1. The MIGHTY Greater
Saphenous Vein
Abbas A. Chamsuddn, M.D.
1-Clinical Associate Professor, Department of Radiology
AlBalamand University-School of Medicine
Beirut, Lebanon
2-Chief, IR Service, Quantum Medical Radiology
Atlanta, GA
3-Director, The Center for Laser and Interventional Surgery,
Beirut, Lebanon
4. VENOUS ANATOMY:
SUPERFICIAL VEINS
• The veins of the lower extremity
that are superficial to the muscular
compartment
• Include innumerable draining
veins as well as the GSV and LSV
5. Lower Extremity Venous
Anatomy
Superficial Veins
Deep veins
Great Saphenous Vein: Replaces “Greater”
or “Long”
Small Saphenous Vein: Replaces “Lesser”
or “Short”
Anterior and Posterior Accessory GSVs
Giacomini Veins
Truncal veins
7. The Great Saphenous Vein
Begins on the dorsum of
the foot
Ascends along the medial
aspect of the leg
Drains in the femoral vein
Resides in a space deep to
the superficial fascia and
superficial to the deep
fascia
8. The Small Saphenous Vein
Begins along the lateral aspect
of the foot
Ascends up the midline of the
calf
In 2/3rd of cases drains in the
popliteal vein
In 1/3rd of cases it drains more
cephalad in the posterior thigh
Also resides in the saphenous
space
9. Anterior and Posterior
Accessory GSVs
Located in the
saphenous space
and travel parallel
anterior/porterior to
the GSV
Anterior AGSV is
more common
12. Venous Anatomy
Deep Veins:
– Femoral and Popliteal Tibial Veins
Superficial Veins
– Small Saphenous Vein
– Great Saphenous Vein
Perforators: Connectors of the deep veins to the
superficial veins
Reticular Veins: Tributaries to the saphenous
vein-connecting branch veins to deep, superficial
or perforators
Telangiectasia: Spider Veins
14. How Do Leg Veins Work?
Blood Travels Easily
downhill!
– pumped by the
powerful action of
the heart from above
– aided by the elastic
recoil of the artery
walls
– and of course, by the
effect of gravity
15. How do Veins Work?
In the standing position:
– blood has to be actively
pumped up the column of
veins
– this is achieved with our
calf muscles which
squeeze the venous
sinuses
– when the muscles relax,
the blood tends to rush
back into the leg
16. Venous Insufficiency
Occur because:
1-Problem with the veins
themselves
2-Weakness of the pumping
mechanism of the calf:
Reflux of the column of
blood through the leaky
valve
Strain on the vein wall
Stretching and weakness at
various points
End result: Varicose veins!
17. Venous Insufficiency
Varicose Veins:
– Dilated, protruding, tortuous saccular superficial veins.
– Develop in the superficial veins of the leg and mainly affect the long
saphenous vein
– Are higgledy-piggledy, dilated veins whose valves have failed allowing
increasing amounts of blood to reflux the wrong way down the limb
Reticular Veins: Dilated, tortuous, non-protruding superficial veins
Telangiectasia: Spider appearing, tortuous, non-protruding or dilated
18. Varicose Veins
Symptoms:
– Often unrecognized by patients and physicians
– Aching pain
– Night cramps
– Fatigue
– Heaviness
– Restlesness
19. Varicose Veins
A health issue: Left untreated:
– 50% will develop symptoms of severe venous
insufficiency:
lower-extremity swelling
eczema
pigmentation
hemorrhage
ulceration
20. Venous Insufficiency
As the vein dilates the wall
stretches in both width and
length so that the vein becomes
tortuous
As the situation gets worse the
veins become so dilated that
large sacs form at the bends
Turbulent flow occurs with
areas of stagnation like extreme
bends…
…in an otherwise fast running
river and the vein can
sometimes thrombose leading
to inflammation called
superficial thrombophlebitis
24. Venous Ulcers
constitute 90% of
the ulcers seen in a
busy specialist clinic
ulcer will never heal
unless the chain of
events which led to
it are reversed
26. Indications for Treatment
Absolute Indications:
– Complications from venous reflux
Relative Indications:
– Desire to have legs without blemish
– Personal body image
– Sexual motives
32. Current Treatments
I-Ultrasound guided sclerotherapy:
– Effective short term but no long term
durability:
Neglen P, et al: J cardiovascular surgery 1993;
34(4): 295-301:
– Compression Slerotherapy (CST): 5 year failure rate: 51%
– Stripping: 5 years: 60% “cured”, 35% “improved”
– High ligation and CST: 5 years failure rate: 84%
36. Surgical Treatment
Dwerryhouse S et al, J Vasc Surg, April
1999; 29(4): 589-592:
– 100 pts randomized to ligation or stripping
– After 5 years, 78 pts available for duplex scan:
29% SFJ incompetence in the stripping group
71% SFJ incompetence in the high ligation group
37. Surgical Treatment
Fisher R, et al, J Vasc Surg 2001; 34
(2):236-40
– 602 pts underwent high ligation and stripping
– 125 limbs in 77 pts available for duplex scan 34
years after ligation and stripping
– 60% limbs showed SFJ reflux by US
– Neovascularization accounted for identified
failure
39. “Mini” Surgical: Ambulatory
Phlebectomy
Permits removal of nearly any incompetent
vein below the saphenofemoral and
saphenopopliteal junctions
Major tributaries; perforators; and reticular
veins, including small reticular veins
associated with telangiectasias
The procedure is well tolerated by patients
and produces good cosmetic results
42. Cyanoacrylate glue for
saphenous ablation
Nick Morrison
Approved in Europe
Not FDA approved
92% GSV occlusion at
1 month
Clot extension to SFJ
in 21%
44. Current Treatments
III-Endovascular ablation of saphenous
vein:
– New treatment out of necessity:
Trauma of surgical treatment
High morbidity of surgical treatment
Minimally invasive treatment
A new “gold standard”??.....YES!
50. RF Closure of the GSV:
Dr Rosenblatt
139 limbs treated in 124 patients
Mean F/U 17.5 months (34-854 days)
Symptomatic improvement in 97%
Persistent and complete occlusion of the
vein in 132 limb (95%) by duplex U/S
51. RF Closure of the GSV:
Dr Rosenblatt
Complications:
– 12.4%
– Transient paresthesia 11% (resolved in all by 4
months)
– Focal skin burn 1.4%
No DVT
52. Endovenous Laser Therapy
FDA Clearance:
– Diomed Jan 02
– Biolitech Jun 02
– Angiodynamics Nov 02
– Dornier Nov 02
54. 980nm Diode Laser
Wavelength
How it works
Water makes up over 80% of blood & Endothelial Cells
The precision of the 980 Wavelength Targets the water to create
a “Steam Bubble”
Resulting Heat Destroys
endothelial wall to cause
Thrombosis & Vessel
Occlusion
Safer more precise treatment
with less chance of collateral
damage to surrounding
tissue or nerves
57. Endovenous Laser Therapy
Robert J. Min et al, J Vasc Interv
Radiol 2003; 14:991–996
– Large published series to date
– 499 limb in 423 patients
– Successful occlusion of GSV in 490
patients (absence of flow by duplex U/S),
98.2%
