Venous valves and major superficial tributary veins near the saphenofemoral junction

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Abstract

Background

Venous valves are still discussed controversially, mainly because it is still uncertain whether primarily missing or insufficient valves or the weakness of the venous walls cause varices. Furthermore, the distribution and frequencies of major superficial tributary veins (MSTVs), which should discharge the great saphenous vein (GSV) between the terminal (TV) and preterminal valve (PTV) gain in importance; a fortiori as remaining MSTVs during primary varicose vein treatment may be a reason of future recurrent varicose veins. Therefore, the aim of this study was to investigate both the frequency and position of the GSV valves and the distribution of MSTVs near the saphenofemoral junction (SFJ).

Methods

We investigated 114 formalin fixed bodies with 217 GSVs. The measurement of the position of the valves and the entrances of the MSTVs was performed in situ from the SFJ to the nodule of the valve or to the orifice of the tributary vein into the GSV, respectively.

Results

On average, the specimens possessed 2.26 valves on the left side and 2.07 valves on the right side. First, valves were present in all 217 legs in a range of 0.0 to 7.2 cm. Taking as a basis the strict definition of a TV that it lies between the orifice of the GSV and the most proximal MSTV we could find only 75 TVs (68.8%) on the left side and 77 (71.3%) on the right side. In total, we found 803 MSTVs entering the GSV, an average of 3.7 veins per GSV. The left GSVs had significantly more MSTVs (P= .000). Most frequently, the superficial external pudendal vein (SEPV) existed in 90.3%, joining the GSV from medial 16.9 mm distally to the SFJ. A complete “venous star” of the MSTVs, as it is described in several textbooks, was present in only 18.4%.

Conclusions

Terminal and preterminal valves of the GSV do not always exist. Using a strict definition whether a valve should be called either “terminal valve” or “preterminal valve”, we will find a lot of them completely missing. This means that in a considerable number of patients reflux from the common femoral vein (CFV) to the GSV and further on into the MSTVs might occur. Several major superficial tributary veins join the GSV within the first millimeters; therefore a thorough exposition and monitoring of these vessels during diagnostic procedures are obviously crucial for a long-lasting success.

Clinical Relevance

Nowadays, there is a trend towards the use of thermal ablation techniques of the GSV and away from stripping. Thus, several groin tributaries remain open. It seems possible that the competence of these tributaries before the treatment play a distinct role in selecting the treatment options. This requires investigation of the flow in these tributaries by duplex scan; therefore the exact location and correct identification of the tributaries are important. The reliability of identification of the groin tributaries by duplex ultrasound is unknown and should be investigated. To match the duplex data with our anatomical data in regard to the frequency and location of these tributaries will be one of the ways to address this issue.

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