs, part II: Anatomy. Eur J Vasc Endovasc Surg 31: 288–99, 2006).
L
B
C
demonstrate, when the angle is empty, that in this area the
GSV is absent or hypoplastic (Fig. 1.20C).
The small saphenous compartment sign
The proximal portion of the SSV lies between the medial and
lateral heads of gastrocnemius muscle, while its frequent thigh
extension (TE) lies between the semitendinous muscle (medially) and long head of the biceps muscle (laterally). The intermuscular grooves, along which these two veins run, are covered
by a thick fascial sheet and appears as a characteristic triangleshaped compartment on a transverse scan (Fig. 1.21A, B).
This triangle-shaped compartment is always present and
allows immediate and certain identification of the SSV/TE and
distinguishes it from parallel subcutaneous and deep collater-
10
als. Distal to the gastrocnemius muscle the fascial sheet is still
present (Fig. 1.21C), albeit less evident as it is thinner as it
approaches the ankle and the marginal vein over the foot
indicating that it is the SSV. As for the GSV, it courses inside
a specific compartment for its entire length.
3
Relationship between saphenous veins
and collaterals
The GSV is often accompanied by parallel veins of different
lengths. They can be so large that they can be wrongly con-
43,44
fused with the GSV itself or ‘double’ or duplicate saphenous
veins. In fact these parallel veins are collaterals that pierce the
superficial fascia to get out of the saphenous compartment
and run subcutaneously at a more superficial level than the
GSV (Fig. 1.22).
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3,28,35
The relationship between the saphenous
trunk and these subcutaneous collaterals could be schematized into three anatomical patterns with specific ultrasound
appearance
45
(Fig. 1.23):
• Type I: The saphenous trunk is present, in full size and
for its complete length in the saphenous compartment,
and there are no large parallel collaterals.
• Type h: The saphenous trunk is present for its complete
length, and there is also a large (even larger) collateral.
• Type S: The saphenous trunk pierces the superficial
fascia and continues as superficial collateral, while distal
to this point the saphenous trunk is either not at all
or only barely visible on DUS (absent or hypoplastic).
Great Saphenous Vein
The GSV begins anterior to the medial malleolus as the continuation of the medial marginal foot vein and then ascends
along the medial aspect of the tibia and thigh to empty into
the common femoral vein in the groin. The GSV lies for its
entire length (Fig. 1.24) in a compartment delimited by the
aponeurotic and the superficial (saphenous) fascia. On transverse scan this compartment appears as an ‘eye’ (see Fig.
Figure 1.22 The great saphenous vein (GSV) is often accompanied by
parallel veins of different length that may be confused with the GSV itself or
mistaken for duplicate veins. They are collaterals that pierce the superficial
fascia and run subcutaneously at a more superficial level than the GSV.
3,28,29,33,35,36
1.15).
may be difficult to recognize in very thin subjects, and in some
areas such as the knee and ankle.
This ‘eye’ is readily visible in the thigh, but
42
Saphenofemoral junction
Situated at the level of the groin crease the SFJ is covered by
the superficial fascia that ends proximal to the inguinal
ligament.
The GSV has a constant (terminal or ostial) valve, which is
usually well visible at its junction (although separated by
1–2 mm from the ostium) with the femoral vein. Another
valve (preterminal valve) can be found about 2 cm distal to
it, at the distal border of the SFJ area. Between the two valves
the GSV is joined by constant tributaries divided into proximal
and distal (Fig. 1.25).
The proximal collaterals are, from lateral to medial: the
superficial iliac vein, superficial epigastric vein and superficial
pudendal vein. They may have different individual anatomical
arrangements. They drain venous blood from the abdominal
wall and pudendal areas. Their clinical importance is relevant
when they feed a retrograde flow of the GSV in the presence
of a competent terminal valve. This situation has been reported
in 28% to 52% of cases of GSV reflux
preclude the need for direct GSV treatment in many cases.
