Describes all venous hemodynamics patterns of Giacomini varicose veins and introduces the principles of hemodynamic treatment. Clearly explains that no classical demolitive treatment is possible in these situations.

1. Hemodynamic Assessment and Strategy
Treatment of Giacomini Varicose Veins
Stefano Ermini M.D.
Florence

2. Giacomini Vein
It is an N2 vein, like the LSV and the SSV
It is a transversal vein that goes from the SPJ to the SFJ and drains the perineal veins

3. Valve Orientation in the Giacomini Vein

4. Origin from an escape point placed above
Flow in the Giacomini vein occurs
during the relaxation phase of the
muscle pump

5. Origin from an escape point placed above
The varicose vein can originate from the Giacomini above or
below the perineal intersection

6. By the interposition of the Giacomini v. , the
perineal reflux can give origin to GSV varicose
veins
In relation to the re-entry
point disposition different
patterns are possible

7. Pelvic escape point
Giacomini Vein
Visible varicose Veins

8. Pelvic escape point
Giacomini Vein
Gluteal perforator

9. Deep veins
LSV
SSV

10. Giacomini varicose veins originate from an escape point placed below
This pattern only occurs in the case of a contractive centripetal
flow in the popliteal fossa , in absence of deep vein obstruction
Various hemodynamic patterns and the presence or not of varicose veins
are possible in relation to the re-entry point’s disposition

11. 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 an
hypertensive pressure gradient

12. Re-entry
point A
Deep veins
If a re-entry point is placed
below the escape point, a
centripetal flow also exists
in the Giacomini vein during
muscle relaxation.
Escape
point
LSV
SSV
Re-entry
point B

13. Contraction
Relaxation
Deep veins
Re-entry
point A
Deep veins
Re-entry
point A
Escape
point
Escape
point
LSV
LSV
SSV
Re-entry
point B
SSV
Re-entry
point B

14. The Siphon Effect
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 A
Tank B
Tank B

15. Hemodynamic patterns of relaxation centrifugal flow
= Perforator

16. Strategy treatment
Pelvic escape point
Risk of escape point
recurrence for anatomical
reasons
Popliteal fossa escape point
Impossibility to perform
an efficient treatment of
an escape point
submitted to the pressure
of the muscle pump and
with anatomical
difficulties
Common solution
Preservation of the N2 Network to drain the pathogenic flow directly in
the deep system using the N2 perforators

17. Strategy treatment of Giacomini varicose veins originating from a
perineal escape point
Goals:
 To reduce the centrifugal flow rate treating the escape point
 To preserve all N2 systems, competent or incompetent, to avoid varicose
vein recurrence in case of escape point treatment failure.
 To reach a good cosmetic and functional result
1
2
1 = escape point treatment
2 = tributary disconnection

18. Strategy treatment of Giacomini varicose veins originating from
the popliteal fossa
Goals:
 To treat the escape point only when it is hemodynamically and anatomically
possible , or in alternative
 To preserve the contractive centripetal flow in the Giacomini, 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

19. The tributary disconnection leads to:
1) The maintenance of the contractive centripetal flow
in the SFJ
or in
in a Giacomini perforator
2) The interruption of the vicious recirculation
(venous shunt)