The superficial veins and the great saphenous vein


These are the great and small saphenous veins and the tributaries of the perforating veins. The correct anatomical nomenclature is 'great' and 'small' saphenous veins (saphena magna and saphena parva), but 'long' and 'short' are still in common clinical use.

The great saphenous vein (GSV) arises from the medial end of the dorsal venous arch of the foot, then passes in front of the medial malleolus and along the medial surface of the leg, enclosed in its own 'fascial sheath'. Caggiati and Ricci have undertaken detailed studies of this sheath by dissection and ultrasound examination and have demonstrated a connective tissue lamina originating from the lateral part of the inguinal ligament and descending over the anteromedial aspect of the thigh and medial aspect of the calf.

The GSV lies in a narrow compartment between this and the underlying muscular fascia, and thick connective tissue strands from the two laminae extend to the saphenous adventitia. The superficial lamina appears to arise from the interlacing of the hypodermal connective sheets in an intermediate plane between the dermis and the muscular fascia and it divides the hypodermis into a superficial and a deep compartment.

The dissection demonstrated the subcutaneous lamina lying superficial to the GSV consistently in the upper third of the leg, but in the middle third it appeared in only one-quarter of cases. The importance of the fascial compartment enclosing the GSV to modern phlebology is that this structure is readily seen on ultrasound imaging and this allows the main saphenous trunk to be identified and separated from its tributaries.

This is helpful in establishing the correct identity of incompetent superficial veins during ultrasonography as well as during ultrasound-guided injection of veins. Fascial sheaths also enclose the anterior accessory saphenous vein in the thigh and the small saphenous vein in the calf.

The GSV lies posteriorly at knee level and then passes up the thigh and through the foramen ovale and the femoral triangle to join the common femoral vein. It crosses the superficial external pudendal artery at the lower border of the foramen ovale.

The anatomy of the GSV and its important tributaries can easily be remembered by thinking of two tridents, or threepart pronged forks, one in the thigh and one just below the knee. In the groin, the important tributaries are the anterolateral and posteromedial veins of the thigh. Smaller tributaries are the superficial and deep external pudendal veins, and the superficial epigastric and circumflex iliac veins.

Just below the knee, the anterior and posterior prongs of the trident are the anterior vein of the leg and the posterior arch vein. The important medial calf direct perforating veins communicate with the posterior arch vein (first accurately observed and drawn by Leonardo da Vinci) and not directly with the GSV.

The tributaries of the GSV commonly become varicose; the saphenous vein itself is only occasionally dilated and varicose in the lower leg and varicose dilatation of the anterior accessory saphenous vein in the thigh may occur without great saphenous incompetence. The GSV is accompanied by the saphenous nerve, which is closely applied to the vein in the lower third of the calf, where it may be damaged by the passage of a vein stripper.

It may seem unnecessary to emphasize that the GSV lies in front of the medial malleolus. The posterior tibial artery passes behind this bony landmark. Failure to remember this very elementary anatomical point has resulted in the femoral artery being stripped on more than one occasion. The GSV is occasionally duplicated, either in part or along the whole of its course.

It is also sometimes crossed by the superficial external pudendal artery in the groin, instead of passing superficial (anterior) to it. Surgeons must be aware of these anatomical abnormalities if they are to dissect safely and effectively in this area.

The dorsal venous arch of the foot communicates with the plantar veins by way of four perforating veins which pass between the metatarsals and the GSV, which arises from the medial end of the dorsal venous arch and gives one or two inframalleolar tributaries to the posterior arch vein and its tributaries, the corona phlebectatica network of malleolar veins that drain into the medial calf perforating veins.

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This article was sent to us by: Mark Cromms at 02182011

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