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The giacomini vein and its pathological flows ( Phoenix, ACP annual meeting 2014)

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Giacomini vein, CHIVA, varicose veins, systolic shunt

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The giacomini vein and its pathological flows ( Phoenix, ACP annual meeting 2014)

  1. 1. The Giacomini Vein and its pathological flows Stefano Ermini MD Florence - Italy
  2. 2. Disclosure I have no actual or potential conflict of interest in relation to this program/presentation. Stefano Ermini MD
  3. 3. Slide 3 Muscle pump contraction and relaxation and flow directions in the SPJ Incompetent SPJ refluxing during the muscle relaxation phase The most common situation in a SPJ is that of an inward( centripetal) flow during muscle contraction and an outward( centrifugal ) flow during muscle relaxation. Contraction flux Relaxation flux Contraction= inward flow Relaxation= outward flow
  4. 4. SPJ that presents an outward flow during both contraction and relaxation During the muscle contraction, an outward flow from the SPJ can occur. In some cases, the flow follows the same direction in both contractive and relaxation phases . This outward contraction flow results from an increasing pathologic pressure. Contraction flux Relaxation flux Contraction = outward flow Relaxation= outward flow ( in some cases) Slide 4
  5. 5. This contractive centripetal flow in the Popliteal fossa can give origin to a centripetal flow in the Giacomini Vein and this can can occur in 2 different situations: 1 - In case of deep vein obstruction. This flow is a part of a compensative circuit (vicarious flow ) 2- without deep obstruction, due to a functional deep vein stenosis or other causes - This situation is the object of this presentation 1 2 Slide 5
  6. 6. If the flow that originates from the popliteal fossa, passes through the Giacomini vein and re-enters into the deep vein through the SFJ , the patient is completely asymptomatic and no varicose vein is visible In this situation the re-entry point is placed above the escape point and the flow goes upwards into the Giacomini vein thanks to a hypertensive pressure gradient Slide 6
  7. 7. Deep veins LSV Re-entry point A Re-entry point B Escape point SSV If the Giacomini Vein drains into an incompetent GSV and a re-entry point is placed below the escape point, a centripetal flow also exists in the Giacomini vein during muscle relaxation. Contractive Flow Relaxation Flow Slide 7
  8. 8. Contraction Relaxation Slide 8 Deep veins LSV Re-entry point A Re-entry point B Escape point SSV Deep veins LSV Re-entry point A Re-entry point B Escape point SSV
  9. 9. The siphon effect explains the presence of a relaxation centripetal flow in the Giacomini v. The siphon effect occurs when a tube in an inverted U shape causes a liquid to flow upwards, above the surface of the reservoir, without pumps, powered by the fall of the liquid as it flows down the tube under the pull of gravity, and discharges at a level lower than the surface of the reservoire it comes from ( http://en.wikipedia.org/wiki/Siphon ).The real siphon effect works in a open circuit. In the venous system the circuit is closed and the effect of gravity’s potential energy is charged by muscle pump activity. Tank A Tank B The Siphon Effect Tank A Tank B Slide 9
  10. 10. Differences between a contractive centripetal reflux and a relaxing centrifugal conventional escape point A contractive centripetal reflux is submitted to muscle pump contractive pressure. This pressure is much higher than the relaxation gradient that originates during the relaxation phase of the muscle pump and that creates a “conventional” escape point. This means that this flow cannot be interrupted with the same positive results that we achieve for the SFJ or for a conventional situation in the SPJ. Slide 10
  11. 11. Consideration about the escape point treatment 1. A flow that originates during muscle pump contraction is submitted to a high lateral pressure 2. A flush ligation in the popliteal fossa is frequently not correctly performed for anatomical reasons. These two events combined lead to a frequent SPJ “flush” ligation recurrence N° Recurrences Venous stump Cavernoma Contractive outward flow SFJ 475 144 (30,3%) 36 (6,5%) 0 SPJ 18 6 (30%) 6(30%) 6 (30%) ( Personal archive from January 2007 to January 2014 ) Slide 11
  12. 12. Strategy Treatment Goals:  To preserve the contractive centripetal flow in the Giacomini vein, draining it directly into the deep system  To only treat the vicious recirculation ( private circulation) that originates during relaxation without interrupting the contractive centripetal flow  To reach a good cosmetic and functional result Slide 12
  13. 13. Surgical Treatments and Results Surgery was performed on 20 patients ( Follow up minimum 3 months , maximum 3 years) 15 strategies on the Giacomini v. 4 strategies on the GSV 1 ligation of the Giacomini v. flush to the SSV arc Slide 13
  14. 14. Disconnection of the Giacomini vein flush to the SSV arc Gastrocnemious perforator Slide 14
  15. 15. Strategy on the Giacomini Vein Slide 15 A B The same surgical disconnection obtains different effects:  In situation A the systolic flow is preserved  In situation B the systolic flow is NOT preserved
  16. 16. Slide 16 What happens when the systolic flow is interrupted by Strategy on Giacomini v the tributary disconnection? No perforator before surgery Systolic flow 1 week later No Systolic flow 1 week later GiacThrombosis 1 week later 15 10 6 4 1 Zero Deep vein thrombosis 2 recurrences ( new tributary originating from the Giacomini v.) in the first 12 months 2 recurrences = 10 % of the entire group 20% of the cases without systolic flow re-entry perforators
  17. 17. Slide 17 The worst thing that we can do in a situation like this is to destroy the saphenous trunk.
  18. 18. Thanks for your attention Stefano Ermini M.D. ( Florence - Italy )

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