By: Paul M. McNeill, M.D. 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
Paul M. McNeill, M.D.
I have no financial relationship(s) to disclose.

2. The Great Saphenous
Vein
Paul M. McNeill, MD FACS
Capitol Vein and Laser Center
Bethesda, Maryland

3. Great Saphenous Vein
 Path of the GSV
 Key branches
 Supporting
structures
 Relationship to
nerves
 Vein valve function
 Pathophysiology
 Anatomy impacting
treatment

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Medial Calf Perforating Veins

13. 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

14. Saphenofemoral Junction

15. Saphenofemoral Junction Variation

16. 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

17. Saphenous Nerve
 Femoral n branch
 Subsartorial canal
 Proximal ½ posterior
 Lower 1/3 anterior
 Adherent to GSV
• Medial malleolus 80%
• Mid leg 97%

18. Anatomic Overview
Vein Wall
 Intima
 Media
 Adventitia
 Endothelia cells
prevent thrombosis
 Muscular
contraction alters
vein volume

19. Anatomic Overview
Compartments of the leg
 Superficial and
deep
compartments
 Fascial envelope
• Defines high
pressure deep
compartment
 Veins traverse the
compartments
• DV, SV, PV

20. Anatomic Overview
Calf Muscle Pump
 Muscles enclosed
in fascial envelope
 Muscular
contraction raises
pressure
 Venous
compression
occurs
 Vein valves affect
direction of flow

21. Venous Histology: Vein Valve
 Thin sheets of
collagen
 Smooth muscle
 Endothelium
 Muscle fibers at
base
 Elastic fibers

22. 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

23. 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

24. Saphenous Vein Reflux

25. Reflux Schemes
 Normal valve
function
 Perforating vein
has one way
flow
 Fascia separates
deep and
superficial
compartments
 GSV normal

26. Reflux Schemes
 Relationship of
superficial veins to
GSV vein valves
 Normal caliber of
veins throughout
system
 Low pressure
maintained

27. Reflux Schemes
 Perforator vein
incompetence
 Dilated GSV
 Dilated GSV branch
vein
 Higher venous
pressure in superficial
system

28. Reflux Schemes
 Increasing pressure
results in valve failure
 Additional vein branches
become varicose
 Further GSV
incompetence and
dilation

29. Great Saphenous Vein

30. Great Saphenous Vein

31. Great Saphenous Vein

32. Great Saphenous Vein

33. Great Saphenous Vein

34. GSV Tortuosity

35. GSV Tortuosity

36. GSV Stenosis

37. Duplex Assessment

38. GSV Position – Close to Dermis

39. Great Saphenous Vein

40. 57M, Denies Symptoms

41. TSA Search and Refer

42. Thank You