The superficial external pudendal artery (immediately identified by color duplex) is intimately associated with the GSV
at the SFJ, where it may bifurcate to enclose the GSV (Fig. 1.27).
The distal collaterals, lateral and medial, may be relatively
large. The lateral collateral – the AASV – is present in 40% of
subjects as a well-distinguished vein (see Fig. 1.19B). In most
cases the AASV joins the GSV within 1 cm of the SFJ, and there
is typically a lymph node in the angle between the GSV and
the AASV before they merge (see Fig. 1.19A).
The medial collateral joins the GSV at a variable distance
from the SFJ, often distal to the preterminal valve. The medial
collateral may be the continuation of a large vein coming
through the posterior thigh from the SSV as the Giacomini
vein. The lymph node that is consistently found between the
GSV and the AASV merger may have a large and incompetent
central vein, sometimes becoming a source of reflux into the
thigh and leg varicose veins.
3,46
47
(Fig. 1.26) and may
47
Great Saphenous Vein
I h S
A B C
Figure 1.23 The three anatomical types (with
specific ultrasound appearance) of relationship
between the saphenous trunk and the
subcutaneous collaterals.
MP: Anatomical bases of ambulatory phlebectomy. In:
Goldman MP, Georgiev M, Ricci S, Ambulatory phlebectomy ,
Boca Raton, 2005, Taylor
(Ricci S, Georgiev M, Goldman
& Francis)
11
Chapter
Femoral nerve
https://t.me/med1917
1
Anatomy
Figure 1.26 Proximal junction collaterals may feed a retrograde flow of the
great saphenous vein (GSV) in the presence of a competent terminal valve.
(Original sketch courtesy of A Pieri)
Figure 1.24 The whole length of the great saphenous vein lies within a
compartment that is delimited by the aponeurotic and the superficial
(saphenous) fascia.
SE
SI
TV
AASV
SP
PTV
PASV
Figure 1.25 The great saphenous vein (GSV) has a constant valve (terminal
valve; TV) at its junction (although separated by 1–2 mm from the ostium)
with the femoral vein. Another valve (preterminal valve; PTV) can be found
at about 2 cm distal to it. Between the two valves constant tributaries
merge – proximal and distal. The proximal collaterals are the superficial iliac
(SI) vein, superficial epigastric (SE) vein and superficial pudendal (SP) vein.
The distal collaterals are the anterior (AASV) and posterior accessory (PASV)
saphenous veins, which may be relatively large.
Pieri)
12
(Original sketch courtesy of A
External
pudendal artery
Great
saphenous
vein
Figure 1.27 Illustration of a possible association of a bifurcated external
pudendal artery at the saphenofemoral junction.
Arrangement of the GSV and its subcutaneous
collaterals in the thigh
Based on the ‘eye’ sign, the following anatomical patterns were
observed in 610 consecutive limbs with and without varicose
3
veins
(Fig. 1.28):
• Single GSV vein running into the saphenous
compartment, with no large parallel tributaries = 52%
(317/610). Thigh portion of the GSV incompetent in
31% (Fig. 1.28A).
• The GSV divided in two parallel vessels, both running
into the saphenous compartment for a length of 3 to
25 cm = 1% (6/610). GSV incompetent in one (17%)
(Fig. 1.28B).
• GSV running into the saphenous compartment plus a
large subcutaneous collateral that joined the GSV
(piercing the fascia) at a variable level in the thigh =
26% (159/610). Proximal portion of the GSV
incompetent in 44% with reflux along the collateral
(Fig. 1.28C).
• Two veins, the GSV and the AASV, in two separate
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‘eyes’ = 10% (61/610) in the proximal part of the
saphenous compartment. An ASV incompetent in
30% with reflux to anterolateral thigh varicose veins
(Fig. 1.28D).
• No GSV visible into the distal part of the saphenous
compartment. A GSV’ substitute’ outside the
compartment as a subcutaneous collateral piercing the
superficial fascia at a variable level in the thigh and
becoming the’ true’ GSV = 16% (67/610). Reflux in
the GSV and its distal subcutaneous continuation in
45% (see Fig. 1.28E).
