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

Thank You