By: John Mauriello, 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
John Mauriello, M.D.
I disclose the following financial relationship(s):
•Speaker/Honoraria: Angiodynamics
•Consultant/Advisory Board: Biolitec, Inc.

2. Important Nerves During Venous
Ablation
John Mauriello, MD, FACPh
Bradenton, Florida

3. Important Nerves during
Venous Ablation
• Saphenous N.
• Sural N.
• Tibial N.
• Common Peroneal N.

4. Nerves of importance during Ablation
Why?
• Saphenous N.
• Sural N.
• Tibial N.
• Common Peroneal N.
Campbell WB, France F, Goodwin HM. Medicolegal claims in vascular surgery.
Ann Roy Coll Surg Engl 2002;84:181-4
Atkin GK, Round T, et al. Common peroneal nerve injury as a complication of short saphenous
vein surgery. Phlebology 2007;22;3-7.
Nerve damage is the most common cause of
litigation following varicose vein surgery/prcedures.

5. Ted King, M.D.
Murakami G, Negishi N, et al. Anatomical relationship between saphenous vein and
cutaneous nerves. Okajimas Folia Anat Jpn 1994; 71(1): 21-33.
•Studied 148 lower limbs of 74 cadavers
• In the thigh, GSV rarely had a close relationship with the
saphenous nerve.
• In the leg, GSV frequently ran intimately along the saphenous
nerve
– 59.5% in the middle third of the leg
– 83.1% in the lower third of the leg
– More than half of the latter showed an adhesive relationship where the
epineurium of the saphenous nerve was seen histologically to be attached to
adventitia of vein
• SSV was often located close to sural nerve
– Adhesive relation between SSV and sural nerve was rarely observed.
Anatomical relationship between saphenous veins and
superficial nerves

6. Nerve Injury during stripping (2,341)
• Great saphenous vein (GSV) stripping in 1,963
limbs. Nerve injury of 4.9%.
Small saphenous vein (SSV) stripping in 570
limbs. Nerve injury of 2.5%.
• Full-length stripping accounted for almost 40%
of the all cases.
GVS stripping had 9% & SSV had 4.5% nerve
injury.
Masaki K, Tetsuyan N, et al. Safety of Outpatient Vein Stripping under Local Anesthesia
and Propofol Sedation. Japanese Journal of Phlebology 2006;17:11-16.

7. Saphenous neuropathy following
EVLA
• Four studies reported saphenous paresthesias
in 1 % to 36·5* % of limbs.
Mundy L, et al. Systematic review of endovenous laser treatment for varicose
Veins. British Journal of Surgery 2005; 92: 1189–1194.
*Chang C-J, Chua J-J. Endovenous laser photocoagulation (EVLP) for varicose veins.
Lasers Surg Med 2002; 31:257–262.
At six months this was 2.8% and 0 at end of study.

8. The saphenous
nerve will lie (about
3 cm) posterior and
deep to the vein.
Variations do exist
but rarely is it
adjacent to the
vein.
Courtesy of Olympia Anesthesia Associates, P.C., a resource affiliate of neuraxiom.com.
Available at http://www.neuraxiom.com/html/saphenous_block.html .
Above the knee

9. Ted King, M.D.
GSV
Fascicle
Epineurium
Saphenous fascia
Deep fascia
Below the knee

10. Cross section of SaphC.
No Nerve Saphenous Nerve
Above knee Below Knee

11. Saphenous Nerve
Sclerotherapy: treatment of varicose and telangiectatic leg veins. MP Goldman
Sensory nerve to
medial calf, ankle and
foot.

12. Sural Nerve
• Sural nerve is the most frequently used
sensory nerve in nerve transplantations.
• Though the sural nerve is considered to be a
sensory nerve, some motor fibers have been
found in 4.5% of nerves.
Amoiridis G, Schols L, et al. Motor fibers in the sural nerve of humans. Neurology
1997;49:1725-8.
Nayak S. Sural nerve and short saphenous vein entrapment-a case report. Indian
Journal of Plasrtic Surgery. 2005;38:171-172.

13. Sural neuropathy following EVLA
• Reported to be 01- 4.42 %.
1Proebstle TM, Gul D, et al. Endovenous laser treatment of the lesser saphenous vein
with a 940-nm diode laser: early results. Dermatol Surg 2003; 29: 357–361.
2Gibson KD, Ferris BL et al. Endovenous treatment of the short saphenous vein: efficacy
and complications. J Vasc Surg 2007;33:614-618.

14. Conclusion
Puncturing the SSVs at the mid-calf will decrease post-
operative paresthesia without affecting the recanalizations
rates. This is due to the very close relationship of the SSV with
sural nerve in it’s course from the distal calf to the ankle,

15. Sural Nerve
Courtesy of Diana Neuhardt, RVT Left
Sural
nerve
SSV
Much closer

16. Sural Nerve
Sclerotherapy: treatment of varicose and telangiectatic leg veins. MP Goldman
Sensory nerve to the
lateral calf, ankle, foot &
heel.

17. Tibial Nerve
•Motor / Sensory N.
•Can't stand on tiptoes (no plantar flexion).
•No sensation to sole of foot.
Sciatic nerve
Left Popliteal Fossa

18. Common Peroneal Nerve
1Lucertini G, et al. Injury to the CPN during surgery of the SSV. Phlebology
1999;14:26-28.
2Atkin GK, et al. CPN injury as a complication of SSV surgery. Phlebology
2007;22:3-7.
3Balasubramanium R, et al. The relationship between the SPJ and the CPN:
a cadaveric study. Phlebology 2009;24:67-73.
• Incidence 2 - 4.7%1-2 during surgery of SSV.
• Incidence during AP or EVTA ?? Under reported.
• Higher the termination of SPJ the closer is the CPN3.
• One cadaver3 the SPJ & CPN was 1.3 mm apart.
Mean of 16.7 mm.

19. Common Peroneal Nerve
Left Popliteal Fossa
Sciatic nerve
•Motor / Sensory N.
•Foot Drop
•No sensation to top of foot

20. Common Peroneal Nerve
Danger zone near the fibular head.

21. Common Peroneal Nerve
Left lateral Knee
Danger zone

22. Common Peroneal Nerve
Cross section Long axis
CPN
CPN
Scan by Joseph Zygmunt, Jr. RVT

23. Conclusion
• With good ultrasound equipment you can see
nerves. If you look for them.
• The more distal the closer is the saphenous and
sural nerves to their respective veins.
• Be cautious when doing AP near the fibular head.