By: Lowell S. Kabnick, MD, FACS, FACPh, RPhS Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.

1. Disclosure
Lowell S. Kabnick, M.D., FACS,
FACPh,RPhS
I disclose the following financial relationship(s):
•Research Grant: BTG
•Ownership Interest: AngioDynamics, Vascular
Insights
•Consultant/Advisory Board: AngioDynamics,
BSN Jobst, Vascular Insights

2. Small Saphenous Thermal
Ablation
Lowell S. Kabnick, MD, RPhS, FACS, FACPh
Director, NYU Vein Center

4. Courtesy JL Gerard

5. Tibial nerve
Common Peroneal
Gastrocnemius nerve
SSV
Courtesy JL Gerard

6. Anatomic Variations
• SSV joins the popliteal vein
at the Saphenopopliteal
Junction (SPJ) and joins
deep veins at a higher level
through its cranial extension
of the SSV or joins GSV via
the vein of Giacomini
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound
Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J
Vasc Endovasc Surg 2006; 31:288-299

7. 2nd Anatomic Variation
• SSV continues upwards
as the cranial extension
of the SSV or vein of
Giacomini but also
connects with the
popliteal vein through an
„anastomotic‟ tiny vein
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound
Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J
Vasc Endovasc Surg 2006; 31:288-299

8. 3rd Anatomic Variation
• SSV has no
connection to deep
veins- it continues
upward as the
cranial extension of
the SSV or vein of
Giacomini
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound
Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J
Vasc Endovasc Surg 2006; 31:288-299

9. Other Veins
• Gastrocnemius veins
may join the popliteal
vein, proximal SSV, or
their confluence at the
SPJ
• SSV may merge with
the gastrocnemius
veins before joining
the popliteal vein (10-
30%)
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound Investigation of
the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J Vasc Endovasc Surg
2006;31:288-99

10. Incompetent Giacomini Vein
• Transmits reflux from
GSV or thigh
perforators and pelvic
veins to SSV through
the intersaphenous
anastomosis (IA)
Georgiev M, Myers K, and Belcaro G. The thigh extension of the lesser saphenous vein: From Giacomini‟s observations to
ultrasound scan imaging. J Vasc Surg 2003;37:558-63

11. Cranial Extension of the SSV
• Continues straight up into the
gluteal area as a single vein or
divides in many deep and
superficial branches
• Joins the deep femoral veins
as a posterior or posterior
lateral thigh perforator
• Connects to the posterior thigh
circumflex vein which then
passes to the GSV in the
medial thigh (vein of
Giacomini)
Caggiati A, Bergan J, Gloviczki P, Jantet G, Wendell-Smith C, Partsch H. Nomenclature of the veins of the lower limbs: An
international interdisciplinary consensus statement. J Vasc Surg 2002;36:416-22

12. Insertion?

13. Saphenopopliteal Junction (SPJ)
• Most often 2-4cm
above the knee
crease
• Higher in 25-30%
• Rarely below knee
crease
Myers,Ken: Making Sense of Vascular Ultrasound, a hands on guide, 2004

14. Procedure
ssv

15. Laser Kit

16. DUS SSV

17. Skin Anesthesia

18. 21 gauge Needle Insertion

19. 018 wire

20. Micropuncture sheath

21. Upsize 035 wire

22. Laser 4 Fr Sheath / RFA 6Fr

23. Tumescent Anesthesia

24. Tumescent Anesthesia

25. “Walking the Line”

26. Laser Fiber / RFA Catheter

27. Placement of Sheath and Fiber
Fiber/RF placed
just before the SSV
“dives” to the popliteal
vein
2-3cms from the
Junction

28. Let‟s Look at the SSV Literature

29. Eur J Vasc Endovasc Surg 2009
Eur J Vasc Endovasc Surg 2009

30. • 810 laser
– 14w @70J/cm
• 169 limbs
• Avg age 57
• 100% Closed at 3 months
• 1.3% sural nerve paresthesia

31. J Vasc Surg. 2009 Apr;49(4):973-979.e1.
• Laser 980
• 226 SSV closure rate
98.7%
• Paresthesia rate
2.5%
• No EHIT2 (LMWH)

32. • J Endovasc Ther 2009;16:500-505
• 940nm
– 14 w pulse 80-90j/cm
• 269 SSV
• 6.7% initial failure and 15% long term
• No parethesia reported

34.  980nm
 210 limbs
 Concomitant GSV reflux was present in
156 limbs (74 %), and these limbs
 underwent EVLT of both the SSV and
the GSV
 4% failure avg 4 month f/u
 1.6% parasthesia

35.  88 (43 %) had type A anatomy
69 (33%) had type B anatomy
 52 (24%) had type C anatomy.
EHIT 2 RATE

36. EHIT 2
5.7 % EHIT 2
No clots present @ 2 to 11
months
Incidence of EHIT2 is higher
for the SSV than the GSV

37. NYU VEIN CENTER
SSV
September 2007-December 2010
 Total SSV 367
 EHIT2 1.1%
 SSV failures 2.72%
AVG US Follow up 145 days
Preliminary Data

38. Volume 53, Issue 1,January 2011

39. Steam Pilot Study
• 3 refluxing symptomatic SSV
• PROCEDURE
• 16 g needle USG into the SSV
• steam catheter (1.2-mm diameter) was
passed through the needle into the vein
until positioned 3 cm below the junction
• 1-2 puffs/cm steam generated at 120 C

40. • 3/20 were SSV of the 20 axial veins
• All closed at 6months
• Pain score1/10
• No DVT etc
• Median satisfaction score 9.25/10

41. Treating the Small Saphenous Vein
AUGUST 2008 I ENDOVASCULAR TODAY

42. Key Points
• 1. Harder than the GSV
• 2. Know the anatomical variations and
relationships
• 3. Endothermal Ablation is preferred in US
– Great outcomes
– Minimal morbidities

43. Thank You

44. Reported SSV