docOverview of Anatomy and Physiology of Superficial Venous
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Overview of Anatomy and Physiology of Superficial Venous
Overview of Anatomy and Physiology of Superficial Venous Insufficiency Robert R. Attaran, MD, FACC, FSCAI, FASE, RPVI Asst Professor, Cardiovascular Medicine, Yale University. No disclosures • Ebers Papyrus (1550BC): ‘serpentine windings’ Acropolis, 4th Century BC Agnotti Furtado de Mederos C. Varicose vein surgery: History and evolution. J Vasc Brasil. 2006; 5(4): 295 Appreciation of Anatomy • REVATA retrospective cohort analysis • Post-ablation 7% had varicose vein recurrence at ~3 yrs • Among the recurrence cases: -2/3 had perforator reflux -40 new AAGSV reflux -24 new SSV reflux BUSH RG et al. Factors associated with recurrence of varicose veins after thermal ablation: Results of the recurrent veins after thermal ablation study. Sci World J. 2014; 505843 Superficial veins: GSV, SSV, AAGSV, PAGSV, intersaphenous, reticular Perforators: Cross fascial planes (superficial to deep) Communicators: Connect in same fascial plane Deep veins: Common femoral, femoral, popliteal, soleal, gastroc, tibial… Caggiati A. Circulation. 1999;100:2547-2549 Glovizki P et al. Journal of Vascular Surgery 2011 53, 2S-48S Glovizki P et al. Journal of Vascular Surgery 2011 53, 2S-48S Updated Vein Nomenclature ✔ ✖ Femoral Superficial femoral Great saphenous Long saphenous Small saphenous Lesser/short saphenous, Intersaphenous Giacomini Perforator of the femoral canal Dodd’s perforator Paratibial perforator (upper leg) Boyd’s perforator Paratibial perforator (mid leg ~24cm) Sherman’s perforator Posterotibial perforators Cockett’s perforators (I II III) Soleal vein Sural vein Caggiati A et al. J Vasc Surg. 2005; 41: 719-24 Pointers: • True GSV duplication (within fascia) ~2% in thigh, 25% in calf. • GSV may exit fascia and become more superficial in distal thigh. • Valve in SFJ 94% • Main GSV trunk: 6+ valves • SSV: 7-10 valves Thomson H. Ann Royal Coll Surg Engl. 1979; 61: 198-205 Somjen GM. Anatomy of the superficial venous system. Dermatol Surg. 1995; 21: 35-45 Leu HJ et al. Basic Res Cardiol. 1979; 74: 435-444 SSV confluence: ~60% Popliteal vein within 8cm of knee joint 20% ~20% GSV via tributaries 20% 60% ~ 20% femoral/deep femoral/internal iliac Leu HJ et al. Basic Res Cardiol. 1979; 74: 435-444 Mozez G et al. In: Gloviczki P et al. Handbook of Venous Disorders: Guidelines of the American Venous Forum. 2nd Ed. London: Arnold; 2001: 11-24 Perforators ~64 in thigh & leg Often accompanied by artery 4 major clinical groups: thigh, medial calf, lateral calf, foot Many have valves. Thomson H. Ann Royal Coll Surg Engl. 1979; 61: 198-205 Mozez G et al. In: Gloviczki P et al. Handbook of Venous Disorders: Guidelines of the American Venous Forum. 2nd Ed. London: Arnold; 2001: 11-24 Calf Perforators Anatomy Old Nomenclature Paratibial GSV – posterior tibial Boyd, Sherman Posterior tibial PAGSV – posterior tibial Cockett Lateral Anterior *PAGSV = Posterior accessory great saphenous vein *PAGSV previously named “posterior arch vein”, “Vein of Leonardo” Cagiatti A, et al. J Vasc Surg. 2002; 36: 416-422 GSV Navix Venous Ultrasound Program. 2012 Anterior Accessory GSV Navix Venous Ultrasound Program. 2012 Pudendal vein Navix Venous Ultrasound Program. 2012 Changes in ankle pressure Vowden K, Vowden P. Wound Essentials 2012; 7(2): Suppl. Pathophysiology Not fully understood • Changes to vein wall matrix, inflammation or thrombosis involving valves • Venous hypertension, obstruction Zsoter T et al. Can Med Assoc J. 1966; 94: 1293 Junger M et al. Microcirculation. 2000; 7: S3 Affetto JD et al. J Vasc Surg. 2008; 48(2): 447 Pathology Analysis of Varicose Veins • ...intimal hypertrophy due to fibrous tissue infiltration, localized thinning of muscle layer and loss of intimal & medial smooth muscle cells. • Loss of the normal elastin/collagen lattice network. Wali MA et al. Int J Angiol. 2003; 22(2): 188 Capillary H2O leakage Capillary Protein leakage Cytokine Edema release from activated neutrophils Fibrosis = Lipodermatosclerosis Recirculating O2-poor high lactate blood Inflammation TGF-β1 Rouleaux formation & Microthrombosis serum VEGF & TNFα Ulceration Smith PD. Cardiovasc Res. 1996; 32: 789-795 Pappas PJ et al. J Vasc Surg. 1999; 30:1129-45 Bollinger A et al. Clin Capillaroscopy. 1991; NY. Hofgrefe & Huber Murphy MA et al. Eur J Endovasc Surg. 2002; 23: Summary • Venous insufficiency a/w incompletely understood inflammatory changes. • Significant variability in venous anatomy. • Careful evaluation with US duplex vital for diagnosis & treatment plan.