A
Figure 1.28 A, A single great saphenous vein (GSV) running through the
saphenous compartment, with no large parallel tributaries. B, The GSV
divided into two parallel vessels, both running through the saphenous
compartment. C, The GSV running through the saphenous compartment,
plus a large subcutaneous collateral piercing the fascia. D, Two veins, the
GSV and the anterior accessory saphenous vein, in two separate ‘eyes’ in the
proximal part of the saphenous compartment. E, No GSV visible in the distal
part of the saphenous compartment, but in the outside compartment in a
subcutaneous collateral acting as a GSV substitute pierces the superficial
fascia, becoming the ‘true’ GSV.
superficial veins of the lower limb, J Vasc Technol 26:183, 2002)
B C D E
(From Ricci S, Georgiev M: Ultrasound anatomy of the
Arrangement of the GSV and its subcutaneous
collaterals at the knee
At the knee the vein anatomy is sometimes difficult to assess
because of the presence of multiple collaterals and perforators
clustered into a limited space.
fascia creating the saphenic eye may be difficult to recognize.
However, the GSV can still be identified by its position in the
angle formed by the tibia bone and gastrocnemius muscle
(T-G angle)29 (see Fig. 1.20A,B,C).
On transverse scan, and based on this sign, in a series of
500 consecutive limbs with and without varicose veins, the
arrangement of the GSV and the collateral veins (CVs) along
its middle portion (between the distal third of the thigh and
the proximal third of the leg) presented the following patterns
(Fig. 1.29):
• Type A: The GSV is present and no large CVs are
observed (23% = 112/500). In 15% of these the GSV
was incompetent down to the distal third of leg where
reflux re-entered into the deep veins via a Cockett or
foot perforator(s) (Fig. 1.29A).
• Type B: The GSV is present, but there are also one or
more CVs below the knee (27% = 133/500). The most
typical example of such CVs is the ‘posterior arch’ or
‘Leonardo’ vein. In 53% of these the GSV was
incompetent, with reflux following the varicose CV, in
most cases, while the portion of the GSV distal to the
CV confluence was competent (Fig. 1.29B).
• Type C: The GSV is present but there is also a large
CV that begins above the knee (18% = 89/500).
In 31% of these the GSV was incompetent. This
CV corresponds to Type h in Figure 1.23
(Fig. 1.29C).
In the three patterns described above the GSV is always
present, although it is sometimes smaller than its normal
or varicose collaterals. However, in about 30% of cases, the
middle portion of the GSV was barely visible or not visible at
all (absent or hypoplastic) for a variable length, with the
‘missing’ portion bypassed by a subcutaneous collateral. This
arrangement presents two separate anatomical patterns:
42
In addition, the superficial
Great Saphenous Vein
Figure 1.29 The arrangement of the great
saphenous vein (GSV) and its collateral veins
(CVs). The percentage of incidence in 500
subjects is given in parentheses, below each of
the possible varicose vein patterns. A, The GSV is
present and no large CVs are observed. There is
GSV incompetence down to the distal third of
the leg to a Cockett or foot perforator(s). B, The
GSV is present, with one or more CVs below the
knee (posterior arch or Leonardo vein). GSV
incompetence shows reflux following the
varicose CVs, while the portion of the GSV distal
A
B C D E
to the CV confluence is competent. C, The GSV is
present with a large CV that begins above the
knee. In GSV incompetence the reflux may follow
this way like in B. D, The GSV is not visible for a
certain distance from the distal thigh down
below the knee, becoming a subcutaneous CV
that distally, at the mid-leg enters again into the
saphenous compartment. E, Same as D but the
absent portion of the GSV is very short.
S, Georgiev M: Ultrasound anatomy of the superficial veins
of the lower limb, J Vasc Technol 26:183, 2002)
(From Ricci
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